Perhaps the single most significant difference between the way medicine was taught when Prof. Yossi Mekori was a medical student and the way it’s taught today is that today, memorization of facts has largely been replaced by learning how to find and use the latest and most accurate information.
Mekori, the outgoing dean of Tel Aviv University’s Sackler Medical Faculty and the first dean to graduate from the school, notes other major changes: An incredible 60 percent of the students are women, and much more time is spent learning at the patient’s bedside in the hospital and using the Internet than poring over the pages of textbooks in the medical school library. The curriculum includes less theory and more understanding.
He finds it hard to judge whether Sackler’s graduates are of higher quality now than in his day.
“Many techniques didn’t exist then. It is so much more complicated, and there is much more medical knowledge. But I can say that our students are excellent.”
The allergy specialist and clinical immunologist at Meir Medical Center in Kfar Saba will soon hand over the deanship to fellow Sackler alumnus Prof. Ehud Grossman, a hypertension (high blood pressure) expert and chairman of the internal medicine D department at Sheba Medical Center Tel-Hashomer.
One of Mekori’s last formal acts as dean has been to mark the 50th anniversary of TAU’s medical school. The other medical schools are the Hebrew University Medical Faculty in Jerusalem (the oldest); the Rappaport Faculty of Medicine at Haifa’s Technion-Israel Institute of Technology; Ben-Gurion University’s Faculty of Health Sciences in Beersheba; and the Faculty of Medicine in the Galilee (the youngest), run by Bar-Ilan University in Safed.
Born in Tel Aviv 66 years ago, Mekori graduated from Sackler in 1975; six years later, he completed a residency in internal medicine at the TAU-affiliated Meir Medical Center. He then moved to Denver for a clinical fellowship in allergy and clinical immunology at the University of Colorado, followed by a research fellowship in pathology at Boston’s Beth Israel Hospital of Harvard Medical School. In 1986, he established and headed the allergy and clinical immunology division at the Kfar Saba hospital. Mekori also served as chief scientist of Clalit Health Services, the country’s largest health fund, and was president of the Israeli Society of Allergy and Immunology.
“The Israeli medical school was founded in 1964, after the Sackler family came up with the idea and the State of New York chose us to do accreditation outside the US. The school moved to its current premises on campus in 1973,” said Mekori in an interview with The Jerusalem Post.
“Like many other medical schools around the world, ours is undergoing a major reform of both the content and methods of teaching of the curriculum. One of the aims of the new program is to prepare our future doctors to be able to cope with the explosive growth of knowledge – currently doubling every 30 months – and with the availability of information through the Internet.
“In the new curriculum, the student is placed in the center and will be trained in the skills that will enable him or her to be responsible for acquiring knowledge independently.
Students will learn the skills and acquire the habits of critical thinking, the basis of evidence- based medicine.”
The outgoing dean also noted that the new curriculum stresses “the integration of clinical and basic knowledge and a systematic approach to solving medical problems.
Equal importance is given to teaching the humanitarian attitude toward the patient and his or her needs. Strengthening the contact between the physician and the medical world and the patient and his social world is accomplished through a program titled Medicine- Patient-Society. Composed of a series of interrelated courses, it trains the medical student to combine the bio-medical aspects of health and disease with mental, ethical and social issues. These skills and concepts will be required for the future physician while treating the patient and the patient’s family.”
The current curriculum, Mekori continued, “combines teaching the disciplines of ethics, anthropology, history and philosophy along with practicing and exercising important medical skills, as well as early exposure to clinical problems at the very first stages of the medical experience of the student in our school.”
Medical education, being a very demanding discipline, is clearly influenced by changes in teaching methods. The modern approach in medical education is integrative, employing an interdisciplinary study of the systems. The principal role of the teacher has become one of facilitation. Thus, the main effort, said Mekori, is put into self-study based on well-planned and well-prepared syllabi. This method of teaching is used throughout the six years before graduation. The number of frontal lectures has been decreased, and students have to assume responsibility to be prepared for these small study groups.
“The principal emphasis is put on independent learning by the student and understanding of clinical procedures.
The student has to understand the fundamental knowledge, analyze it and manage the clinical cases presented to him.”
About 960 Israeli students are enrolled in Sackler’s regular six-year MD program, said Mekori. It already boasts 4,000 graduates. Mekori’s son Udi graduated from Sackler and specializes in child and adolescent psychiatry at Sheba Medical Center.
Another son, Tal, graduated from the medical school in Jerusalem and is doing his internship at Shaare Zedek Medical Center.
Some 250 Americans with bachelor of science degrees are enrolled in Sackler’s four-year MD program, established in the mid-1970s, with a curriculum patterned after those of US medical schools; the program already has 1,500 graduates who have been accepted for work in top-level medical centers from the University of California at Los Angeles to Johns Hopkins. The vast majority are Jews; a few of them even came on aliya. The students include children of Israeli emigrants.
THE DENTAL school, only the second in the country after the Hebrew University-Hadassah School of Dental Medicine in Jerusalem, has about 200 students in a six-year program toward the DMD degree. It has several times been under threat of closure because of the huge cost – significantly more than needed to train MDs – of producing dentists.
“We accept around 50 new students a year, and we are doing a makeover. We will continue to keep the dental school open,” Mekori promised.
The Sackler faculty also has about 2,000 students studying communications disorders, nursing, physical therapy and occupational therapy.
“IN THE past six or seven years, we have introduced many elements involving doctors’ behavior. We were the first medical school to change the usual interviews of candidates for the medical school; now they must go through a long series of challenges, some of them presented by actors in the role of patients to see if they have the natural ability to cope with them. The applicants are filmed and their performance assessed. After we set down the concept, we were joined by Prof. Amitai Ziv, the deputy director-general of Sheba Medical Center at Tel Hashomer, who founded and heads the Israel Center for Medical Simulation [Messer].”
Ziv, a former Israel Defense Forces pilot, became so enamored with simulation in the air force that he established and continues to head the simulation center. After helping to select candidates with the most potential, Messer provides the students, as well as medical residents who have already graduated, with new skills and techniques.
“There is no proven way to predict who wants to be a doctor due to altruism rather than just to have prestige and make money. We try to identify candidates who have compassion for other people, curiosity and competence. With personal interviews and questionnaires that ask indirectly about personality, we try to uncover their motivation,” said the outgoing dean.
Sackler’s innovative concept of student selection was later adopted by the Technion’s medical school, followed by the Hebrew University Medical Faculty.
Sackler is among the leading medical schools in the world, according to an international review and accreditation committee, which noted that foreign student scores on the US Medical Licensing Examination were among the highest in the world (about 20 points above the average success rate of all other international medical schools). Its curriculum includes lots of work in small groups and individually by the student. There are workshops in delivering bad news to patients, a subject that medical schools had long ignored, said Mekori. Students are learning about the impact that body sensors will have in the future on monitoring patients from afar.
“But the personal, patient/physician connection and clinical judgment will always be important.”
Worldwide, clinical teaching is gradually shifting from in-hospital to ambulatory settings.
“Our students also perform more of their clinical training in outpatient clinics than students have in the past. Special emphasis is given to tutoring and monitoring students’ clinical performance, improving their interpersonal skills, teaching them to communicate with patients effectively and with sensitivity,” he said.
The female majority among the student body is a revolution.
“The 50% to 60% figure is similar all over the world. The image of medicine will change. More men prefer to make money more quickly through careers in hi-tech, business and computers. I don’t know if women physicians are more emotional or have more compassion than men. But since there will be many women doctors, especially young mothers, more of them will work part time. That means that more doctors will be needed,” Mekori said. “And hospitals will have to have day care centers to make it easier for them.”
As women doctors are drawn to certain specialties over others, there will also likely be shortages in certain fields such as anesthesia, surgery orthopedics and urology, for example. It used to be rare to see women in obstetrics and gynecology, as well as pediatrics. Now the vast majority in these fields are women.
EVEN THOUGH Israel has slightly more physicians per 100,000 residents than other members of the OECD nations, the gap is rapidly closing. Physicians from the former Soviet Union who settled here in the 1990s are retiring.
“We need more doctors. There is a new medical school in Safed, but the first graduating class will have only about 50 doctors,” said Mekori. The most important limiting factor is not the number of medical schools but the availability of ‘teaching beds’ in the hospitals. There aren’t enough places to teach medical students and medical residents in medical centers and community clinics.”
Mekori and his fellow deans and the other medical faculties have been warning the Health Ministry that significant amounts of money are needed to create such an infrastructure, but it has fallen on deaf ears.
“There are too few job slots for residents, and all this requires money. I spoke about it to Prof. Ronni Gamzu, the former director-general, at least 10 times. Now he is gone, and Prof.
Arnon Afek has taken over. Arnon understands the problem, but he knows that it costs millions of shekels to open new departments for residents to learn a specialty. Unlike the past, most hospitals in the country are teaching hospitals, but there are not enough clinical teaching beds with senior physicians who have time to teach as well as to treat patients. Unlike the US, most Israeli physicians who teach do not get paid for it, but they have the opportunity to rise to become professors in the medical schools.”
Although physicians in most Western countries need to undergo testing from time to time to receive reaccreditation, this is not the practice here due to opposition from the Israel Medical Association. As doctors of all ages have to meet higher standards of knowledge, this process means that doctors are updated in the latest techniques and treatments.
“But we at TAU suggested offering mandatory continued medical education for all doctors. It could be done by computer,” said the dean.
“We suggested it three times to the IMA, but so far, the idea has not been accepted.” Apparently, the growing shortage of physicians, especially in some specialties, makes the idea unachievable for now.
Although he will soon leave the dean’s seat, Mekori will continue to treat patients.
“Even as dean, I have run my internal medicine department in Meir Medical Center and seen allergy and immunology patients every week.
Now, I will do this full time.”
And what his advice to his successor at Sackler? “Prof. Grossman must continue the teaching revolution and increase the links between the hospitals and the medical school.”