When the establishment of a fifth Israeli medical school - to be located at Safed in the Galilee - was approved by the Council for Higher Education two years ago, all four existing schools protested - arguing that the looming shortage of physicians could be more cheaply relieved by expanding their own classes. Now Ramat Gan's Bar-Ilan University is bidding for a tender to set up the school, competing against a joint bid by the University of Haifa and the nearby Technion-Israel Institute of Technology (which already has its own school and says it wants only to "nourish the fifth school with our experience" during its initial years). Before Ben-Gurion University's Goldman Medical School was founded in Beersheba in 1973, heads of the three pre-existing schools voiced opposition. Prior to the establishment of the Technion's Rappaport Medical School in 1969, the two pre-existing schools voiced their opposition. Before Tel Aviv University's Medical School was founded in 1964, heads of the country's only medical school objected. Only when plans for Israel's first medical school by the Hebrew University and Hadassah women from the US were released in 1949 did no one protest. Now, four months after the government approved the plan for a fifth school, a two-day workshop was held in the city to suggest how young Israelis keen on becoming physicians would be educated there. Senior representatives of the four existing schools attended and voiced a positive view. The deans explained that they still feel it would have been better for them to be allowed to take in more students, but that a new school would significantly boost the development of Safed and the Galilee, including Ziv Hospitals and others in the north where students would complete their clinical work. By attending and speaking at the workshop, they were able to have some influence. THE INTERNATIONAL Workshop on Medical Education in the 21st Century: New Paradigms, Innovations and Challenges - held in English at the Canaan Spa Hotel on top of Mount Canaan - was organized by the Israel National Institute for Health Policy and Health Services Research (chaired by Prof. Shlomo Mor-Yosef), with support from the Gertner Institute at Tel Hashomer and the Rashi Foundation. The establishment of a medical school is a major academic event; even in the US, only five new ones have been opened in the past two years, and there hasn't been a new one in Israel for 36 years. Medicine has been transformed since the early 1970s, so many participants suggested that the Safed school be created by "starting from scratch" and not merely by building a clone of an existing facility. Dr. Bishara Bisharat, medical director of the Nazareth Hospital (EMMS) and formerly the physician of Kibbutz Ein Dor in the Lower Galilee, noted that the health situation and medical services in the north are very different than in the center of the country. Fifty-two percent of Galilee residents are Arab, he said, with a high fertility rate and a much younger population. "Arabs have the diseases of developing countries such as infectious hepatitis, brucellosis, gastrointestinal infections, higher infant mortality and lower life expectancy, as well as the chronic disorders of developed countries such as heart disease, stroke, obesity and diabetes," he said. Nazareth has three venerable hospitals including his own, which was established in 1924 when a "camel was the first ambulance." Today, the area has a total of 2,300 hospital beds. Still, the survival rate after a heart attack is 50 percent lower in the Galilee than in the center of Israel for a variety of reasons. The "ideal student" at the fifth school "should study medicine in the spirit of unconditionally helping the poor and needy out of love and respect for all human beings. There must be cooperation between Jews and Arabs, community and hospital," Bisharat said. THERE IS also a shortage of doctors (and nurses), and especially in certain specialties who do not want to settle in the Galilee. The four medical schools currently train fewer than 400 doctors each year due to Treasury limitations, while at least 600 are needed to replace retirees and ensure easier accessibility around the country. Since it takes seven years to train a general practitioner and many more to produce a specialist, BGU president Prof. Rivka Carmi said she expected the first doctors would be minted by the new school around 2025. Eventually, there are plans to open a university in Safed as well, although a bioscience research center is to be established there with the medical school. Prof. Jonathan Halevy, director-general of Jerusalem's Shaare Zedek Medical Center, who headed a public committee that a few years ago recommended the establishment of a fifth school, called the government decision to do so "the fulfillment of a dream. There will be more competition among the medical schools, and some Israelis who were previously not accepted and went to study in Eastern Europe and elsewhere will come home to study. Today, there are 1,000 of them studying medicine in Hungary alone." The school was also strongly boosted for years by President Shimon Peres, who flew to Safed by helicopter to greet the 70 or so participants. Israel Prize winner Prof. Mordechai Shani, head of the Gertner Institute, for decades director of Sheba Medical Center and who twice served as Health Ministry director-general, said he hoped that at least half of what the new medical school will teach will be in community clinics and not in hospitals, as most medicine today is practiced in primary-care facilities. He added that some NIS 500 million shekels would be needed to upgrade medical services in the area so students would learn at a high level. He predicted that in 10 or 20 years, doctors will rarely touch their patients, and often not even be in the same room with them. Doctors could see chronically ill patients in their clinics annually, and the rest of the time could carry out "virtual visits" using computers and video, Shani suggested. Instead of working alone in the community, there will be a doctor who serves as a "clinical leader," with a "caseworker" integrating the patient's data into an electronic file. With these different functions, the criteria for choosing whom to admit will have to be changed, stressing not only cognitive abilities but also "teamwork, commitment, integrity, dedication, compassion, communication, self-confidence, honesty, and empathy with patients and family members." PROF. JORDAN COHEN, a kidney expert and president emeritus of the Association of American Medical Colleges, who came specially for the workshop, told the Israelis that while the US experience may not exactly suit Israel's, "you have a unique opportunity facing you. Don't blow it. Planning a new medical school is a once-in-a-lifetime opportunity. Bypass the resistance to change that typically stifles innovation." Curricula must be fundamentally changed to suit the era and location, Cohen advised. "Prepare students and residents to be lifelong learners. Provide the scientific foundation necessary for the practice of evidence-based medicine, and assimilate new discoveries. Prefer students with character traits that promote professionalism and sustain medicine as an ethical practice," he advised. The focus should be on continuously treating chronic disease and disability instead of episodically dealing with only acute disease; preserve health rather than only saving lives; take advantage of the genetics revolution to determine while patients are young when they will develop risks and minimize them, he said, and be aware of the costs of the care you give; be sensitive to cultural diversity in your patients; and develop teaching and mentoring skills. Canada has empirically proven guidelines to help establish new medical school curricula and competencies, said Dr. Yvonne Steinert, who received her BA in clinical psychology at the Hebrew University 38 years ago and now is on McGill University's faculty of medicine. Called CanMEDS, it views the physician as a medical expert, communicator, collaborator, manager, health advocate, scholar and bearer of professional skills. Medical schools, said Steinert, have to teach all these. "CanMEDS is only as good as what it can do for you. It is a means to an end, not an end in itself." Prof. Eran Leitersdorf, an internal medicine specialist and lipid researcher who has been named the new dean of the Hebrew University Medical Faculty, said that even now, preventive medicine is hardly taught in medical school; he intends to change that. Today's young students feel completely comfortable with digital technologies. "When I was a student, we often spent days in the library looking for a journal article; today it takes seconds. They are also very interested in social conventions, ethics and teamwork. They get bored if they don't get something new all the time." This should be reflected in what is taught and how it is taught, and combined degrees that offer MDs along with master's degrees in health administration, public health, law or biotechnology should also be offered, he said. "I would also like to know more about graduates. Do they practice medicine after graduation? Do they go into a specialty? Some graduates don't go to get their license and disappear." The choice of students for admission to medical schools has already been revolutionized by simulation, said Dr. Amitai Ziv, founder and director of MSR, (the Israel Center for Medical Simulation), who previously served in the Israel Air Force as a combat pilot and is today a deputy director of Sheba Medical Center. Applicants go through a long series of video taped encounters with actors playing patients to determine how much they know and how they behave. "Simulation is a safe environment, making it possible to forgive mistakes." Simulation of medical treatment with electronic dummies also objectively assesses the skills of graduates, interns and residents. "After a lecture, you retain just 5% of the information, but when learning with practice, you retain 75%," Ziv said. THE LAST person to launch an Israeli medical school was Prof. Moshe Prywes, who moved from Jerusalem to the Negev and established BGU's faculty of health sciences, said Prof. Carmi Margolis, who himself was later co-founder and dean of of BGU's culturally sensitive International Medical School for International Health in collaboration with New York's Columbia University. Margolis came on aliya with his family to work with Prywes, who insisted that BGU's school differ from the first three by stressing community care, student involvement in the Beersheba region and "producing mentsches." As for what he would advise for the Safed school, Margolis said: "Decide what your central goal is; use methods that have been shown to work; use information technology discriminatingly; and teach cross-cultural competence." As a large chunk of the Israeli public seek out complementary & alternative medicine (CAM) practitioners and practices, Dr. Opher Caspi - head of integrative medicine at the Rabin Medical Center - said tomorrow's physicians have to learn techniques that have been shown to help patients. Major medical journals recognize acupuncture as helping with some conditions, along with natural products such as fish oil and vitamins, he said. "Even desperately ill patients can feel better if not be cured. CAM cannot be ignored, and should be incorporated into the curriculum." Perhaps not all medical students and not all residents in a certain specialty should have the same training, suggested urological oncologist Prof. Arie Lindner, chairman of the Israel Medical Association's powerful Scientific Council. "Must a gastroenterologist be required to go through all internal medicine material? Must a pediatric or vascular surgeon have to get general surgeon certification?" he asked. Such issues should be considered by the fifth school, Lindner advised. As the mass of knowledge in the sciences doubles every 18 months to two years, memorizing facts will be much less important than knowing how to obtain accurate information and applying it, said Dr. Pablo Yagupsky, deputy dean of BGU's health sciences faculty. "I started medical school in Buenos Aires in 1968," he said, noting that his brain then weighed the average 1,360 grams. It still does, but medical students with the same-sized brain have to absorb much more knowledge, and those in the first class in Safed will be exposed to even more. "Medical education is a moving target. Today's answers may be all wrong and replaced by new answers. We have to be ready to change our views."