[THE MINI-CLINICAL EVALUATION EXERCISE (MINI CEX): PROMOTING OBSERVATION, EVALUATION AND FEEDBACK IN MEDICAL EDUCATION: TOWARDS THE IMPLEMENTATION OF COMPETENCE-BASED MEDICAL EDUCATION IN ISRAEL].

INTRODUCTION: Competence-based medical education (CBME) re-shaped medical education in North America and in Europe and is making its first steps in Israel in recent years. This article reviews the literature regarding the Mini-Clinical Evaluation Exercise (mini-CEX), a tool for the evaluation of clinical competencies in CBME. The mini-CEX has been adopted by the American Board of Internal Medicine (ABIM) and the European Federation of Internal Medicine (EFIM) and is cited in leading documents of these organizations on medical education. The mini-CEX allows direct observation on a clinical encounter of a learner (medical student or resident) and a patient by a skilled clinician (observer). The mini-CEX provides the basis for the provision of feedback to the learner by the observer following the observation.

From skepticism to openness: a qualitative narrative analysis of medical students' attitudes following an integrative medicine course.

OBJECTIVE: The present study aimed to explore attitudes of medical students following a course in integrative medicine (IM) focused on palliative and supportive cancer. METHOD: Attitudes to IM among pre-clerkship medical students were assessed following a 3-day required course, which included interviews with international experts in IM and "hands-on" workshops mentored by IM and non-IM healthcare professionals. Student reflections were analyzed qualitatively, and written narratives were examined thematically. RESULTS: Of 161 students, 102 (63.4%) provided post-course reflections. The main narrative themes included pre-course attitudes, attitude changes and influencing factors, and insights on implementing IM in clinical practice. Pre-course attitudes were predominantly skeptical, with post-course attitudes more open and non-judgmental, addressing research on IM effectiveness and safety. Students looked favorably on the implementation of IM in clinical practice and felt the course enhanced communication with patients. CONCLUSIONS: Student attitudes to IM shifted following the course, from a skeptical to a more non-judgmental and accepting approach. IM course may facilitate a better understanding of the limitations and risks of IM practices, particularly in the supportive cancer care setting, as well as implications regarding students' own resilience and professional growth.

[EXPERTISE IN MEDICINE].

INTRODUCTION: The Israeli state accords the status of "specialist", after an authorization by the Israeli Medical Association (IMA) Scientific Council and Ministry of Health (MOH), to physicians who fulfilled the requirements for the title in the 56 recognized specialties in the country. An "expert" and "specialist" are synonyms in Hebrew. However, there is no doubt that these two terms are not identical. The scientific council defines the specialist it approves as the practitioner who can practice independently in the professional domain in which he was authorized. The literature in the domain portrays a more nuanced scale, starting from novice, to advanced novice, competent, proficient, expert and finally master. Research on expertise is associated with Anders Ericsson's name, who coined the "ten thousand hours" as the average time needed to attain expertise. Ericsson also asserts that it is not just about time, but also about the method. i.e. Deliberate Practice, in which the learner has to leave his comfort zone, focus on practice with clear and distinct goals and receive external feedback. The literature describes pedagogies that employ Deliberate Practice that accelerate expertise acquisition. There is also extensive research in which physiological markers including imaging measure the expression of expertise in the brain and other systems. The dangers of expertise are also described, the most extreme being those of rigidity and hubris. While in the surgical professions, performance improves as a function of seniority and volume, in the non-surgical fields there is attrition of skills unless an infrastructure of life-long learning skills that include Deliberate Practice is incorporated. A new evidence-based paradigm is offered: the goal of physicians' formation is expertise (adaptive, not just routine expertise) and not competence or proficiency alone. However, in spite of the fact that the paradigm is supported by a multitude of theoretical and empirical data, beyond surgical skills and simulation, it is not yet fully implemented and on a large scale.

[WHY EVERY HEALTH PROFESSIONAL NEEDS TO CONTEMPLATE MEDICINE DURING THE HOLOCAUST].

INTRODUCTION: A growing interest in the realization, understanding and lessons of medicine and physicians' behavior during the Holocaust, is noted in the last two decades. In this incomprehensible time, the dark and enlightened faces of medicine reached an unprecedented (and hopefully will not ever recur) climax. We learn of the criminal conduct of Nazi medicine and Nazi physicians on the one hand, and the noble, faithful to the Hippocratic oath, behavior of some prisoner physicians and nurses on the other hand. The understanding that learning about medicine during and beyond the Holocaust is a unique platform with exceptional impact on professional identity formation for present and future health professionals, is becoming clearer. In the present paper we will briefly delineate the historical background, its place in the professional discourse, describe a seminal conference that took place in Israel in 2017 that also launched the Galilee Declaration, and thoughts for the future. In Israel, Professor Shaul Shasha's initiative to hold a yearly meeting on medicine and health in the Holocaust in the Medical Center for the Galilee in Naharia, for the last 20 years, is central to this important subject. This paper is dedicated to him with profound gratitude.

[MEDICAL EDUCATION IN COVID-19 CRISIS DAYS - REFLECTIONS AND INSIGHTS, ON-LINE CLINICAL LEARNING RESOURCES].

BACKGROUND: The COVID-19 pandemic is a demonstration of an unforeseen event that disrupts normal life routine and greatly affects medical training. With its outbreak, clinical studies in medical schools were discontinued throughout the country, and the pre-clinical studies channeled into online learning, like all other university teaching activities. Since similar situations occurred in most western countries, a methodological approach of online teaching is required - principles, goals and implementation, with reference to the tension between the duty of care versus the duty of maintaining the clinician's and student's health. In this paper we will present the dilemmas faced by the various medical education institutions in the world, along with the ways of coping and the experience gained from similar situations - including in Israel. We will discuss the techno-pedagogical principles that are at the heart of online teaching, demonstrate the experience gained in Israel and around the world, and offer a framework for comprehensive discussion for situations that threaten medical education learners. Finally, we will provide a list of online teaching resources for clinical teaching (that are mostly free and can be readily used by medical education faculties).

Grappling with complexity: Medical students' reflective writings about challenging patient encounters as a window into professional identity formation.

AIM: Clerkship-specific interactive reflective writing (IRW)-enhanced reflection may enhance professional identity formation (PIF), a fundamental goal of medical education. PIF process as revealed in students? reflective writing (RW) has been understudied. METHODS: The authors developed an IRW curriculum within a Family Medicine Clerkship (FMC) and analyzed students? reflections about challenging/difficult patient encounters using immersion-crystallization qualitative analysis. RESULTS: The qualitative analysis identified 26 unique emergent themes and five distinct thematic categories (1. Role of emotions, 2. Role of cognition, 3. Behaviorally responding to situational context, 4. Patient factors, and 5. External factors) as well as an emergent PIF model from a directed content analysis. The model describes students? backgrounds, emotions and previous experiences in medicine merging with external factors and processed during student?patient interactions. The RWs also revealed that processing often involves polarities (e.g. empathy/lack of empathy or encouragement/disillusionment) as well as dissonance between idealized visions and lived reality. CONCLUSIONS: IRW facilitates and ideally supports grappling with the lived reality of medicine; uncovering a "positive hidden curriculum" within medical education. The authors propose engaging learners in guided critical reflection about complex experiences for meaning-making within a safe learning climate as a valuable way to cultivate reflective, resilient professionals with "prepared" minds and hearts for inevitable challenges of healthcare practice.

[COMPETENCY BASED MEDICAL EDUCATION - A NEW PARADIGM FOR ISRAELI PHYSICIAN TRAINING].

INTRODUCTION: During the last decades the dominant paradigm, in which the duration of a rotation/course, the required content to be learnt (the material covered) and a test (usually a multiple choice one) evaluating the knowledge of the content, were paramount, is being replaced by a new paradigm: outcome/competency based medical education (CBME, OBME). In this paper the reasons for adopting this change in the developed world are presented, its nature and basic assumptions enumerated and national examples of its adoption from Scotland, Canada, UK and USA described. We will present in some detail the changes this approach entails, the new definitions it adopts, the learning outcomes it aspires to and how to evaluate them. Finally, we will present a draft outcomes proposal adapted to the Israeli reality. Since the Medicine Deans Forum and the Scientific Council of the Israeli Medical Association have adopted the new paradigm for the training of Israeli physicians, it is an opportune moment to expose the readership of Harefuah (i.e. Israel's physicians and medical students) to this relatively new paradigm.

[THE DOCTOR IN THE DIGITAL AGE - COMPETENCIES NEEDED AND A ROAD MAP FOR THEIR ACHIEVEMENT].

INTRODUCTION: The digital age has profoundly transformed our lives, including health and healthcare. The computer, the smart cellphone, digital communication, social networks, applications, the Electronic Medical Record, web-based medical knowledge availability, tele-medicine and a host of additional tools progress rapidly and seem to leave physicians behind, while the public adapts them willingly. This article enumerates the characteristics of the digital era in healthcare, Israel's leadership in health care application of information technology, the different domains of impact, additional competencies they mandate presently and, in the future, as well as associated ethical dilemmas. Subsequently, a road map is outlined to achieving the additional skills in all stages of the professional life cycle and through competency-based medical education, together with a vision of future medicine and the future physician. In conclusion, the hope that Israel's' doctors will resume a leadership role in the digital transformation of healthcare is expressed.

Students as anatomy near-peer teachers: a double-edged sword for an ancient skill.

BACKGROUND: A near-peer instructors (NPI) program was designed for 1st year medical students who successfully finished the Anatomy course, in order to develop their didactic ability and teaching skills, mostly for cadaver dissection. METHODS: Graduates of the training program were administered a voluntary survey at the end of the program, annually. Best graduates of the training program were offered a NPI position in the next academic year. They were evaluated by the first-year students, at the end of the Anatomy block. RESULTS: In a debriefing questionnaire at the end of the NPI training, on the five-point Likert scale (1 = lowest to 5 = highest), the overall rating ranged from 3.63 in 2013 to 3.71 in 2015. Learning prosection and anatomy demonstration skills scored on average from 4.30 to 4.36, respectively. The NPIs were then evaluated by first-year students at the end of the next year's Anatomy block. On the Likert scale, the average score of NPIs ranged from 4.10 in 2014 to 4.75 in 2016, on the par with the general satisfaction score for the professional preclinical teachers during the same period (which ranged from 3.80 to 4.26). CONCLUSIONS: It is suggested that students as near-peer instructors can make a valuable contribution to the teaching faculty, especially in a new medical school.

[THE DISCUSSION CONCERNING THE PLACE OF LECTURES AND COMPULSORY LECTURE ATTENDANCE IN MEDICAL EDUCATION].

Luder shows that there is a lack of correlation between lecture attendance in medical school and examination performance, and thus draws attention to a discourse concerning the place of lectures and lecture attendance enforcement in 2015 and beyond. The paper addresses 4 questions: First, what is the current place of the traditional lecture in the education of medical students? Second, are there alternatives to this format of teaching? Third, what are the educational consequences of mandating lecture attendance; and fourth, should there be such enforcement? The author discusses these questions and concludes that lectures should be used sparingly, after a careful evaluation that they have an added value over learning away from the classroom. Furthermore, that there are clear guidelines on how to make the traditional lecture enhanced and educationally effective, as well as alternatives such as the "flipped classroom", e-learning and more to lectures. In addition, that lectures frequently drive learning negatively and enforcing attendance in Israel entails serious unintended consequences such as a need to monitor attendance, and a host of disciplinary adverse reactions. Finally, that besides lecture efficiency and economy (when having added value) one reason to consider compulsory attendance, may be when poor attendance negatively influences teachers morale.

Fostering professional formation in residency: development and evaluation of the "forum" seminar series.

BACKGROUND: Residency training is a critical time for physicians' professional formation. However, few structured interventions exist to support residents in this transformative process of integrating personal and professional values, a process that is essential to physician identity formation and preservation of core values such as service and compassion. PURPOSES: The authors created a seminar series, the "Forum," to support resident professional formation and address the hidden curriculum as part of a larger intervention to support self-directed learning skills such as goal setting and reflection. METHODS: Ninety-minute sessions with senior residents and faculty held every other month include opportunities for individual reflection, small- and large-group discussion, and brief didactic components focused on skills such as teaching and leadership. The qualitative program evaluation included analyses of individual semistructured interviews with resident and faculty participants from 2008 to 2011 and of notes recorded by an observer during the 1st year's sessions. RESULTS: Residents appreciated the focus on relevant issues, presence of faculty, opportunities for reflection and interactivity, and inclusion of practical skills. Effects attributed to the Forum included gaining practical skills, feeling a deeper connection to one another and a sense of community, and recognizing progress in their own professional development and growth. Elements described in the literature as essential to professional formation, including encouraging reflection, use of narrative, role modeling, addressing the hidden curriculum, and fostering an authentic community, were recognized by participants as integral to the Forum's success. CONCLUSIONS: A group forum for reflection and discussion with peers and role models, tailored to local needs, offers an effective structure to foster professional formation in residency.

The Hamas massacre of Oct 7, 2023, and its aftermath, medical crimes, and the Lancet commission report on medicine, Nazism, and the Holocaust.

BACKGROUND: The report of the Lancet Commission on medicine, Nazism, and the Holocaust, released in November 2023, calls for this history to be required for all health professions education, to foster morally courageous health professionals who speak up when necessary. MAIN BODY: The report was released a month after Hamas' October 7 invasion of Israel, with the accompanying massacre of over 1200 people, taking of civilian hostages, and gender-based violence. These acts constitute crimes against humanity including genocide. Post-October 7, war in Gaza resulted, with a legitimate objective of Israel defending itself within international law. The authors discuss an accompanying Statement to the report condemning Hamas crimes and denouncing the perpetrators' use of their own civilians as human shields, including in healthcare facilities, and with the Hamas attack unleashing immense and ongoing suffering in Israel and beyond. With some exceptions, the medical literature shows a marked absence of condemnation of Hamas atrocities and includes unsubstantiated criticisms of Israel's military. A significant surge in global antisemitism including on university campuses since October 7, 2023, has occurred; and health professionals, according to the Commission, have a special responsibility to fight antisemitism and discrimination of all kinds. In this context, the authors discuss the controversy and criticism regarding diversity, equity, and inclusion education programs ("DEI") including such programs failing to protect Jews on campuses, especially as the U.S. President Biden's "The U.S. National Strategy to Counter Antisemitism," released in May 2023, calls for the inclusion of issues of antisemitism and religious discrimination within all DEI education programs. The authors support an evidence-based approach to the Hamas massacre, its aftermath and its relevance to health professionals both within medicine and their global citizenship, including refuting the international community accusations and anti-Israel libel. CONCLUSIONS: The report of the Lancet Commission on medicine, Nazism, and the Holocaust has striking relevance to the Hamas massacre of October 7, 2023 and its aftermath. This is further conveyed in an accompanying Statement, that describes the report's implications for contemporary medicine, including: 1) provision of skills required to detect and prevent crimes against humanity and genocide; (2) care for victims of atrocities; (3) upholding the healing ethos central to the practice of medicine; and (4) fostering history-informed morally courageous health professionals who speak up when necessary.