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I
THE
BEER SHEVA
EXPERIMENT
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Edited by
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S. Glick/ L. Naggan/ M. Prywes
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THE BEER SHEVA EXPERIMENT
An Interim Assessment
Edited by
« V-
Shimon Glick, M.D/*
Dean and Professor of Medicine. University Center for Health Sciences and Services, Ben-Gurion
University of the Negev, Beer Sheva, Israel
Lechaim Naggan, M.D.
Former Dean and Professor of Epidemiology, University Center for Health Sciences and
Services, Ben-Gurion University of the Negev, Beer Sheva, Israel
Moshe Prywes, M.D.
Founding Dean, Professor of Medical Education and Chairman, Center for
Medical Education, University Center for Health Sciences
and Services, Ben-Gurion University of the Negev, Beer Sheva, Israel
Israel Journal of Medical Sciences
Jerusalem 1987
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A
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1
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CONTENTS
Vol. 23, Nos. 9-10, September-October 1987
THE BEER SHEVA EXPERIMENT: AN INTERIM ASSESSMENT
Guest Editors:
Shimon Glick
I i C HAIM Naggan
Mosul Prywi s
I. PREFACE
S. Glick, L. Naggan and M. Prywes
5
II. INTRODUCTION
Context and purpose of the volume. The Beer Shew
'a Experiment: an assessment
of the first 13 years
A. Antonovsky and S. Glick
Coexistence—the rationale of the Beer Sheva Experiment
M. Prywes
The Arad statement
A. Antonovsky
III. EDUCATIONAL ISSUES
A. Principles
The curriculum. A 13-year perspective
A. Segall, D. E. Benor and O. Susskind
Academic promotions in the University Center for Health Sciences and Services
M. Sacks
Medical student selection at the Ben-Gurion University of the Negev
A. Antonovsky
Teacher training and faculty development in medical education
D. E. Benor and S. Mahler
Student-faculty interactions: a model of active student participation
r. Henkin
The debriefing method of curriculum evaluation: 13 years’ experience
D. E. Benor and S. Glick
A historic look at research in the Ben-Gurion University Center for Health
Sciences and Services
•S’. W. Moses
lhe Visiting Faculty Program—a cornerstone in the development of the
mversity Center for Health Sciences and Services
J. Beck
Center for Medical Education
M. Prywes and M. Friedman
B. Special Educational Foci
Biochemistry and more
A. Livne and N. Bashan
Epidemiology leaching, prospects and problems
S. Weitzman
7
13
21
23
32
37
44
51
55
60
63
72
74
78
continued overleaf
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Early clinical program for novice medical students: 13 years’ experience
at Ben-Gurion University of the Negev
D. E. Benor
The fluctuating fortunes of the behavioral sciences
A. Antonovsky
The community-oriented primary care clerkship
C. Z. Margolis, N. Barak, B. Porter and K. Singer
Problem-based clinical confrontation modules planned and conducted by students
M. Phillip, M. Friedman and D. E. Benor
Emergency care curriculum of the Beer Sheva medical school
E. Lunenfeld, M. Levin and R. Lazin
Lacunae in the educational program
S. Glick
IV. HEALTH SERVICES
A. General
Has the quality of the health care process in the Negev improved?
A. Naggan
The Beer Sheva Experiment—past, present and future. The hospital
management viewpoint
Y. Shapiro, D. Hauben and H. Reuveni
Division of health in the community: development, structure and function
C. Z. Margolis
Administration of the Ben-Gurion University for Health Sciences and Services
D. Singer
The challenge: child health in the Negev
R. Gorodischer
Psychiatry and primary care
B. Maoz
Geriatrics in the framework of university-based community medicine
D. Galinsky
B. Special Community Programs
The Graduates {Bogrim) project—my experience in Netivot
A. Elhayany
Community-oriented primary care provided by internists and pediatricians—
the example of Yerucham
R. Boehm
Pioneering and settlement in health services: a case study
B. Porter and C. Z. Margolis
Community Health Activists Program: a new model of community health involvement
D. Hermoni. D. Mankouta, A. Sivan, Y. Colander and B. Porter
The Negev Primary Care Project: practical continuation of the Beer Sheva
Experiment in medical education
B. Porter
V. AN INTERIM SUMMARY
The Ben-Gurion University graduate profile:: an evaluation study
M. Prywes and M. Friedman
And now: what about the future?
M. Prywes
81
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95
103
106
109
112
115
119
124
130
♦
133
136
139
143
147
152
156
161
170
■r
PREFACE
''A
I
Thirteen years of age is the age of transition at
which, by Jewish tradition, a young man celebrates
his Bar Mitzvah* and enters into adulthood. So too
in 1987, 13 years after the Ben-Gurion University
Center for Health Sciences and Services opened its
doors in 1974, its first graduates have begun to com
plete their various residency programs and reach
professional maturity. This juncture represents an
ideal opportunity for a review and critical assess?
ment of the accomplishment in what has become
widely known as the “Beer Sheva Experiment.”
Indeed we are in the process of such a detailed
detailed evaluation (pages 1093-1101 in this issue).
The present volume is an attempt to bring
together over 30 articles describing various facets of
our program. The institution has attracted enor
mous interest over the years, has been visited by
hundreds of distinguished scientists and educators
from all over the world, and has been repeatedly
reviewed by different experts, agencies and groups.
We are subjected to many inquiries about one or
another aspect of our program, and the present
volume is a partial attempt to share our experience
with others. We make no claim for comprehensive
ness in the present volume as not all areas of our
activities are described. In some cases, the failure isl
simply because we have not made major innovations
worthy of note. Thus, we have only a small section
on research, but not because we consider it uni mportant. On the contrary, we feel it is essential, and
almost from the very start we have offered many
small research grants to students to stimulate such
efforts. But the scope and magnitude of our research
effort is not unique and so we have not devoted
much space to it. Other areas may not be discussed
for technical reasons—we found no one to describe
them well. Nevertheless, most areas in which we
have demonstrated some creativity and feel that
there may be a useful message beyond the confines of
Beer Sheva are included.
The articles vary in their length, scope and depth,
depending on the inclination of the authors. Some
are self-critical, others more optimistic, some scho
larly and perhaps even pedantic, and others more
narrative in nature, each reflecting different person
alities and outlooks. We hope that they will all,
individually and collectively, convey a common
thread of commitment, enthusiasm and devotion to
major educational goals, which we hope have borne
fruit.
We should like to take this opportunity toexpress
our appreciation as Dean and former Deans of this
institution, to our professional, administrative and
technical staff, who have made Ben-Gurion Univer
sity their labor of love. They have carried work loads
well beyond accepted norms, and have had to adapt
constantly to the stresses of ever-changing demands
upon them. All that we have achieved is the result of
their enthusiasm, persistence and devotion.
The students in particular have made the endea
vor worthwhile, and have b’pen a constant source of
stimulation, usually most constructive—albeit occa
sionally abrasive. They have kept us honest, iprevented backsliding and been true partners in every
sense of the word. In addition, it ii worth noting^that
seven of our authors in this volume are graduates of
our medical school.
Finally this issue bears the unmistakable imprint
of Caroline Simon whose indefatigable efforts to get 4
this issue typed represent only a fraction of her
devoted efforts on behalf of the Center in diverse
ways.
Thanks are also due to the staff of the Israel
Journal of Medical Sciences whose labor of
love enabled them to work under difficult time con
straints, tolerate our shortcomings, and manage to
publish the Journal within our stated deadline.
Shimon Glick
Lechaim Naggan
Moshe Prywes
!
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* Bar Mitzvah—religous rite accompanied by celebration to
signify a young man’s passage into adulthood with assumption of
personal responsibility for fulfillment of mitzvot, ethical and
ritual duties enjoined by the Jewish religion.
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INTRODUCTION
CONTEXT AND PURPOSE OF THE VOLUME
The Beer Sheva Experiment: an Assessment of the First 13 Years
AARON ANTONOVSKY 1 and SHIMON GLICK 2
1 Department of the Sociology of Health, and 2 Dean, University Center for Health Sciences and Services,
Ben-Gurion University of the Negev, Beer Sheva, Israel
lsr.l Me<l Sci 23: 939-944, 1987
Key Words: Beer Sheva Experiment; medical education; assessment
Confronted with a problem of atavistic racial hatred
among his crew members, the space ship’s captain
consults with the ship’s doctor, since “Israelis are
good at sensing that sort of thing.” The doctor’s
name was Yitzhak Villin. He was an Israeli, a
graduate of the new medical school at Beer Sheba.
the Council on Higher Education of the Govern
ment of Israel.
The Kleeman report noted some of the
particularistic features of this medical school about
to be born: the special health care needs of the
Negev; the “growing difficulty in providing highquality medical care in the local and regional clinics,
particularly in the outlying communities”; the “need
to integrate the ambulatory care and hospital-based
services”; and the “possibility of a co-operative
arrangement between the University of the Negev
and Kupat Holim.” But the full ideologicalconceptual clarification received concrete
embodiment only in February 1972, when Moshe
Prywes, the long-time Associate Dean at the Hebrew
University-Hadassah School of Medicine, was asked
to chair the Committee to Plan the Establishment of
the Center for Health Sciences in the Negev. Dr.
Prywes’ paper, which opens this volume, sets forth
the basic concepts that emerged from the
deliberations of the Committee he headed, and
which provided the spirit and paradigm of the
medical school, as described in this volume.
From “Holdout,” by Robert Sheckley. Fantasy and
Science Fiction, December 1957, p 292.
Mrs. Sheckley, the source of any “Jewish” elements
in her husband’s science fiction stories, told us in
1977 that she had no recollection of how the
imaginative element arose when the book was
written in 1957. But surely, no one else al that lime
entertained the idea of a medical school in Beer
Sheva. It was strictly in the realm of science fiction
then and for a decade to come. Not until publication
of the Gillis report in September 1969 by the
committee planning the University of the Negev is
reference found: “in due course of time, there will be
a need to establish a school of medicine in the Negev,
based on the Central Negev Hospital.” Thereafter,
matters moved rapidly. In February 1970, at the
initiative of the Rector of the University, Haim
Hanani, and the Medical Director of Kupat Holim
(Health Insurance Institution of the General
Federation of Labor), Haim Doron, the Kleeman
Committee was constituted. Its report, submitted in
May 1970, served as the first draft of the proposal
ultimately submitted formally by the University to
The Feldman Committee, established by the
Council on Higher Education*, considered the
* The bulk of university budgets in Israel is provided by the
Government, which set up the Council to make formal
recommendations (in practice, decisions) concerning university
requests to establish a degree-granting department or program,
since these always have financial and educational policy
implications. The Council, chaired by the Minister of Education
and Culture, is comprised of individuals appointed from
universities and cultural institutions as well as from public life. A
specific request is first considered by a committee of the Council,
which in this case was headed by Michael Feldman, one of the
leading scientists al the Wei/mann Institute of Science. Rchovot.
Address for correspondence: Dr. A. Antonovsky. Department of
the Sociology of Health. University Center for Health Sciences
and Services. Ben-Gurion University of the Negev. POB 653.
K4I05 Beer Sheva.
f71
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Israel J. Mi d. Sci.
A. Antonovsky andS. Glick
detailed proposal of the Prywes Committee. Its
positive recommendation to the Council, submitted
in October 1972, specified that “the supply and
demand forecast of physicians for the next 10 years
indicated that no more physicians than will be
available are needed. Hence quantitatively, there is
no need to increase the number of medical students
in the country.” Its recommendation was based on
the core premise of the Prywes proposal: “...a
different quality of physician: the education of
physicians different from those educated today in
the country...a new medical school whose
establishment will be integrally related from its
inception to a substantive and basic transformation
of the structure of medicine in the Negev.” Feldman
and his colleagues were sceptical; high-sounding
promises had been made before. They were,
however, evidently persuaded that the goal was so
important and that both the objective conditions in
the Negev and all the persons involved—at the
University, in Kupat Holim (particularly Haim
Doron, the director), and a growing number of
people in Israel and abroad who expressed interest,
enthusiasm and commitment—augured well.
The Feldman Committee report to the Council
was adopted in March 1973 after fierce debate not
devoid of vested interests. The Israeli cabinet, from
all reports more enthusiastic than the Council,
placed its final stamp of approval on the proposal to
set up what came to be known as the regional
University Center for Health Sciences and Services
(UCHSS) in the Negev. The onus to transform
words into deeds now lay on Moshe Prywes, on
Haim Doron, on their colleagues serving in the
Negev and on newcomers attracted to the new
institution, and—to anticipate an important theme
of this volume—on the students, the first 34 of whom
started their studies in August 1974. Would the new
medical school in Beer Sheva rapidly become a
replica of its very respectable but traditional
predecessors in Jerusalem, Tel Aviv and Haifa, or
would it fulfill its promises?
Administratively, the Southern District of Israel
was divided into the smaller but more densely settled
(132.3 persons/km2) Ashkelon subdistrict and the
vast (by Israeli terms) Beer Sheva subdistrict (16.9
persons/km2). Table 1 gives a sense of the
population distribution in the district. The Negev
consisted of substantially smaller communities than
those of the rest of Israel. Even its capital, Beer
Sheva, located in the center of the northern Negev,
was relatively provincial. Distances between com
munities were far greater than elsewhere in Israel.
Health services in the Negev
Health services in Israel are overwhelmingly
institutionalized, and private practice is marginal.
As part of the heritage of the British Mandate (191748), ambulatory and hospital services are sharply
divided. Most of the former are provided in primary
care neighborhood clinics or regional clinics with
specialized services, though hospitals also provide
specialized outpatient services. The great majority of
the 9,143 licensed physicians in 1973 (362 persons
per doctor) were employed either in a neighborhood
health center or a hospital, or were responsible for
providing medical services in rural communities.
The other crucial datum relevant at this point is that
the average Israeli, as an outpatient, saw a physician
no fewer than 10 times/year—a visit rate far higher
than anywhere else in the world.
A few Israelis, largely of higher income, choose to
pay privately for medical services. Over 95%,
however, obtain near-total coverage by membership
in one of the five (in 1973) health insurance orga
nizations. Kupat Holim means “sick fund” and can
refer to any one of the five organizations. In practice,
however, when an Israeli says Kupat Holim,
reference is to the sick fund of the General
Federation of Labor. Health insurance coverage is
Table 1. Population of the Negev by administrative status 1973
Status
Beer Sheva
(city)
5 other cities
7 municipal
councils
13 regional
councils
91 moshavim
56 kibbutzim
16 villages or
institutions
Bedouin tribes
THE NEGEV
The Negev, then, was to be the site for this
experiment. The Negev is a semi-arid district in the
south of Israel, comprising 67.9% of its land mass. In
Zionist ideology at the time, particularly as
expressed repeatedly by David Ben-Gurion and
symbolized by his own settling in Kibbutz Sde
Boker on retirement from active politics, the Negev
was the future of Israel, much as the West had been
in American history. But in 1973, no more than
11.6% (385,000 persons) of the Israeli population
lived in the Negev.
Total
Population
% of
Negev
population
Population
range
90.400
155,600
23.4
40.3
13,000-45.000
46.900
12.2
2.000-9.000
60,200
35,500’
17.600’
15.6
800-9.000
7.100"
32.600
8.5
385.700
100.0
’ This number is included in the population of the 13 regional
councils.
[8]
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Vol. 23, Nos 9-10, September-October 1987
Context and Purpose of the Volume
one of the benefits of trade union membership;
nonunion members are also covered by Kupat
Holim, through contract with organizations, (e.g.,
as self-employed individuals) or with government,
(e.g., welfare cases and Bedouins). In 1973,21.6% of
the Israeli population were covered by one of the
four smaller organizations. Almost all others
(~ 75%) received medical services from Kupat
Holim. Moreover, none of the four directly provide
inpatient services, whereas Kupat Holim has 14
hospitals (general, psychiatric, and geriatric).
In 1973, there were 26,117 beds in 157 hospitals in
Israel (1 bed/7.87 people). With the exception of a
few small proprietary hospitals, largely for the
chronically ill aged, Israeli hospitals are publicly
owned and nonprofit. In 1972, 28.4% of all general
hospital beds were in Kupat Holim general
hospitals.
Kupat Holim was by far the single most important
deliverer of health services nationally, and it has an
almost total monopoly on health service delivery in
the Negev, particularly in the Beer Sheva subdistrict.
This fact is crucial to understanding the Beer Sheva
Experiment. Well over 90% of the subdistrict
population received health services through Kupat
Holim. The 653-bed (now ~ 800) Soroka Medical
Center in Beer Sheva and the 64-bed Yoseftal
Hospital in Eilat—both Kupat Holim owned—were
the only hospitals in the Negev. The Negev residents,
then, almost without exception, saw their family
doctor in a Kupat Holim neighborhood primary
care clinic (or in rural areas, when the Kupat Holim
doctor visited the community in which a Kupat
Holim nurse was on daily duty); saw a specialist
either at the hospital or at a Kupat Holim regional
clinic or hospital outpatient clinic; and were
hospitalized at a Kupat Holim hospital. It should be
noted that Kupat Holim in most of the Negev
(except Eilat) administered its hospital services via a
self-contained administrative structure separate
from its ambulatory services.
The enthusiastic support of Kupat Holim for the
creation of the UCHSS was therefore crucial, and
the formal agreement that was later signed between
Ben-Gurion University and Kupat Holim has since
then been the basis for all constitutional and
organizational development of the UCHSS. This
agreement is a unique document signed between a
health maintenance organization and an academic
institution.
But this was not the total picture. The Negev
region of Kupat Holim was not coextensive with
government administrative boundaries. Part of the
Ashkelon subdistrict belonged to a different region
of Kupat Holim, and the 31 1-bed Barzilai Hospital
[91
in Ashkelon was owned by the Ministry of Health.
Mental health servies in the Negev were provided by
two small Kupat Holim and Ministry of Health
outpatient units until 1977,. when the Ministry’s
Center for Mental Health in Beer Sheva, including a
hospital with 180 beds, was opened.
Public health and preventive services in the Negev,
as throughout Israel, are the responsibility of the
Ministry of Health. By far the major focus of activity
of the Ministry’s regional office was what is still most
often known in Israel as “Tipat Halav" (literally, a
drop of milk}—a network of Maternal and Child
Health clinics. Ministry nurses were also responsible
for school health and for chronically ill patients in
the community. The regional office also had a
sanitation unit and a public health laboratory, a
mental health center, a child development station
and an epidemiology unit. In addition, the office
provided some curative and preventive services for
the Bedouins in the Negev.
Kupat Holim did, however, provide preventive
and child health services for all kibbutzim and some
other rural settlements in the region. Further, its
Department of Occupational Medicine was
responsible for problems of occupational health and
industrial medicine, on the individual and plant
levels, in the Negev, where a fair number of heavy
industries are located.
Thus the context in which the Beer Sheva
Experiment was to take place comprised: 1) near
total health service coverage provided over
whelmingly by Kupat Holim; 2) a strong structural
separation of ambulatory from hospital services; 3)a
conceptual distinction, expressed structurally,
between preventive and curative services (in
practice, between the Minstry of Health and Kupat
Holim); and 4) a distinction between physical and
mental health.
The one major additional component was a very
young university, committed to science and know
ledge, but with an expressed strong commitment
to service in the region, which it saw as the heart of
the future of Israel.
PURPOSE OF THIS VOLUME
In the fall of 1986, the 13th class of lhe Ben-Gurion
UCHSS enibajked on its studies.* At the same
ceremony, members of the 6th class were awarded
* Nonli American readers should note (hat (he UCHSS. as almost
all schools outside the United States and Canada, has a 6-year
curriculum. Entering students have completed secondary school.
Starting with the 5th class, we have accepted 50 students. Ten of
them are army reserve Hudem*. aged 18;all the others are over the
age of 20. and almost all. men and women alike, have completed
army service.
A. Antonovsky andS. Glick
israit J. Mi d
the MD |one of the symbolic innovations of the
Sci
munication, which in turn will explain its structure.
school is a true commencement ceremony: the
It would have been pleasing had we been able to
entering class is asked to avow the Israeli physician’s
oath (composed by the late Israeli physician and
present a series of research papers, using strict
scientific canons, with sound data to evaluate the
scholar Dr. Halperin) at the same time that the
Beer Sheva Experiment. Several such papers have
indeed been published, and others are under way,
graduating class is given the right to practice
medicine]. The 13th or Bar Mitzvah (confirmation)
year is a good point to take stock. Indeed, recent
years have seen various seminars and symposia
devoted to stocktaking. There is little doubt that the
subjective motivation of the editors and
contributors is one of self-assess men I.
But this volume appears as a special issue of a
scientific journal with worldwide circulation. We are
focusing on one issue or another. But for the most
part, many of the appropriate studies have not yet
been done, and may never be. Alternatively, a
historical case study analysis might have been
appropriate. We would be delighted were this to be
undertaken in the near future.
What we do have in this volume is, in a sense, (he
outcome of applying one of the cardinal principles of
medical education as it is conducted in Beer Sheva:
acutely aware of the fact that we are not our own
audience. Our planning has been guided by the
consciousness that the volume is legitimate and
significant only if it speaks to our colleagues the
adopted in Beer Sheva, concluded by a tentative
world over. We see them as located in a series of
concentric circles, f irst, there arc those who. for
professional and personal reasons, have taken a
evaluation of the adequacy of that solution.
Obviously, the Beer Sheva Experiment is not an
ideal experiment in that there has not been a variety
particular interest in the Beer Sheva medical school
and who, for the most part, have had some personal
of experimental treatments and controls except for
“historical” controls. The creation of an entire
contact with the school. Second, there are the
medical school does not lend itself readily to a
colleagues who are fellow experimenters, organized
in 1979 into the Network of Community-Oriented
Educational Institutions for Health Sciences of
rigorous comparison with an identically matched
control.
which the Ben-Gurion University, in collaboration
concrete issues that we in Beer Sheva have defined as
the specification and clarification of a problem, and
the presentation of the solution which has been
This volume is intended as a presentation of
with WHO, was a founding member. The third circle
highly germane to medical education and health
would include colleagues in institutions that are
service delivery. These issues confront every reader
consciously concerned with the inadequacies of
of the Israel Journai of Medical Sciences;
some default by ignoring or denying the issue, others
have proposedanswersthat differ considerably from
medical education, and its relation to the delivery of
health services, as we move toward the close of the
century. And finally, there are many individuals
deeply involved in medical education and health
service delivery who are not only disturbed by the
deficiencies, but are also disturbed by the relative
complacence
institutions.
and
conservatism
of
their
own
The image of concentric circles should not
mislead. We address ourselves equally to one who
has been a guest lecturer at Beer Sheva as to one who
feels himself or herself isolated in a strongly
traditional medical school, and who may not even
those adopted in Beer Sheva, and still others have
gone in directions similar to ours. We hope that by
providing a clear presentation of each problem, a
comprehensive analysis of the reasoning underlying
the solution adopted, and a relatively objective
evaluation of the outcome, each paper in this volume
will contribute constructively to the intellectual
ferment we regard as essential today, perhaps more
than ever, in the realm of medical education.
Two further comments are in order. On the one
hand, we 'have intentionally excluded from this
have heard of Beer Sheva. But we would go further;
because medicine is both a scientific and humanistic
profession, we should like to think that even those
who are unshaken in their pride in medical
education today will be open to a serious con
sideration of the issues raised in this volume. So
volume the fair number of questions that are not
particularly controversial or to the resolution of
which the UCHSS has nothing particularly new or
exciting to say. A catalog of the school’s courses is
much for our intended audience, from whom we
on the trees. The issues identified and the solutions
adopted are not isolated particles. They derive from
expect the same’critical and sceptical, though openminded, attitude and judgmental criteria that are
not of major interest. On the other hand, there is a
danger of losing sight of the forest by concentrating
extended to any professional communication. We
an overall, hopefully integrated, action-directed
philosophy. It would be painfully wearisome to the
turn now to the intended contents of this com-
reader had each author explicitly linked the issue
fioj
Vol 2 1, Nos 9 II), Si i'll Mill l< ()< lom i< 19X7
Con ii x i and Puri’oxi oi i in Vol uml
discussed to the overall concept. We ask the reader
to create the link. In fact, failure to perceive the link
would indeed suggest that the terms in which the
question was conceived and the solution adopted
were ad hoc—in itself an expression of failure.
STRUCTURE AND CONTENTS
Moshe Prywes would be the first to assert that the
Beer Sheva Experiment is a collective enterprise. But
there is no doubt that he is primus interpares. He first
fully formulated the guiding ideology and the
educational organizational principles that Bow from
it; his will, skills and reputation were crucial in
transforming theory into practice; he gave up the
presidency of the University to devote himself to
being the founding Dean of the Faculty and Director
of Health Services in the Negev; his.spirit touched all
ot us, laculty and students, in time of crisis; and his
name is near-synonomous with Beer Sheva
throughout the world. What should be added is that
Dr. Prywes came to Beer Sheva after two decades of
serving as Associate Dean (elected deans serve for 3year terms) of the Hebrew University-Hadassah
Medical School in Jerusalem, years devoted to
building a medical school in the best tradition of
establishment medicine. This is not the place to
discuss this revolutionary transformation. But it is
relevant to note that Dr. Prywes had come to
Jerusalem after serving during the years following
World War II as the medical director of the UnionOse, the medical arm of the American Joint
Distribution Committee, which was responsible for
rebuilding the health services of the Jewish com
munities in Europe and North Africa.
Haim Doron, Chairman and Medical Director of
Kupat Holim, was Moshe Prywes’s partner in the
creation of the UCHSS. Without the full
cooperation and financial and moral support of
Kupat Holim. the full “merging of medical
education and medical care” could not have become
a reality. He considers as unique the relationship
between Kupat Holim. “its” medical school, and the
grove ol academe, Ben-Gurion University of the
Negev, within which the medical school is located.
Dr. Prywes’s paper opens this volume. He
specifies the core issues confronting Israeli medical
education and health service delivery as we move
toward the last quarter of the century, issues largely
shared though not often confronted throughout the
Western world of modern scientific medicine. His
analysis, presenting the perspective that guided the
faculty when it opened its doors, focuses on the
“anatomy of change,” leading consequently to the
emerging concept of coexistence between the
diversifying and increasingly fragmented parts in
modern medicine. The idea is to bring together into a
more harmonious relationship the often juxtaposed
elements of which medicine is composed today. The
molding of this coexistence may be considered as the
basic “credo” of Beer Sheva, demonstrating how
far-going changes may flourish out of a linkage
between the systems of medical education and
medical care.
Dr. Prywes’ paper sets the stage for everything
that follows. But before turning to detailed issues,
we thought it appropriate to provide, as a
touchstone, the statement adopted at the meeting in
Arad 2 days before the outbreak of the Yom Kippur
War in October 1973.1 am referring to a special task
force whose assignment was the formulation, in
succinct and behavioral terms, of the educational
and institutional objectives of the medical school
soon to be opened. The date is important, for it
reminds the reader that the school was not opened
after years of careful planning, recruitment,
acquisition of buildings and accumulation of
resources. It was during the period between the Arad
meeting, held in the lovely but isolated town from
which one looks out at the Negev wilderness towards
Massada, and the opening of the summer course of
1974, that Israel experienced the profound trauma of
the Yom Kippur War and its aftermath.
The volume is essentially divided into two
parts—Educational Issues and Health Services. In
the first half of Educational Issues, consideration is
given to a variety of problems that are intermediate
between the overall ideology and its application to
specific substantive matters. Thus, for example,
• Ascher Segall, the key architect of the curriculum
and for many years Associate Dean for Education,
discusses together with his colleagues Dan Benor
and Oded Susskind some of the code words soon
learned by (and soon generating anxiety in) new
students, such as spiral, vertical and horizontal
integration, the clinician as consumer,
interdisciplinary planning, the natural history of
disease, etc. The first author (A. A.), Chairman of the
Student Admissions Committee, which bore the
responsibility for accepting the lirst nine classes,
analyzes the strategy, tactics and consequences of a
procedure that varies radically from that adopted in
most medical schools throughout the world. Dan
Benor, Vice Dean for Educational Development,
considers the problems that emerge when teachers
are asked to be learning facilitators and to teach in
ways that are considerably different to the way in
which they themselves had been taught and had been
used to teaching. Shimon Moses, the first Chairman
ol the Division of Pediatrics, discusses the role of
research in a faculty committed to both maintaining
mi
A. Antonovsky and S. Glick
Israel J. Med Sa
high academic standards and to heavy involvement
to the Beer Sheva Experiment: few schools of
of teachers in a complex curriculum as well as in
medicine have epidemiologists as deans) is germane
transforming the delivery of health services.
to an attempt at global assessment of what we have
Section III then focuses on substantive matters in
defined as the “$64,000 question”—Has the quality
education. Again, we remind the reader that we have
of health care in the Negev improved? Yair Shapiro, >
intentionally omitted presentation of many matters
former Director of the Soroka Medical Center'
that are unexciting”—not because they are
considers the extent to which the barriers between
unimportant, but because Beer Sheva has nothing
hospital-based specialities and ambulatory care
particularly new to say either in formulation of the
have been affected. David Singer, Administrative
issue or in proposing an answer. The chapters
Director of the UCHSS, focuses on the work of the
included are designed to meet this criterion, at least
committee whose responsibility it was to try and
in part. That is, no contention is made that Beer
restructure the services in the Negev, so that the
Sheva was committed to change for the sake of
training of the Beer Sheva graduate could be
change, that what is done elsewhere is invariably
translated into practice. As a final example of the
inadequate, that we have not had a great deal to
papers in this section, we cite that by Benjamin
learn from the experience of others. Thus, for
Maoz, the second Chairman of the Division of
example, the chapter by Shimon Weitzman,
Psychiatry and Mental Health; he discusses the
Chairman of the Epidemiology Unit, points to no
relation between psychiatry and other medical
major transformation in the content and methods of
services, the former often being ignored, particularly
teaching epidemiology. His focus, rather, is on the
in primary care.
relatively rare integration, and not just inclusion, of
Partial success, failure, and success are the respec
the approach, concepts and tools of epidemiology ' tive themes of three stories of experiments in devel
into the curriculum of a medical school. Carmi
opment [owns, as told by: 1) Rafi Boehm, an
Margolis, Chairman of the Division of Health in the
internist who took the revolutionary step of integrat
Community, goes beyond the discussion of the
ing his work in the hospital with primary care service
relatively prominent place of the primary care
in one of the most neglected towns in Israel; 2) Basil
clerkship, and points to the aspiration, not
Porter, a pediatrician who sought to eliminate the
necessarily realized, of primary care principles being
distinction between sick and healthy children and
applied in the early clinical training and the other
the separate services designed for them; and
clinical clerkships. The second author (S.G.), first
3) Doron Hermoni and David Mankouta, Beer
Chairman of the Division of Internal Medicine and
Sheva graduates who, working in a primary care
present Dean, concludes Section III with a mea
clinic, became enthusiastic about the idea that peo
culpa-, he considers those subject matters to which
ple from the community can be trained to be effec
we, whatever the theoretical commitment, have
tive health educators.
given minimal, if any, attention.
We have sought in this section to do no more than
Implied throughout this introductory paper,
give a flavor of what the volume contains. As is
though not stated specifically, is that the UCHSS
evident, it moves from the global to the principled to
from its inception was seen as a means towards
the detailed. It is only fitting, we thought, that the
improving the level of health of the Negev
volume close with the two papers in Section V. First,
population. We have, as yet, no way of knowing to
Moshe Prywes and Miriam Friedman, research asso
what extent this end has been achieved. One of the
ciate of the Center for Medical Education, profile
early profound lessons our students learn is the
the 132 Beer Sheva graduates to date. Finally,
complexity of the chain ‘‘medical education... health
Moshe Prywes looks back at his dream and ours, in
services... level of health,” and that many other
as sober an attempt as possible to make an interim
factors, in addition to the crucial component of
evaluation. And, as those of us who know Moshe
formal health services, influence the level of health.
Prywes would expect, he also looks forward, guided
Section IV of this volume, then, is devoted to a
by the Saying of the Fathers: “Yours is not to finish
consideration of what has happened in these 13 years
the labor, but neither are you free to desist from it.”
to the health services in the Negev, and how the
changes are linked to the school.
REFERENCES
Again, we give only a few examples of the subjects
1. (1975) Statistical Abstract of Israel. 1974, Bureau of Statis
in Section IV. It opens with a paper by Lechaim
tics. Jerusalem.
Naggan, second Dean and Director of Health
2. Survey of Health Services in the Negev (1974). University
Center of Health Science and Services. Beer Sheva. Internal
Services, whose training as an epidemiologist (a clue
publication.
[12]
...
-'2A'
(
■
COEXISTENCE: THE RATIONALE OF THE BEERSHEVA
EXPERIMENT
MOSHE PRYWES
Founding Dean and Chairman. Center for Medical Education. University Center for Health Sciences and Services.
Ben-Gurion University of the Negev. Beersheva. Israel
Isr J Med Sci 23: 945-952, 1987
Key words: Beer Sheva Experiment; medical education; medical care; coexistence
Medical education is not an aim in itself. It is a
mission-oriented endeavor that can be judged only
by its contribution to society, mainly through
improving a nation’s health and developing new
models of medical care. However, the two systems—
medical education and medical care—are moved
by different ideologies and too often turn in separate
orbits.
In view of the deep involvement of medical educa
tion in the ever-growing needs and demands of a
changing society, it appears inevitable that the aca
demic medical center will bring the two systems into
a more harmonious coexistence. This involvement
will increasingly impose on medical schools the
responsibility of searching for new models of health
care delivery in addition to their traditional roles of
expert clinical performance and developing new
models of molecular biology. Academic medicine
too often complains that it has not been given the
opportunity to regulate or the responsibility to
direct health care delivery systems outside its own
sphere. Actually, only seldom has it tried to assume
this responsibility, and often has turned its back on
such opportunities when they presented themselves.
Medical academicians have preferred to remain
within the comfortable microenvironment of their
university hospital and research laboratories.
If the academic medical community would fight
tor the privilege of molding medical care delivery
systems with the same strength and vigor it has
traditionally employed in defending its research and
Address for correspondence: Dr. M. Prywes. Center for Medical
Education. University Center for Health Sciences and Services.
Ben-Gurion University of Negev. 84120 Beer Sheva.
teaching privileges, a balance might be found, not
only between medicine and science, but between
medicine and society as well. If, however, the aca
demic medical community continues to disregard
society’s demand for better, cheaper, and more eas
ily accessible health care, and if it does not educate
health care professionals who are aware of their
community role, medical education will not fulfill its
objectives and will retreat into a no-man’s-land.
Israel, although fortunate in having welldeveloped health services with direct and free acces
sibility for all, one of the world’s highest ratio of
physicians to population and four medical schools
for a population of some four million, has not
escaped the common pitfalls in the delivery of health
care. Its health services today are split into three
areas, each with its own facets: 1) between govern
ment. health insurance, and public and voluntary
institutions; 2) between highly specialized hospitals
and primary care facilities in the community, and
3) between the system of health care delivery and the
academic institutions of medical education.
I Tagmentation has become a common trait of our
times. The universe is split and we discovered space;
the five continents of the globe have been divided
into a multitude of new nations, some of which are
not even monolithic; society is split into a plethora of
political parties and systems: the four leading reli
gions not only differentiate between themselves but
are also fragmented within themselves; families are
losing their cohesiveness, and we face a growing
disruption of family life. Arts and music, technology
and science, education and culture—none escaped
the process of differentiation. An additional look at
both contemporary health systems and health scien-
ri3]
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imtBtaMMiiili
M. Prywfs
ISRAI-I J. Mi l) S( I
ces educational institutions reveals an amazing con
glomeration of split elements: We face a mosaic of
dispersed health agencies, institutions, depart
ments, units, disiciplines—each encircled by a hard
shell and living a separate life, with its own jargon
not understandable to those that were once its bed
fellows. The health arena is full of conflicts, many of
which contribute to the paradoxical reality of confu
sion in the current period of great crisis in the world
health system. This in turn calls for safeguards to
preserve the essential nature of medicine as a science
and an art. In this context, and aware of medicine’s
humane and social obligations, the Beer Sheva
Experiment emerged as an effort to restore coexist
ence between the dispersed elements. The linkage
between the systems ol medical education and medi
cal care became the cornerstone of the new
institution.
It is impossible to change the education of physi
cians until the health care delivery system in which
they work is changed. Therefore, the Beer Sheva
Experiment has been conceived to respond to the
double challenge of: 1) joining all health care servi
ces in the region onto one integrated system in order
to provide comprehensive medical care for the entire
population through better use of organizational,
financial, and manpower resources, and 2) merging
this system with the academic responsibility for
medical education by attempting to educate physi
cians and other health workers who are aware of the
system’s needs and who wish to work in community
hospitals and primary care clinics.
LINKAGE OF MEDICAL EDUCATION AND
MEDICAL CARE
Rarely has an academic institution with responsibili
ties in health manpower training participated in the
planning and implementation of all levels of health
services for an entire region. This has been the intent
in Beer Sheva. There is an implication here of mutual
benefit: the potential impact of the academic com
munity on the quality of health services through
direct involvement can improve the health care sys
tem. Concurrently, health manpower training,
anchored in all facets ol health care delivers foi the
community, makes instruction more relevant since
instructional objectives are derived from the real
world of professional practice. This interface
between health manpower education and health care
enables the educational process to both stimulate
and reflect changes in the patterns of health services.
Both challenges can be met only through their syn
thesis within one integrated institution, under one
administrative authority with equal responsibility
for both the functions of health care services and
medical education. Thus, no true changes in the
system of medical education is possible until the
medical school accepts responsibility for the provi
sion of medical services within its geographic region.
This acceptance appears to be feasible only when the
objectives are incorporated equally within one
regional center for health sciences.
1 he University Center for Health Sciences
(UCHS) in Beer Sheva provides a unique model for
studying the deployment of academic resources in
the development of an integrated health care system.
In addition to the preparation of qualified man
power, members of the UCHS actively participate in
the planning and implementation of all levels of
health care for an entire region. To achieve the goal
of integrated health care, a regional consortium was
established and granted a charter. It consisted origi
nally of the health-related agencies operating in the
Negev—Kupat Holim (KH) (Health Insurance
Institution of the General 1 cderalion of Labor), the
Ministry of Health, and the Ben-Gurion University
of the Negev. Ils purpose is to ensure effective com
munication among the various agencies and to pro
vide a regional framework for the coordination,
administration, and sharing of resources. The Dean
of the UCHS of the Ben-Gurion University of the
Negev serves as the Director of the health services
and chairman of the regional health authority.
Recently, an important Jewish welfare agency (JointIsrael) joined the consortium, making community
health care more comprehensive by adding the
dimension of social welfare and consumer
participation.
A network of model primary care clinics is gradu
ally becoming a community-based counterpart to
the clinical facilities of the teaching hospital. The
scope of the clinics extends beyond the provision of
curative services, which was their main function in
the past. Greater emphasis is now placed on preven
tion. on'the continuity of care throughout the var
ious phases of illness, and on outreach programs to
meet those needs of the community that are less than
effectively served within the confines of traditional
health care. The slogan of the Center is “All who
serve leach and all who teach serve,’’ and the staff
employed by the health services and the educational
system are becoming accustomed to the collabora
tive nature of their functions. Academic titles are
granted to primary care physiciansand community
nurses. Thus, real partnership has evolved through
appointing staff with joint academic and service
responsibilities and introducing an appropriate
reward system. Identification with the precept that
health care should respond to community needs is
being encouraged as a means of cultivating profes-
|I4|
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Vol 23. Nos 9-10. Si pii mbi k Ot'iOBi R 19X7
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C< >1 x IS 11 N( I
sional pride in community health work. Of the first
batch of 30 graduates in medicine. 21 volunteered to
serve for at least 1 year in a primary care clinic before
starting residency training and. in 1981. 18 of those
decided to work in clinics in the Negev. In all. 59 of
the 135 graduates of the first lour classes followed
this pattern achieving more in 4 years by their partic
ipation than was achieved in the 7 years prior to
1980.
The Dean of the Center realizes (as did the deans
before him) that his dual Junction is Dean of the
health sciences faculty and head of the health servi
ces. the latter constituting the main source of power.
Many of the problems that confront the medical
school of the Ben-Gurion University of the Negev
resemble those encountered in medical schools in
other parts of the world.’The experience at Beer
Shcva demonstrates that effective cooperation
between the health and educational systems may be
dillicull but is possible (I).
While generalization should be approached with
caution, it may be noted that some of the lessons
learned in Beer Sheva have found applicability else
where. Besides the advice and guidance given to
medical schools abroad. Beer Sheva was also one of
the founders of the Network of CommunityOriented Educational Institutions for Health Scien
ces. and has been one of its leading members. The
potential contribution of the Beer Sheva Experiment
has been recognized by the World Health Organiza
tion. The UCHS has been designated by WHO as a
Collaborating Center for Integrated Health Services
and Manpower Development for the last 13 years
(since 1973).
ADDITIONAL CHARACTERISTICS OF THE
UC IIS
Besides the permanently ongoing effort to sustain
the linkage of medical education and medical care,
there are as well some factors within the UCHS that
contribute in a great measure to its existence and
progress. To enumerate just a few:
I )1 he IIC1 IS isa mullischool institution. Il contains
the Recanati School for Allied Health Professions in
the Community (including a nursing school and a
physiotherapy school), a School for Health Adminislralion and Health I conomics and a School for
Continuing Education: in order to safeguard inte
gration. all of these schools, including the medical
school, are part of a singlefaculty ofhealth sciences.
While each school is administered individually and
has independent admissions and curriculum com
mittees. all the teachers are members of one faculty
under one Dean and all the service facilities are
common Io the entire Center.
2) Basic sciences are grouped in small (five tenured
members) teaching-research units with a strong
health-applied orientation. There is no departmen
tal structure in the basic sciences.
3) All clinical departments integrate hospital and
community responsibilities. Department heads arc
charged with the supervision of patient care in their
particular specialties throughout the region. The
establishment of divisions (comprising a number of
departments) with broad areas of responsibility
reduces the chances for the formation of multiple
feudal “empires.” Physicians of the hospital are
encouraged to become involved in the community
services. Today, as a result of this policy, dozens of
the 300 hospital doctors and many other health
workers spend considerable amounts of time in
regional clinics, some of which arc quite remote
from Beer Sheva. Numerous general and family phy
sicians from the region arc affiliated with different
hospital departments and hold academic titles. This
two-way How of medical personnel constitutes a
principal feature of the UCHS.
4) Attaching medical students to practitioners in
urban and rural clinics is the best form of continuing
education for community-based doctors. Since the
physician is expected to leach students, he must
continue to learn in order to function as a teacher.
5) The UCHS operates an independent Regional
Unit for Health Care Evaluation and Planning,
which is headed by the Professor of Epidemiology."
Its findings serve as feedback in the assessment of the
ongoing service facilities and needs.
6) The curriculum, the admissions policy and student
participation are very basic components of the Beer
Sheva Experiment, and each one of them is des
cribed in sepaiaie papers in this issue (Segall et al..
Antonovsky: I lenkin).
7) A major outcome of thv UCHS has been the
closing of the gap between preaching and practice.
It becomes clear that it is not the charter of pro
claimed aims and goals of a medical school that
affects motivation for learning: rather what counts is
the commitment of the teaching staff to such aims. It
is the performance of teachers (hat enhances the
students' will, enthusiasm and devotion to learning.
Many medical schools today talk about community
medicine, primary care, comprehensive and family
health, and epidemiology, but neither (he student
nor the young doctor sees his teacher working out
side the university hospital or the research labora
tory. Indeed, il some efforts arc made to expose
students to the community and its health problems,
it almost always is “too little and too late":even this
drop-in-the-bucket is never under the supervision of
the head or senior person of a main clinical depart-
115]
\1
/
Israfl J. Med Sci
M. Prywes
ment with whom the students naturally identify.
How many medical schools have a clerkship in prim
ary care and how many family doctors are members
of the main faculty committee? It has recently
become quite fashionable (fashion may also influ
ence motivation for learning) to stress self-learning
and a problem-solving approach in medical educa
tion. Again, many schools talk about it but forget to
provide the students with the main tool: FREE
TIME. “In many outstanding medical schools, stu
dents are still lectured to death—hours and hours a
day. What kind of ‘continuing learner’ can such a
student become when he does not find fun in study
ing and learns a lot for his examinations from his
fellow paid note-taker. Ask medical students what
they would like more of. and their answer will be free
time” (2). But if the curiosity of the student is evoked
by making the learning relevant, joyful and full of
responsibility towards their patients from the very
first year, then they will respond with great motiva
tion. identifying themselves individually and collec
tively with the social objectives of the school. 1 he
same is true of members of the leaching staff. If you
demand service but reward research by counting the
number of published papers, the most dangerous
conflict in a university medical institution is created:
between science and service. The two must go
together. They cannot be separated because one
serves the other, and by no means are they exclusive.
The higher the scientific standards the higher should
be the standard of the service provided. To be more
scientifically oriented a medical school must not be
less society minded, and vice versa—a more societyoriented medical school must not be eo ipso less
scientific minded. There is no either/or; there is no
white or black. Any antithesis between sciences and
service is false (3).
8) Another asset of the UCHS is its multinational
faculty, by origin and education. Over 60% of our
faculty were born and educated abroad and came to
Israel as new immigrants. Only less than 40% are
Israeli-born, some of whom were trained abroad.
Thus, we have teachers of European, American,
Asian and African origin. It is fascinating to see how
their past training, language and educational psy
chology absorbed the concepts of Beer Sheva, and
how many of them became not only participants of
the program but leaders of high prestige and stand
ards. All of us speak 14 languages, and yet we all
speak one language.
AND SOME CONSTRAINTS AND
<
PROBLEMS...
The barriers that separate the University from the
service institution, the hospital from the primary
care clinic in the community, and the basic scientist
from the clinician, continue to exist because of iner
tia. The creation of a regional consortium to achieve
cohesion is a significant step in overcoming the iner
tia. In the 13 years of its existence, the innovation at
Beer Sheva has acquired direction and momentum.
The consortium fulfils a utopian dream that has
become a reality, but has not always functioned as
well as it should. Some of the agencies involved have
not always been fully committed in word and deed to
the concept of merging academic and service respon
sibilities. Even when agreement has been reached at
the highest national policy level, local functionaries
and organizations with their own plans and habits
have frustrated directives. Despite such setbacks,
collaboration between the educational systems and
the health services in the Negev has become a reality
and is taking root in other parts of the country.
Let us take a closer look at the fate of a medical
•school that finds itself in a situation of double loy
alty towards its two big patrons—the university and
the health service organization. We need both and
we would like both to leave us alone, from time to
time. In our case we have to deal with two separate
administrations that have different approaches: the
Ben-Gurion University, with its headquarters in
Beer Sheva, where we had to compete with the con
flicting priorities of a University system, and KH,
with its headquarters in Tel Aviv. To them we were
only one of some 20 regions in the country, all
bureaurocratically controlled from the center (all
our health facilities, hospitals and ambulatory clin
ics belong to KH). It is no wonder that living in such
a schizophrenic atmosphere we eventually deve
loped a great talent for acrobatics, trying to keep
balance between the two.
The University setting
The advent of modern times, with the spectacular
results of scientific and technological progress, and
the social and political upheavals that resulted in
broad educational and social welfare legislation,
brought about a great change in the University’s role
in society. The modern university, be it state or
private, developed a kind of schizophrenic personal
ity. In Eric Ashby’s description, “Round every
Senate table sit men for whom the word university
stands for... the kingdom of the mind. At the same
Senate table sit men for whom the university is an
institution with urgent and essential obligations to
modern society... Both kinds of men... are right*’(4).
We live, today, in the congruence of what Alvin
Weinberg calls “mission-oriented society” and
“discipline-minded universities” (5). Academic
medical institutions have, besides their traditional
fl6]
Voi 23. Nos. 9-10. Si ph mbi r-Octobi r 1987
Cof >
university objectives of teaching and research, a
third most vital social component—service to the
sick. Society at large, consumers and students,
numerous types of health insurance agencies, hospi
tals and community councils, medical professional
organizations, and private foundations and charities
all intervene within our medical centers. As a result,
we are called to create a “mission-discipline
duality.”
We, in medicine, having been part of the univer
sity setting lor a long time, have been fortunate
enough to live and observe this split personality. We
have much experience in this regard and perhaps
have developed some biased opinions. We know that
association with a university works both ways.
While the natural and social sciences and the
humanities have made and continue to make a deci
sive contribution to modern medical education, the
development of the basic medical and clinical scien
ces has broadened the academic framework of the
university and strengthened the interrelation with
various faculties.
This challenge is, however, not devoid of some
serious conflicts; let us enumerate a few. The basic
science departments in medical school are called
upon to assume broad educational functions beyond
those involving medical students; they are partici
pating in the preparation of a growing number of
personnel for the allied health professions. Graduate
education for the MSc and PhD degrees has grown
in all basic science departments. Thus, though they
are under the aegis of the medical school, basic
science departments have come to function as uni
versity “life-sciences” departments. This is a some
what new concept that may be regarded by their
colleagues from the Faculty of Natural Sciences as
usurpation of a long-standing tradition and becomes
a source of friction based mainly on jealousy. A
deeper and much more relevant cause for tensions
may lie in the fact that a medical school differs from
other faculties in one important aspect: in addition
to teaching and research it fulfils a third important
function: serving the sick. Service, in the eyes of
university scholars, is a kind of nonacademic activ
ity, thought to be of secondary importance by many
colleagues from other faculties which ignore its
preeminent educational value. Another source of
occasional difficulty is the fact that the teaching
hospital, one of the most valuable instruments in
medical instruction and research, is not an integral
part of the University but has its own administration
and budget. Finally, there is the fact that research in
the fields of health and medicine attracts a con
stantly growing flow of new “extra-university”
resources. This sometimes enables us to extend facil
ities beyond the balance-minded university pc
which does not favor the creation of what maj
termed a “medical empire.” The University prol
sors might fear that the UCHS personnel are pro
moted’ too rapidly and that consequently they will
gain too much influence in the Senate.
Within the UCHS itself one has to keep in mind
that there is a danger of a growing gap between the
clinicians and the scientists due to the fact that they
face different criteria in recruitment and promotion.
The scientists, like other academics, arc promoted
by a general university committee, while the clini
cians' promotions are determined by a special clini
cal committee. Regardless of these difficulties, which
we may face as a result of our integration within the
university, there is no road back, and there is no
substitute for the University in keeping the profes
sion tied to scholarship.
The service setting
Although the Ministry of Health's medical facilities
in the Negev are de facto a part of the UCHS. the
Ministry never signed a formal agreement with the
University and KH. The main health service agency
in the Negev is KH with its 750-bed Soroka Medical
Center in Beer Sheva—the Yosephtal ^Hospital in
Eilat, all primary care clinics in the region (about
160), laboratories, health centers etc. KH is the
major health services associate of the UCHS; with
out it the Beer Sheva Experiment could neither have
been conceived nor established.
The Gordian knot, which symbolizes our deeply
interwoven relationship with external health service
factors, is a result of the inseparable interaction
between medical education and medical care organi
zation in modern society. Weinerman sounds right
when stating that:
The method and quality of medical education define
the potential competence of the physician, but it is
the system of medical care organization within which
he actually works that determines the degree to
which this potential is translated into effective per
formance... A good organizational system can
maintain an effective level of performance among
practitioners of only average quality, hut a poorly
organized health service will ultimately negate the
value of even well-trained personnel (6).
The Negev is only one of 20 regions serving 85% of
Israel’s population whose health activities are con
trolled by KH. The doctrine of “parity and equality”
prevails in Israeli public institutions. It limits KH’s
special relationship towards the UCHS. In addition,
the four trade unions of physicians and workers,
separate in the hospital and in the community, do
F17]
a- WiriMlWli'I^f' ~ Ml"'
ISRAI I J. Ml D S<I
M. Prywis
[
i.
not facilitate easy decision making. Nonetheless.
I
KH’s contribution, both moral and material, is cru
cial lor the existence and function ol the I >(’l IS. Il is
is not easy to stay alert all the lime; it is not easy to |
maintain local relevance in order to achieve interna-
important that the director of KU, who was a close
associate and a devoted initiator ol the Beer Sheva
F’xperiment, is still the functioning Director General
lional eminence (7).
It seems to me that we did not discover Amer
ica. What we did in essence was to shift the empha
sis from exclusively hospital-based clinical
education to primary care, from “bedside” educa
tion to “community-side” approach. Consequently. ^
ol KI I headquarters in lei Aviv and has developed a
deep commitment to the UCHS despite all the con
straints under which he acts and the pressures
1
exerted upon him from all sides.
It is noteworthy that since 1972 KH has appointed
three national special committees to study reorgani
zation of its structures. Each ol the three have been
chaired by one of the three deans of Beer Sheva.
<
t
population needs in health gain in value, and
humane and comprehensive medicine becomes a
pattern of medical practice in health and disease..
Rather, the introduction of change in our own old
but sound medical tradition created a new tradition ■
Some members of the loreign faculty ol the Beer
for the medicine of tomorrow.
Sheva UCHS also serve as advisors to KH headquar
ters. Il may also be said that the deans of the UCHS
TRADITION AND CHANGE
contributed financial support in equipment, build
When we pronounce the word
ing or research funds lor the clinical departments ol
tional medical schools, we immediately have in mind
K 11 in the Negev. In addition, it was the first oppor
tunity lor KH to enter an equal partnership with a
university in the field of academic medicine. This
something old and outmoded, something to be
ashamed ol. something that was beautiful and
attractive a long time ago, but now is covered with
made the KH a total health care system including
health manpower development. Thanks to KH the
<
big threat that can stop us or jeopardize our plans? Il»
UCHS was able to fulfill its concept of not erecting a
building of its own and currently docs not intend to
build one. Instruction and research are conducted in
all the medical facilities in the region’s hospitals,
Mirai and. urban clinics, preventive centers, etc.
When one asks: “Where is the medical school?”The
answer is: “nowhere and everywhere.” Wherever
there is a teaching or research activity goingon.be it
in a laboratory, clinic room, ambulance, or Bedouin
lcnl—there is the medical school.
Because of the rigid centralization of KH, there is
still no single authority for the Negev; the UCHS is
tradition
or tradi
dust or rust.
Medical schools throughout the world are catego
rized today as “traditional” or “innovative.” The
term “innovative” was not conferred on them by
anybody; they simply call themselves that, implying
a pretentiousness. However, we learned that in order
to introduce a new look, it is not obligatory to
start from scratch. There is never an excuse for not
introducing new aims and goals into old wellestablished medical schools. Let us consider “tradi
tion” in medical education. To our great
amazement, the basic academic freedom in the selec
tion of students and staff, in shaping a curriculum
rich in electives, in close teacher-student relation
not yet an organizational entity.
ships, and in independent research—all accompan
ied by state - financing and reasonable student
A RETROSPECTIVE LOOK
participation and control—were included in the sta
tutes, published in 1589, of the first state university
\ When KH and the University of the Negev in 1970
approached me, then Professor of Medical Educa
tion at the Hebrew University-Hadassah Medical
School in Jerusalem,and asked me to prepare adrall
for a new medical school in Beer Sheva, I have to
admit that it was rather an easy task. I prepared a list
of all the shortcomings of the highly scientifically
oriented medical school in Jerusalem (which I
headed for 22 years), the reverse of which became the
draft program for Beer Sheva. I did believe then that
this dream may become a reality. It happened
indeed, and I was asked to implement it. Now. after
15 years in Beer Sheva and the school’s 13th birth
day, 1 think one can say that we survived quite well. 1
see three dangers: routine, fatigue, and deception. Is
it hidden in the system or in the people*’ What is the
medical school in Padua. Italy, which flourished
between the 13th and 16th centuries (8). It was a
“student university” originally controlled andr
wholly financed by the students, who hired their
professors and kept them in unbelievable servitude,
though they had the go<xl sense to leave to their
professors the responsibility of conducting the
examinations. All that, together with academic free
dom and a degree of student control that woulcf be
considered revolutionary today, comprised the sys
tem that allowed the ascendancy of Padua over Paris
and Oxford, where the students had but little or no
authority. The facts are that these well-motivated
and ambitious students founded a university which
they controlled over several centuries, and which
i
1181
A
I
...
Vol 23, Nos 9-10, Si-ptembi:r-Octobi-r 1987
Coi XIS 11 NCI
surpassed in academic excellence the other universi
medical education. We would like our students to
ties of Europe that were controlled by the students’
learn that not everything new is better and not every
masters only. It was a State university, as long as the
thing published is correct. The two, tradition and
State did not interfere with academic affairs; it was a
change, are not contradictory; they may, or even
highly successful cooperative venture of teachers,
should be, complementary. This is seen today in
students and the State (8).
many medical schools throughout the world. There
Such a medical school, if it could only be found
must not be an either/or. An antithesis between the
today, would easily deserve the denomination
two is false, although they may well work in tandem.
“innovative.” But looking back some 50 years when
We love classical music but we may love it even more
I started my medical studies in France, we had some
while listening to a modern stereophonic recording.
wonderful experiences: it was fun to be a medical * Some of us love modern art but we al I visit museums
student and it was exciting to study medicine and be
in Italy, Spain, France, England and elsewhere to get
a member of the “congregation.” Already in the
the inspiration of eternal beauty. Looking at Cha
second year we spent much of the morning in the
gall s paintings we see how the traditional and the
hospital wards. Not that we understood too much,
modern create a harmonious perfection. We all love
but we began to breathe the atmosphere of clinical
Jerusalem with its unique mixture of tradition and
medicine. Since we did not know medicine, we tried
change.
very hard to care about patients’ comforts, rather
We hate servitude, feudalism and compartmental
than to cure them.
ization—there is no place for them in our medical
Before approaching proposals for change let us
schools. We fight for individual academic freedom
always be rather cautious, since tradition for the
for each of our teachers and students. Institution
sake of tradition and change for the sake of change is
ally, however, we are committed, each one of us, to
a curse, a misfortune.
our country’s and population’s health needs. Let us
not copy others but establish different approaches
In this regard, it is useful to recall the conflict of
from which others may learn. Both tradition and
interest in health care, the responsibility for the
change have elements of truth in themselves. Let us,
health of the individual in contrast to the responsi
therefore, cherish and respect our great heritage but
bility for the health ol society. This dualism is the
not use it as an excuse for not encouraging and
heritage of physicians, cither by tradition or default.
breeding innovations and changes.
While some aspects ol both responsibilities may
appropriately rest with physicians, they must also
CONCLUSIONS
be shared with cxpcils from a variety ol disciplines
It is perhaps justified to ask ourselves, on this 13th
beyond those with which medicine has traditionally
birthday and before concluding, whether we did
interacted, such as law. ethics, economics, sociol
commit mistakes. Yes, of course we did. Only those
ogy, management and information sciences, etc. (9)
who do nothing do not commit mistakes. It is my
Let us return for one moment more to the past.
impression that we have made mistakes or misjudge
The famous Flexner report in 1910 was crucial in
ments in strategy here and there, but not mistakes in
shaping American medical education by placing
ideology. The built-in systems of evaluation and
American medical schools under the auspices of
debriefing in both education and services have
universities and giving them the sound basis of scien
always been alert to put on the “red light” in time, so
ces. However, his report is not always cited to its
that, using feedback, we could correct the mistakes. I
very end. I would like to quote his final remark:
would rather restrain myself from going into details.
During the 13 years of the existence of the Beer
“The physician’s function is fast becoming social
Sheva medical school, we have had three deans. I
and preventive rather than individual and curative.
was the first and would prefer others to speak about
Upon him society relies to ascertain and to enforce
my mistakes. My successors have enough insight to
the conditions that prevent diseases and make posi
see their mistakes, if any. In any case, the effort to
tively for physical and moral well-being. It goes
maintain the momentum and to care for the streng
without saying that this type of doctor is first of all
thening of coexistence in both the different and mul
an educated man.’’
tiple elements of the Beer Sheva Experiment has
been one continuous collective process of survival
Tradition and change live within ourselves con
and dynamic progress.
stantly. The changes that we introduced, supported
Notwithstanding the important structural ar
strongly by student participation, have their roots in
rangements made to enhance integration, the suc
both international and our national tradilion in
cess ol the project is most dependent on the spirit of
|19|
M. Prywi s
ISRAI I .1. Ml I) S( I
the team and its leadership. The structure provided a
conducive framework, but the dedication of the staff
and the commitment to collaboration could not
have been achieved through design of structures
alone.
It appears to us that the single most important
force in the Beer Sheva Experiment is its student
body. A critical mass of strongly committed gradu
displaced. But it is hard for us to conceive of the Beer
Sheva UCHS turning into a traditional, departmen
talized, fragmented health center. The momentum
for integration is definitely there.
The help of Ms. Heather Rockman in the preparation of
this manuscript is deeply appreciated.
ates could be expected to become the guardians of
the Beer Sheva concepts and not allow the program
to stagnate. They will keep the faculty honest with
regard to the institutional goals. They are bridging
the gap between the clinics and the hospitals. The
students are not permitted to stop with their critical
evaluation, but they are required to participate in
designing corrective measures and implementing
them. Certain conditions seem to be essential. The
partners to any collaboration must want, and know
how, to work together. Within a flexible framework
of agreement there is a need for much negotiation,
consultation and mutual adjustment. The motiva
tion to work together in Beer Sheva is based on a
team spirit, proud of its achievement and convinced
in its directions. It is inevitable that as the organiza
tion grows older some of its original goals may be
REFERENCES
1. Rotem A. Barnoon Sand Prywes M (1985). Is integration of
health services and manpower development possible? The
Beer Sheva case study. Health Policy 5: 223-229.
2. Rogers DE (1982). Some musings on medical education.
Pharos. Spring p 11-14.
3. Brotherston Sir .1 (1979). Community medicine revisited
Inaugural lecture No. 66. University of Edinburgh.
I dinburgh.
4. Ashby E (1959). “Technology and academics.’' Macmillan.
London.
5. Weinberg AM (1965). But is the teacher also a citizen?
Science 149: 601.
6. Weinerman AM (1969). “Social medicine in Eastern
Europe.” Harvard University Press. Cambridge. MA.
7. Evans JR (1985). Medical Education—the search for inter
national eminence and local relevance. 1st J Med Sci 21:
557-563.
8. Christie RS (1969). Medical education and the slate. Hr Med
./ 4: 385-390.
9. Beck JC (1979). Dualism in medicine: a scenario. Health
Policy and Education I: 97-106.
Willoughby La them
Editor
“The future ol academic community medicine in develop
ing countries.”
Rockefeller Foundation. New York. 1973
“1 his extraordinary development in Israel is without
parallel: It is most unlikely that the events which have
taken place there could occur in any other country. One
may look for causes and explanations, but these can only
be general and speculative. It is the history of Israel, the
culture of the Jewish people, with its emphasis on health
and admiration for the medical profession, and the nature
of Israeli society, that have created the Beer Sheva expe
rience. No two countries are the same but no country has
any greater claim to uniqueness than Israel has.”
|20|
■
-......................................
f
THE ARAD STATEMENT
AARON ANTONOVSKY
Depanmenl of (he Sociology of Healih. llniversiiy Center loi Health Sciences and Services. Hen-Gtnion University
ol the Negev. Beer Sheva. Israel
Zvr./ Med Sci 23: 953-954. 1987
Key words: Beer Sheva Experiment: medical education: task force
The year of 1972 and early 1973 might best be called
the year of the laith. Well before the of ficial govern
ment decision approving the establishment of the
Center for Health Sciences was taken in May 1973,
extensive preparatory activities were under way.
Many meetings were held with Negev health practi
tioners, including “pre-facully council” assemblies.
Politicians, key University faculty and other public
figures became involved. Visitors from abroad and
colleagues from the north of Israel came to Beer
Sheva. The first draft of a curriculum was prepared.
An international symposium was held on health
services. An atmosphere of intense excitement and
enthusiasm was generated.
One finds varying ideas in the documents that
appeared in those heady days:
The primary objective of the Medical School is best
expressed in the word “service”—to turn out
service-minded physicians, trained and dedicated to
serving the community... We shall fail should less
than 509? of our graduates go into primary care and
will likewise fail should all 1009? restrict themselves
to primary care, for we want our philosophy of
“service” also to spill over into the specialities
which by and large control the tone of the world of
medicine... (although in a sense primary care is itself
a highly specialized area)...
lorccd by encouragement and appropriate training.
(iiaduales will be able to work in both the hospital
and the community and and provide high-quality
health can* in any organization or institutional
framework. Those who became traditional special
ists at least will have had experience in comprehen
sive medicine...
By the summer ol 1973 a core group had been
established al (he University. The time had come to
begin.translating generalities into specifics. Moshe
Prywes convened a Special Task Force Meeting,
held in Arad on 4 October 1973. whose assigned
mission was to formulate the educational objectives
of the medical school of the University Center for
Health Sciences and Services in the Negev. The
professions ol the nine task force members are worth
noting. In addition to Moshe Prywes. a trained
surgeon and a long-time medical educator, the force
comprised a pediatrician/cell biologist, an epidemi
ologist. a child psychiatrist, a veterinarian/immunologist, a neurobiologist, a medical sociologist, a
nurse administrator/educator, and a health services
administrator.
By the end of the day’s discussions, what has come
to be known in the local jargon as “The Arad
Statement” was formulated:
Upon completion of the formal course of studies, a
graduate ol the Ml), program will have acquired or
developed knowledge, abilities and attitudes so th^t
he* will be able to:
I he iiilenlion is not (<> < irate an insliluiion loi the
training ol general practitioners or family physi
cians (although many may follow this pattern), but
to educate physicians whose initial interest in com
prehensive medicine has been systematically rein-
Address lor correspondence: Dr. A. Antonovsky. Department of
the Sociology of Health. University Center for Health Sciences
and Services. Ben-Gurion University of the Negev. FOB 653.
Ml05 Beer Sheva.
[21]
* Note that in 1973 we spoke of “he:" today we would probably
write he/she.” As a matter ol tact, however, there was some
consensus in the Student Admissions Committee that the traits we
were looking for among candidates would favor the selection of
women. This has not turned out to be true. Over the years, the
proportion ol women in the class has been around one-third,
which is just a lew percent more than the proportion of women
applicants.
ISRAl I J. Ml I) Sci
A ANIONOVSKY
A. Perform professional services within a
community health care system compatible with the
overall policies of University Center for Health
1. Take part in postgraduate training (residency
program, specialization, courses, etc.) and
Sciences and Services:
teaching (students and colleagues).
1. Identify and define present and future
community health problems and work to resolve
such problems by the planning, implementation
and evaluation of preventative or remedial
2. Periodically evaluate his professional
activities, recognize his educational needs, select
appropriate learning resources and evaluate his
progress.
programs.
C. Aid the development of the health sciences by
2. Use clinical skills, knowledge, original
observations and appropriate records to
identify, diagnose, manage (prevent, rclcr. Heal
rationally) and follow up health problems ol his
patients, taking into account the physical,
engaging in teaching and research:
I. Seek solutions to new health problems ol his
patients, community or health care system with
which he is not familiar.
psychological and sociocultural aspects.
1). Maintain and develop personal characteristics
and altitudes required for professional life, such as
personal integrity, sense ol responsibility and
dependability, and ability to relate to. communicate
with and show concern for and respect to his
3. Work as a leading partner in a health care
team.
4. Educate the population and motivate them to
improve their health.
patients and colleagues.
Frederick C. Robbins
President
Institute of Medicine. National Academy ol Sciences.
Washington DC
Moshe Prywes Distinguished Lecturer. 1982
“Dr. Prywes is one of the best known medical educators in
the world. This school, which many of you have helped
him create, is looked to as one of the boldest and most
imaginative innovations in medical education in a very
long time. The combining of the service and educational
activities in a truly integrated way. and the inclusion ol
services other than those that are hospital based are impor
tant efforts that are significant to all parts ol the world.
From what 1 know of the educational program ol the
Ben-Gurion University Medical School, it would seem to
me to be designed to prepare its graduates to deal with the
rapidly evolving and not entirely predictable future. The
combination of education and responsibility lor medical
and health care of a defined population within one organi
zation offers a unique opportunity to conduct epidemio
logic and sociologic research in combination with the
more traditional biomedical investigations and avoids the
preoccupation so prevalent in many medical schools
throughout the world with tertiary hospital-based care.”
[22]
I
•
I
EDUCATIONAL ISSUES
A. Principles
THE CURRICULUM: A 13-YEAR PERSPECTIVE
A. SEGALL,1 D. E. BENOR 2 and O. SUSSKIND '
Disjji^n of Heahh Manpower€)eveloplheni..JWHO. Geneva. Switzerland, and 2'Curriculum Unit. University
, Center for
Scie:‘nces and Services.'Ben-Gurion University of the Negev. Beer Sheva. Israel
‘ Health --J-
/.sr J Med Sci 23: 955-963, 1987
Key words: Beer Sheva Experiment; medical education; curriculum; regional orientation;
health care delivery
The University Center for Health Sciences and Ser
vices at the Ben-Gurion University of the Negev
accepted a dual mandate when it was established in
1974: to serve as a catalyst for the development of an
integrated community and hospital system of health
care in the Negev, and, in parallel, to educate stu
dents to be motivated an^l competent to function
within this system. Implied were basic changes in the
pattern of health services, calling for physicians,
nurses and other health personnel to assume unfa
miliar roles and responsibilities. Traditional atti
tudes would need to be modified and new
professional competencies acquired. Recognition of
the interdependence of innovations in health care
and in medical education gave rise to what has
become known as the Beer Sheva Experiment (1-3).
It was in this context that a 6-year program of
medical studies was designed. Two facets of the Beer
Sheva Experiment have had a particular impact on
curriculum development: a regional orientation
based on the merging of medical education with the
. delivery of health care in the Negev, and a commit
ment to address t|hc broader issues confronting med.ical cilucaii^i^ throughoull the world. Interaction
’'between the two is reflected throughout the educa
tional program. Indeed, the thread of curricularcontinuity over the past 13 years is represented by the
values that underlie both the regional orientation
and the concern with student learning. As circum
stances change, so do the form and content of the
curriculum; but now, as in 1974, both reflect the
basic social, educational and professional values
Address for correspondence: Dr. D.E. Honor. Curriculum Unit.
University Center lor Health Sciences and Services. Ben-Gurion
University of the Negev. BOB 653. 84105 Beer Sheva.
that informed the process of curriculum develop
ment at its outset.
REGIONAL ORIENTATION
Responsibility for coordinating both service and
training is vested in a single health authority, the
University Center for Health Sciences and Health
Services in the Negev. This is a consortium estab
lished by the Ben-Gurion University of the Negev,
through agreement with Kupat Holim (Health Insur
ance Institution of the General Federation of
Labor) and the Ministry of Health. The Center pro
vides a framework for integration of services, collab
oration in teaching and. ol particular relevance to
curriculum development, defining the professional
roles of the medical school graduates.
This interface between medical education and
health care enables the medical school to both stimu
late and reflect changes in the patterns of health
services. By participating in the consortium, it can
mobilize academic resources for the improvement of
regional health care. Changes in the delivery of ser
vices remain the responsibility of the health care
agencies (4^8).
•
t/
Impact on the curriculum
Medical education is anchoredtrt
Ucets of health
care delivery represented in the consortium. Educa
tional objectives are derived from professional prac
tice in the Negev, based on analysis of the
competencies needed for effective physician perfor
mance. This approach to curriculum development
has had a significant impact on the program of
medical studies. Rather than focusing exclusively on
hospital-based episodic care, the educational per
spective encompasses the full spectrum of health and
1231
israi i J. Mm. Sa
A. Segall et al.
disease, ranging from early prevention through
At the level of undergraduate medical studies, the
acute care to rehabilitation. It is postulated that a
comprehensive and balanced study of all phases of
curriculum helps shape the health care system and
serves as a stimulus for change in several ways. The ,
multifaceted curriculum results in the creation of ’
the natural history of disease will better prepare
students to function in the type of integrated hospi
tal and community health care system being devel
many new links between the health care facilities
involved. Collaborative teaching tends to stimulate
oped in the Negev.
Consequently, teaching takes place in a wide
range of primary and secondary health care settings.
new patterns of interaction in the delivery of service.
The influence of contact with students on their
clinical teachers has not been negligible. For some,
They include community health clinics, hospital
professional practice in the hospital or in the com
wards and outpatient services, rehabilitation facili
ties, public health stations and occupational health
clinics. Not only does the curriculum bear the stamp
munity had become an unquestioned routine. In the
climate of enquiry generated by contact with stu
dents, many have been spurred to reexamine long-
of a general community orientation but also a signif
established patterns of practice and, in the process,
icant proportion of learning experiences arc com
munity based (9-1 I).
.Judicious sequencing of these experiences exposes
set higher standards for patient care. For others,
participation in teaching within the community has
opened new vistas for meeting those health needs of
students to the intellectual challenge and opportuni
ties for service, associated with the primary care
dimension of successive stages in the natural history
the population that are less effectively served in
traditional medical care settings.
Student involvement in health care often helps to
of disease. This dimension is of particular impor
highlight unmet health needs of the population,
tance in resolving the health problems of the Negev.
which, in turn, leads to the initiation of needed
It enables the patient to have ready access to health
health care programs. In addition, public health
care, it integrates health care and assures its conti
projects conducted by students often provide basic
nuity through the various phases of illness, and it
makes use of community outreach programs (12-
data that can be used in the planning and evaluation
of health care (17).
What long-term consequences can be expected of
15).
the collaboration between the educational and ser
vice sectors? The answer, in great measure, lies with
those graduates who will choose to practice medi
This perspective emphasizes the acquisition of
competencies in prevention and rehabilitation as
well as in acute care. It is therefore appropriate that
the natural history of disease constitutes a major
cine in the Negev. During the early years it was
thought that changes in health care delivery could be
synchronized with the educational process: it was
expected that the environment in which new gradu
theme in the curriculum. As used for curriculum
planning al Beer Shcva. il refers to the progress of
disability resulting from disease. Intervals can be
identified along the time axis during which interven
ates would practice would permit them to provide
the comprehensive health care they had been taught
in the curriculum.
The reality proved to be different. Changes in
tion may prevent the onset of disease, lead to its
reversal, slow its progress and reduce personal and
social disability.
Two consequences are anticipated. One. a signifi
health care were introduced more slowly than had
been projected. The early graduates opting for
cant proportion of graduates will consider career
careers in primary care had to choose between two
apparently irreconcilable alternatives: to serve coni- .
munities in the Negev by working within the con
pathways in primary care. Two. il is expected that all
students, whatever their eventual careerchoices, will
have acquired sensitivity to the primary care dimen
sion of all types of medical practice, as well as basic
straints of existing community-based clinics or to
competencies in primary care.
achieve a higher standard of patient care by leaving
Impact on services
the Negev to practice less restrictive forms of pri
mary care elsewhere. Both service in the Negev and
high-quality primary care are values that the curric
Clearly, the integration of the regional health care
system with the curriculum has strongly influenced
the program of medical studies. This is reflected in
the educational objectives, the content of teaching,
methods of instruction and the settings in which
learning takes place. To what extent is the converse
true? Has the curriculum influenced the delivery of
health care? (16)
ulum seeks to transmit.
The original expectations were therefore revised.
Accelerating change in the regional health care sys
tem now became one of the foremost challenges to
graduates. (Ways in which they have met the chal
lenge arc described elsewhere.) Whether the momen
tum generated by these efforts can be sustained
|24|
Eli
Voi 23. Nos 9-10. Si pii mbi r-Octobi r 1987
Tm Ciirrk l'| |!M
depends only in part on the curriculum. Limiting
factors may be unrelated to what happens in under
graduate medical education (18. 19).
EDUCATIONAL ISSUES AND RESPONSES
Scope of ihe curriculum
While the Beer Sheva curriculum is designed to
reflect regional priorities in health, these are
addressed within the wider context of medical edu
cation in the world today.
Among the key issues is the scope of the curricu
lum and the relative weight allocated to its various
components. While the duration of undergraduate
medical curricula has remained relatively constant
over many years, the rate at which new knowledge
accumulates in the basic sciences and the clinical
fields is increasing rapidly. The resulting pressures
towards ever-increasing specialization give rise to
new demands lor representation in a curriculum that
is already limited by lime constraints. Often, the
problem is resolved arbitrarily. The outcome is
determined by the interaction of faculty interests
with the power structures of institutions.
A more rational approach is to set criteria for
deciding what a curriculum should include. There
are both qualitative and quantitative dimensions to
these decisions, and they affect the depth as well as
the breadth ol teaching in each component of the
program. Beyond these considerations of curricu
lum content, there is a need to address the nature of
the learning process itself as a means of preparing
students to adapt to the constantly changing techno
logical and social basis of medical practice.
Curriculum development at Beer Sheva requires
that decisions concerning each area of study be made
according to explicit critcri.i. l or the most part,
these are expressed through instructional objectives
that define the outcome of student learning in terms
of competencies to be acquired. Specification of
objectives encourages systematic course planning
and promotes accountability in the allocation of
time and ollici ins!iuctional resources. Methods ol
leaching and evaluation can then be selected in rela
tion to specific objectives, rather than on a priori
grounds (20).
Since the program of studies is designed to facili
tate achievement of competency-based objectives,
the way in which these are derived assumes consider
able importance. The approach adopted at Beer
Sheva is to base the competencies expected of stu
dents on those that practitioners need. Many are
generic in that physicians need them wherever they
practice and in whatever specialty. They include
problem solving, self-assessment, independent study
and communication skills. Others arc categorical.
reflecting more situation-specific determinants.
Geographic variation in patterns of disease preva
lence. modalities of health care or available technol
ogy. for example, give rise to dif ferences in the range
of specific diagnostic and therapeutic skills needed.
Categorical objectives at Beer Sheva relied, in part,
the health and health care characteristics of the
Negev (21).
Of no less concern than technical competencies
ate the values that will guide students in applying
knowledge and skills. 1 hese values arc equally ame
nable to performance analysis. Altitudinal objec
tives are thus grounded both in the values espoused
by the medical school
and
-.............
J in the reality of medical
practice in the Negev.
Ibis approach responds to student needs as cur
rently perceived, it does not. however, by itself,
prepare graduates who will be able to cope in the
luture with the rapidly evolving scientific and social
basis ol medical practice. Undergraduate medical
education is but the first phase of a lifelong continu
ing education for the physician. Study habits and
patterns of reasoning are important determinants of
the future practitioner’s ability to adapt to new cir
cumstances and problems. Concern at Beer Sheva
with these dimensions of education has had several
si gn i I ica n t con se q u c nces.
Developing capabilities lor self-assessment and
self-education have been designated as generic
objectives throughout the curriculum. The evalua
tion system provides continuous opportunites for
self-assessment by students, supported by resources
for icmedial intervention. Individual initiative is
thereby encouraged and reliance on external sources
of motivation diminished.
Another, related, generic objective that tran
scends course boundaries within the curriculum is the
development of problem-solving skills. These
involve application ol the following sequential steps:
I) problem identification and lormulalion of objec
tives for intervention: 2) selection ol an intervention
from among possible alternatives: 3) implementa
tion of the intervention selected: 4) evaluation of
outcome in terms ol objectives and unplanned con
sequences (22).
The curriculum gives prominence to how prob
lems are identified and structured. Problem defini
tion impinges on all subsequent stages of problem
solving, as it circumscribes both the objectives and
the modalities of intervention. In the clinical con
text. for example, delineating patient problems
exclusively in terms of their pathophysiologic com
ponents will result in interventions directed solely at
these components. Hence, emphasis from the first
yeai ol medical studies is on a more comprehensive
[25]
A. Si GAI 1 11 Al .
ISRAI I J. Mil) S(l
framework for diagnosing clinical problems, in
which the psychological, social and pathophysio
logic dimensions are integrated.
A comprehensive approach is also encouraged in
dealing with health problems in the community.
These are defined not only in medical terms but also
in relation to other factors that affect the well-being
of communities. Social, economic or educational
interventions, for example, may be critical to the
solution of a particular public health problem. They
are liable to be overlooked, however, if the frame of
reference for problem identification is confined to
medical considerations alone.
Problem-based learning has also found increasing
application in the teaching of basic sciences, where it
has led to a shift in emphasis from memorizing
details to critical thinking. It should be noted, how
ever. that the Beer Sheva curriculum uses various
methods of instruction, from didactic lectures to
independent, problem-based learning.
Selecting instructional methods for a particular
segment of studies is generally influenced by several
considerations. These include the educational goals,
the learning resources available, and the teaching
styles and competencies of instructors. The empha
sis on selected generic objectives, for example, varies
according to instructor preferences and course time
allocated.
Relevance of the curriculum
1 he widespread debate in reeenl years on the issue of
relevance in medical education has challenged the
traditional curriculum structure as being inade
quately responsive to students’ learning needs.
Although at lunes more rhetorical than reflective,
this debate has stimulated reassessment of undergraduate medical education by students as well as by
the admm.stration and the teachers.
1 he operational context in which the question of
relevance arises is the relationship between parts of
the curriculum and their sequencing. The main
issues concern the interval separating the acquisition
of knowledge from its application under conditions
that stimulate professional practice. In the tradi
tional curriculum, courses are taught in relative iso
lation and layers of basic studies are separated in
time from layers of clinical application. While this
strictly hierarchical approach may seem logical and
have administrative advantages, how students per
ceive it has important motivational consequences
and affects retention of knowledge and skills
acquired.
The spiral concept ol the Beer Sheva curriculum is
based on the '^mise that learning and its retention
occur more effectively when reinforced concurrently
across diverse components of the curriculum and
longitudinally over its successive phases. Basic sci
ences, clinical medicine and public health are the ;
three principal areas of teaching. Instruction in each
begins in the f irst year and continues throughout the
6 years. Just as clinical studies begin in the first year
and continue until graduation, so the basic sciences
are not confined to the early years. Both proceed in
tandem, drawing on whatever fields of knowledge
can contribute to solving the particular problem
under consideration. This approach stresses the con- 1
tinning utilization ol knowledge from the basic
sciences lor solving problems similar to. or identical 1
with, those of clinical practice. The complexity of
problems and level of simulation increase progres
sively as students advance through the several
phases of the curriculum.
As the students gradually acquire new knowledge |
and skills, they progressively assume independent
responsibility for patient care. This begins in the first
year with the early clinical program, when it is
limited and exercised under direct supervision; As
the student progresses, the scope of responsibility is
gradually enlarged and the degree of student auto
nomy increases. This is in contrast to the more tradi
tional. sharp demarcation between preclinical and
clinical studies, which results in students assuming
clinical responsibilities in large, and at times over
whelming. increments.
The emphasis on problem solving calks for consid
erable interdisciplinary learning. It is postulated that
I
this occurs best
after students have acquired a basic
< ’ of the relevant disciplines. This
foundation in each
implies a sequence in which relatively short ir.tr.introductory courses in the various disciplines
<•
’'—
,
appro
priate 1to each phase w
,I1V uumcuiuiii
of,’ the
curriculum precede
blocks of problem-based interdisciplinary learn
_,
•
i--------- j
These
courses
enable students to acquire
the ling,
these courses enable students to acquire the essen
•■ ■ vocabulary,
■ ■
tial
basic concepts and principles, as
well as the methodological tools of the respective
disciplines, before proceeding to their integration.
Sequencing components of the curriculum is gen
erally guided by the principle that the knowledge
base underlying clinical or public health measures
should be acquired prior to experience in their appli
cation. At times, however, an approach more akin to
the discovery method is used. Students are exposed
to problems for which they have not learned the
theoretical background. The premise is that, under
circumstances in which questions arise out of per
sonal experience, students will use their own initia
tive in seeking answers. Resources for this purpose,
including formal instruction and informal access to
teachers and libraries, are made available. This
approach introduced early in the curriculum is
[261
Voi 23, Nos 9-10, Siii’H Mill r-Octobi-r 1987
Till ClIRRICUl UM
designed to channel experiential sources of student
institution. Available resources and the degree of
motivation into the development of patterns of inde
flexibility in their allocation often set limits to inno
pendent study.
vation. The organizational structure and relation
The clarity with which expectations concerning
ships among the various administrative units
academic performance arc communicated to stu
determine the routes by which it occurs. Attitudes
dents is an important determinant of how they dis
and vested interests'of faculty members who are
tribute their time and effort. Often, considerable
called upon to implement the changes either facili
student effort is misdirected because of lack of
tate or impede the process. Academic leadership
understanding of what is expected. The process of
may play a decisive role by creating a climate in
curriculum development at Beer Sheva encourages
which teachers and students accept the risks of
the preparation of units of instruction for each sub
innovation.
ject area, clinical internship or field assignment.
A decade of experience at Beer Sheva provides a
These may include explicit competency-based objec
case history of an attempt to introduce innovation in
tives, recommended learning activities and instru
medical education under circumstances character
ments for self-assessment.
ized by meager resources, an unstable infrastructure,
It is recognized that the various measures taken to ’ an atmosphere of openness to change, and strong
leadership.
achieve relevance of the curriculum to learning
needs require validation through examination of
It should be noted that the context within which
their consequences. To this end, the evaluation sys
innovation at Beer Sheva occurs is determined by the
tem provides for students, teachers and members of goals of the medical school. These set the terms of
the curriculum development unit to review together
reference for assessment of all curriculum proposals.
each segment of the curriculum. The “debriefing”
In considering possible educational alternatives, the
sessions are based both on learning outcomes related
effort is to select those, whether traditional or innov
to the specific objectives, as measured by examina ative, that facilitate attainment of the institutional
tion, and on analysis of the teaching/learning pro goals. There is no commitment to novelty as an end
in itself.
cess, as perceived by both students and instructors.
After each review, steps may be recommended to
The process of curriculum development itself has
improve conditions for learning, and these sugges helped to introduce and sustain an environment
tions serve as a basis for the revision of instruction.
within which the program of studies can respond to
The role of students is broader than merely pro changes in health priorities, student needs and insti
viding feedback as “consumers” of the educational
tutional resources. It has been characterized consist
process. They are encouraged to participate in devel ently by a wide base for decision making. Broad
oping solutions to the problems identified at the
participation of teachersand students is encouraged,
debriefings and, with members of the teaching staff,
and opportunities are provided to express and
to assume operational responsibilities in their imple exchange opinions before decisions are taken.
mentation. In this way, students can acquire
Although the criteria for curricular decisions form
problem-solving skills in relation to the first profes
part of institutional policy, responsibility for their
sional problem which they face—their own medical
application is broadly delegated.
education. In the process, they provide a self
In matters involving issues of policy, decisions are
renewing source of energy to counterbalance the
taken by interdisciplinary committees acting for the
entropic tendency of a complex curriculum to
medical school as a whole, rather than on behalf of
become simpler and less demanding.
any particular dcpartincnl. The committees have
authority to require changes in instructional objec
tives, to redelineate subject area boundaries, and to
Introducing and sustaining innovation
determine how instructional resources, including
In the climate of change in medical education today,
curricular time, are distributed. The specific mecha
questions related to introducing and sustaining cur
nisms whereby this is accomplished have varied over
riculum innovation are of increasing concern. Estab
the years with changing faculty resources and
lished medical schools in the process of reassessing
constraints.
their educational programs are affected, as are new
This process has tended to increase the overall
schools, which are perhaps less constrained in their
coherence of the curriculum and facilitates both
efforts to respond to the forces of social and techno
horizontal and vertical integration. However, indi
logical change.
vidual departments are apt to perceive it as an in- The interplay of factors is complex, involving
fringement on their academic freedom. This view
overt and more subtle pressures and counter
has changed gradually as a growing proportion of
pressures from outside, as well as from within the
[27]
-
Ml
A. Segall et al
Israel J. Med. Sa
faculty members have internalized the values under
A sense of commitment and involvement among
the teaching staff is a necessary, but insufficient,'
lying the Beer Sheva Experiment. It has therefore
been possible, over the past 13 years, to progres
condition for successful introduction of innovation
into the curriculum. 1 his must be complemented by
sively increase the degree of decentralization in cur
riculum development without compromising its
the ability to apply new skills to the design and
basic principles. This trend is likely to continue as
implementation of instruction. Otherwise, the rhe
more graduates ol the school become members of
the faculty and take part in curriculum development.
toric of curriculum change is unlikely to result in
educationally valid programs. Enthusiasm cannot
The rate at which innovation has been introduced
substitute for competency, and teachers who do not
over the first decade is related to the notion of pro
have these skills cannot be expected to apply them.
ceeding by successive approximations. A potential
pitfail in planning for change is to regard the out
At Beer Sheva the need to train teachers for their
educational tasks was recognized from the begin
ning. Initially, short introductory workshops in edu
come in dichotomous terms: either the innovation in
its entirely will be accomplished immediately, or it
will never occur. Often, it is neither feasible nor
cational methods were offered several times a year.1
As the number of these workshops grows, opportu
nities for more advanced training are being pro
desirable to institute all aspects of an innovative
measure at the same time. Unrealistic expectations
can lead to premature and unwarranted pessimism
vided. In addition, in-service training in the form of
technical consultation by the curriculum develop
and to the abandonment of effort. The approach by
successive approximations, utilized at Beer Sheva,
adapts the rate of change to the resources available
ment unit is provided throughout the year to individ
ual teachers, as well as to committees responsible for
educational planning. The result of these efforts is a
and the constraints not immediately amenable to
steady increase in the proportion of faculty members
control. Objectives are phased over an appropriate
period of time and motivation is reinforced as each
with the background and skills to implement inno
successive approximation is achieved
In this way, modifications can be made continu
vative aspects of the curriculum (23).
It would be simplistic to maintain that the impact
of the curriculum can be completely explained in
ously in the light of cumulative experience. The eval
uation procedures built into curriculum develop
terms of the variables discussed above. Human fac
tors and interaction between students and faculty
ment ensure a periodic review ol each instructional
segment, which results in its retention, revision or
elimination.
are more difficult to delineate and assess. Their
influence on outcomes of the Beer Sheva Experi
Innovation almost invariably results in greater
ment, however, has been crucial. In the early years
there was a sense of shared purpose and determina
demands on faculty time. Most members of the rela
tively small faculty would find teaching in a tradi
tional curriculum difficult. This is particularly true
1 his ethos arose, in part, as a response to the difficul
ties encountered, including a fragile academic infra
tion to succeed in the face of overwhelming odds.
of the clinical teachers, who must cope with an over
structure, the dearth of clinical role models (particu
larly in pi imary care), and the inertia encountered in
whelming clinical load. Although most are prepared
to accept the added burden associated with the
experimental nature of the medical curriculum,
without sufficient staff support, their best intentions
changing patterns of health care.
would be of little avail. This was recognized and a
curriculum development unit was established when
the medical school opened. It provides technical
mythical perceptions of the medical school’s
mission, which transcend the realities at any point in time. The result has been numerous individual and
consultation and staff support to individual teach
group initiatives on the part of teachersand students
To a significant extent, the atmosphere of chal
lenge and excitement has been sustained by quasi-
ers, planning committees, coordinating councils and
to improve both health care and education. These
their executive committees. It mobilizes instruc
tional resources, assumes responsibility for the
training of the teachers for their educational func
tions and oversees evaluation. The unit takes the
have gone far beyond the structured opportunities
for introducing changes that the curriculum
provides.
Towards the end of the first decade, the initial
high level of enthusiasm had started to taper off.
Commitment to the basic values that had character
ized the medical schools at its inception was. how
lead in curriculum development and, at the same
time, responds to the needs of faculty and students.
The Beer Sheva experience underscores the impor
tance of this type of leadership and staff support in
translating :-*-nvative educational ideas into viable
ever, still, very much in evidence. Many of the early
innovations had become institutionalized and were
programs.
now firmly anchored in the curriculum. Others, such
I 28>
Vol 23, Nos 9-10, Septembi r-October 1987
I he Curriculum
as those imposing unrealistic or excessive demands
on students, could not be sustained and were either
modified or discarded. Continuity in the curriculum
has therefore been more in terms of the values it
reflects than in specific patterns of instruction.
Innovation in medical education often develops
out of circumstances that are specific to individual
institutions rather than as a result of planning for
change at a national or international level. The
impact of an innovative curriculum must therefore
be judged against the goals set by the particular
medical school and the constellation of resources
and constraints within which it is implemented.
Considerable caution is necessary when attempting
to generalize from the results obtained at any one
institution.
dialectic had brought about a more empirical
approach to student evaluation. Concern for con
sonance between educational objectives and the way
they are evaluated was balanced by an increased
sensitivity to the amount of change that could be
absorbed without jeopardizing other important ele
ments of the curriculum (26).
In addition to its impact on students and gradu
ates, the curriculum is also expected to have a direct
’ influence on the regional system of health services in
Evaluating the outcomes
Of primary concern is the effect of innovation in
medical education on the accessibility and quality of
health care. Curricular change, for example, may
result in graduates being better able to meet health
priorities of the community. The distribution of
career choices may become more responsive to the
needs of the health care system, and the standard of
care may improve. These outcomes, however, are
affected by determinants other than the nature of
undergraduate medical studies. Choice of specialty
and of place of practice may depend more on such
factors as personal background, economic incen
tives and family considerations. The relative contri
bution of undergraduate medical education to the
quality of ultimate physician performance, as com
pared with that of subsequent postgraduate studies,
has yet to be clearly established. Longitudinal stud
ies of Beer Sheva graduates to elucidate these rela
tionships are currently in progress (24, 25).
With these considerations in mind, the evaluation
system is designed to assess student progress
through successive phases of the curriculum and
.afterwards to monitor the professional activities of
graduates al subsequent stages of their careers. A
principal concern has been to adapt the method of
evaluation to the school’s educational goals. This
has probably caused more controversy over the past
decade than any other aspect of curriculum develop
ment. Initial attempts to use formative evaluation as
a learning tool, rather than for certification, met
with considerable resistance. It clearly ran counter
to deeply ingrained habits of most students and
teachers. Efforts to introduce integrative, problem
based, rather than disciplinary, examinations in the
early phases of the curriculum met with a similar
fate.
Towards (he end of the decade the evaluation
the Negev. As described earlier, physicians, nurses
and other health workers in community health clin
ics, hospitals and public health centers collaborate in
the teaching programs. Linkages among health care
facilities lor educational purposes foster communi
cation and open the way for the development of new
lunctional relationships. Interaction between practi
tioners and academic staff tends to stimulate reas
sessment of current practice, preparing the way for
change. As part of several large-scale studies cur
rently under way, the qualitative and quantitative
dimensions of these service-related outcomes of the
curriculum are being explored.
CONCLUSION
During the first decade the medical curriculum at the
Beer Sheva medical school has acquired both direc
tion and momentum. The direction has been consist
ent with the regional orientation of the University
Center lor Health Sciences and Services, as well as
with its commitment to addressing the broader
issues that confront medical education. It is reflected
in the responsive environment brought about by the
process of curriculum development and in the form
and content of the study program. Both have
evolved with changing circumstances; new health
priorities have emerged, as have fresh educational
insights. The resources and constraints that impinge
on implementation of the curriculum are continu
ously recast.
Adapting to these changes has called for both
procedural and substantive flexibility. As a result,
the potential for innovation has not been transient,
limited to the early years, but has extended through
out the first decade. Innovations, however, have not
been arbitrary. Rather, they have been shaped con
sistently by the same set of basic values upon which
the medical school was founded.
Curriculum momentum, in turn, has largely been
a consequence of the direction that the school has
taken. The high level of commitment among faculty
and students would have been unlikely without such
a challenge as the Beer Sheva Experiment. Strong
academic leadership, an ethos that stimulates colla
borative educational and service initiatives among
[29]
A. Sigai i et ai
teachers and students, and a relatively high level of
technical support for curriculum development, have
1SRAII J. Mi d Sa
also contributed significantly to the momentum.
acquired overl he years and reflect a growing body of,
research on the educational program (27).
Secondly, the educational cycle is now complete,
Continuing rather than episodic evaluation has
tended to produce gradual rather than abrupt
changes, and much of what was new and tentative
with Beer Sheva graduates assuming an increasing
role in instruction. As their numbers increase, so will
their impact on (he curriculum. Thirdly, curriculum’
has become customary and stable.
What has the impact been? To what extent have
expectations of the curriculum been met? As regards
impact on health services, two limiting factors were
development as a process responsive to changingcircumstances has been progressively institution-alized. It thus can adapt to new challenges as the)(
encountered: inertia and resistance of the health care
There is little doubt that teachers, students and
administrators are prepared to continue in the direc
tion charted during the first decade. Their ability to
system to change, and the lack of a critical mass of
practitioners with the credibility and leadership
qualities needed to overcome these barriers. Cer
tainly, changes have taken place in the climate of
opinion, and even individual instances of “break
throughs” brought about by the efforts of students
or graduates can be cited. However, the system can
absorb these without changing fundamentally.
Innovation is occurring, but more slowly than was
originally anticipated, probably reflecting national
trends more than regional determinants. Under
these circumstances, the role of the curriculum, as
one element of the Beer Sheva Experiment, in bring
ing about change has been quite modest.
The educational impact is more evident. T'ollowup of the first cohorts of graduates suggests that
their attitudes and performance during early post
graduate years bear the imprint of the curriculum.
However, the effect of medical studies is probably
confounded with that of student selection. A conser
vative assessment of the curriculum might be that it
provides students who have the potential for devel
oping certain personal and professional qualities,
consonant with the Beer Sheva ethos, with encour
agement and opportunities to do so.
The curriculum has had educational reverbera
tions outside Beer Sheva. Other medical schools in
Israel have adopted some of its elements. In addi
tion. through publicationsand personal contact,the
educational dimension of the Beer Sheva Experi
ment has had an influence on the training of health
professionals in other countries.
What of the future? Will the curriculum continue
as a dynamic instrument for achieving the goals of
the University Center for Health Sciences and Servi
ces? Several considerations suggest that this may be
the case. Firstly, members of the Center have reaf
firmed their commitment to the values embodied in
the curriculum, after several successive comprehen
sive reviews. More effective and efficient implemen
tation emerged as the overriding concern. In many
respects, these recent positions adopted by the Cen
ter are more informed than those taken in 1974.
They are based on a critical sifting of experience
a rise.
do so, however, will be limited by constraints in the
Beer Sheva situation. Some are beyond the control
of the medical school, and are determined by politi
cal, economic and social development in the country
as a whole and, more particularly, in the Negev. 11
past experience is any guide to the future, the final
chapter has not yet been written on the contributions
ol (he Beer Sheva Experiment Io regional health care
and to the advancement of medical education.
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22. Margolis C. Barnoon S and Barak N (1982). A required
course in decis'on making for pre-clinical students. J Med
Educ 57: 184-190.
23. Mahler S and Benor DI- (1984). Short and long-term effects
of teacher naming workshop in medical education Hiehcr
Educ 13: 265-273.
24. Prywes M and Friedman M (1987). The Ben-Gurion Uni7irSi‘nofr?m?te pro,lle: an valuation study. Isr J MedSci
Z J. 1 Uv J-] 101.
25.
26.
27.
(1985). Center for Medical Education. Ben-Gurion Uni
versity of the Negev. Beer Sheva. Report for 1984 Pub
lished in Beer Sheva.
Segall A. Benor DE and Susskind (1978). Consonance be
tween instruction and evaluation in medical education. The
Beer Sheva Experience. Hum Perform Quan 7- 189-196
Umversity Center for Health Sciences and Services BenGunon Umversity of the Negev (1981). Towards the next
decade^ a report of a 2-day faculty seminar held in January
1981. Beer Sheva.
aalMMtMn
A
ACADEMIC PROMOTIONS IN THE UNIVERSITY CENTER FOR
HEALTH SCIENCES AND SERVICES
MARTIN SACKS*
Dcparimcnl ol Pathology. University Center lor Health Sciences and Services. Ben-Gurion University of the Negev
Beer Sheva. Israel
/at./ Med Sei 23: 964-968. 198’
Key words. Beer Sheva Experiment: medical education: academic promotion: appointment committee
There are probably few topics in academic life that
give rise to more anxiety and emotion than the pro
cess and criteria whereby. the academic staff of a
university are promoted. The problem is particularly
complex in a medical school where the clinical staff
have service responsibilities and commitments to
patient care that are not shared by their colleagues in
the basic science departments of the school or in
other faculties of the university. This difference is
not always reflected in the promotion policy of the
university, with the result that the clinician/teacher
may be expected to present a research record com
parable to that of the basic scientists. An unfortu
nate consequence of this state of affairs is that the
clinician may tend to downgrade his clinical or
teaching responsibilities, at least until he has begun
his advance up the academic ladder or has achieved
academic tenure. One of the main considerations in
formulating the promotion policy of the University
Center for Health Sciences and Services of the BenGurion University of the Negev has been to avoid
such a situation, which would clearly conflict with
the basic aims and concepts of the school.
All members of this medical school receive their
academic appointments from the Ben-Gurion Uni
versity of the Negev. The academic ranks, as in the
rest of the University, are instructor, lecturer, senior
lecturer, associate professor and full professor.
Address for correspondence: Dr. M. Sacks. Department of
Pathology. University ( enter for Health Sciences and Services.
Ben-Gnrion University ol ihc Negev. POB 653. X4IO5. Beei
Sheva.
* Formerly Associate Dean lor Academic Appointments
The Founding Dean of the school recognized that
lhe promotion policy would have a strong influence
on the type of individual attracted to the school. It
was essential to attract clinical teachers who would
be dedicated to the educational and health missions
of the school and who would feel assured that this
commitment would be given an appropriately high
rating by those responsible for their academic
promotion.
One of the main ways in which this medical school
differs from the other schools in Israel is that the
promotions of members of the basic sciences and
those ol the clinical faculty arc dealt with by separate 1
appointment committees. The regular promotion
policy and system of the University arc followed for
members of the basic science departments of lhe
faculty, most of whom receive their salaries from the
University. This also applies to the small group of
nonphysicians (PhDs) who arc employed in var
ious hospital departments and paid by Kupat Holim
(Health Insurance Institution of the General Feder
ation of Labor). The ultimate decision on the aca
demic promotions of these two groups of faculty
members is taken by lhe Higher Appointment Com
mittee of the University. The procedure and criteria
for these promotions are similar to those at other
medical schools in Israel and will not be discussed in
this report.
A different procedure, however, is followed for
faculty members who arc physicians and who have
clinical responsibilities in the hospital departments
or community clinics. Their promotions are handled
by a separate Medical Appointment Committee
equal in status to that of the regular Higher Appoint
ment Committee of the University.
|32|
'■
Voi
A< ADI Ml( PUOMO I IONS
Nos 9-10. Si i’ll mhi h Oi iohi k 19X7
SENIOR MEDICAL APPOINTMENT
COMMITTEE
With the establishment of the University Center for
Health Sciences and Services, an agreement was
signed between the University and Kupal Holim,
which contained a special section dealing with the
academic appointments of the clinical staff. Accord
ing to this agreement, which was approved by the
Senate of the University, a committee known as the
Senior Medical Appointment Committee was set up
to handle the academic appointments of all physi
cians (faculty members with MD degrees) in the
medical school.
The members of the Senior Medical Appointment
Committee include the Dean of the medical school,
the Director-General of the Kupal Holim and a
number of full professors chosen from the clinical
faculty of the school. The committee also includes
outstanding physician-scientists from other institu
tions in Israel, one of whom serves as chairman of
the committee. Ben-Gurion University is repres
ented by the Rector of the University, who serves as
cochairman, and by an elected representative of the
University Senate.
All promotions of the clinical staff of the faculty,
at the senior lecturer or professorial level, are
initiated, handled and finalized by the Senior Medi
cal Appointment Committee. Most of these physi
cians receive their salaries from Kupat Holim, but
some are employed by the Ministry of Health and a
few by the University itself.
The existence of a special Medical Appointment
Committee is a unique feature of the Beer Sheva
medical school and has undoubtedly had an influence on the promotion policy of the faculty. On the
one hand, a committee composed mainly of physi
cians is better able to evaluate the faculty member’s
contribution to patient care and clinical teaching
than is a general university committee. On the other
hand, the fact that the chairman is a distinguished
member of another institution, and that the Rector
of the University is cochairman of the committee,
has helped ensure that the promotion criteria arc in
step with general University policy and that ade
quate importance is attached to the research
achievements of the candidate.
GENERAL PRINCIPLES OF THE
PROMOTION POLICY FOR CLINICAL
TEACHERS
In accordance with the promotion policies of most
medical schools, the achievements of the faculty
members in teaching, clinical practice and research
are evaluated. A guiding principle in the promotion
policy of the Beer Sheva school has been that the
clinician who balances his activities in the three
fields should be as worthy of academic promotion as
his counterpart in the basic science departments
whose orientation is primarily towards basic
research.
A problem encountered by promotion commit
tees in medical schools throughout the world has
been to determine the relative weighting that should
be assigned to achievements in teaching, clinical
service and research at the different levels of promo
tion. In formulating and applying the promotion
policy of the Beer Sheva school, it was felt that
flexibility was essential when assessing the faculty
member’s contribution in each of these fields, and
that a synthesis of the physician’s activities should be
judged rather than the ai ithmclic mean of his contri
bution in each field.
The need for a flexible approach seemed to be of
particular importance in a medical school where the
physician’s involvement in patient care would serve
as a role model for the students, but in which there
was also a critical need to encourage research and to
build up a strong basic faculty.
While it was recognized that the major contribu
tion of most of the clinicians in the faculty would be
in clinical medicine and teaching rather than in basic
research, the clinical teacher was also expected to
participate in research leading to publications in
peer-reviewed medical journals. Assessment of the
faculty member’s research contribution is therefore
an important part of the evaluation process, espe
cially at the higher academic levels. On the other
hand, the aims of the school are such that it is
inconceivable that a physician will be promoted to a
high academic level on the basis of his research
achievements, if these are accomplished at the
expense of his responsibilities to his patients in the
hospital or community.
GUIDELINES TO APPLICATION OF
THE POLICY
While I he need l or flexibility has made it dil l icult to
define precisely the promotion requirements at the
different academic levels, it was important that
faculty members have a clear understanding of the
principles on which the promotion policy was based.
In order to meet this requirement, a set of general
guidelines was drawn up several years ago by the
present Dean of the faculty and approved by the
Higher Medical Appointment Committee. I will dis
cuss some of the more important guidelines, since
they emphasize several aspects of the policy that
were given special attention by the Appointment
Committee over the years.
In the preamble to the guidelines, it is pointed out
[33]
M. Sacks
Israel J. Mm Sci
that a medical faculty cannot lay down strict criteria
that apply equally to each-and every teacher. Where
as the faculty member’s contribution to research,
teaching and patient care will be evaluated in each
case, it is recognized that some faculty members will
be stronger in one aspect than in another, and that
particular achievements in one field may compen
sate for relative weakness in another. In the case of
faculty members who carry a heavy service load, a
lesser contribution to research may, for example, be
balanced by their achievements in patient care and
teaching. At the higher academic levels, however,
the expectations arc increased with respect toa posi
tive contribution in ail three fields.
In conformity with the general principles of the
faculty’s promotion policy, the guidelines indicate
that greater emphasis is placed on the faculty
member’s contribution to clinical service and teach
ing than in many other medical schools, but that
dedication to patient care will not, on its own. ensure
the right to academic promotion. The guidelines give
some indication of the expectations with respect to
the various activities of the faculty member al the
different promotion levels, although no attempt was
made to spell this out precisely. Excellence in clinical
care and/or teaching would, for example, be re
garded as a minimal requirement for promotion to
associate professor, but the candidate for promotion
at this level would also be expected to show clear
evidence of a significant contribution in either clini
cal or basic research. A candidate for promotion to
the rank of full professor is expected to have
achieved national or international recognition in his
particular field.
The guidelines also indicate that the faculty
member’s contribution to the administrative needs
of the school and to the community at large will be
taken into consideration in the overall assessment of
his achievements. An important point mentioned in
the guidelines, and often overlooked by academic
promotion committees, is the question of personal
example. Evaluation of the clinical teacher should
include not only an assessment of his performance in
formal lectures, seminars and bedside teaching, but
also the extent to which his personal behavior and
attitudes can be regarded asa positive example to his
students within the framework of the general aims of
the school.
Although the Senior Medical Appointment Com
mittee is very much influenced in its decisions by the
promotion policy and guidelines discussed above, it
is recognized that there may sometimes be circum
stances in which unusual departmental needs may
justify a promotion that is not st rictlv in accordance
with the guidelines. 1 he guidelines are not intended
to prevent a flexible approach; on the contrary, they
are meant to provide a context for determining to
what extent it is necessary to compromise.
EVALUATION OF TEACHING
A detailed discussion of the evaluation of the teach
ing skills of a university teacher is beyond the scope
of this review. The usual procedure at our medical
school is that the Associate Dean responsible for
coordinating teaching activities in the faculty is
asked to submit fo the Appointment Committee an
evaluation of the faculty member’s ability and con
tribution as a teacher. The Associate Dean is aided
in his assessment by the student evaluation of indi
vidual teachers, as expressed at the debriefing ses
sions held at the end of each course. The assessment
of the Associate Dean is particularly important in
the case of younger faculty members whose impact
on leaching will often not be known to members of
the Appointment Committee. Prior to their appoint
ment as instructors or lecturers, new faculty mem
bers are expected to participate in an orientation
workshop at which the aims and teaching policy of
the faculty arc outlined. In the case of more senior
promotions, the candidate’s contribution to
curriculum planning is also taken into account by
the Appointment Committee.
EVALUATION OF RESEARCH
While aH members of the Ben-Gurion medical
school are expected to engage in research, it is clearly
recognized that physicians who are concerned pri
marily with patient care cannot be expected to produce
papers of the same type or at the same rate as their
colleagues in the basic sciences.
The promotion guidelines referred to above give
some indication of the type of research achievement
expected at the different levels of promotion. Evi
dence of “some research activity” is expected before
appointment as lecturer, and of “independent re
search” in the case of appointments at the senior
lecturer level. At the professorial level, the faculty
member is expected to have shown ample evidence
of his ability to carry out “significant independent
research.” These are clearly very general guidelines
and allow the Appointment Committee to exercise flexibility in assessing the candidate’s research contri
bution.
As in most universities throughout the world, the
actual evaluation of research achievements is based
primarily on the candidate’s list of publications,
despite the awareness that this is not always a true
reflection of the candidate’s research activities. In
general, the main assessment of the publications is
lef t to the members of the professional subcommit-
|34|
;
■■
Acadi mic Promotions
Voi 23. Nos 9-10. Si ph mbi r-Ociobi R 1987
ments or promotions at the lecturer level are recom
mended by the appointment subcommittee of the
faculty and confirmed by the Senior Medical
Appointment Committee.
Appointments or promotions at the senior lec
turer or professorial level are handled by the Senior
Medical Appointment Committee. In the case of
these senior appointments, great importance is at
tached to the opinion of recognized experts from
other institutions in Israel or abroad. For promo
tions to associate or full professor, an evaluation by
overseas referees is regarded as mandatory. 1 he
external referees are asked to express an opinion on
the professional standing, academic attainments,
teaching capabilities and research contributions of
the faculty member. When requesting letters of
appraisal from the external referees, care is taken to
explain the special aims of the Beer Sheva school.
The following paragraph in the letter to the referees
is intended to serve as a guide to the promotion
policy of the school:
tee. Since these subcommittees arc composed of
experts in the candidate’s major field of interest (see
below), it is hoped that they will be in a better
position to judge the quality of the publications and
will avoid the temptation to merely count the
number of papers listed in the candidate’s curricu
lum vitae. Two additional aspects arc considered by
the Appointment Committee in evaluating the candi
date’s research contribution and. in certain cases,
these may carry even greater weight than the length
of the list of publications. The first is the realization
that the head of a clinical department who has suc
ceeded in encouraging the younger members of his
department to carry out independent research or to
publish papers based on their clinical experience
may have made a greater research contribution than
his own list of publications indicates. A second point
taken into consideration is that the interest and
enthusiasm that a senior faculty member stimulates
when working with his residents and young doctors
may be as much a reflection of his creative activity as
the number of papers he has published.
Our school attaches great importance to the
integration of hospital and community medicine
and to the fostering of a positive attitude towards
primary health care. In considering the promotion
of our clinical staff, we therefore pay special
attention to their contribution and achievements
within the sphere of hospital and/or community
medicine in addition to their research achievements.
DECISION AGAINST A CLINICAL TRACK
In many medical schools in Israel and abroad, the
problem of faculty members whose commitment to
patient care leaves them little time for research is
solved by the existence of a separate clinical track.
Such faculty members are eligible for promotion to
the rank of clinical senior lecturer or clinical profes
sor. The question as to whether a separate clinical
track should be introduced at the Beer Sheva school
was discussed at length at a meeting of the Faculty
Council a few years ago. Several senior faculty
members favored the institution of such a track in
which the major weighting in promotion decisions
would be given to the candidate’s clinical achieve
ments. The majority view, however, was against the
creation of two classes or categories of faculty
members. In view of the clearly stated aims of the
school, it seemed particularly inappropriate that cli
nician-teachers whose major commitments were to
patient care and clinical teaching could not be
advanced in the regular academic track even if their
research achievements did not match those of their
colleagues in the basic science departments.
The letter to the external referees has recently been
modified to indicate that the Beer Sheva school does
not have a separate clinical track and that the clinical
practitioner and full-time academic researcher are
appointed within the same regular track.
Should the Senior Medical Appointment Com
mittee be satisfied that the candidate’s record war
rants consideration lor promotion at the senior
lecturer or professorial level, a special professional
committee is appointed for each candidate. The
committee is composed of three or four experts in
the candidate’s particular field. The chairman is usu
ally a member of the local faculty, but the committee
always includes representatives from other medical
schools or scientific institutions in Israel. The pro
fessorial committee reports back to the Senior Med
ical Appointment Committee where the final
decision is taken.
THE ACTUAL PROMOTION PROCEDURE
Apart from the existence of a separate Senior Medi
cal Appointment Committee, the actual promotion
procedure is similar to that in other medical schools
in Israel. The recommendation for promotion is
usually initiated by the departmental or divisional
head. Appointments at the instructor level are
decided on by the Dean of the faculty. Appoint-
EVALUATION OF THE PROMOTION
POLICY
No systematic evaluation of the promotion policy
has as yet been carried out. This is clearly desirable
and should be one of our future aims, although the
task will not be an easy one. In his recent “Moshe
Prywes Lecture on Medical Education,’’ Evans (1)
[35]
A
ISHAM J . Ml l> S( I
M. SA( KS
pointed out that evaluation of an educational experiment may be a frustrating process since “what is
important is difficult to measure and what is measur-
motion standards in the medical school arc lower
1
than those in the rest of the university. It was there
t
fore gratifying to hear the then Rector ol the Univer
I
sity state at a Senate meeting that his experience asa
member of the Senior Medical Appointment Com
mittee had convinced him that the promotion crite
ria of the committee, although different, were not
less demanding than those of the regular Appoint
ment Committee of the University. Il is this message
of “different" rather than “lower" criteria that char
acterizes the promotion policy of the school with
able is usually not important."
It is meanwhile difficult to draw definite conclu
sions on either the validity of the basic concepts of
the promotion policy or the consistency with which
the policy has been applied. Outside observers, and
even members of the faculty itself, have often asked
whether the declared promotion policy ol the laculty
has in fact been applied in practice. Two contrasting
regard to its clinical teachers.
sets of doubts have been expressed, depending on the
During the winter of 1985-86. the Ben-Gurion
personal viewpoint of the questioner. There are
University of the Negev invited a group of distin
those who imply that the major weighting has in fact
guished academicians from Israel and abroad to
been given, as in most other medical schools, to the
conduct an in-depth review of its faculties and aca
number of publications rather than to the faculty
demic units. It was encouraging to read in the report
member’s contribution to clinical service and teach
of this academic review committee that the stan
ing. Others have claimed that there has been an
dards and criteria used by the promotion committees
undesirable downgrading of the importance of
• of the University Center for Health Sciences and
research, and that the emphasis on clinical service
Services were high, and that both the clinical and
and teaching may have a stilling effect on research in
basic science departments were composed largely ol
the medical faculty as a whole. The fact that the
teachers and investigators of high caliber.
criticisms have been voiced in two different direc
tions—some claiming that we pay no more than lip
HAS THERE BEEN A CHANGE WITH TIME?
service to clinical service and teaching, and others
As the basic science departments have developed
that we downgrade research—is perhaps an indica
and more young clinicians have joined the faculty,
tion that the promotion policy has been a truly
opportunities for research have become greater.
balanced one. More credit has been given for high
This has, I believe, been accompanied by a slight
quality clinical care and excellence in teaching than
increase in the emphasis placed on research achieve
in many other medical schools, but contributions to
ments by the Senior Appointment Committee. This
research have certainly not been disregarded, partic
should probably be seen as a positive development
ularly in the case of promotions at the professorial
as long as the overall balanced approach is pre
level. In some ways, the expectations have perhaps
served. A more active participation of clinical
been greater than in other medical schools. On the
faculty members in basic or clinical research pro
one hand, clinical service alone has not been
grams is a positive step in the right direction, pro
regarded as an adequate reason for promotion to the
vided that the commitment and devotion of the
higher academic ranks. On the other hand, a long list
clinician to patient care and teaching do not decline
of publications has not been accepted as a substitute
as a result. Special heed must be paid to the danger of
for clinical and teaching achievements.
creating an atmosphere whereby physician-teachers
Despite their heavy clinical responsibilities, many
would feel tempted to join the “publish or perish
of the clinical faculty have succeeded in making
bandwagon” at the expense of their clinical and
substantial research contributions, and most ol
teaching responsibilities.
those who have been promoted to the rank of asso
ciate or full professor have achieved a high level of
I wish to thank the Founding Dean of the University
scientific productivity. There are, however, faculty
Center for Health Sciences and Services, Dr. Moshe
members who have not published extensively but
Prywes, for his help in preparing this review and in
who have been promoted to the rank of senior lec
particular for his advice on the historical aspects of the
turer and, in a few instances, even associate profes
promotion policy. I am also deeply indebted to the present
sor on the basis of their exceptional contributions to
Dean, Dr. Shimon- Glick, from whose promotion
teaching and to clinical care in the hospital and
guidelines 1 have quoted extensively.
community.
Since the academic promotions of the clinical
teachers are not handled by the regular Higher
Appointment Committee of the University, it has
been important to avoid the criticism that the pro-
REFERENCES
„
.
I. Evans JR (1985). The Moshe Prywcs lecture in Medical
|36|
Education. Medical education—the search lor interna
tional eminence and local relevance, /.vr ./ Med Sei 21:
557-563.
MEDICAL STUDENT SELECTION AT THE BEN-GURION
UNIVERSITY OF THE NEGEV
AARON ANTONOVSKY ♦
Dupaiuncut ol the Sociology of Health, University Center lor Health Sciences and Services, Ben-Gurion University
of the Negev, Beer Sheva, Israel
Isr J Med Sci 23: 969-975, 1987
Key words. Beer Sheva Experiment; medical education; student selection; interview; cognitive and
noncognitive characteristics
Among the innovations introduced in the Beer
Sheva Experiment, few are as radical, well-known
and controversial as the student selection procedure.
It has been the subject of invited talks before medical
circles in Berkeley and Geneva, Madrid and
Stockholm, as well as in Jerusalem, Tel Aviv and
Haifa. Responses have been spirited, ranging from
hostility through scepticism to enthusiasm, tenors
which often accompany scientific controversy about
issues that challenge convention. The procedure was
adopted alter much deliberation, but with
considerable trepidation. For those not exactly
sympathetic to the Experiment, it was additional
evidence that we were setting up a school for medics.
At the time of writing, the 12th class has been
accepted in very much the same way, in principle and
procedurally, that marked the acceptance of the first
class in 1974. Technical changes have been made and
the personnel involved has changed, but student
selection has been institutionalized and remains
essentially the same. This paper is designed to
describe the procedure briefly for those not familiar
with it, to consider the problematics,and to evaluate
it as best as one can without a thoroughly
respectable scientific study.
(In some countries, all candidates who meet a very
modest set of requirements are automatically
accepted; severe weeding out occurs later, mostly in
the first year. We never seriously considered this
option. This paper is addressed only to the issues
that arise when selection is done before admission.)
PRINCIPLES
Three principled decisions were taken at the very
outset, which expressed a radical departure from con
ventional wisdom in the selection of medical students.
These relate to the role of noncognitive factors, the
authority and responsibility of the Admissions Com
mittee, and the threshold concept of cognitive factors.
Details and concretizations flow from these decisions.
Each will be dealt with in turn.
Address for correspondence: Dr. A. Antonovsky, Department of
Noncognitive factors
The Ben-Gurion University of the Negev (BGU) can
hardly lay claim to originality in its concern about the
cut-throat competitiveness, egotism, coldness and the
like with which medical students have so often been
the Sociology of Health, University Center for Health Sciences
charged. The desire to admit students characterized
and Services, Ben-Gurion University of the Negev, FOB 653,
84105, Beer Sheva.
by compassion, sensitivity and responsibility was not
born in the Negev desert. Conventional wisdom,guid
ing selection procedures throughout the world, how
ever, is predicated on the primary axiom of selection
according to cognitive criteria, i.e., grades and
achievement and/or ability test scores. The perspec
tive was shaped by the question: who can be expected
* The writer served as first chairman of the Admissions
Committee for 9 years. Thus he has all the advantages of intimate
familiarity with the subject, and all the disadvantages of the
committed. The reader is duly warned.
(37]
I I ...m..HI. N
u
israi i .1. Mi n S(l
A. Anionovsky
membership (now 25) were physicians and half
nonphysicians. Some of the latter are basic scientists
who are members of the medical faculty, others are
members of other faculties, and still others are
citizens with no university affiliation. Selection is
always individual, by persons believed to identify
fully with the aspirations and values of the school.
1 he members who are not physicians provide a
valuable different perspective. Through them word
gets around the entire community: this is a medical
school that tries to pick real menschen (human
beings); it is beyond reproach and has totally
eliminated proteksia (pull); this is “our” school.
A sense of identification flows from having auton
omy. The consequence of accepting responsibility is
the willingness to be trained to perform well. The
heart of the committee’s work is the heavy,
concentrated investment in interviewing candidates.
However, in order to make policy decisions, to
resolve the many concrete issues that arise and.
above all. to learn from experience and to prepare
for the interviewing, the committee meets
throughout the year. A collectivity emerges from a
collection of individuals. Over the years, a sense of
pride in membership has emerged, camaraderie
enhanced by jokes and stories, but above all. by the
The Admissions Committee
feeling—warranted or not (an issue to be considered
When cognitive factors are the sole selection
below)—that a crucial job is being done well.
criterion, the admissions procedure can safely be
Finally, what is to be noted is that committee
placed largely in (he hands of computers and
members serve a 3-year term, some returning altera „
bureaucratic officials. When additional factors are
few years. Moreover, an ex-member is always called
to be taken into account, faculty members most
upon to put in a day or two of interviewing. Oneoften are enrolled to evaluate letters of recommen
third of the members are thus replaced each year.
dation and autobiographies, or to hold an interview.
1'his rotation has ensured continuity, while making
Since (he noncognitive data are defined as adjunct,
room for new ideas and challenges, as well as for an
the duty to judge and vote becomes onerous and
ever-larger circle of faculty and community
adjunct to one’s real work. This is not to suggest that
participants in the process.
it is not taken seriously. But it is hardly a
professional role, in the sense that there is scope for
The threshold concept
autonomy, policy formation, and complexity of
The hidden assumption of most medical schools
choice.
would seem to be that the goal of selection is to
The first Admissions Committee al BGU was
admit potential Nobel prize winners. Alternatively,
handpicked by the Dean, in consultation with the
it is assumed that none but the very top scorers on
intended chairman. Its assigned mandate was to
ability and achievement have the cognitive potential
formulate the policies and procedures for selection
to perf orm well as medical students and physicians.
in keeping with the purpose and spirit of the school
Despite the massive evidence lhal the predictive
and Io be icsponsible lot cairying Ihein out. I hits
value
of scores, within the narrow range of those that
from the outset, authority and responsibility were
allow
admission, is at best marginal for even the first
vested in the same body. Obviously, it was ultimately
years
of school, this assumption has continued to
to be responsible to the Dean and. when it was
guide
most selection procedures.
formed, to the Faculty Council. In actual fact, its
This
assumption was totally rejected at BGU from
near-total autonomy has been maintained.
the
outset.
With full appreciation of the intellectual
The second characteristic of the committee
difficulty,
the
capacity for self-discipline, and the
expresses, in its way. the community orientation of
need
for
a
variety
of cognitive skills required for
the school and the physician/patienl partnership
success
in
medicine,
we made the assumption that
conception of health care. From the outset, half its
to cope with great competence with the rigorous cog
nitive demands of medical school? Once this elite is
identified, there might be room for looking for other,
“softer” qualities.
Our approach was fundamentally different. Our
initial question was: What are the behaviors we wish
to sec manifested by our graduates as practicing
physicians, whatever their specialties? Further,
given the raison d’etre of a fourth medical school in
Israel, it was incumbent upon us to ask about
qualities that might predict to a community
medicine orientation. Once these questions are
asked, cognitive abilities are seen as an important
part of the picture, but no more than that. They are
not seen as taking precedence over, as more crucial
than, noncognitive factors. The latter have come to
be seen as essential in selection, rather than as a
residual component. The noncognitive factors are
neither to be totally disregarded, nor given minimal
weight or are merely for the purpose of weeding out
potential psychiatric casualties. They are, rather, to
be accorded crucial weighting, to be used as a posi
tive selection criterion and to constitute a sine qua
non component.
[381
--
Vol. 23, Nos. 9-10, September-October 1987
Mi dicai Studi ni Sei i ction
!
examinations in a variety of subjects. In order for an
application to be approved, the candidate must have
obtained a grade of 8 or better (out of 10; this is the
equivalent of the American B) and have taken at
least two exams at a 4 or 5 point level (the equivalent
of the British A level). This cutoff was determined
alter analysis of national grade achievement, which
showed that approximately one-third of all those
with a matriculation certificate (i.e., excluding those
who do not complete 12 years of schooling ordo not
obtain a certificate) reach this level. Having passed
this threshold, matriculation grades play no further
role in selection.
these are found among a considerably larger
proportion of candidates than is usually thought to
be the case. At the time of making this principled
assumption, we were fully aware of the fact (and
duly afraid) that it was an assumption without
documentation.
This is not to say that there is an inherent
contradiction between outstanding intellect and the
humane qualities essential to the practice of
medicine. (The one Nobel prize winner I have had
the fortune to meet personally is one of the most
compassionate and cultured persons I have ever
met.) Our assumption, rather, is based on three
arguments. First, a considerably more modest
cognitive level than is usually thought to be the case
is perfectly adequate for highly successful
performance in medicine. Second—if the first is
indeed true—by selecting students from a con
siderably larger pool than is usually the case, one
paves the way for the search for those who are
outstanding on noncognitive characteristics. We are
delighted by a brilliant candidate who is also a fine
person. But fine people are not any more frequent
among the brilliant candidates. And. third, we
argued that those candidates who were top scorers
were more likely, relatively speaking, to be attracted
to a narrow research career than to communityoriented medicine.
Cognitive potential
Candidates to Israeli medical schools take a battery
of what may loosely be called intelligence tests
(although components of knowledge of English and
of general knowledge are included). The other three
schools use the scores in somewhat different ways;
the individual’s rank, however, is always crucial. At
BGU the threshold concept is applied: a cutoff point
is established at close to the 60th percentile. Again,
the actual individual test score plays no further role
in selection.
IMPLEMENTATION
Having made these decisions in principle, we were
then faced with the difficult task of translating them
into concrete practice. How were we to select a class
of 50. plus an adequate waiting list, from among the
1,000 to 1,200 applicants? A four-stage procedure
was evolved. Over the decade, a variety of details
have been modified, but the procedure has remained
essentially the same.
Application
The great majority of Israeli young women and men
enter army service for 2 and 3 years, respectively,
upon graduation from secondary school al about age
18. Thus most candidates are at least 20 (or older, for
those who have served as officers), having had a
highly significant, maturing life experience. In order
to apply, those who have not served (largely religious
women, most Israeli Arabs and some disabled per
sons) must also be at least 20 years of age. The age
requirement does not hold true for the one-fifth of the
class accepted in the army reserves, who serve as
medical officers for 5 years after graduation.
The threshold concept is applied to the use of
secondary school grades. Israeli high school
students all lake national matriculation
Noncognilive factors
I he roughly 40^ who have passed the second stage
are then invited to a personal interview. This
interview attempts to assess the extent to which the
candidate’s personality, valuesand life behavior are
indeed expressive of the sought-after qualities. The
interviewers only know that the candidate has
passed the two threshold points of matriculation
grades and test scores. They have available to them
letters of recommendation and an autobiographical
account, which are used as tools in conducting the
interview. In its initial consideration of how these
are to be assessed, the Admissions Committee
discussed a wide variety of alternatives: personality
tests, group interviews, experimental situations, etc.
All were rejected in favor of the personal interview,
conducted by a team of two members of the
Admissions Committee.
Those candidates who receive high evaluations in
the first interview are invited to a second interview,
conducted by another team in very much the same
manner as the first. “High” is defined as
approximately that evaluation achieved by about
359? of the candidates.
Final selection
Candidates are presented at a final session of the
entire Admissions Committee according to the order
of the sum of their four interview assessments. All
1391
r
A. Antonovsky
Israel J. Med Sci
data in the candidate’s file are available at this point.
Discussion generally centers on those who have not
received very high evaluations, particularly when
one of the four interviewers is unenthusiastic.
Preference is for making beta errors, i.e., mistakenly
rejecting the hypothesis that a candidate is good,
rather than accepting false positives. (Interestingly
enough, this mode of thought is at variance with the
usual medical screening mode, which prefers
inclusion of cases that later turn out to be
nondiseased.) In this manner, places are offered to
50 applicants, and a ranked list of about 20 reserve
applicants is prepared. The summed data for the
selection process, 1974-83, are presented in Table 1.
It is clear, then, that for those candidates passing
the hurdle of the generous thresholds of gradesand
scores, the personal interview is the cardinal tool of
student selection at BGU. We now turn to this issue.
THE INTERVIEW
Few issues in medical education have generated as
much heat, from opponentsand proponents alike, as
the use of the interview in student selection, even
when used as an adjunct tool. Unfortunately, heat
has seldom been transformed into light. The core of
the problem, in our view, is that “the interview” is so
global a concept as to make its evaluation im
possible. It ranges from a 5-minute encounter
between an applicant and a busy professor, totally
unprepared, called from his lab or clinic—to what
we believe is serious, reliable and valid interactidn
appropriate to its intended purpose. In our view, the
BGU procedure comes reasonably close to being
such, and should be evaluated in its own terms,
rather than being blanketed with everything else
called an interview. We have identified a number of
crucial issues which, we believe, are decisixe in
making the interview a powerful tool and warrant ns
use.
Who interviews?
Many highly competent researchers are incapable of
establishing the essential rapport with a young
woman or man that would allow drawing out and
fair evaluation. Good clinicians and teachers should
Table 1. From application through selection, 1974-83
No. of applicants
Registration approved,
took psychometric
exam
I 'irst interview
Second interview
Selected
9,78 r
7,833 (80.1% of applicants)
3,455 (44.1% of those taking exam)
1,127 (36.3% of Interview If
408 (36.2% of Interview II)b'
* Range of annual number of applicants from 719 to 1,201.
Data exclude 1974, when only one interview was conducted.
b
be better at it, but this is not always the case. We
have sought those persons, in and outside the
faculty, who a priori have the potential of being good
interviewers. We have, moreover, made it clear that
dedication and commitment, both to the task at
hand and to the specific values of the school, are
essential prerequisites. In order to realize potential,
however, skill training is essential. Long before the
interview period, many hours are put into evaluating
past performance, role playing, exchange of
techniques, etc. When the interviews start, new
committee members are always paired with
veterans.
Whatever the training, we each remain with our
individual preferences and biases. These are
somewhat muted in the course of committee
member interaction, as a common language is
hammered out in the pre-interview discussions.
Perhaps not surprisingly, given the character of the
school, the most dangeous possibility created by use
of (he interview—its use to discriminate against
minorities, including those who have not followed
the straight and narrow path of conformity—has
never been a problem at BGU. If anything, we have
leaned over backwards. Thus the proportion of
women and ethnic minorities selected has invariably
been a bit higher than these groups constituted of the
applicant population (and, with respect to the
latter, considerably higher than the proportion who
pass the “objective” tests). The atmosphere created
in the committee is such that the member who
evinced bias against an Israeli Arab, ora woman, or
a candidate with a given political or religious
persuasion would be subject to severe pressure. We
remain with our individual preferences: X is
impressed by the candidate who plays music, Y by
the army combat officer, and Z by the one who has
made it despite a broken home. The saving grace is
that four positive evaluations are required for
selection. Thus it is the collective, institutionalized
process which more than offsets the fallacies of
individual judgment. The collective can, of course,
and has been wrong. But the chances are fewer when
four evaluations constitute the picture, particularly
given the often obstreperous independence of most
committee members.
Structure of the interview
Each interview follows its individual course, taking
off from an issue raised in the interviewer’s mind by
the autobiographical form or by the written
response to three standard questions (on moral
dilemma, significant experience, major
achievement). Each interviewer develops, over time,
favorite questions (which are occasionally collated
[40]
Vol.. 23, Nos 9-10, Si.pti.mber-Octobfr 1987
Ml DK Al SniDl NTSri K'TION
and distributed to the committee). Each team
develops its own pattern of taking turns, but we are
all guided by commonalities. Above all, we seek to
be aware of the trap of the smooth talker, the
charmer. No less a trap is falling for the response to
one issue which creates enthusiasm, but is not
corroborated on probing. We focus on deeds, on life
experiences, and not on the right words. (Woe to the
candidate who is dying to be a primary care
practitioner in a development town, but who has
never gone out of his or her way to do something for
anyone or to know anything about people in other
social classes or ethnic groups than his own.) From
discussion of nonmedical issues, we move slowly to
motivations for medicine. (The reader should recall
that very often, in Israel, candidates have a “my son
the doctor” background, though often reference is
to an Arab father.) We shift, particularly for
promising candidates, from a relaxed to a more
stressful questioning. The interview, never less than
35 minutes and averaging 50, is invariably concluded
by asking whether the candidate would like to add
anything we should know. Each of the two
interviewers then records a global evaluation and
evaluations on eight specific traits on a scale of 1 to 5
(in practice nine half-point ratings).
These, then, are the characteristics of the BGU
interview. It is, we believe, as well-prepared and
well-applied a tool as possible, though we would be
the first to agree that it can be improved. Does it
work?
RELIABILITY AND VALIDITY
After the 1980 round of interviews, having
conducted almost 3,000 interviews, data analysis
produced the following results: 1) Without
exception, in each year intrateam agreement was far
beyond the P= 0.001 level. These are not, of course,
strictly independent ratings, both interviewers
having taken part in the same interview.
2) Evaluations in first and second interviews,
conducted by two different teams, were compared in
each of the 6 years with two interview rounds. Again,
in each year, the correlations went well beyond theP
= 0.001 level—this, despite the use in the second
interview of a small control group, and the relatively
narrow range of those passed on for a second
interview.
But perhaps the most telling evidence for the
reliability of the interviews was the comparison of
evaluations of 235 candidates who, rejected in 1 year
after having been interviewed, reapplied and were
reinterviewed. At most, the second team learns from
the candidate (recall that the record is not available)
that he or she has been interviewed previously and
not accepted. In this stringent test, the correlations
too are beyond the P = 0.001 level.
Reliabilty, of course, is but a prerequisite for
validity. Is there evidence for the validity of the BGU
selection process, at the heart of which is the
personal interview? Does it produce the kind of
medical student and physician we set out to
produce? Putting the question this way, of course,
makes it clear that, short of experimental
manipulation, there is no possible final answer, for
it suggests that the 6-year curricular and life
experience, and the medical practice setting, have no
impact on performance—an obvious absurdity.
Conceivably, one might ^argue that the same
curriculum, faculty/student relations, etc. would
produce the same results with students selected by
any procedure. We doubt it, but the reader will have
to judge for him/herself. Our contention would be
that personality and value variables are largely
shaped by the time of entry into medical school.
There is shaping, for better or for worse, during the 6
years, but it is not likely to be very profound.
But before turning to the question of validity, let
us consider a crucial issue—dropouts. Let us grant
for the moment that BGU indeed selects line,
humane men and women, oriented to community
medicine. But is this done at a cost of widespread
inability to do well by rigorous cognitive medical
school standards? After all. some 50 to 60% of our
students could not be accepted, by virtue of their
grades and test scores, in any of the other Israeli
medical schools. (The reader will simply have to
accept on trust that our cognitive standards
throughout the 6 years are as tough as elsewhere.)
Dropout data are presented in Table 2.
Of BGU’s first six classes, 22 students (8.9% of.
those admitted) will not be physicians. Another
8.9% took 7 years to complete their studies. But of
the former, nine withdrew of their own volition,
none of whom were in danger of failing and all of
whom went into different fields of study. Of the 22
who took 7 years to finish, almost half took a year
off voluntarily (to travel, to have a child, etc.).
Moreover, of the 13 who were clear academic
failures, 3 were accepted in full awareness that they
were academic risks. Analysis of the matriculation
grades and the psychometric test scores (the reader is
asked to recall that these contain a far wider spread
than in any other medical school) show that neither
failures, withdrawers nor repeaters have lower
scores than their peers.
If we disregard all these qualifications, and take
the most stringent measure, i.e., those not com
pleting medical school in 6 years, we reach a figure of
17.8%. This may be compared to the 15.5% of
[41]
A. Antonovsky
isRAi-i J. Med Sa
Table 2. Dropouts by class. 1974-79
No. of
Class
Students Completed
entered in 6 yr
Completed Voluntarily
in 7 yr
withdrew
1974
1975
1976
1977
I97K
1979
34
34
39
43
49
48
1
3
I
3
6
4
3
2
2
2
I
1
2
5
0
I
5
2
8.8
11.8
7.7
9.3
10.2
6.3
22
8.9
9
3.6
13
5.3
K.9
Total 247
9? 100.0
30
27
30
35
41
40
203
82.2
Failed
Percent
dropout1
Withdrew + failed.
dropouts only until 1966 at the medical school in
Jerusalem (1). The latest American data (2) show
that 11.4% of medical students in the 1970s were
dropouts or repeaters in 4 years alter having
completed 4 years of college. This most authoritative
study predicts a rise Io IS";, (I) Inlcicsiinplv
The BGU medical school selection procedure is a
tool, not a goal. Whatever investment, particularly
emotional, there has been. I believe that faculty
pressure would inevitably have swelled in protest
and cast it aside had not the great majority been
persuaded that it wojks This may happen in llic
enough, among its most .sinking proposals we lind
the following (3): “Determine the minimum
threshold of academic ability needed to succeed...
and then select students above that threshold on the
basis of personal qualities without regard to their
relative academic standing.” They recommend as
reasonable a 2.7 grade point average in contrast to
the much higher one in current use (4).
Are BGU students and graduates, then, a different
breed? By the very nature of the question, there can
be no hard, scientific answer. Other papers in this
volume, discussing the Graduate Program in primary
care, suggest as much. Many faculty members who
come to teach the students with much scepticism
about the admissions procedure have become
converts. The committee members are. of course,
largely enthusiastic about their choices (but also
occasionally rue their mistakes). Perhaps most
important of all. a self-image of BGU medical
students as being different has emerged. The most
consistent “complaint,” voiced with pride, of
graduates coming home to receive their MDs after
internships throughout the country, is that
department heads invariably expect more of them
than ol then peers Irom other schools. Coming
closest to any objective evaluation arc two sou ices of
reports. First, there have been several dozen visiting
professors from Israel and abroad, who uniformly
are enthusiastic, above all. about the attitudes,
values and behaviors of students. Second, in each
class, between the fifth and sixth years, exchange
programs bring BGU students to elective programs
abroad. Formal reports have consistently given the
same picture, while expressing satisfaction with
cognitive and instrumental competence.
luturc. As ol now. it docs not seem to be in the
offing. Hopefully, what other schoolscan learn from
our experience is that the “interview” is not magic,
what seems to work is a very carefully thoughtthrough procedure, using a very specifically
designed interview.
One final word should be said about cost. The
actual financial outlay is probably considerably less
than the most computerized procedure in existence.
No personnel have been hired to work on selection.
Secretarial duties have somehow been assumed by
personnel with other responsibilities. Roughly, an
annual total ol about 1.700 hours arc invested in
interviewing, committee training and discussions,
and the work of the committee chair throughout the
year. No financial compensation is made. For those
from other faculties, or from the community, it is a
labor of love. For those from the medical faculty,
there is some price in hours devoted to clinic or
research, though less than might be. for somehow it
is always the busiest people who find the time to
devote to selecting the coming generation of
physicians.
| 42)
Illi POWI R ()l rill MYTH
Myths nuiy.be grounded in objeetive reality, at least
in part. But to whatever extent this may be the case,
they have a motive power of their own. In our case,
there has come into being a widespread beliel among
faculty and students that, given our admissions
procedure, we select a different breed of students:
more humane and responsible, less individualistic
and competitive, more compassionate and con
cerned. more oriented to family medicine and
community care, and so on. when compared to most
Midicai Studi ni S11I C1ION
Vol 23, Nos 9-10, Slki i mblr-Octobir 1987
other Israeli medical students. I suggest that this
comes to be a self-fulfilling prophecy.
There are, of course, those who tend to the
extremes: the selected candidate who is really all that
Beer Sheva looks for and who will behave
accordingly, no matter where, and the one who turns
out to be a sad mistake. Havingacted superbly in the
interview, true colors come out as a student, no
matter what is done. But for the great majority, the
very labeling provides a push in the right direction.
For some, this tendency is already internalized, and
the myth reinforces it. For others, the myth
influences external behavior.
Given that the curriculum, which from the first
year brings the student into frequent contact with
patients in a wide variety of clinical settings, requires
group projects and sets up mechanisms for student
responsibility, the myth has institutionalized
channels through which to operate. It is put to the
test. Obviously, should the Admissions Committee
make too many mistakes or should, for some reason.
a class leadership come into being that dissipates the
myth, it will not last for long. But it is our sense that
what many students and faculty members refer to as
the “Beer Sheva spirit,” after more than a decade
(even if the reference to it is often to note that it is in
danger of being dissipated), expresses the myth
initiated by the admissions process.
1 wish to take this opportunity to thank Drs. Naomi
Meyerstein and Viola Torok, who succeeded me in
chairing the Admissions Committee, for so successfully
carrying on the traditions and values that my colleagues
built, while maintaining a fresh, healthy scepticism and
constant process of reexamination.
REFERENCES
1. Sarell M. Herl? DG and Prywcs M (1973). Success and fail
ure of Israel medical students, hr J Med Sei 9: 1064-1076.
2. Johnson DG (1983). “Physicians in the making.” Jossey
Bass. San Francisco, p 120.
3. Ibid, p 129.
4. Ibid, p 97.
Sir John Brotherstone
University of Edinburgh, Edinburgh, UK
Excerpts from his letter, June 1, 1982
“I had a number of discussions with your young graduates
and was most impressed. In a sense, their dilemma arises
from the very success of your programme. You have
instilled two significant ambitions into them which may
bring a kind of internal conflict for them.
On the one hand you have succeeded in giving them a
sense of the needs of their communities and their responsi
bility to help to meet these needs. I felt that you have
achieved this more effectively than anywhere else I have
encountered. In this your project has been very successful.
But on the other hand you have also instilled into them
an ambition to practice medicine at the highest level ol
quality of which they are capable.”
f431
TEACHER TRAINING AND FACULTY DEVELOPMENT IN
MEDICAL EDUCATION
DAN E. BENOR and SOPHIA MAHLER
Curriculum Unit, University Center for Health Sciences and Services, Ben-Gurion University of the Negev, Beer
Sheva, Israel
Isr J Med Sci 23 : 976-982, 1987
Key words: Beer Sheva Experiment; medical education; teacher training; multiphasic program; group
dynamics; self-learning
Teacher training is gradually becoming prevalent in
medical education. A variety of training methods is
used, ranging from independent competency-based
modules (1) to systematic didactic courses (2). The
prevalent method, however, which is also the most
recommended one for in-service teacher education,
is still the short training workshop (3, 4). Some
evidence suggests that even a rather short workshop
improves the quality of instruction, probably by
increasing the teacher’s self-confidence (5). Never
theless, almost no long-term and wide-range evalua
tions have been made of the effectiveness of the
various training methods and the duration of their
effect. Teacher training thus remains the province of
each institution, which develops its own program,
often based upon beliefs rather than on facts, and on
contingency rather than needs.
The following is a description of a multiphasic
teacher-training program that has been imple
mented by the University Center for Health Sciences
and Services, Ben-Gurion University of the Negev,
(BGU) during the past 5 years. The program is based
on the assumptions that different teachers have dif
ferent needs and expectations, that no single format
can meet all these needs, and that training in didac
tics and in instructional methods should be preceded
by attitudinal change. The program acknowledges
the great variability in teachers’ abilities, competen
cies, needs and wishes. It also reflects the concept
that training should be stepwise, gradually progres
sing towards mastery through repeated reinforceAddress for correspondence: Dr. D. E. Benor, Currriculum Unit,
University Center for Health Sciences and Services, Ben-Gurion
University of the Negev, FOB 653, 84105 Beer Sheva.
ment. Further, the numbers and characteristics of
the participants are presented; and finally, the pro
gram is evaluated by two independent methods that
relate to personal growth on the one hand and
faculty development on the other.
THE TRAINING PROGRAM
The program includes three phases, and an addi
tional fourth phase is planned for the near future.
The first phase aims at enhancing the identification
of the individual teacher with the institution, its
philosophy and its educational approaches (6, 7).
This phase thus appeals to the attitudinal domain.
The second phase introduces the teacher to the
educational language, concepts and methods. In
addition to the acquisition of this generic knowl
edge, an attempt is made in this phase to develop the
participants’ self-acceptance as teachers, rather than
as professionals who are obliged to teach. It is
assumed that this role/profession conflict (8) is more
pronounced in medical teachers than in other aca
demic teachers because of their strong professional
identity, service orientation and partial detachment
from the academic, scholastic environment of the
general university. The second phase thus addresses
both the cognitive and attitudinal domains. It does
not, however, provide the teacher with specific skills
for instruction. These are acquired in the third
phase, which offers a variety of specific workshops,
each designed to improve a specific instructional
skill. The third phase thus refers mainly to the psy
chomotor domain and capitalizes on both the occur
rence of attitudinal change and the acquisition of the
knowledge base achieved in the former phases (9).
The fourth phase has not yet started. It will aim to
[44]
Vol 23. Nos 9-10, Si pi i mdi r Oc iobi r 19x7
I I A( III R I RAININC, AND I A( l:l n |)l VI I DPMI Nl
combine all three domains, the cognitive, attitudinal
and psychomotor. The teacher will be expected to
acquire additional detailed educational knowledge,
to further develop instructional abilities and skills,
to train other teachers and to conduct research, as
well as to develop a new self-perception as a future
educational leader.
The four phases may also be illustrated in a differ
ent way: the first phase presents the framework
within which the teacher will perform. The second
phase introduces the teacher to a set of educational
building blocks” and teaches him or her the rules
by which these blocks may be interlocked to form
constructions. The third phase enables the teacher to
use the blocks to construct his/her own structure
within the framework. The fourth phase develops
the ability to create frameworksand to modify them.
A description of the workshops in the program
follows. Fig. 1 summarizes the program and illus
trates its muhiphasic structure.
The first phase
The first phase is a 2-day Orientation Workshop. The
participants are 10 to 15 faculty members of varying
backgrounds, experience and seniority from various
clinical and scientific disciplines. Most of them are
new to the faculty. The workshop is based on small
group activity. Each group of four to six participants
tries to identify health needs and to delineate in
rough outlines an ideal medical school that may
meet these needs. This imaginary scheme is then
confronted with the BGU philosophy,history, struc
ture and curriculum. Within this framework infor
mation is provided on the various facets of the
medical school’s life, including open discussions
with the Dean, senior faculty membersand students.
The expected outcome of the workshop is a ttitudi nal
change. The teacher finds out that the institutional
objectives are not arbitrary, and that the curriculum
indeed stems from defined objectives and meets real
needs. Moreover, the novice teachers discover that
many of their own ideas and suggestions are incor
porated into the curriculum, and that their further
involvement is sincerely welcomed. The educational
approach of the school is thus no longer perceived as
capricious innovation for its own sake, but rather as
an understandable solution to well-defined prob
lems. Participation in this phase is a prerequisite for
academic promotion.
The second phase
The second phase is an intensive 3-day workshop
entitled Basic Instructional Skills. The second phase
also hosts a multidisciplinary assemblage of
teachers, working in small groups, as is the case in.
the first phase. The workshop is modularly struc-
Phase 1ORIENTATION
Phase 2=
ACQUISITION OF BASIC
INSTRUCTIONAL SKILLS
Phase 3STRENGTHENING OF
SPECIFIC INSTRUC
TIONAL SKILLS
'preceptor?
for early
clinical
\prograny
/'leaching'1
physical
diagnosis
I couaw*i(ic
Phase 4:
PREPARING EDUCATIONAL
LEADERSHIP
writing ’
tesl items
/preparing^
[audio-visual
\ teaching >
\ aids /
technical instructional!
L_ ,_sk Ils_____J
/lulorinq\
[self-learning]
\ groups j
/leaching b/
high-level
questioning
general didactic |
skills
L,____ -Skilly
J
'educalional'
lheories 8r
< research^
Fig. I. A muhiphasic leacher-
iraining model.
145]
j
i?
D. E. Benor andS. Mahler
Israei J. Med Sci
tured. Each module includes a written or audiovisu
al simulation related to a single concept. This
triggers small-group activity in which participants
both accomplish a structured task and create their
own solution to a problem. The group work i\ fol
lowed by a plenary discussion and is summarized by
a short lecture. The concepts that are covered
include formulating instructional objectives, select
ing appropriate instructional methods, defining sub
ject matter for learning, and selecting appropriate
student evaluation procedures. These modules,
when organized in sequence, comprise a systematic
approach to instruction, both on the macro level of
curriculum design and on the micro level of the
instructional unit (10).
The module devoted to instructional objectives
illustrates the process. The group starts by roughly
delineating a multidisciplinary course of its choice,
and then elaborates on its objectives. The product is
presented to the plenary for feedback, which is sum
marized by a short lecture on purpose, use and for
mulation of objectives. On this basis, the group then
reformulates a given set of improperly stated objec
tives, which are also scrutinized later in the plenary.
A summary discussion on the interplay between
objectives, method, subject matter and evaluation
summarizes the module. The rephrased objectives
will later serve the group for selecting instructional
methods and evaluation measures. At the end of the
second phase each teacher is expected to be able to
identify his or her own needs and interests to be
addressed in the third phase.
The third phase
The third phase offers four different workshops of 3
to 4 days each. The first one is entitled High-Level
Questioning. It aims to improve instructional
havior in two respects: The first is to replace the
traditional lecturing modality by a pattern that elic
its students’ self-initiated verbalization (11). The
second is to both use and stimulate the students to
use the highest possible cognitive level in their verbal
exchange (12). The workshop hosts 8 to 10 partici
pants During the first day. ihcy practice intensively
I he skills ol idenlil vmg cognitive levels ol given qties
lions using Bloom’s taxonomy (13). raising lowci
levels to higher ones by reformulating given ques
tions, and composing new questions on various lev
els. During the following 3 days, each participant
presents a 15-minute lesson each day to his peers.
The teachers are encouraged to use the same content
area and the same method they use in their real-life
teaching. On termination of the presentation, the
group provides feedback to the presenter, specifi
cally relating to his or her success in stimulating
student discussion by proper questioning. Following
this, the presenter leaves the group for 30 minutes of
private review of his videotaped performance with
an educationalist. On the last day, all three daily
performances are reviewed, enabling the teachers to
evaluate their progress. This microteaching tech
nique has long been adopted and proven effective in
teacher training in general education (14).
The second workshop in this phase prepares
tutors for self-learning problem-based instruction
(15). The expected behavior of a tutor requires a
major departure from the traditional teaching palterns. Unlike a teacher, the tutor is neither the source
of information nor the leader of the learners (16).
This situation is threatening to many teachers and
requires aggressive behavior-modification training
methods in order to achieve behavioral change
within 3 days, lor this purpose, both group dynam
ics and microteaching techniques are used. The 8 to
10 participants, representing various disciplines, act
out, in turn, all of the following roles: as a learner in
a group, solving an unknown problem taken from a
discipline other than his or her own: as a tutor to the
peer group, which studies a problem; as a member in
the group, which provides feedback to the acting
tutor on his performance immediately after the
learning session; as a moderator of the peer group,
which provides this feedback, both directing the
discussion and protecting the feelings of the acting
tutor; and finally, as a personal instructor to the ■
acting tutor, either in private or in front of the group,
helping him to gain insight into his performance.
Each participant also has an opportunity to discuss
his own performance in private with an educational
ist while reviewing the videotaped tutorial. 11 may be
noticed that the workshop oscillates between hereand-now and there-and-then, as well as between the
processes of learning new subject matter, learning
how to tutor, and training another tutor. This “mul
tiple layering” considerably increases the vigor of
the workshop. It is hoped that the requirement to
apply the nondirective, nonimposing mode of
instruction to so many different situations may
increase the transferability of the newly acquired
skill to ival lilc educational activities.
The thud workshop ollercd in the third phase
develops the skill of writing test items. This 3-day
workshop hosts up to 20 teachers, preferably from a
few disciplines. It is structured in modules, each
devoted to a different aspect of evaluation, such as
various formats of test items, their cognitive level
and the mental processes that are actually evaluated
by the item. Other issues addressed are scoring, item
analysis, reliability and validity. Each module in
cludes a short presentation, a group exercise on
[46]
Vol . 23, Nos 9-10, Si pii mui r-Octobi r 1987
Ti achfr Training and Faculty Development
elsewhere (22, 23). It included monitoring of both
the lesson time spent by teachers’ talk compared
with the time students spoke, and the kind of verbali
zation (self-initiated, responses to questions, asking
questions), as well as its cognitive level. The combi
nation of these parameters indicates the extent of
problem-solving activity in the class in contrast to
passive acceptance of factual knowledge. The shift in
teachers’ behavior following the training reflects the
achievements of its goals.
EVALUATION OF THE TRAINING
The results of such repeated observations on 60
The above-mentioned lack of systematic, quantita
teachers
for 500 days reveal a most significant
tive assessment of the effectiveness of teacher
change
in
teachers’ performance. The data, which
training programs is due to several factors. The most
are
presented
elsewhere (22, 23), show that the
important of these is the lack of clear objectives for
activation
of
students
both increased and was sus
the training, which stems from lack of criteria for
tained
at
the
new,
high
level
for the entire 2academic
good teaching (17). Still another hindrance is the
years
of
observations,
indicating
establishment of
large number of confounding variables that arise
new
instructional
patterns.
The
cognitive
level was
during a longitudinal follow-up of training, such as
also
significantly
raised,
but
the
new
level
was
main
changes in the teachers’ status and seniority or in the
tained
only
for
1
year,
indicating
a
need
for
rein
curriculum, instructional methods, class size and the
forcement
at
this
time.
like. Nevertheless, three major evaluation ap
The authors wish-to suggest an additional, nonproaches are used. It should be noted that these are
conventional approach to assessment of teacher
in addition to the participants’ end-of-workshop
training. This is based upon the changes in teachers’
questionnaires, which invariably reflect a high
educational
responsibilities following the training.
degree of satisfaction and can hardly be considered
For this purpose, a role of “educational leader” has
an evaluation. The first approach is a pre-post test
been defined by meeting any two of the following
ing, usually written before and immediately after the
three criteria: 1) The teacher is also a coordinator of
training, followed by a retest after a period of time
a major course, providing guidance to a number of
(17, 18). Such evaluation may reveal only the cogni
other teachers. 2) The teacher has developed an
tive component of the training. It does not reveal
educational innovation which may be an instrucactual teacher behavior and says little about his or
her attitudes. Pre-post testing is thus used in BGU • tional method, evaluation instrument, integrative
course, etc. 3) The teacher assumes an active role in
for training rather than for evaluation purposes,
and contributes to one of the educational decision
and, therefore, it is anonymous.
making committees or task forces. This approach
The second approach to evaluation of training is
thus relates to the outcome of training on an institu
based upon students’ questionnaires relating to
tional rather than an individual level.
posttraining teacher performance (19). The strength
Using these criteria. 128 educational leaders were
of this approach is that it relates directly to perfor
identified during the screened period of 1980-85.
mance, yet it may bear a price in the teacher-student
Thirty of these assumed their roles during the early,
relationship. It was also shown at BGU that inter
formative years of the school and were defined as the
nalization and implementation of nondirective tu
“founding fathers.” Fifteen additional teachers were
toring or questioning skills taught in the workshops
hired specifically for educational tasks, which means
sometimes received negative response from students
that they possessed the leadership qualities before
who were not prepared for the abrupt change in the
joining the faculty. Of the remaining 83. 21 teachers
instructional method (20).
(25.39?) undertook their educational responsibilities
The third approach to evaluating the outcomes of
teacher training utilizes direct observations of per shortly after the training. It may be said that they
were discovered in the workshops. Table 2 summar
formance, either live or videotaped (17, 18. 21). Dif
izes the faculty development aspect of teacher train
ferent authors, however, recommend different
ing at BGU.
criteria for the observations. The teachers’ behavior,
It is not suggested that the training allots leader
which was monitored in BGU for assessment of
ship qualities to individuals. It is more probable that
training, relates to some of the objectives of the
training specified earlier, namely: activation of stu existing creativity, instructional competencies and
administrative abilities were channeled to educa
dents and raising the cognitive level of the lesson.
tional avenues by the training. Such “discovered”
The method of observation is described in detail
gatory first one. This may indicate a real need, keen
interest, and a good reputation of the program.
Tabic 1 shows a small group of teachers who
completed all phases of training. These form the
nucleus of the future educational leadership of
(BGU). The fourth phase of the program, mentioned
earlier, will begin when their number reaches a criti
cal mass, hopefully in the near future.
[47]
D. I:. Bi nor and S. Maui i r
ISRAI I .1. Mi d Sci
given material, a plenary discussion composing test
items and a summary lecture. Nonconventional eval
uation instruments are briefly described, and crite
ria for selecting a particular instrument are both
discussed and practiced.
The third phase also offers a workshop for precep
tors instructing first and second-year students in the
early clinical program. This course-specific 4-day
workshop is devoted primarily to the teaching of
communication skills. The training methods include
a number of role-playing sessions followed by group
discussions in which the “patient” and the “inter
viewing student” may reveal their feelings and
expectations from the “preceptor,” while the ob
servers may provide more objective feedback. Role
playing sessions with real students are interwoven
into the workshop. Also, an overview of the entire
early clinical program enables each preceptor to
regard his or her part in the teaching in a wider
context.
f inally, the third phase includes a number olT/r/
hoc miniworkshops of one or two sessions each on
specific issues, such as teaching physical diagnosis,
tutoring students who follow upa family, improving
communication skills of family practice residents,
etc. These miniworkshops are set up in response to
an expressed need of a group of teachers. In a sense,
those extracurricular workshops are boosters that
reinforce previously acquired skills.
The fourth phase has not yet started and will not
be discussed here apart from mentioning that it aims
at a small selected group of teachers who have been
through all previous phases. They will be trained to
become future educational leaders in the fields of
curriculum design and management, educational
research and teacher training.
RANGE OF PARTICIPATION
All workshops are offered several times each year.
The attendance is voluntary, except for the orienta
tion phase which is conditional for promotion. Par
ticipation is usually self-initiated. However, teachers
may be recommended for training by chiefs of ser
vices, heads of departments or course coordinators
on the basis of observed need to improve perfor
mance. In both cases, the teacher may take part in a
workshop only if his or her service obligations per
mit it. In spite of this restriction, 304 faculty
members have taken part 470 times in workshops
during the 5 academic years between 1980 and 1985.
This figure constitutes 62% of the 490 scientists,
physicians and allied professionals who held faculty
appointments at any time during this period.
Table 1 presents the background of the partici
pants and the attended phases. The table reveals a
high participation rate in disciplines that are not
traditionally found in the front line of medical edu
cation. BGU philosophy may, perhaps, account for
the high involvement of allied professionals (in
cluded in Tabic I under “Others”) and of family
practitioners. It does not explain, however, the fre
quent participation of basic science teachers and of
surgeons. Further, the data indicate higher partici
pation in the voluntary third phase than in the obli-
Table 1. Participation in teacher training program
Rank of participants
No. of workshops attended
Discipline
Senior
Internal
medicine
8
Surgery
Pediatrics
Inter
mediate
Phase3
Junior
1
2
3
^4
Isl
2nd
3rd
21
18
29
14
3
I
17
9
45
5
18
31
31
18
3
2
25
20
39
2
13
22
32
4
15
8
20
ObstetricsGynecology
3
17
15
4
I
9
7
10
Psychiatry
I
4
21
18
5
3
15
15
7
medicine
2
7
15
11
7
I
5
4
10
35
Basic
sciences
4
16
24
17
16
7
4
22
23
42
Others
6
II
35
35
15
1
15
13
45
Total
28
93
183
188
83
20
122
105
243
I'amily
13
3 Isl phase is Orientation: 2nd is Basic Instructional Skills, and 3rd is High-Level Questioning.
|48|
1
Voi 21. Nos •) I(|. Si pji miii k ()< loin i< |<)K7
11 a< in i< I kainini. ani» I a( hi iy Di vi iopmi ni
Xablc 2 E<^tional leaders “discovered” in the teacher-training workshops
Number of educational leaders
Discipline
Excluding
founders
Discovered
in workshops
Discovercd in workshops
Total
9?' of total
% of new
Internal medicine
Surgery
Pediatrics
Obstetrics-Gynecology
Psychiatry
Family medicine
Basic sciences
Others
Total
31
17
15
7
7
13
26
12
128
22
13
13
6
3
10
10
6
83
6
3
1
1
I
6
2
I
21
19.4
17.6
6.7
14.3
14.3
46.2
7.7
8.3
16.4
27.3
23.1
7.7
16.7
33.3
60.0
20.0
16.7
25.3
educational leaders were drawn mostly from junior
and intermediate ranking staff rather than senior
members, suggesting that perhaps junior teachers,
including residents, are underestimated in medical
education.
SUMMARY AND CONCLUSIONS
Many components of the described teacher-training
program arc implemented elsewhere (2, 4, 6, 8, 16);
however, two features of the BGU program, when
combined, make it unique. One is the timewise hier
archical structure, which enables gradual acquisi
tion of instructional skills, progressing from generic
to specific (9) and from curricular generalities to
particulars of a course and of a lesson. The teacher
him/herself determines the pacing. Opportunities to
implement already acquired skills precede the devel
opment of additional ones. Moreover, the program
acknowledges individual differences, and thus offers
a variety of themes and training methods to fit per
sonal needs and expectations.
The second feature is the emphasis placed through
out the program on the motivational aspects. Indeed,
the term training ’ becomes alien to the program. Its
very essence is to create personal involvement of every
trainee on both emotional and practical levels. The
individual is guided to become a member in a multidis
ciplinary team, working together towards an under
standable and worthwhile cause. The involvement of
the teachers is encouraged and welcomed. When this
feeling is combined with the realization that educa
tion is a discipline in its own right, a feeling of
belonging to both the institution and to the teaching
profession arises. Such feelings might well be a pre
requisite for any educational innovation (7). The
high proportion of educational leaders who emerged
from the program illustrates these two features. Per
sonal growth and institutional development are
intertwined.
The BGU training program has been rigorously
evaluated and has proven to be effective. However,
continuous assessment must be instituted and main|49]
tained. Such formative evaluation may also meet the
requirement of an ongoing on-the-job reinforcement
(17). Nevertheless, BGU cannot yet afford further
expansion of the program—this will have to wait for
the graduation of the fourth-phase trainees.
REFERENCES
I
Cooper JM. Weber WA and Johnson CF. (1973). A system
approach to program design, in: “Competency based
teacher education 2.” McCutchan Publications. CA.
2. Schaeler R (1970). Teacher education in the United States,
in: Yates A (Ed). “Current problems of teacher education."
UNESCO. Hamburg.
3. Guilbert JJ (1977). “Educational handbook for health per
sonnel." WHO. Geneva.
4. Bland CJ (1980). “Faculty development through work
shops.” C.C. Thomas, Springfield. IL.
5. Greenberg I.W. Goldberg RM and Jewett I.S( 1984). Teach
ing in the clinical setting: factors influencing residents’
perceptions, confidence and behavior. Med Educ 18: 360365.
6. < ole ( C Jr. (1982). Improving instruction: issues and alter
natives lor higher education (Monograph). American
Association for Higher Education.
7. Shulmann LS (1979). Research on teaching: the missing link
in curriculum implementation, in: Tamir P. Bloom A. Hol
stein A and Sabar N (Eds). “Curriculum implementation
and its relationship to curriculum development in science.”
1 he Hebrew University ol Jerusalem. Jerusalem.
K. Bazuin CH and Yonke AM (1978). Improvement of teach
ing skills in a clinical setting. .7 Med Educ 53: 377-382.
9. Segall AJ (1980). Generic and specific competence in medi
cal education and health care. MedEduc 14 (suppl.): 19-22.
10. Segall A J. Vanderschmidt H. Burgland R and Froslman T
(1975). “Systematic course design." John Wiley & Sons.
New York.
11. Flanders NA (1970). “Analyzing teacher behavior.” Addison-Wesley. Reading, MA.
12. Hunkins PP (1972). “Questioning strategies and tech
niques.” Allyn & Bacon. Boston.
13. Bloom BS. 1 ngclhart MD. Hill WII. ITust F.l and Krathwohl DR (1956). “ laxonomy ol educational objectives.”
David McKay. New York.
14. Allen DW and Ryan K (1969). “Microteaching." AddisonWesley. Palo Alto. CA.
15. Schmidt HG (1984). Introduction, in: Schmidt HG and De
Voider (Eds). “Tutorials in problem-based learning.” Van
Gorcum. Assen. Netherlands.
16. Barrows IIS. Tamblyn R and Jenkins M (1976). Preparing
faculty for innovative educational roles. .7 Med Educ 51
592-594.
‘ '
17. Rezler AG (1973). Suggested scheme of evaluation for
health personnel teacher-training programmes. Document
HMD 73.41. WHO. Geneva.
IX. Sheets KJ anti Henry RC (1984). Assessing the impact ol
laulty development programs in medical education. .7 Med
Educ 59: 746-748.
JU^a
»
Hi. Bi M)K \M» s M Mil I R
19.
20.
21
22
Israi I .1. Ml n Si
Calkins I V and Wakeford R (1983). Perception of instruc
tors and students of instructors’ role../ Med Educ 58: 967969.
Mahler S (1983). Raising cognitive level of medical school
teaching. PhD thesis. The Hebrew University of Jerusalem,
lei usalvm (m I lebrew).
(iall Ml> Dtiniiing B and Weathersby R (1967) "llighvi
cognitive t|ucstioning: minicoir.se 9.” Macmillan I ducalional Survey. New York.
Mahler S and Benor DI (1983) Changes in the ihvihm of
23.
24.
lessons following a teacher-training workshop in medio
education, in: Tamir P. Holstein A ami Ben-Perctz N'
(Fds). “Preservice and inservice training of sciena
teachers.” Balaban International Science Service'
Philadelphia.
Mahler S and Bcnoi DI (1984). Short and long term aflcc?
ol a tcachci-training workshop in medical school, l/tizhc
Educ 13: 265-273.
Sarason SB (1971).' 1 he culture ol the school and the prob
lem ol change.” Allyn A Bacon. Boston.
Robin F. Badgley
Consultant
WHO. Geneva
Symposium on the Regionalization of Health Services.
Israel. 1981
“The medical education programme at BeerSheva is built
upon the strong humanistic tradition of progressive facul
ties elsewhere. Upon brief encounter, it aspires to and
apparently achieves a modification in the career perspec
tives of its graduates. Its chances for success or failure lie
not so much within itself and its recruitment of an ideolog
ically passionate and committed staff, as in those matters
which are well beyond its control. These include: 1) the
inevitable changes through time in the composition of its
staff: 2) the prevailing medical division of labour accen
tuating specialist careers; and 3) the inability of a single
medical faculty to restructure the prevailing health system
in terms of establishing family doctor/specialist quotas (as
in the case in Canada or the UK) or providing equitable
financial career incentives. Beyond these, there is the
stigma that the ‘family doctor’ is a disabused career in the
eyes of the majority of Israel physicians(specialist/family
doctor ratio of about 3 or 4:1) with the exemplary Beer
Sheva medical education programme characterized by
physicians elsewhere in the nation as Israel’s ‘feldsher’
|medic) school.
Despite this invidious caricature, the Ben-Gurion Medi
cal School at Beer Sheva is the most strongly committed of
the nation’s four faculties to the concept of comprehensive
social medicine teaching. Indeed, this commitment is
believable and impressive, h is strongly reaffirmed by
senior clinicians and all levels ol medical students (first
through final years). In addition, this Faculty appears to
have been highly motivated by the passion of its academic
leader. Dr. Moshe Prywes, wholefl the Hebrew University
to set a new course of medical education in the Negev.
Forty percent of the graduating class are prepared to
spend a year of medical service in underserviced areas of
the Negev...”
[50]
*
w
■■ w»>-
STUDENT-FACULTY INTERACTIONS: A MODEL OF ACTIVE
STUDENT PARTICIPATION
YAAKOV HENKIN
Division of Internal Medicine. University Center for Health Sciences
and Services. Ben-Gurion University ol the
Negev. Beer Sheva. Israel
Isr J Med Sci 23: 983-986. 1987
Key words: Beer
participation
Sheva
Experiment;
student-faculty
“There will be no ‘you’ and ‘us’ at this school, only
‘we’.” This was the opening sentence at the Dean’s
first meeting with the students in July 1974 on the
occasion of the opening of the medical school, and at
many meetings since then. To prove this point, the
faculty’s founders set out to encourage student par
ticipation and input into the program and to create
an appropriately informal and collegial atmosphere.
Subsequently, during periods of crisis and tension in
student-faculty relations, the students sometimes
poked fun at this slogan and threw it back at the
faculty. Nevertheless, this Beer Sheva spirit has sur
vived, with slight modification, throughout the
school’s history.
Was this idea of student participation in the crea
tion of this new and experimental school part of the
school’s unique ideology or only a means of getting
better cooperation from the students? Most proba
bly it was a combination of both; but whatever the
reason, this framework deserves consideration and
analysis.
THEORY
“Student participation will evolve into a deeper,
more intellectual and more mature factor in the
shaping of social and academic systems of medical
educational institutions. One outcome which we are
already witnessing, of the campus rioting at the end
of the sixties, is a kind of sublimation of feelingsand
relationships within the teacher-student community,
where each group has discovered that it has a lot to
Address for correspondence: Dr. Y. Henkin. Division of Internal
Medicine. University Center for Health Sciences and Services,
Ben-Gurion University of the Negev. FOB 653.84105 Beer Sheva.
interactions:
active student
learn from each other. The main change will be to
give our students the feeling that the medical school S
also belongs to them and that they, equally, belong °
to it.”This paragraph, extracted from “A look to the f
future” (1), was written in 1972 by Dr. Moshe < o
«o
Prywes who, a year later, became the first Dean of £ “
o
o
o
the Ben-Gurion University Center for Health Scien- co
ces and
:
Services, and reflects the basic idea behind L
7
’ given
’
the role
to the students in this school.
§ 5 F 0 «J
> * co
In selecting students who would benefit most from
—•
. E Q) •‘2
the school s educational philosophy and program q <0 ?
£- £
<0
and who would implement its goals, more than 1,000 ° co O flQ
applicants for 50 available places are evaluated
annually not only by their academic achievements,
but also by their personality, valuesand intellectual
qualities. The Admissions Committee includes 10
faculty physicians and 10 laymen from the commu
nity (2).
tn
1 he main goal ol this system is to create an atmo
sphere in which the risks of innovation are accepted 0<2
by both teachersand students. From the moment the
students arrive at the medical school, they are
encouraged to participate in the planning, imple
mentation and evaluation of the curriculum. This
atmosphere contributes to the development of the
capacity to respond continuously to feedback, and
to monitor progress. The new cohorts of students do
not allow the program to stagnate but keep the
faculty integrated with regard to the institutional
goals. The students also acquire experience as con
structive critics, which they apply to their work in
various health settings. The students are not permit
ted to merely evaluate critically, but are required to
participate in designing corrective measures and
implementing them (3). The imposition of such
■
o
0^
e-
ISRAi I .1. Ml I) Sc
Y. ! Il NKIN
At the individual level, students may be involvec
in lhe tutoring of other students, in helping course
coordinators organize courses and even in set ting u[
and teaching courses themselves. These activities art
in accord with the students’ qualifications, and the
students in turn are paid. One good example of sue!
involvement is the first aid course given to first anc
second-year students, which from the outset wa?
planned and taught almost exclusively by studenb
who had served in the army as medic instructors.
Extracurricular activities, which involve boll
staff and students, include commencement celebra
tions (when the new class is welcomed), the farewcl
party for the graduating class of each academic yeai
and a joint Purim party with masks and costumes
responsibilities on the students from the start streng
thens their fueling of being an integral part of lhe
school.
The faculty pays the price of having students
intrude on its meetings, criticize its activities and
decisions, and disrupt the traditional barrier
between teacher and student. In return, it earns the
students’ cooperation and feedback in its innovative
and sometimes experimental programs. The stu
dents pay a price mainly by losing the valuable time
consumed by these activities, but profit by having
the opportunity to voice their opinions and sugges
tions and thereby influence the course of events.
They also obtain invaluable training in medical edu
cation, institutional operation and interpersonal
relationships early in their professional careers.
METHODS
The student-faculty interactions occur at three
levels—faculty, class and individual. At the faculty
level, students arc represented in most of the faculty
committees. These include the Faculty Council, the
Student Selection Committee, the Steering Commit
tee, the Curriculum Committee and the Regulations
Committee. The student representatives are chosen
by the local medical students’ union, to which they
also report. The students have no voting rights on
the committees, but their suggestions, questionsand
criticisms are usually taken seriously.
At the class level, students participate in two types
of activities. The first is via representation on the
coordinating committees for each year, which are
responsible for planning, coordinating and evaluat
ing the program of studies for each class, as well as
for mediating between the studentsand faculty when
problems arise. The student representatives partici
pate in the bimonthly meetings, report to the com
mittee on problems arising in their class, help the
committee find solutions to the problemsand report
back to the class on these activities. One of the senior
members of the committee serves as student advisor
to the class and is expected to help individual stu
dents solve academic or personal problems.
The second aclivilv al the class level, which is
inleii'.itc and adixalc. nloic *.liidi nls. r. lhe
participation al dcbiiehng meetings during and/oi
after every course. Al these meetings, the teachers,
students and representatives of the Curriculum
Development Unit and the coordinating committees
for each year evaluate the course and submit sugges
tions for improvement. These sessions are designed
to ensure the adequacy of the curriculum in meeting
the students’ learning needs. The students provide
feedback to the teachers on the basis of surveys
conducted among their peers.
iiioic
RESULTS
Evaluation of any new technique or educations
approach should be based, as far as possible, or
objective and unbiased data. To my knowledge, tin
subject has never been systematically analyzed ir
our institution, and I shall have to rely on my per
sonal impressions (both as an ex-student and pres
ently a staff member in lhe faculty) of lhe impact o
the above approach on the relations within th
faculty. 1 shall consider lhe first 13 years of th
faculty’s history in three phases.
1) The phase of “creation.” which encompassci
the first two or three classes throughout their 6 year
of medical school. This phase was responsible to
establishing the basic curricular goals and structure
and for establishing standards and norms of be hat
ior. Both staff and students were filled with excite
ment and naivety, despite the knowledge that the
were acting as guinea pigs in this new school. Mos
(though not all) were prepared for the consequence
and eager to prove themselves. There was an alnio
sphere of openness for change. As a result of thi
altitude and because lhe faculty was still small ani
intimate, the personal relations between student
and staff were warm and rather informal. Emphasi
was pul on staff accessibility, flexibility and respon
siveness to the needs of the students. There wen
several crises in these relations, which were exaccr
baled b\ adiiiinislialivc and udmalional enol
made by the lauully as well as by the great anxicl'
and insecurity exhibited by some of the students
Not all lhe staff members were happy with the powe;
and privileges that were given to lhe students, am
some claimed that too much emphasis was put oi
student evaluation of teachers and courses. Hou
ever, the general attitude remained one of optimisn
and Satisfaction.
2) An “intermediate phase,” which encompassci
the ensuing classes, was more problematic. Man1
|521
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k
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Voi 23, Nos. 9-10, St eh mber-October 1987
Student-Faculty I nter act ions
students enrolled in this school with high expecta
tions, alter having heard such glowing reports from
upper classmen. Unfortunately, several changes had
already occurred in the faculty: it had grown bigger
and less intimate, initial enthusiasm had decreased,
and bureaucratic procedures had been instituted. In
addition, a reshuffling in the administrative person
nel accompanied a change of altitude towards
faculty-student relationships. As the first classes
were graduating and embarking upon their new role
as physicians, the faculty could at last relax, result
ing in innovative fatigue. Furthermore, the students
themselves were of a new generation—less enthusi
astic for experiments, and less tolerant of change and
uncertainty. The students had developed a new con
cept of the faculty, with a clear differentiation
between the academic and administrative staff.
Relations with their teachers remained excellent and
unique. Faculty were regarded by and large as openminded, available with little formality or delay, and
ready to help those in need. However, the adminis
trative staff was viewed differently. Students now
felt as if the administrators had become more de
tached, formal, bureaucratic and inflexible. There
was frustration because of the feeling that despite
their participation in faculty committeesand activi
ties, the students’ influence on curricular changes
was limited (a feeling not always justified, in my
opinion). Logistics and academic mishaps were less
well tolerated. Although the students continued to
participate in all the faculty activities as before, an
atmosphere of mistrust developed. This atmosphere
differed in its intensity from class to class and tended
to improve as the students entered their clinical
yea rs.
3) A phase of “stabilization,” which is only now
beginning, is (he third and hopefully the longest
phase, hollowing the ups and downs of (he first
decade, a new equilibrium seems to be evolving. The
students have acquired more realistic expectations,
while the faculty has become more aware of the
students’ distress and f rustration and is making an
effort to rectify the situation. Some of the factors
that had earlier been a cause for tension, such as the
quality of teachers and courses, shortage of lecture
halls, student promotion regulations, and the char
acter of examinations, have been solved or
improved. The Beer Sheva spirit is still present,
though in a modified way, and neither students nor
faculty are ready to give it up and revert to the
pattern of student-faculty relationships of more tra
ditional medical schools.
DISCUSSION
Medical educators’ growing concern over the high
level of student stress has been accompanied by a
shift in their conceptualization of the problem. Stu
dent stress is increasingly seen as a problem resulting
from the individual’s interaction with the learning
environment and not as an indication of personal
deficiency (4).
Rogers, in a pessimistic article about today’s med
ical education (5), describes his dismay during a
session with a group of medical students in a school
where he was serving as a visiting professor.
“I told thcni (hat. alter overcoming my initial ter
rors. medical school has been an unadulterated,
intellectual joy and described how being treated as a
' colleague-in-learning by my faculty had rapidly
moved me toward adulthood... The message from
the students was simple and monotonous. They felt
they were being lectured to death. It was their view
that from 8 am to 6 pm every day. they sat passively
while faculty, whom they did not know and who did
not know them, spewed enormous volumes of facts
at them. There were blistering testimonials about
the poor quality of lectures, about the lack of faculty
interest in them as individuals, of dreary, neverend
ing series of quizzes, tests and other bracings, of
insufficient time for study, of the absence of per
sonal contact with the faculty, of school unre
sponsiveness to their needs or their complaints...
They vigorously denied that any real discussions
had taken place to explore (he root causes of the
problem.”
He suggests that most medical students nowadays
do not enjoy their studies in medical school, and
proposes his ideas on how to change the situation.
There is no doubt that the Beer Sheva medical
school has made a genuine and successful effort in
forming a unique pattern of the sludcnt-facully rela
tionship, which emphasizes support goals as well as
output goals (6). The students’ role in this relation
ship is one of active participation, in contrast to the
passive role given to students in most traditional
medical schools. However, several questions
remain: l)What effect does this pattern have on
student and staff satisfaction and involvement in the
medical school? 2) Does it influence the graduates’
quality as doctors? 3) Can this climate be maintained
in the long run, or will it fade as the faculty ages and
becomes well established? 4) What is the cost-benefit
balance in terms of student and faculty time, money
and expectations? 5) Can this model be copied and
adopted by other, more traditional faculties? 6) Will
the school’s graduates have sufficient commitment
and satisfaction to stay in Beer Sheva and perpetuate
the existing climate? I feel that these and other ques
tions are important and deserve to be studied.
153]
..
.*
.
..... ...Jam,
*■
Israel J. Med Sc
Y. Henkin
The author gratefully acknowledges all those who assisted
in the preparation of this manuscript, especially Dr. M.
Prywes, Dr. S. Glick and Mrs. M. Friedman for their
helpful remarks.
REFERENCES
1. Prywes M (1973). “A look to the future.” Br J Med Educ 6:
264-268.
2. Antonovsky A (1976). Case study: student selection in the
school of medicine, Ben-Gurion University of the Negei
Med Educ 19: 219-234.
3. Rotem A. Barnoon S and Prywes M (1985). Is integrationo
health services and manpower development possible? Th
Beer Sheva case study. Health Policy 5: 223-239.
4. Marshall RE (1978). Measuring the medical school leamin
environment. ./ Med Educ 53: 98-104.
5. Rogers DE( 1982). Some musings on medical education Th
Pharos of Alpha Omega Alpha. Spring 1982. vol. 45.;
11-14.
6. Gross E and Grambsch PV (1968). “University goalsan
academic power.” American Council on Higher Edua
lion. Washington D.C.
154]
i t
THE DEBRIEFING METHOD OF CURRICULUM EVALUATION*
"
•licul.iiis
whenever a
representatives oi the CuiiiciTiim ( o.niniiire t*»r
13 YEARS’ EXPERIENCE
nee (I i. I‘ is i
DAN E. BENOR* and SHIMON GLICK2
'Curriculum Unit, and ’Dean. University Center lor Health Sciences and Services. Ben-Gurion University of the
Negev. Beer Sheva. Israel
Zsr ./ Med Sei 23: 9K7-991. 1987
Key words: Beer Sheva Experiment: medical education: curriculum evaluation
The evaluation of teaching and learning processes
and curricular content is a generally accepted prac
tice (1). It is particularly important whenever a
change in the curriculum is considered oran innova
tive approach is implemented. This process of cur
ricular evaluation enables informed decisions to be
made concerning retention, modification or discon
tinuation of programs. Although ongoing evalua
tion is less critical in a relatively unchanging
curriculum, it may be useful to ensure early detec
tion of undesirable trends before they reach crisis
proportions. The most commonly used instruments
for curricular evaluation are questionnaire surveys
of either students or faculty (2) and results of the
students’ performance (3). Both methods have
serious shortcomings (2-5).
We report here more than a decade’s experience at
the University Center for Health Sciences and Servi
ces with a curricular evaluation tool that has proven
itself in ongoing field testing and has much to recom
mend it. The system, referred to as debriefing,
involves both students and faculty, and uses ques
tionnaire surveys, lace-to-lace studenl/laculty inter
actions, immediacy of feedback, and timely
application of conclusions for future courses.
THE METHOD
A standard debriefing session is held at the comple
tion of each course and sometimes after a major
segment in a given course, especially in the case of
major, semestral courses. There are thus about 150
debriefing sessions each academic year.
Address for correspondence: Dr. D. E. Benor. Curriculum Unit.
University Center for Health Sciences and Services. Ben-Gurion
University of the Negev. BOB 653. K4I05 Beer Sheva.
The participants in the session usually comprise:
I) a course coordinator, other key teachingstaffand
representatives of the Curriculum Committee for
that specific year; 2) student representatives,
appointed by their classmates at the beginning of the
course [these students have monitored the course,
have distributed a questionnaire (Appendix) among
their classmates and have discussed pertinent issues
formally and/or informally with their classmates];
and 3) vice dean in charge ol the curriculum, who is
responsible for planning, coordination and imple
mentation of the curriculum. When courses are in
the process of change, or when new courses are
evaluated for the first time, such sessions may also
include coordinators of both courses that are prere
quisites for the course being evaluated and of subse
quent courses for which the evaluated course
provides prerequisites. In the case of very short,
minor courses, the debriefing sessions may be shor
ter, less formal, and involve fewer participants.
The debrief ing session takes place within 2 weeks
of completion of the course in order to preserve
immediacy and a sense of relevance. The agenda lor
the meeting has been standardized and generally
follows the sequence described below: I) brief, over
all impressions by the course coordinator; 2) brief,
overall impressions by the students—based on the
questionnaire survey and informal feedback from
the students to their representatives; 3) detailed
screening of the questionnaire, item by item, and
discussion between faculty, students and course
coordinator in an attempt to reach conclusions; and
4) recommendations and decisions for future imple
mentation. The sessions generally last 1 to 2 hours,
in an open and friendly atmosphere. Minutes of the
session are published, distributed to the participants
(55]
D. I
til N<
ISRAI I .1 Ml l> S
/X NI > S Cil l( k
of the meeting, to other teachers ol the course and to
the Dean.
More than a thousand such sessions have been
held during the course ol the faculty's existence,anti
there is general agreement that in spite of the consid
erable amount of time demanded of both students
and faculty, the results are worthwhile. The response
rate of the students in filling out the questionnaire
has continued to be gratifying (about 80r< ). and the
teachers’ willingness to participate in the debriefings
has continued unabated.On the rare occasions when
time schedules force any delay in scheduling debrief
ing sessions, the outcry from students and faculty
attest to the importance attached to these sessions by
both.
i Although the basyc,(principles and structure have
remained unaltered, the curriculum al the school
undergoes constant change. Almost ail the changes
have been either a direct or indirect result of the
information and recommendations elicited by the
debriefing sessions. The minutes also provide a lon
gitudinal record of progress or regression in given
courses over the years.
DISCUSSION
The system has a number of advantages. Firstly, it is
ongoing and does not stem from difficulties or crisis
situations. By having sessions after every single
course and often after a segment of a course, “in
course” corrections can often be instituted imme
diately. This corrective action arrests possible
damage from a poor or ineffective course, and min
imizes student and faculty disaffection that might
otherwise fester and be aggravated over a long
period of lime.
Secondly, the program evaluation does not rely
solely on the written questionnaires, but supple
ments them by personal, infprmal data gathered by
student representatives and by face-to-face contact
with teachers, in the presence of the vice dean in
charge of curriculum. This kind of personal contact
provides deeper understanding of the precise nature
of the problems, permits debate and discussion in
order to avoid misunderstanding, and allows faculty
members to respond to criticisms and present their
point of view as well to the students. Nevertheless,
the face-to-face meeting with the individual student
does not reflect the personal views of randomly
chosen students, but is based on quantitative infor
mation gathered from the entire class. Thus, the
system combines the advantages of a class question
naire with that of individual student presentation,
while avoiding some of the pitfalls of each.
1 hirdly, the face-to-face meetings also allow for
faculty feedback to class representatives on student
performance and behavior, both cognitive and noit
cognitive. This give and lake is a healthy and con
structive phenomenon that cannot be achieved b
merely tabulating the results of a standard studen
questionnaire.
Fourthly, the students not only fill out a question
naire but are drawn into the process as active partict
pants. They are expected to gather information a
well as to inlcipicl it maturely and in a balance
manner, and to come forth with constructive suggis
lions. Since the class representatives arc appointee
specifically for evaluation of a particular course
most students have the opportunity to participaten
the process quite often. This reduces the dangert<
alienation and leads to a feeling of meaningful stu
dent participation. Furthermore, the students gait
understanding of the decision-making processesam
learn to appreciate the professional and educationa
considerations governing the curriculum. The'
acquire critical skills for understanding institutiona
operation, and they gain insight into objective con
straints, political obstacles and financial restric
lions. As they progress from year to year, thei:
suggestions become increasingly more feasible
Many of our young faculty members—graduateso
our school—have benefited greatly from their earlie:
experiences as student representatives at debriefini
sessions.
Finally, in addition to evaluation, the sessions ar
used for decision making, and operative decision
are often taken and implemented immediately
When an impasse is reached or when a problem ha
ramifications beyond the immediate course, th
group decides to present the problem to the ful
Curriculum Committee or to the Executive Commit '
tee of the faculty. However, some operative decisioi
is almost invariably reached, which is then brough
back to students and faculty. The policy of impk
menting suggestions from debriefing sessions give
this system a distinct advantage over most progran
evaluation procedures in current use (Ij.Oursysten
is thus judgmental rather than merely descriptive (6)
and fulfills the “classic” requirements for evaluatior
methods, which aim to imparl instruction (7).
In dealing with a face-to-face meeting, in whicl
students evaluate teaching, the potential exists fo:
serious misunderstandings and unpleasant con
frontation. All participants must come to the meet
ing with a degree of openness, a measure of civility
and an understanding of their own limitations and o:
the inherent limitations of the change process int
complicated and institutionalized system. Th
leader of the sessions plays a key role in directing
criticism constructively, preventing tempers froir
Haring and egos from being badly bruised. Faculty
156]
Vol 23. Nos 9-10. Si pii mbi r-Oc iobi r 1987
members learn that in the long run they benefit from
constructive criticism and learn to appreciate it. The
students develop a heightened sense of responsibility
and social consciousness towards their classmates
and teachers.
Because the danger of serious confrontation is
ever present—and our experience shows that con
frontational situations reduce teachers’ re
sponsiveness to student criticism—individual
evaluations ol specific teachers' performance have
been removed from the debriefing sessions. Teacher
performance is assessed on a continuous basis, using
separate student questionnaires. These, however,
are handed in individually, are not summarized or
analyzed by the student representatives, and reflect
individual, rather than group evaluation. This sepa
ration of teacher evaluation from course evaluation
has been distinctly beneficial.
Tor the success of the system it is essential that
both faculty and students feel that their suggestions
arc implemented and not merely filed in some
drawer to gather dust. Yet one must resist the temp
tation ofchanging courses every semester in a hasty
response to the passing whims of a particular class.
A balance must be struck between responding to
suggestions at debriefing sessions in order to pre
serve credibility and eternal fluctuation of a curricu
lar content. This delicate balance requires mutual
Di brii uno Mi l hod i or Curricui hm Evai uation
trust, open-mindedness and tact from both students
and faculty.
In summary, the debriefing session method of
program evaluation meets the six requisites of Mar
shall (4) for a positive learning environment: it ena
bles student interaction, preserves curricular goal
orientation, ensures a flexible rather than authori
tarian atmosphere, provides meaningful learning
experiences as well as favorable emotional climate,
and demonstrates nurluiancc anil support by the
institution.
REFERENCES
I. Neufeld VR. Woodward C. Van Bovcn C. Clarke R and
Segall A (1978). What are the new medical schools doing
about curriculum evaluation: an international perspective.
Annu Conf Res Med Educ 17: 449-459.
Rolem A and Cilasman NS (1979). On the elTcctiveness of
students' evaluative feedback to universilv instructors. Rev
Educ Res 49: 497-511.
3 Barta MB. Ahn |IR and Gaslrighl .11 (1976). Some prob
lems in interpreting rclcrcnced test results in a program
evaluation. SEE 2: 193-202.
4. Marshall RE (1978). Measuring the medical school learning
environment../ Med Educ 53: 98-104.
5. Coslin F. Greenough WT and Menger R.l (1971). Students'
ratings of college leaching reliability, validity and useful
ness. Rev Educ Res 41: 511-535.
6. Stake RE (1967). The countenance of educational evalu
ation. Teacher College Record. 68.
7. Cronbach L.l (1963). Course improvement through evalu
ation. Teacher College Record 64: 672-683.
157 I
■
MlWWMWli11'
>.
^..asaSiM;
D. E. Bl NOR AND S. G1 ICK
Israi i J. Mid &
APPENDIX
Date:
Course:
Year:------- Semester:
BEN-GURION UNIVERSITY
CENTER FOR HEALTH SCIENCES AND SERVICES
EVALUATION UNIT
STUDENT QUESTIONNAIRE
Please write next to each question the number that most closely represents your opinion. Use the following scale. Do not skip
questions. If not applicable, write 0.
1
NOT AT ALL
2
LITTLE OR
SOMETIMES
3
QUITE OR
USUALLY
4
VERY MUCH OR
ALMOST ALWAYS
1. WAS THE COURSE INTERESTING?
Following is a list of factors. Which one(s) influenced your interest or disinterest in the course? (Circle all the major factor*
A. QUALITY OF INSTRUCTION
E. OPPORTUNITIES TO APPLY LEARNED MATERIAL
B. INTFL1 F.CTUAI STIMULATION
F. REL ATION TOOTHER SIMULTANEOUSLY I E ARNED
C. IMPORTANCE OF THE SUBJECT
COURSES
D. SCHOOL’S OBJECTIVES & ATTITUDES
G. RELATION TO PREVIOUSLY LEARNED COURSES
2. HOW RELEVANT IS THE COURSE TO YO
3. DID YOU H
AND WHAT WAS EXPECTED FROM YOU, AT THE BEGINNING OF THE COURSE?
4. DID THE READING ASSIGN
------- 5. WAS THERE ENOUGH TIME FOR LEARNING?
6. WERE THE LECTURES BASED UPON
7. DID THE COURSE
Use the following key:
A. INAPPROPRIATE GUIDING QUESTIONS
B. TOO DIFFICULT
C. OUTDATED INFORMATION
D. REDUNDANT
UNIT NAME
8. INDICATE FAULTS IN THE HAND
FAULT
E. IRRELEVANT TO LEARNED MATI RIAL
F. UNCLEAR
9. WHAT WAS THE USEFULNESS OF EACH OF THE FOLLOWING?
------- A. LECTURES
D. LABORATORIES OR DEMONSTRATIONS
------- B. PRACTICAL EXERCISES
E. OTHER (please specify)
C. SMALL GROUP DISCUSSIONS
10. WHICH INSTRUCTIONAL METHODS ARE THE MOST APPROPRIATE FOR THIS COURSE?
(You may mention methods whether they have or have not actually been used.)
WERE
11. THERE ANY DISTURBING ORGANIZATIONAL PROBLEMS?
12. DID YOU FELL ANY LACK OF KNOWLEDGE NECESSARY TO UNDERSTAND THE COURSE?
Please specify
13. Vvlkl THERE REDUNDANCIES IN THE COURSE IN YOUR OPINION?
Please specify
[58]
Vol 23, Nos 9-10, September-October 1987
Debriefing Method for Curriculum Evaluation
14. FOR WHICH REASONS DID YOU LEARN? (Circle all the major factors.)
A. PERSONAL INTEREST IN THE SUBJECT
D. PREPARATION FOR EXAMINATION
B. RELEARNING UNCLEAR MATERIAL
E. SELF-EVALUATION
C. PREPARTION FOR A LECTURE
F. COMPLETION OF REQUIRED KNOWLEDGE NOT
COVERED IN CLASS
15. WHEN DID YOU SELF-LEARN?
----- BEFORE CLASSES
AFTER CLASSES
BEFORE EXAMS
16. FOR WHICH OF THE FOLLOWING REASONS DID YOU USE THE GUIDING QUESTIONS? (Circle reasons)
A. PREPARATION FOR A LECTURE
D. PREPARATION FOR EXAMS
B. GOING OVER LECTURE MATERIAL
E. SELF-EVALUATION
C. CLARIFICATION
F. DID NOT USE THEM AT ALL
—17. DID THE FINAL EXAM INCLUDE A REPRESENTATIVE SAMPLE OF THE LEARNED MATERIAL?
—18. WAS THE DIFFICULTY OF THE TEST ITEMSTHE SAME AS OFTHE GUIDING QUESTIONS & INSTRUCTIONS?
—19. WAS THE SELF-LEARNED MATERIAL. NOT COVERED IN CLASS. REPRESENTED ON THE EXAM?
— 20. HOW WELL DID YOUR GRADE CORRESPOND TO YOUR SELF-ASSESSMENT?
21. WHAT ARE THE MAIN ADVANTAGES OF THE COURSE?
A. ACQUIRING KNOWLEDGE
C. ACQUIRING PROBLEM-SOLVING SKILL
B. APPLYING ACQUIRED KNOWLEDGE
D. ENHANCING MOTIVATION AND CURIOSITY
22. WHAT IS YOUR OVERALL ASSESSMENT OF THE COURSE? (check one)
SUPERB
VERY GOOD
GOOD
REASONABLE
23. WHAT ARE YOUR SUGGESTIONS FOR IMPROVING THE COURSE?
| 59]
POOR
VERY POOR
A HISTORIC LOOK AT RESEARCH IN THE BEN-GURION
UNIVERSITY CENTER FOR HEALTH SCIENCES AND SERVICES
S. W. MOSF.S
Division ol Pediatrics, t'niwrsiis Center lor Health Sciences and Services. Ben-Gurion University ol the Negev.
Beer Sheva. Israel
Isr J Med Sei 23: 992-994. 19t
Key words: Beer Sheva l:\perinieni; medical education: research; basic sciences: publications
When the medical school was established in 1974.
the main thrust went into setting up an educational
framework geared to address certain basic problems
in the delivery of health care in Israel. Thus, during
these early days, a major effort was concentrated on
organi/alihnal goals. Simultaneously, attention had
to be given to urgent educational objectives such as
the development of a goal-oriented admissions pol
icy. the hiring and training of teaching personnel,
and curriculum development. It is therefore not sur
prising that the three major goals that wercconcep-]
tualized by the Founding Dean specified
educational and service objectives, but did not elab
orate on the need for the promotion of research (I).
Vet clearly the establishment of a quality medical
school, with a broad teaching base in many medi
cally oriented basic science aspects, required the
establishment of an appropriate infrastructure, for
basic and clinical research. This altitude guided the
Founding Dean who had extensive experience
regarding the place of research in a medical school,
when he hired people, provided space and allocated
resources for the basic science infrastructure. At the
same time, he took pains not to create white ele
phants in the form of large basic science departments
that could easily become ivory towers, detached
from the special needs of the medical school.
By 1974. the hospital had grown from its initial
300 beds in 1962 to a 650-bed hospital providing
regional tertiary care. The hospital was equipped
with laboratories in clinical chemistry, pathology,
bacteriology, hematology and endocrinology. Since
Address for corrcspoiidcncc: Dr. S.W. Moses. Division <>l Pedialiics.
Univeisiis ( vnlei l<n llvallli Sciences and Sciviccs. Ben
(inrion Ihiivcrsiiv ol ibe Ncj'cv. I’OB 653 K-IIOS Bcci Shc\a
the main objectives were the provision of media
service, little attention and meager resources wen
directed to research. Most ol the physicianshad no:
been trained in research procedures, and laboratory
personnel were also geared by and large to provide
service. I bis tradition began to change several yean
before the medical school was established, wher
some new heads of clinical departments who hada
research background were recruited and were giver
space and equipment to do research. Thus, bask
research began to appear even before 1974, mainlyir.
the areas of nephrology, endocrinology, carbohy
drate metabolism and hematology. But whereas the
clinical manpower and patient material in thehospi
tai were by and large sufficient for clinical leaching
the research and basic science infrastructure had k
be developed almost from scratch. This develop
ment included the provision of space and the acquir
ing of university funds and grants for research. Th
recruitment policy included the hiring of investiga
tors who were not able teachers, but were will
ing and able to contribute to service development
each in his field—such as virology, immunology
endocrinology and metabolism. Recruitment ol
teachers for the basic sciences, epidemiology ant!
sociology and the provision of proper conditions It
conduct research had a major impact on the upsurge
of research. This is reflected in a near logarithmic
increase in the number of publications and th
amount of research money generated, which in 1984
exceeded 1 million dollars. This policy did not only
create research centers of excellence that have gained
international reputation, but also diversified and
upgraded the level of services provided to both hos
pital and outpatient clinic patients. In addition, an
active visiting professor program was initiated
I 60 |
I I IS I (*l<l( I (»< IK A I Rl SI AK< II
Vol 23, Nos 9 10, Si n i Mill k ()< loin k 19X7
whereby each year about a dozen internationally
renowned scientists spend 4 to 6 weeks in Beer
Sheva. This program has been most helpful, not only
with respect to educational objectives, but also
regarding the stimulation of research.
Additional steps were undertaken to strengthen
the medical library by reorganization to include
audiovisual aids, a computerized retrieval system
and the addition of trained personnel. The library
was moved to new attractive quarters and the needs
of both students and faculty were met by the acquisi
tion of 900 journals annually and approximately
2,000 books.
A research-oriented approach was also empha
sized in the curriculum by a course on quantitative
methods. In addition, students are given free time in
their 5th year to be actively exposed to research for
at least 1 month. They are expected either to plan a
research proposal in detail, to perform research or to
summarize and critically evaluate relevant litera
ture. These research exposures are refereed by senior
faculty and are a prerequisite for graduation.
A grant program was established to support stu
dents interested in research. The purpose of this
program was to motivate students to collaborate
personally with faculty in basic or clinical research.
During 10 years, 88 students (20% of the student
body) received such grants from the medical school.
It is thus evident that in addition to the emphasis on
holistic clinical care, varied opportunities for
research orientation have been provided through
different channels beyond that to which medical
students are usually exposed in other medical
schools. Several students have also interrupted their
medical studies to obtain advanced degrees in basic
sciences before resuming their medical training.
In order to provide the proper background for the
teaching of scientifically based medicine, another
group, whose research base needed strengthening
was the young faculty. This was done in several
\Vays. Firstly, the 6-month period of exposure to
basic sciences, which is part of the requirements for
specialization in this country, provided an oppor
tunity to involve residents in research. This research,
which in the past was performed mainly in extramu
ral settings, became almost exclusively an intramu
ral program. Young physicians were thereby
exposed io research methodology and quantitative
thinking, while they assisted the basic science units
to increase and diversify the units' research activi
ties. Secondly, many gifted clinicians were given an
opportunity to obtain postgraduate training in the
U.S. or other Western countries which included
exposure to research. Thirdly, the medical school
allocated, even during financial hardships, between
$40,000 and $50,000 annually to finance refereed
research proposals of young faculty members. The
intention was to stimulate research activity among
junior faculty, often enabling the performance of
pilot studies that could then serve as a basis for
applications to external funding sources. This local
“seed money” was spread rather thinly to activate a
maximum number of people. Finally, last but not
least, even if the “publish or perish” attitude does
not prevail in our medical school, academic promo
tion does take into account, in addition to teaching
and service, evidence of research activities in the
form of refereed publications in scientific journals.
What was the impact of all these endeavors? What
has been accomplished in the 10 years of the medical
school and where do we stand today? In responding
Io these questions. I will limit myself to the following
areas: 1) the impact of research on service and vice
versa; 2) centers of excellence; 3) the scope of
research in the medical school: and 4) future needs.
IMPACT OF RESEARCH ON SERVICE
There is ample evidence that the linking of research
and service benefits both. It is apparently as impor
tant to expose the PhD to a clinical problem as it is
helpful to expose the clinician to the way of thinking
of the basic scientist. Today in our medical school,
nearly each major clinical setting has its basic scien
tists who are also involved in service and teaching.
This collaboration has resulted in clinically relevant
basic research, be it in epidemiology, biochemistry,
immunology or cancer research.
CENTERS OF EXCELLENCE
The faculty’s administration supported the creation
of several centers of excellence that have been of
major importance in promoting research.generating
funds and attracting scientists. Many of these centers
have become internationally renowned, and some,
in addition, have become involved in high technol
ogy, applied scientific activities. Moreover, interdis
ciplinary collaboration with investigators from
other faculties of the Ben-Gurion University and
with other Israeli universities was developed. Uni
versity funding for travel abroad in the form of
training grants and sabbaticals enabled members of
our faculty to spend time in performing research
and/or teaching in renowned universities and
research centers abroad, thus promoting interna
tional collaboration between academic centers of
excellence and our medical school. Many interna
tional medical and basic science symposia that were
sponsored by our medical school and held in Beer
Shcva proved to be a great success in attracting
161 I
israei J. Mi d Si
S.W Mosi s
renowned scientists and developing international
relationships.
SCOPE OF RESEARCH IN THE
MEDICAL SCHOOL
A trend towards community-oriented research is
seen, as reflected in the relatively high percentage of
papers dedicated to these subjects. The establish
ment of a strong unit of epidemiology, which in
addition to performing its own extensive research
and providing advisory planning and statistical ser
vices to many other projects in the medical school,
was very helpful in planning and supporting various
fields of research with special emphasis on
community-oriented research.
FUTURE NEEDS
Several basic science fields lack a critical mass of
investigators and depend on one or very few people.
Most of these scientists have a major commitment to
teaching, which further curbs their research oppor
tunities. It is essential to increase their numbers,
both to enable them to expand their research as well
as from the teachingstandpoint. Since Israel isgoing
through a severe economic crisis, which is felt
seriously in our University, a proposal to increase
the number of faculty positions is impractical at this
time. However, it is essential to strengthen these
weak links in the chain, even on the basis of “soft”
money. The fact that the medical school has recently
received authorization to train graduate students for
masters’ and doctoral degrees will have an impact in
increasing research potential.
We have a unique opportunity of being a centra!
hospital with a large and stable patient community,
excellent communication with the clinics in the field,
and a Bedouin population that presents Third
World problems, such as a high birthrate, relative
malnutrition and a high prevalence of childhood
infections. This population is in a unique position of
having access to modern medical services. This sei
ting, which has had a remarkable effect on the;
infant mortality, has been studied to some extent b:
our epidemiologists, but could undoubtedly b
investigated from other angles; such studies ar
expected to be of interest to international agencie
such as WHO, AID, etc.
As an institution grows and becomes established
it runs the danger of developing redundancies ii
both clinical services and research settings that an
frequently created in order to solve personal prob
lems. In the past, this has not been a major problen
in our medical school; however, we should in th
future try to avoid unnecessary duplications ant
rivalries that have had negative effects in other medi
cal schools.
In the first decade, the medical school has mad
much progress in developing a basic science infra
structure to serve teaching and service needs, in add;
tion to developing its own research interests. It ha
made its mark in research, not only in terms o
quality and quantity, but also in its unique orienta
tion. The policy was to develop certain units whici
would become centers of excellence. The strength o
these units should be determined inter alia on th
basis of their capability to generate internationa
financial support. In addition to strengthening th
weak links of basic sciences mentioned above, th
medical school should in the second decade of it
existence promote collaborative research both oi
an intra- and extramural level. Today, in the compel
itive field of research, one has to pool forces, com
up with new ideas and work hard. If we will be abk
to do all of this, we can look towards the secont
decade of the medical school with confidence.
REFERENCES
I. Segall A. Prywes M. Benor Dand Susskind O( 1978). “Un
versity Cenicr lor Health Sciences. Ben-Gurion Universii
of the Negev: an interim perspective.” Public Health Papei
No. 70. WHO. Geneva, p 112-132.
|62]
n.-
THE VISITING FACULTY PROGRAM — A CORNERSTONE IN THE
DEVELOPMENT OF THE UNIVERSITY CENTER FOR HEALTH
SCIENCES AND SERVICES
JOHN BECK
Multicampus Division of Geriatric Medicine. UCLA School of Medicine, University of California, Los Angeles,
CA,USA
Isr J Med Sci 23: 995-1003, 1987
Key words: Beer Shcva Experiment; medical education; visiting faculty; models
HISTORICAL PERSPECTIVE
Our historical perspective on the Visiting Faculty
Program (VFP) derives from memory since the
archives are incomplete.
The year was 1971. Moshe Prywes, still in Jerusa
lem, had a vision of the Beer Sheva Experiment. He
approached a distinguished American colleague,
Dr. Sam Proger (Chairman of the Department of
Medicine at Tufts University Medical School in Bos
ton), about possible financial as well as moral sup
port. Dr. Proger was an influential member of the
Board of the Ziskind Foundation, a Boston-based
family foundation. Moshe Prywes learned that the
Ziskind Foundation was being phased out, and that
the remaining $50,000 under Dr. Proger’s control
would be awarded to the still-forming University
Center for Health Sciences and Services at the BenGurion University of the Negev in Beer Sheva
(BGU). It was understood that the most important
immediate use of the money was to support visiting
faculty, i.c., experts from around the world; at the
same time, final plans were being made to establish a
permanent faculty. The Ziskind Visiting Faculty
Program (VFP), most people thought, would be of a
short duration, probably not lasting beyond 1975.
Al a meeting of the International Congress on
Medical Education in Copenhagen, Denmark, in
1972, Moshe Prywes approached Lord Max Rosen
heim, President of the Royal College of Physicians,
London, about serving as the leader of the VFP;
Address lor correspondence: Dr. .1. Beck. Mullicampus Division
of Geriatric Medicine. UCLA School ol Medicine. 10833 Le Cone
Avenue, Los Angeles. CA 90024.
Lord Rosenheim agreed to assume the chairman
ship. Perhaps the first visiting faculty member, he
visited Beer Sheva that year and renewed his
acquaintance with the town of Gaza where he had
served as a medical officer in World War II. Unfor
tunately, Max Rosenheim never took up the task, as
he passed away prematurely from a ruptured aortic
aneurysm in the late fall of 1972.
Moshe Prywes had gotten to know me and knew
of the very close personal bonds between Max and
myself. Pehaps because of this, he asked me to lead
the VFP, a task envisaged as a short-range commit
ment; thus a program began, whose life continues
unexpectedly until this day.
In the 1970s Dr. Prywes was President of the
University, and later he was appointed Dean of the
newly formed University Center for Health Sciences
and Services. Events in Israel seemed to indicate that
the need for the VFP would extend longer than
anticipated, and that efforts should be made to
secure ongoing funding, especially since the pro
gram was deemed highly successful during its initial
years. The dearth of faculty for the emerging medical
school necessitated bringing teachers and adminis
trators from outside of Israel to aid in planning,
implementation of programs and handling of major
teaching assignments'.
We were able to convince Mr. Harry Dozor and
his family of Philadelphia, PA and Palm Beach, FL
of the merits of the VFP, and, since 1977 — through
his continuing support — the program has grown in
size and prestige while continuing to fulfill an urgent
need in the medical school. A total ol 78 distin
guished medical educators from around the world
[63]
ISKAI 1 .1. Ml n Sci
J. Beck
have graciously given up their time (some of them
repeatedly) since the beginning of the VFP, and
several more have made commitments to participate
within the next 2 years. (See Appendix for list of
visiting professors.)
EVOLUTION OF THE PROGRAM —
IMPETUS OF THE DOZOR VISION
Prywes’ visionary Beer Sheva Experiment and Harry
Dozor’s ideals and continuing financial support
have permitted stable planning of the Harry J.
Dozor Visiting Faculty Program, which had hereto
fore been lacking. In the beginning, decisions about
need and recruitment of faculty were made by the
Dean and myself in my role as Chairman of the VFP.
This leadership was replaced later by an appointed
committee of the faculty who, together with the
chairperson, were responsible for the management
of the Program. All faculty were encouraged to sub
mit the names of potential visiting faculty persons to
the committee. Selection of visiting faculty was
made, usually twice a year, and was dictated by
educational and other priorities. Recruitment was
largely the responsibility of the chairperson.
Other important decisions were made by the
faculty committee. For example, the visiting faculty
member was expected to devote a minimum of 4
weeks to BGU. At least 1 month was considered
necessary, partly because of the expense of bringing
persons to Israel. Also, the “culture shock” of par
ticipation as a medical school faculty member in a
rather unusual environment (to many people) fre
quently required at least 1 week of adaptation. A
second decision was that the visiting faculty’s airfare
should be paid from the Dozor Visiting Faculty
fund, in addition to providing the member a modest
per diem while in Israel. A third faculty committee
decision was that spouses be invited, but at the visit
ing faculty member’s expense. Fourth, the commit
tee decided that a BGU faculty member be
responsible for the visitor throughout his/her stay in
Israel. Objectives of the visit, together with an imple
mentation plan, were to be conveyed to the visiting
faculty person. Finally, the committee decided that
whenever possible, a conference should be arranged
in Beer Sheva to focus on the visiting faculty
member’s area of expertise, and that invitations be
sent to interested persons in the rest of Israel. 'Hie
implementation of these decisions has been evolu
tionary and has become increasingly effective as the
VFP has become institutionalized.
In the first years of the program, the visiting
faculty member was requested to write a detailed
report to both the Dean and the Chairperson of the
program on some aspect of the medical school’s
function. This proved to be a two-edged sword; on
the one hand, it usually deepened the commitment of
the visiting faculty person, but at the same time it set
expectations by the visiting faculty member for the
implementation of recommendations that were not
always met. Currently, this reporting mechanism is
requested only under certain highly specified cir
cumstances, but all visiting professors are encour
aged to discuss the medical school with Mr. Dozor
and his family. An annual report is forwarded to Mr.
Dozor by the Dean of the Center for Health
Sciences.
CONTRIBUTIONS OF THE VFP TO THE
FACULTY AND BGU
An analytic appraisal of the views of the visiting
faculty members and the faculty at BGU suggests the
following conclusions about the VFP:
1) The original objective of filling major gaps in local
expertise and in curricular options has been largely
achieved. As the number of faculty recruited to Beer
Sheva has increased, the visiting faculty has supple
mented and strengthened the contributions of the
local faculty to the educational, research and service
missions of the University Center for Health
Sciences.
2) In many instances, the visiting faculty person has
made important contributions to curricular plan
ning and revision. The objectivity of the outsider has
been a valuable addition to the ongoingevolution of
the undergraduate curriculum, to the development
and implementation of the graduate medical educa
tional program, and to the critical review of research
activities. In addition, assistance has been given to
the Beer Sheva faculty in future research planning
and development. In some instances, joint research
activities have been developed to the benefit of both
BGU and the visiting faculty person’s home
institution.
3) A substantial number of visiting faculty persons
have made contributions to the planning of the sys
tems that have to be implemented in order to more
effectively merge the University’s educational
research and service missions with the service mis
sions of the Ministry of Health and Kupat Holim
(Health Insurance Institution of the General Feder
ation of Labor).
4) Visiting faculty members have played an exceed
ingly important part as role models for the indigen
ous faculty as well as for the students in the health
sciences (regardless of educational level).
5) The visibility of the Beer Sheva Experiment has
been heightened greatly by the first-hand acquain|64|
Voi 23. Nos 9-10. Si ph mbi r-Oc iori r 1987
Visiting Faculty Program
tance that visiting faculty persons usuallv achieve.
The visiting faculty have in many instances become
important and effective ambassadors for the Univer
sity Center for Health Sciences.
1
6) The formal organization of the Overseas Faculty
and their regular annual meetings have aided in the
development of a broader base of commitment by
influential non-lsraelis to the faculty and to the Uni
versity as a whole.
7) The VFP has permitted the development of a
limited number of highly effective exchange pro
grams at the undergraduate level, a model of which
is the Albert Einstein College of Medicine/BGU.
Other informal, but less institutionalized exchanges
have taken place, particularly facilitating the devel
opment of more effective elective placement of Beer
Sheva students in the UK. Canada and the USA.
8) The VFP has aided in the development of fellow
ship training opportunities for the best of the gradu
ate medical educational trainees at BGU. This serves
as an important contribution to the development of
a future generation of faculty at the University Cen
ter of Health Sciences.
9) Faculty recruitment to Beer Sheva has never been
an easy task. In some instances, committed visiting
faculty persons have played a critical role in convinc
ing a prospective faculty recruit to go to Israel, and
on several occasions, the visiting faculty member has
facilitated the generation of additional financial
resources necessary for a successful recruitment
process.
10> In some instances, visiting faculty persons,
inspired by the Beer Sheva Experiment and imb.jed
with missionary zeal, have aided the Associates’
Organization in some countries to generate funds
from outside Israel in support of BGU activities.
11) One ol the obstacles in recruiting new faculty to
this University has been the potential and sometimes
very real isolation of the new person from his/her
colleagues overseas. Visiting faculty have made real
contributions in breaking down this isolation or
preventing its occurrence.
12) In some instances, former visiting faculty have
become important spokespersons for the University
Center for Health Sciences and its individual faculty
members. The value of an influential North Ameri
can being able to vouch for a relatively unknown
faculty member in the Negev desert is not to be
underestimated.
13) The visiting faculty person has brought to Israel
both Jews and non-Jews, many with only a limited
knowledge of the constantly evolving new State of
Israel. After their stay, substantial numbers have
developed an unusual commitment to the country
that extends far beyond the Negev.
SOME FAILURES OF THE PROGRAM
Some of the leaders of the VFP had envisioned the
development of several parallel activities that have
not yet come to effective fruition. These activities
include the establishment of a vital and effective
Overseas Faculty Organization. The Organization
was to consist ol all past visiting professors and be
governed by a board of directors or executive com
mittee whose members would rotate. It was hoped
that this organization would be able to aid the Dean
and the University President in carryingout specific
tasks. Perhaps the most important reasons for the
failure in the Overseas Faculty Organization were
the absence of a stable secretariat, the Dean’s failure
to designate explicitly stated tasks (rather than gen
eral notions described at the annual board meeting),
and overseas faculty’s failure to spend adequate time
to complete requested tasks.
Another failure of the program is that overseas
faculty from the larger urban areas in the United
States have not effectively fostered local chapters in
support of the Center for Health Sciences’activities.
The main reason for thisappears to be the unwilling
ness of Associates’ organizations to provide staff
support to the visiting faculty member. In my view.
Associate support is crucial; the faculty member’s
own university or academic medical center staff can
not be depended upon for this purpose.
It had also been hoped, particularly by Dr. Prywes
during his tenure as Dean, that overseas faculty
would facilitate the development of an Association
of Physicians (Friends of the Center for Health
Sciences and Services) and would, for a relatively
modest investment, make annual contributions to a
capital fund. The problem in implementation of this
laudatory objective has been the Associates' organi
zations’ understandable competition in then fund
raising for other purposes.
THE FUTURE — IS THE MODEL
REPLICABLE?
Futurism is an inexact science (or perhaps it is an art)
and can also be misleading and even dangerous.
However, some statements about the future can
clearly be made accurately. The need for the VFP
persists and will continue to do so for a foreseeable
period. Fortunately, the investment in the program,
although substantial, has been modest in terms of
the benefits gained from it. We can expect that
pledged contributions will become more critical with
each passing month. Also, we can anticipate that the
recruitment of faculty in the Western world will
become increasingly difficult because of decreased
financing of health sciences education, research and
service programs in the USA, Canada and the UK.
[65]
Israi i .1. Mbd Sci
Bick
forces that led to its implementation can be found or
The ease with which distinguished faculty members
developed elsewhere. Other institutions may well
from these countries can leave their usual positions
build on this experience in launching new programs
for a month is also diminishing, and many must
of this type.
sacrifice their vacations to do so. In many instances,
faculty members’ absence from their parent depart
ments or schools is at a substantial financial sacrifice
I thank Mrs. Noga Porter and Mr. David Singer for their
to the department or institution. Faculty members
help in identifying archival materials that were essential
for the preparation of this manuscript.
not involved in the program do not take lightly to
this kind of commitment. Philanthropic funding is- 1 also wish to pay tribute to the memory of Lord Max
Rosenheim, former President of the Royal College of Phy
never secure, yet if asked what the sums of money
sicians. London who accepted Dr. M. Prywes’ invitation
invested in the VFP might buy of equivalent impor
to chair the Visiting Faculty Program at its inception.
tance, one arrives at the conclusion that the same
The
author wishes to pay personal tribute to Harry and
financial commitment to a more restricted purpose
Shirley
Dozor and to their three children for the ongoing
or to the general funds of the University would never
support
of what can be documented as an unqualified
achieve a result of equal worth to the VFP.
success.
is
If one were to ask whether this model program
The seminal role of the late Dr. Proger ol Boston in
replicable elsewhere, ! would have to answer affir
acquiring the initial funds for this program is also grate
matively. Although the circumstances that fostered
fully acknowledged.
the creation of the VFP had unique features, the
|66J
Vol. 23, Nos 9-10, September-October 1987
Visiting Faculty Program
APPENDIX
A VISITING FACULTY AND YEAR OF VISIT, 1975-87
John Beck, MD, Chairman 1975-87
Charles Hollenberg, MD, Chairman 1987-
Robert Adolph, MD
Professor of Medicine (Cardiology)
University of Cincinnati
Cincinnati, OH, USA
1977
Joel Alpert, MD
Professor of Pediatrics
Boston University
Boston, MA, USA
1979
Arlene Barro, PhD
Acting Associate Director of Education
National Cancer Institute
Bethesda, MD, USA
1983
Fritz K. Beller, MD
Professor and Chairman
Department of Obstetrics and Gynecology
Universitat Frauenklinik
Munster, ERG
1987
Lowell E. Beilin, MD, MPH
Professor of Public Health
Columbia University
New York, NY, USA
John Collins, MD
Professor and Chairman
Department of Surgery
Stanford University
Stanford, CA, USA
1981
Avram Cooperman, MD
Professor of Clinical Surgery
Columbia University
New York, NY. USA
1980
Hiram B. Curry, MD
Chairman, Department of Family Practice
University of South Carolina
Columbia, SC, USA
1976
Carl Eisdorfer. MD, PhD
Scholar in Residence
NAS Institute of Medicine
Washington, DC. USA
1980
1981
Max Elstein. MD
Professor of Obstetrics and Gynecology
University of Manchester
Manchester, UK
1981
James R. Boen. PhD
Professor of Biometry
University of Minnesota
Minneapolis, MN, USA
1983
Isidore Edelman. MD
Professor of Biochemistry
Columbia University
New York. NY. USA
1980
Michael Brennan, MD, CCFP, FCPP
The Family Medical Center of Victoria Hospital
London, Ontario, Canada
1986
1976
Baruch Bromberger, MD, PhD
Professor of Environmental Medicine
Johns Hopkins University
Baltimore, MD, USA
1977,
1978
Nathan B. Epstein. MD
Department of Psychiatry
McMaster University
Hamilton, Ontario. Canada
Stephen Epstein, MD
Chief of Cardiology
National Heart. Lung and Blood Institute
Bethesda. MD, USA
1983
Sir John Brotherston, MD. DrPH
Professor of Community Medicine
University of Edinburgh
Edinburgh. UK
1982
Wallace Epstein. MD
Professor of Medicine
University of California. San Francisco
San Francisco. CA, USA
1980
Peter Carlen. MD
Professor of Neurology
University of Toronto
Toronto, Ontario. Canada
1981
Manning Feinlieb. MD. DrPh
Professor of Epidemiology and Biometry
National Institutes of Health
Washington. DC. USA
1979
Victor Chcrnick. MD
Professor, Department of Pediatrics
University of Manitoba
Winnipeg, Manitoba, Canada
1985
Alvan Feinstein, MD
1982
Prolessor of Medicine and Epidemiology
Yale University
New Haven. CT. USA
(67]
Israel J. Med. Sci
J. Beck
Herman C. Grillo, MD
Professor of Surgery
Chief of General Thoracic Surgery
Massachusetts General Hospital
Boston, MA, USA
1985
Roberto J. Groszman, MD
Associate Professor of Medicine
Yale University
New Haven, CT, USA
1981
Jules E. Harris, MD
Director, Section of Medical Oncology
Rush-Presbyterian-St Luke’s Medical Center
Chicago, IL, USA
1987
Martin S. Hirsch, MD
Infectious Disease Unit
Massachusetts General Hospital
Boston, MA, USA
1985
1983
Charles Hollenberg, MD
Chairman, Department of Medicine
University of Toronto
Toronto. Ontario, Canada
1975
Stephen G. Gerzof, MD
Professor of Radiology
Tufts University
Boston. MA. USA
1983
1987
John P. Geyman. MD
Professor and Chairman
Department of Family Medicine
University of Washington
Seattle. WA, USA
1985
Geoffrey R. Howe, PhD
Professor and Director
Epidemiology Unit
National Cancer Institute of Canada
Toronto, Ontario, Canada
Bernard Isaacs, MD
Professor of Geriatrics
University of Birmingham
Birmingham, UK
1980
1986
Richard Glassock, MD
Professor of Medicine
University of California, Los Angeles
Medical Center
Harbor General Hospital
Torrance, CA, USA
1987
Michel Ibrahim
Professor of Epidemiology
University of North Carolina
Chapel Hill. NC, USA
1981
1986
Bernard M. Jaffe, MD
Professor and Chairman. Department of
Surgery
Downslale Medical Center
Brooklyn, NY, USA
1985
David S. Goldstein. MD. PhD
Senior Investigator
National Heart. Lung and Blood Institute
Bethesda, MD, USA
Leon Gordis, MD
Professor and Chairman
Department of Epidemiology
Johns Hopkins University
Baltimore, MD, USA
1980
Norman Kagan. PhD
Professor of Education and Medical Education
Michigan State University
East Lansing. ML USA
1976
Robert E. Greenberg, MD
Professor and Chairman of Pediatrics
University of New Mexico
Albuquerque. NM, USA
1985
Harry Keiser, MD
Chief Investigator
National Heart, Lung and Blood Institute
Bethesda. MD, USA
1981
Sheldon Greenfield, MD
Associate Professoral Medicine
University of California, Los Angeles
Los Angeles, CA. USA
1981
Sidney Klaus, MD
Professor of Dermatology
Yale University
New Haven, CT, USA
1979
1980
Alfred P. Fishman, MD
Professor of Medicine (Cardiopulmonary)
University of Pennsylvania
Philadelphia. PA. USA
1975
Lawrence R. Freedman, MD
V.A. Wadsworth Medical Center
Univeisily ol Caliloinia, I os Angeles
Los Angeles, CA. USA
1986
Gerald Friedland. MD
Chief, Infectious Diseases
Beth Israel Hospital
Boston. MA, USA
1975
Charles P. Friedman, PhD
Director of Research and Development of
Education in the Health Professions
University of North Carolina
Chapel Hill, NC, USA
1987
Catalina Gagneten, MD
Chief Division of Cytopathology
Hospital Ramos Mejia
Buenos Aires. Argentina
[68]
Vol. 23, Nos. 9-10, September-October 1987
Charles R. Kleeman, MD
Professor of Nephrology and Medicine
Director of the Center for Health
Enhancement, Education and Research
University of California, Los Angeles
Los Angeles, CA, USA
Visiting Faculty Program
1984
Kenneth Melmon, MD
Professor of Medicine and Pharmacology
Stanford University
Stanford, CA, USA
1981
1987
Jack Metz, MD
Director
South African Institute for Medical Research
Johannesburg, South Africa
1978
1987
Hendrick J. Koomhof, MD
Head, Department of Pathology
South African Institute of Medical Research
University of the Witwatersrand
Johannesburg, South Africa
1981
Norman Kretchmer, MD, PhD
Director, National Institute of Child
Health and Human Development
Bethesda, MD, USA
1976
Paul W. Mielke, PhD
Professor of Statistics
Colorado State University
Fort Collins, Co, USA
1983
Leo S. Lange, MD, FACP
Professor of Neurology
Middlesex Hospital
London, UK
1977
Arie Moran. PhD
Senior Scientist
National Heart, Lung and Blood Institute
Bethesda. MD. USA
1985
1986
Stephen H. Lazar, PhD
Assistant Dean
Albert Einstein College of Medicine
Bronx, NY, USA
1983
Milton Z. Nichaman, MD
Professor of Nutrition and Epidemiology
University of Texas
Houston, TX. USA
1982
1984
Aaron B. Lerner, MD
Chairman, Department of Dermatology
Yale University
New Haven, CT, USA
1975
Claude Nicolau, PhD, DSc
Director of Research
Centre de Biophysique
Orleans, France
1982
Fima Lifshitz, MD
Professor of Pediatrics
Cornell University
New York, NY, USA
1976
Max Pepper. MD
Professor and Chairman,
Department of Community Medicine
St. Louis University
St. Louis, MO. USA
1982
David T. Lowenthal, MD. PhD
Professor of Geriatrics and Adult
Development, Pharmacology and
Medicine
Mount Sinai Medical Center,
New York, NY, USA
1987
Fred Plum. MD
Professor and Chairman.
Department of Neurology
Cornel) University
New York. NY. USA
1986
Peter T. Macklem, MD
Chairman, Department of Medicine
McGill University
Montreal, Quebec, Canada
1982
Dennis Pointer. MD
Department of Health Administration
Medical C’ollegc of Virginia
Richmond. VA, USA
1986
Marshal Marinker, MD
Professor of Community Health
University of Leicester
Leicester, UK
1981
Helen Rehr. DSW
Edith J. Baerwald Professor
of Community Medicine (Social Work)
Mount Sinai Medical Center
New York. NY. USA
1979
Betty H. Mawardi, PhD
Professor of Medical Education Research
Case Western Reserve University
Cleveland, OH. USA
1985
David I. Roberts. MD
Professor of Urology
University of Tasmania
Hobart. Tasmania. Australia
1975
Kenneth A. McKusick. MD
Clinical Director
Division of Nuclear Medicine
Massachusetts General Hospital
Boston. MA. USA
1987
Cyris F. Rubin. MD
Professor of Medicine (Gastroenterology)
Washington University
Seattle. WA. USA
Steve Scharf. MD. PhD
Research Fellow (Pulmonary Diseases)
Harvard University
Boston. MA. USA
1977
l
[69]
Israfl J. Mi d Sci
J. Bick
Ronald Schneeweiss. MD
Professor of Family Medicine
University of Washington
Seattle. Wa. USA
1978
Hugh A. Smythe, MD
Professor of Medicine (Rheumatology)
The Wellesley Hospital
Toronto. Ontario. Canada
1986
Edwin Schneidman. PhD
Professor of Thanatology
Neuropsychiatric Institute
University of California, Los Angeles
Los Angeles. CA. USA
1983
Albert J. Solnit. MD
Professor of Psychiatry
Director of Child Study Center
Yale University
New Haven, CT. USA
1981.
1984
Steven A. Schroeder. MD
Professor of Medicine and Chief
Division of General internal Medicine
University of California
San Fransisco. CA. USA
1987
Emanuel Stadlan. MD
Professor of Pathology and Neurology
University of Tennessee
Memphis. TN. USA
1977.
1978.
1979
1976
Donald W. Seldin. MD
Professor and Chairman
Department of Medicine
University of Texas
Dallas TX. USA
1983
Leo Stern. MD
Professor of Medical Science
and Pediatrics
Brown University
Providence. RI. USA
David Seligson. MD
Chairman, Department of Clinical Chemistry
Yale University
New Haven. CT. USA
David B. Stoller. MD
Professor of Biochemistry
Tufts University
Boston. MA. USA
1986
1976
James A. Sharpe. MD, FRCP
Professor of Neurology and Ophthalmology
Toronto Western Hospital
Toronto, Ontario, Canada
1985
Joseph Sheehan. PhD
Head of Research in Health Education
University of Connecticut
Farmington, CT, USA
1979
Cecil G. Sheps, MD. MPH
Professor of Social Medicine
University of North Carolina
Chapel Hill. NC, USA
1977,
1978,
1982
Kenneth I. Shine. MD
Dean, Professor and Executive Chairman
Department of Medicine
University of California, Los Angeles
Los Angeles, CA, USA
1987
Arnold Shkolnik, MD
Professor of Clinical Radiology
Northwestern University
Chicago, IL, USA
1985
Benjamin Siegel, MD
Associate Professor of Pediatrics
Boston University
Boston, MA, USA
1981
Stanley Simmons, MD
Chief Consultant, Gynecology and Obstetrics
1978
Windsor Hospital
Windsor, UK
Marcus Singer, MD
Professor of Anatomy
Case Western Reserve University
Cleveland, OH, USA
1975
Gene H. Stollerman. MD
Professor and Chairman,
Department of Medicine (Infectious Diseases)
University of Tennessee
Memphis, TN, USA
1976,
1983
Fred H. Stone. MD
Professor and Chairman
Department of Child and Family Psychiatry
Royal Hospital for Sick Children
Glasgow. UK
1983.
1987
Norman Tallal. MD
Professor of Medicine and Microbioliogy
and Head. Division of Clinical Immunology
University of Texas Health Sciences Center
San Antonio. TX. USA
1987
Sam Thier. MD
Professor and Chairman.
Department of Internal Medicine
Yale University
New Haven, CT, USA
1979,
1982
Stanley Uretzky, MD
Professor and Associate Chairman of Pediatrics
Mount Sinai Medical Center
New York. NY. USA
1979
Jaques C. Van Der Meulen, MD
Professor and Chief
Plastic and Reconstructive Surgery
Academic Hospital
Rotterdam, Netherlands
1983
Arthur J. Vander, MD
Professor of Physiology
University of Michigan
Ann Arbor, ML USA
1978
[70]
Vol. 23. Nos 9-10. Si pti mbi r Octobi r 1987
Visitin<. I At uriY Program
Allen Vullon, MD
Middlesex Hospital
London, UK
1982
James W. Winkelman, MD
Professor and Director
Department of Pathology
State University of New York
Upstate Medical Center
Syracuse, NY, USA
1983
Morton M. Wooley. MD
Professor of Surgery and
1987
Surgeon in Chief
Children’s Hospital of Los Angeles
Los Angeles, CA, USA
[71]
Neville Woolf. PhD. FRCPath
Professor and Head of Department
The Bland Sutton Institute of Pathology
The Middlesex Hospital
London. UK
1985
Barry Zaret. MD
Director. Division of Cardiology
Yale University Hospital
New Haven. CT. USA
1986
CENTER FOR MEDICAL EDUCATION
MOSHE PRYWES12 and MIRIAM FRIEDMAN2
■Founding Dean and Chairman, and 2Center for Medical Education. University Center tor Health Sciences and
Services, Ben-Gurion University ol the Negev. Beer Sheva. Israel
Is, J Med Sei ?V. 1004-1005. I9K7
Key words: Beer Sheva Experiment; medical education; educational objectives
I he Standing Committee of the Senate ol the BenGurion University of the Negev (BGU) established
the Center for Medical Education in January 1982,
with Dr. Moshe Prywes, founding Dean of the BenGurion University Faculty of Health Sciences, as its
chairman. The Center operates with five full-time
staff members—ar. educational psychologist, a
research assistant, an administrative assistant and a
secretary. Faculty members from the clinical, basic
sciences and behavioral sciences disciplines are at fil
iated with and participate in the various research
activities of the Center. The Association of Deans of
Medical Schools in Israel has proclaimed the Center
as the National Center for Medical Education forall
four medical schools in Israel.
The Center’s activities were aimed at two main
goals that were essential to further develop the Beer
Sheva innovative approach to medical education.
The first goal was to evaluate the Beer Sheva Experi
ment, which was introduced in 1974 by the establish
ment of the BGU Center for Health Sciences and
Services, to assess its impact on the profile of the
BGU medical school graduates and to investigate
the interaction of the educational and health deliv
ery systems within the University Center for Health
Sciences and Services in the Negev. The second was
to establish an academic medical education center
for students and young physicians who wish to
pursue an interest or a career in medical education,
and thus prepare future young leaders who may
carry the Beer Sheva spirit to their own local medi
cal systems. Such important goals were likely to be
achieved only in an academically oriented center
Address for correspondence: Dr. M. Prywes. Center for Medical
Education. University Center for Health Sciences and Services.
Ben-Gurion University of the Negev. 84120 Beer Sheva.
that is continuously updated with the latest develop
ments in medical education in Israel and abroad.
Consequently, the following objectives provided the
framework for the Center’s academic activities:
1. To initiate, support, encourage and implement
scientific studies of methods, techniques, philosophy
and planning of medical education.
2. To encourage communication and exchange of
ideas, research information and findings among
teachers and researchers of medicine and those from
other faculties (education, social sciences, technol
ogy, etc.) in order to promote and expand the scope
of medical education.
3. To plan and organize symposia, national and
internati Jnal conferences, and meetings on medical
education.
4. To encourage faculty, researchers and education
alists from all medical schools in Israel to become
members of the Center, by participating and initiat
ing collaborative activities and comparative studies
in the field of medical education.
5. To host and welcome researchers affiliated to
other medical institutions in Israel and abroad.
6. To encourage both physicians and students to
become actively involved in issues related to medical
education.
7. To provide guidance lor medical students who
wish to pursue their MD theses in the field of medical
education.
Since the establishment of the Center, a compre
hensive, follow-up, comparative study of BGU grad
uates has been operating on an ongoing basis (see
“The Ben-Gurion University graduate profile: an
evaluation study” in this issue). The Center is also
preparing a complete student data base of all 13
cohorts, which will provide a comprehensive profile
of a Beer Sheva student and graduate and will de-
[72]
Vol. 23, Nos. 9-10, Sm i mbi.r-Octoblr 1987
Center for Medicai Education
scribe in depth the characteristics of the school's
student population.
Twenty-three students and young physicians were
selected from all four medical schools in Israel to
serve as Fellows of the Center. The Fellows are
chosen on the basis of recommendations from their
Deans. The criteria for selection are meant to iden
tify individuals who indicate leadership characteris
tics through outstanding activities. Most of the
Fellows are in close touch with the Center. Some
receive academic consultation for special projects,
others ask for either administrative assistance or
sponsorship of innovative ideas as well as profes
sional advice and support. The main idea is to estab
lish an informal dynamic group of concerned, young
and able potential leaders who interact with each
other through issues of medical education. These
encounters serve also as a medium of vivid inter
change of experience and ideas between students of
different schools. Informal meetings and periodical
retreats with the Fellows’ families add an atmos
phere of one big family to this special group. The
Fellows are involved in some extra professional
activities above and beyond the professional routine
work. They choose their own fields of interest and
activities and report on their work in a very informal
way at the Fellows’ quarterly gatherings. Each Fel
low is granted a modest scholarship to support
his/her professional development—a onetime allo
cation of $1000. They are permitted to spend their
scholarship money in any way they may wish; no
receipts are requested. The range of interest of the
Fellows varies from medical education, the medical
arts to innovations in medical teaching. With time it
has become prestigious to become a Fellow of the
Center. Whenever the Center becomes interested in
a national survey in medical education, the Fellows
serve voluntarily as delegates of the Center in their
respective medical schools or hospitals. In addition,
about 50 clinical and basic sciences faculty from all
medical schools in Israel are members of the Center
and are invited to special meetings and discussions
organized by the Center. Many are senior teachers
with established authority in their field. Others are
young faculty members who look for more training
in medical education. Many are physicians, nurses.
health workers; others are educationists. They all
find in the Center a national encounter forum.
Research studies carried out by the Center touch
many facets of medical education, including: cogni
tive development of medical students, clinical prob
lem solving, evaluatiorf of educational programs,
student evaluation, curriculum development, inter
action of medical education and medical care. In
addition, the Center provides consultation for var
ious faculty committee members regarding evalua
tion of research issues. Recently the Center was
asked by the headquarters of Kupat Holim in Tel
Aviv to take the responsibility for activating a
national program—Faculty Development in Family
Medicine in Israel.
The Center has hosted several outstanding inter
national scholars who have served as visiting profes
sors in medical education, as well as foreign students
who spent some time in the Center working on var
ious projects.
The authors have established professional ties
with other centers abroad, mainly through informal
meetings in medical education conferences. The
organization and planning of the annual conference
of the Association of Medical Education in Europe
(AMEE) and the Association of Medical Deans in
Europe (AMDE), which took place in Jerusalem in
September 1985, was one of the highlights of the
Center’s work. The conference, whose theme was
“Tradition and Change in Medical Education,” was
attended by 150 participants from 20 European
countries.
During the 5 years of its existence, the Center for
Medical Education has proved to be another unique
feat!”-0 of the Beer Shcva medical school. As the
Center is supported financially by private endow
ment funds and allocations from private donors, its
activities arc kept independent of the University’s
budget. While situated in the medical school, it has
succeeded in remaining an independent, yet inte
grated component of the school. This independence
permits objectivity of evaluation, while the inte
grated position enables the Center to monitor the
pulse of the school’s dynamic development and
observe the forces for both stability and changes.
[73]
EDUCATIONAL ISSUES B. Special Educational Foci
BIOCHEMISTRY AND MORE
AVINOAM 1.1VNE' and NAVA BASHAN2
‘Department of Biology, Faculty of Natural Sciences, and 2Clinical Biochemistry Unit, University Center for Health
Sciences and Services, Ben-Gurion University of the Negev, Beer Sheva, Israel
Isr J Med Sci 23: 1006-1009, 1987
Key words: Beer Sheva Experiment; medical education; biochemistry; self-learning; cognitive and
applicative skills
Many preclinical medical students tend to view basic
biochemistry as a subject that does not play an
important role in medicine (1). In Beer Sheva,
however, the basic biochemistry course for first and
second year medical students is uniquely popular.
For 10 consecutive years, students have exhibited
willingness to study biochemistry intensively, and
their overall rating of this course has been
particularly high. Professional evaluations by
visiting biochemists reinforce this high rating. For
example, in his report of February 1980, Dr. Isadore
S. Edelman (Professor of Biochemistry and
Chairman, Department of Biochemistry, College of
Physicians and Surgeons at Columbia University,
NY), stated:
The organization of the biochemistry course is
novel, with considerable emphasis on self-learning
and problem solving; both commendable goals of
course. I was especially impressed by the close, even
personal, relationships between the students and
faculty. Thus, the overall quality of the teaching
program in biochemistry is high and in some
respects superior to those with which I am familiar
in the U.S.
Since the curriculum of biochemistry, including the
topics studied and the major textbooks used, is
common and similiar in most medical schools, it is
clear that other factors must be responsible for the
success of the course in Beer Sheva. Several
possibilities should be considered: objectives, course
Address lor correspondence: Dr. A. Livnc, Department of
Biology, Facr' , f Natural Sciences, Ben-Gurion University of
the Negev, 84120 Beer Sheva.
design and implementation, staff, student activities
and evaluation.
OBJECTIVES
The main objectives for the basic course in
biochemistry are: 1) to enable students to acquire
information in biochemistry when they require it,
through familiarity with the language and major
concepts (cognitive phase); 2) to enable students to
apply the acquired biochemical information to
unfamiliar conditions or situations (applicative
aspect); 3) to enable students to use their cognitive
and applicative skills to solve problems (problem
solving stage); and 4) to enable students to read
original scientific literature and to present a paper
both effectively and critically.
These statements are similar but not identical to
the objectives formulated by Mehler (2), who
contributed much to our model.
COURSE DESIGN
How can such objectives be implemented? The
central theme of the course is a combination of two
components—appealing content and demanding
structure.
Modern medicine requires a grasp of knowledge
of immense proportions. There is no chance to
introduce it all during the several years of study and
of course not in a given course. This limitation leads
us to use a curriculum that is essentially universal,
with the emphasis on interesting and relevant
aspects. We were careful not to convert the course
into clinical biochemistry, but where applicable, the
study material was “flavored” with clinical
examples. For example, protein synthesis was
174]
Vol 23. Nos 9-10. Si hi mbi r-Octobi r 1987
Bloc Hl MISTRY AND MORI
introduced on the background of a specific case,
1) cognitive,
namely 0-thalassemia. yet the biochemical aspects of
assignment, 2) applicative, and 3) problem solving.
The inclusion of the applicative aspects and the need
protein synthesis were not compromised.
An important feature of the biochemistry course
is a framework that formulates explicit demands
directly
to
the
reading
to solve problems demonstrate to students that the
subject matter is indeed relevant to biochemical and
clinical practices.
concerning assignments for self-learning, for group
discussion and for presentation within a given
timetable. The trend in many modern programs is to
stimulate
relating
The requirement that the students submit written
assignments regularly (almost weekly) for review has
of
resulted in two beneficial effects: 1) the students are
selected topics, reading materials, etc. To cope with
generally well-versed in the topic and are thus
prepared for the discussion in the study group, and
2) they receive personal feedback pertaining to their
by
self-learning
recommendation
modern biochemistry, we have chosen the good old
educational approach of assignments and
timetables.
ability to copc with challenging questions, as their
assignments are returned promptly with comments.
The original paper included in many of the units
does not merely provide an opportunity to study an
interesting scientific paper, but serves an
Unit of instruction
The basic component of the course is the unit of •
instruction. The entire course comprises two
semesters (the second semester of the first year, and
the first semester of the second year), totaling 32
weeks. The curriculum is divided into 20 main topics
educational purpose as well, namely to practice
critical
in-depth
reading.
The
student’s
comprehension of the central points of the paperand
the extent of his/her critical powers soon become
evident by means of the written assignment and the
(units), as outlined in Table 1. Every unit lists the
subtopics, the pages that should be read thoroughly
(from texts, mostly Lehninger (3) and Montgomery
weekly discussions in the study groups.
ct al. (4)]. and an original paper. Sets of
approximately 20 questions are prepared for every
unil. some from the literature and some original.
The questions are organized on three stated levels:
These consist almost entirely of small group
discussions (12 to 15 students per group), with an
Table I. Curriculum of biochemistry course
occasional lecture to the entire class for the purpose
of summing up a topic or the introduction of an
Topic
Hours
Nutrition
Amino acids and peptides
Proteins—covalent structure
Pro I e i n s—con fi gura I io n
and conformation
Enzymes a
6
4
6
Enzymes b
Introduction to
metabolism
Nucleotides—structure
and metabolism
Nucleic acids—
structure
Nucleic acids—
metabolism
Carbohydrate structure
and glycolysis
The citric acid
cycle
Oxidative phospho
rylation
Gluconeogenesis and
pentose phosphate
pathway
Glycogen metabolism
Lipid metabolism
Lipoprotein metabolism
Sphingolipids, gangliosides
and mucopolysaccharides
Amino acid metabolism
Integration of
metabolism
6
6
6
Original
paper
Frontal
lecture
+
+
+
+
+
5
+
+
+
+
+
6
4
6
4
+
+
+
4
4
x
4
2
4
important concept. The groups and their teachers
(usually senior faculty) meet twice a week for 2
hours, while students devote an additional 12 to 16
hours on their own.
+
4
6
Class activities
For obvious reasons, the small study group is
quite a burden on the teaching staff .especially at the
senior level. Nevertheless, we insisted upon this
format and regard it as a crucial element in the
successful implementation of the course. Was this
insistence justified? The virtues of studying in small
+
+
+
groups are well recognized. In a small group, the
individual student has the opportunity to participate
actively, he can test his ideas in a less formal context,
question concepts and statements that he does not
fully comprehend, and obtain important feedback
from the experienced teacher about his grasp of the
subject. The small group provides an opportunity
for the teacher to discover whether the students,
4
+
+
+
+
both as a group and as individuals, understand the
subject. Moreover, the teacher can ascertain the
difficulties of individual students and encourage
them to learn in the manner best suited to their own
needs. In the context of the small group, students can
learn from one another by discussion. They can
present varied points of view on a problem and can
learn through an interchange of ideas. We have
4
[75]
Israel J. Med Sci
A. LivneandN. Bashan
noticed that during the course the students gradually
learned to listen to their colleagues. In conclusion,
we have found, like so many before us, that teaching
in small groups is a powerf ul educational medium
that provides the conditions under which students
can study and understand a subject for themselves.
Evaluation
Assessment of students’ achievements is based on
written tests. The students study in three groups,
with a different teacher assigned to each group for
the entire semester or for the major part of it. By
comparing the grades of the students in these
groups, we had the opportunity to evaluate whether
the achievement of an individual relates to the
teacher. Grades obtained in four consecutive
semesters, during the courses of seven different
teachers, were compared. The teachers varied
greatly in their teaching and research experience,
ranging from 2 to 12 years post-PhD. yet the average
grades in the three groups were similar, with
insignificant differences. We conclude that the
students’ efforts and activities, rather than the
background of the teachers, played the major role in
their achievement.
Student seminars
While self-learning and motivation to study are
valuable attributes, how can we mold these behavior
patterns into a structured course? One of the most
effective means is the presentation of a case report
type seminar. During the course, every student
presents a topic to his fellow students, teachers and
guests, related to the material studied. Generally
speaking, the 1-hour presentation is derived from a
genuine case, which is presented briefly (about 5
minutes), mainly in order to introduce biochemical
questions and to explain its principal features. A
condensed review of the biochemical background
follows, but the main challenge for the speaker is to
lead an active discussion dealing with alternative
explanations and different views of a given problem.
The seminar is summed up by referring back to the
case mentioned initially. These presentations
contain a wealth of educational benefits, especially
for the student who prepares and presents the
seminar. Even practical aspects, such as learning
how to prepare slides, are constructive fringe
benefits. But most important is the experience of
presenting a given subject in a lucid and logical
manner, as well as accommodating it within a given
time span and scope.
Laboratory -sions
The laboratory aspect of the curriculum has
undergone considerable changes. Originally, six 4hour sessions were scheduled, but in practice only
three or four took place. These dealt with proteins,
enzyme activity, glycolysis and glycogen
metabolism. Eventually, after several years, one of
these sessions was replaced by the exposure to an
active research program in a laboratory of one of the
staff members. The laboratory sessions were never
intended to develop the students’ practical and
analytical skills in biochemistry, but rather to
promote self-learning and to facilitate the grasp of
abstract and diffuse biochemical tools. Wc have
noticed that when the need arises for an approach to
solving a problem, students will frequently describe
a procedure such as X-ray diffraction which, albeit
valid and sound, is absolutely unrealistic in terms of
cost, instrumentation, time etc. We believe that the
laboratory sessions help rectify this somewhat naive
approach.
PROBLEMS
The design of the course is not free of problems, and
they should be pointed out. The course is demanding
and attractive and has reached dimensions that
naturally take time from othei activities. Due to the
magnitude of the course, its design is not readily
applicable to other subjects, particularly those
offered concurrently. 1 he implementation of the
course imposes a heavy teaching load on the staff.
The teachers meet weekly for several hours prior to
every unit in order to coordinate the activities of the
three parallel groups, as well as to discuss the correct
answers to the questions given to the students.
An intriguing question relates to the students’
knowledge of biochemistry several years after taking
the course. During the course the students are highly
motivated, eager to do well, and indeed appear to
fulfill the specific objectives. The level of knowledge
and comprehension of biochemistry of most of the
students by the end of the course and when evaluated
during the same year is impressive. However, several
years later, by the end of their studies towards the
degree of MD, there is no proof that our students’
knowledge of biochemistry is on a higher level than
that in other schools.
CONCLUSION
This paper describes the objectives, design and
operation of a course, featuring a particular
emphasis on self-learning and organizational
aspects. A structured system with specific demands
on the one hand and claims of self-learning on the
other may sound contradictory, but in effect these
two factors have proved to be complementary.
Medical students are obviously quite busy and tend
1761
Vol, 23, Nos. 9-10, Si m mbi r-O<iohi r 1987
Biochemistry and More
to devote their time primarily to the demands made
on them. Whether it is the continuous feedback they
receive during group discussions, inspiration from
the teachers or the interesting material studied
—whatever the stimulatory factoifs), the fact
remains that for over 10 years now our medical
students have uniformly indicated that they have
worked hard, enjoyed the course and studied
willingly and eagerly. Judging by the students’
attitudes and the skills they have acquired, it is not
merely biochemistry they have learned. Indeed, it is
biochemistry and more.
We thank our fellow teachers for their contributions in the
planning and teaching of the course: David Chipman,
Yossi Granot (Graziani) and Reuben Chayoth, from the
Biology Department, as well as Shraga Shany, Joseph
Levy, Ilana Nathan, Sergio Lamprecht, Ruth ShainkinKestenbaum and Yoav Sharoni from the University
Center for Health Sciences and Services. Finally, we wish
to thank Asher Segall for his insight and inspiration in
designing the unit of instruction.
REFERENCES
1. Kogut M (1974). The tree of knowledge? Biochemistry for
medical students: “Not just a lot of facts, more a way of
life.” Biochem Educ 2: 51.
2. Mehler AH (1973). An approach to medical biochemistry.
Biochem Educ 1: 26-27.
3- Lehninger AL (1982). “Principles of biochemistry.” Worth
Publishers. New York.
4. Montgomery R. Bryer'RL, Conway TW and Spector A A
(1980). “Biochemistry. A case-oriented approach.” CV
Mosby, St. Louis.
Stephen Abrahamson
Medical Education
University of South Carolina, Columbia, SC
Nurses and Physicians of Tomorrow, WHO Publi
cation, 1984
“The brief history at the beginning gives the reader some
sense of the excitement of founding a new school in a
country which itself is only thirty-four years old. It is
evident from the description that the school was founded
to meet carefully identified health-care needs in ?.
particular area of the country. It is made quite clear that
this school responded to changing health needs of the
society which it was to serve. Thus, it is important to note
that those changing health needs are what became the
basis for the institutional learning objectives for the new
school.”
[77]
I
EPIDEMIOLOGY TEACHING: PROSPECTS AND PROBLEMS
SHIMON WEITZMAN
Department of'Epidemiology, University Center for Health Sciences and Services, Ben-Gurion University of the
Negev, Beer Sheva, Israel
Isr J Med Sci 23: 1010-1012, 1987
Key words: Beer Sheva Experiment; medical education; epidemiology teaching; health care services; biostatistics
The teaching of epidemiology is intensive during
the first 2 years, where the foundations of this disci
pline, together with biostatistics and their practical
applications during the field projects, are particu
larly emphasized. During the clinical days of those
years, this knowledge is applied to the natural his
tory of cardiovascular diseases (1st year) and breast
cancer (2nd year).
The epidemiology field project at the beginning of
the 2nd year deserves special comment. It was
designed with the objective of applying this knowl
edge and the skills acquired during the 1st year to
subjects relevant to the population’s health. Exam
ples of subjects that have been addressed are: child
injuries at school, the prevalence of high blood pres
sure in development towns, home mortality after
stroke, and birth weight and maternal smoking. This
exposure to planning, data collection and analysis,
and inference making has a powerful effect on the
student’s understanding of the various selection pro
cesses involved in the health care system that may
affect the natural history of disease.
In the 3rd year, epidemiology is built into the
teaching of the various body systems. The objective
is to describe different models of the natural history
of disease which may be used for the better under
There is no longer any dispute about the close rela
tionship between epidemiology and medicine. The
contribution of epidemiology to the understanding
of etiology and prevention of diseases, as well as to
their natural history, is widely recognized (1). In
addition, epidemiology provides the tools for the
evaluation of diagnostic procedures and therapeutic
strategies. Despite these well-accepted attributes,
epidemiology is still taught as an elective course in
most medical schools, usually at the end of the medi
cal curriculum. This paper addresses the approaches
and problems related to teaching epidemiology at
the University Center for Health Sciences and Servi
ces of the Ben-Gurion University of the Negev.
EPIDEMIOLOGY COURSES
One of the main objectives in the creation of the
Ben-Gurion University medical school was to inte
grate service, teaching and research in a way that
would benefit the Negev and eventually other areas;
epidemiology teaching, therefore, was aimed at pro
viding medical students with the knowledge and
skills that would facilitate the practice of
community-oriented medicine.
To reach this objective, it was decided that the
areas in the epidemiology curriculum deserving par
ticular emphasis should be: 1) the critical approach
to collecting and analyzing data, 2) community diag
nosis, and 3) the natural history of disease. Table 1
displays the epidemiology courses taught through
out the 6 years in our medical school.
standing of chronic conditions. Models selected
Address for correspondence: Dr. S. Weitzman, Department ol
Epidemiology, University Center for Health Sciences and Servi
ces, Ben-Gurion University of the Negev, FOB 653, 84105 Beer
Sheva.
include coronary heart disease, hypertension,
chronic respiratory disease, diabetes and colorectal
cancer. During lectures and seminars, the preventive
aspects of disease as well as those of diagnosis and
prognosis are emphasized. Time is provided for dis
cussion of the benefits and drawbacks associated
with early diagnosis and the methods for evaluating
the impact of interventions.
During the 4th year, teaching of epidemiology
1781
Vol. 23, Nos. 9-10, September-October 1987
Epidemiology Teaching
Table 1, Epidemiology courses at the Ben-Gurion University Center for Health Sciences and Services
Ycar
Course
Content
Method
1st (two
semesters)
Epidemiology and
Quantitative Thinking
1) Epidemiology:
investigations of epidemics,
screening, natural history of
disease, study design
2) Biostatistics:
distributions, graphic
display of data, sampling,
estimation, hypothesis
testing
3) Natural history of
cardiovascular disease
Discussion, using coronary
heart disease as a model;
interview of patients
Groups of 6 to 7
students with instructor. Data
presented to the whole class
for discussion plus written
report
2nd (3 weeks)
Epidemiology Field Project
1) Planning, executing,
analyzing and reporting on
a subject. Short SPSS
course included
2) Natural history of breast
cancer
3rd
Epidemiology of
Various Body Systems
Natural history of:
1) Cardiovascular disease
2) Gastrointestinal disease
(Colorectal cancer,
hepatitis)
3) Respiratory disease
(chronic pulmonary disease)
Lectures, class exercises and
small group discussions
Lectures
Seminar and case
presentations
4) Endocrinology (diabetes)
Evaluation of therapy
4th
Clinical Epidemiology
1) Testing diagnostic
procedures
2) Application of epidem
iology to medical practice
6th
Epidemiology
Planning, executing and
reporting on a subject
related to primary care
Project in Primary Care
uses two complementary methods. The first is
represented by seminars with exercises on testing
diagnostic procedures, as part of a preparatory
course on clinical decision making given before the
students begin their clinical clerkships. The second
method, which is still in a developmental stage, con
sists of clinical practice. This approach attempts to
facilitate the integration of the courses learned dur
ing the first years into clinical practice. It is felt that
at this point of the medical curriculum, epidemiol
ogy teaching would have the greatest impact on the
students’ future behavior as physicians. Ideally, the
instructors should be clinicians with a strong epide
miological background, who would emphasize those
epidemiological issues that have key implications for
the care of patients during the clinical clerkships (2).
This ideal situation can be attained only by training
our residents in epidemiology. As the medical school
curriculum and the epidemiology courses were
developing, it became clear that a gap existed
between our medical students and clinical instruc-
1791
Seminars and
clinical rounds
Collection of data during
primary care clerkship
tors concerning issues of epidemiological concepts
and skills. That was explained by the clear differ
ences in curriculum between the medical schools
where our residents were trained and that of our
students. Many of the residents had not had epide
miology courses at all. Postgraduate courses in
epidemiology (which will be discussed later) may
provide a solution to this problem.
During the last year of medical school, students
complete their clinical clerkship, including that of
primary care. During the latter, students are
required to define a problem relevant to primary
care practice in the community and to analyze it in a
systematic way. Instructors from the Epidemiology
Unit serve as consultants for this purpose. This pro
ject is similar to that in the 2nd year, yet is specifi
cally different in that it is carried out on an
individual basis and is generally clinically oriented.
In addition to the epidemiology courses at the
medical school, there is a curriculum in epidemiol
ogy at the School of Nursing and Physiotherapy, as
Israel J. Med. Sci
S. Weitzman
well as seminars for graduate students in the Health
Economics and Administration program. These
courses are also complemented by field projects per
formed in groups of five to six students.
POSTGRADUATE EDUCATION
1 epidemiology courses are at a very early stage of
implementation for residents. Two departments,
Family Practice and Obstetrics and Gynecology,
have requested our teaching as part of their resi
dency programs.
In addition, there are alternative methods of both
formal and informal training in our medical school.
An example of the former is the 6-month rotation in
basic sciences required by the Israel Medical Scien
tific Council for completing speciality boards. Until
1980, only two residents in our hospital chose a
rotation in epidemiology. Since then, seven more
have completed this rotation and an additional four
are presently working in our Unit, including two
residents from internal medicine, five from pediat
rics, one from surgery, two from opthalmology and
one from obstetrics and gynecology. The growing
interest in epidemiology shown by clinicians reflects,
at least in part, the recognition of the uses of this
discipline in medical practice and in the planning,
performance and analysis of research work.
Undoubtedly, the medical literature has been a fun
damental factor in facilitating this recognition.
During the rotation in epidemiology, residents are
required to plan, execute, analyze and report on a
survey or clinical trial relevant to their area of spe
cialization. They also have parallel tutorial training
in the Unit, which is intended to expose them to
relevant issues in epidemiology and statistics. The
residents’ tutors are also responsible for advising
them about their research projects. Some of the
residents’ research projects have been published (3)
' or presented at scientific meetings.
Informal training is represented by the daily con
tact between students, physicians and other health
providers and the Unit’s staff. Since the Unit is
located in the hospital, there is easy access to it.
Consultation services on research issues as well as
collaboration in clinical research are widely devel
oped. These contacts are very useful in arousing
interest among clinicians about the role of epidemi
ology in medical practice.
EVALUATION
Student and staff evaluation of the courses has
played a very important role in planning changes in
the epidemiology curriculum. Although there are
year-to-year fluctuations in the students’ rating of
the courses, the rating for the first year’s course has
always been very high; most students recognize the
need and importance of the epidemiology and bio
statistics teaching. It is worth noting that ranking of
the importance of epidemiology by students grows
with increasing seniority of the students and reaches
a peak among the graduates. This undoubtedly
reflects both a successful integration of epidemiol
ogy within the framework of the medical curriculum
and the recognition of this discipline as an essential
part of medical education.
REFERENCES
1. Evans JR (1985). The Moshe Piywes lecture in medical
education. Medical education—the search for international
eminence and local relevance. Isr J Med Sci 21: 557-563.
2. Weitzman S (1983). Use of epidemiology in primary care. Isr
J Med Sci 19; 739-741.
3. Charuzi I, Ovnat A, Reiser J. Saltz H. Weitzman Sand Lavie
P (1985). The effect of surgical weight reduction on sleep
quality in obesity-related sleep apnea syndrome. Surgery
97: 535-538.
[80]
EARLY CLINCAL PROGRAM FOR NOVICE MEDICAL STUDENTS:
13 YEARS’ EXPERIENCE AT BEN-GURION UNIVERSITY OF THE
NEGEV
DAN E. BENOR
Curriculum Unit. University Center lor Health Sciences and Services. Ben-Gurion University of the Negev. Beer
Sheva, Israel
hr J Med Sci 23: 1013-1021. 1987
Key words: Beer Sheva Experiment; medical education; early clinical program
Medical education has been increasingly challenged
ground of previous knowledge and experience and
during the last decade. The major faults ascribed to
would thus shape future expectations. McGaghicct
al. (9) argued that early clinical exposure would
it have been a lack of responsiveness to changing
health needs (1. 2). overemphasis of biomedical
converge learned elements into a meaningful con
models while ignoring the psychosocial aspects of
health and disease (3), and concentration on acute
ceptual construct. Many others stressed the advan
tages of earlier patient contact for strengthening
interpersonal competencies of graduates.
care within the walls of the specialized hospital while
neglecting primary care (1,2, 4). Medical education
These suggestions for curricular change were con
was criticized even more for producing graduates
who arc oriented toward disease rather than health,
gruent with learning theories and models, which
were recently created, studied and confirmed outside
medical education. Among these arc student
and toward cure rather than care, resulting in profes
sion orientation rather than patient orientation (5).
centered education, suggested by Rogers (10); the
These critical voices were followed by a plethora
of calls for curricular changes. Advancing contact
concept of the advanced organizer as a vehicle for
integration and conceptualization of learned mate
with patients to an earlier stage in the education was
rial, suggested by Ausubcl (II); the confluent educa
tion theory of Brown cl al. (12), calling upon
merging cognitive and affective processes in order to
one of the more frequent suggestions. Early clinical
exposure was expected to remedy some of the “dis
eases of the curriculum.’’ as Dr. S. Abrahamson
called them (6), by redirecting the students' attention
to the care of patients in theirfamiliesand communi
ties. utilizing personal and societal resources.
promote learning; interdisciplinary integration pro
posed inter alia by Taylor et al. (13) and Schwab (14,
15), and the Brunerian learning by discovery in a
spiral progression from lower to higher levels of
The calls for curricular reform also highlighted
faults in the teaching-learning process in medical
education, which early clinical exposure might cure.
Houts and Bench (7) called for a curriculum in
which clinical material would precede conceptual
material in order to achieve relevance. Nadelson el
al. (8) suggested early clinical exposure in which
current reality would be examined against the back-
Address for correspondence: Dr. D. F. Benor, Curriculum Unit.
University (enter lor Health Sciences and Services. Ben-Gurion
University of the Negev. POB 653, 84105 Beer Sheva.
sophistication (16).
The combination of a strong need for changing
the traditional curriculum with the appropriate
theoretical grounds should have created a revolution
in medical education. I his, however, did not occur.
Some attempts Io advance student-patient encoun
ters have been described by a number of authors.
Yet, the majority ol those encounters a re quite brief,
limited toshort, un repea I cd exposures (17-19). More
successful arc early clinical programs, which aim to
transmit a limited number of specific clinical skills,
such as emergency care (20, 21), physical diagnosis
(22), and especially communication skills (22-25).
[811
Israi I .1. Ml I) Sci
I). I . Bl NOR
Most of this clinical leaching takes place within the
campus walls—in classrooms or in some “clinical
skills laboratory”—with a limited, if any. exposure
to the real world. Very few curricular innovations
that advance clinical studies to the earliest possible
phases of medical education were indeed compre
hensive and continuous, involving the student in real
clinical life within the community (26-28). Unfortu
nately. many of these attempts were discontinued,
and not necessarily because of educational failure.
Nevertheless, several early and comprehensive clini
cal programs do exist, but they are elective pro
grams, directed toward a self-selected group of
students (29, 30). Thus, contrary to expectations,
clinical studies in the earliest phases of medical edu
cation. defined as both continuous and encompass
ing exposure to patients, communities, societal
institutions and health care services, are extremely
rare.
I his article describes a required eai ly clinical cur
riculum that is both comprehensive and continuous.
This curriculum has been successfully implemented
in the Ben-Gurion University Center for Health
Sciences and Services (UC'HSS) lor the past 13 years.
The program is analyzed in terms of its general
goals, instructional objectives, specific advantages,
educational by-products, and some difficulties and
problems. The program has previously been des
cribed elsewhere (2, 31. 32). In spite of some evolu
tion over the years, the basic structure and
educational approaches have not changed.
Recognition should be given to the American
Joint Distribution Committee whose extensive and
long-standing financial support has enabled the
UCHSS to introduce changes in the primary health
clinics adapting them for teaching purposes.
EARLY CLINICAL PROGRAM
In a 6-year curriculum, the duration of. the early
clinical program (ECP) at UCHSS is 3 years. The
piogiani begins in the-very 1st week ol school,
although the students have not been through any
premedical program and possess only high school
qualifications. The program ends when the students
start their rotating clerkships.
lour conccpls, or “didactic axes.” guide the I CP:
1) the life cycle axis, “from cradle to grave”: 2) the
axis of the natural history of a disease, from screen
ing populations under risk and identifying health
problems through ambulatory maintenance, to the
acute hospitalization phase and back to the family
and the community via the rehabilitation process;3)
the health axis, from normal growth, development
and functioning to the pathological processes: and
finally. 4) the responsibility axis, from being a recip-
ient of knowledge and learner of skills, to service
obligations with a growing level of responsibility.
These four lines are highly interwoven, yet distinct.
The learning-teaching methods differ in the 1st.
2nd and 3rd years, so it is thus more convenient to
describe the ECP of each year separately.
Firsi year
J he ECP in the 1st year includes 1 day/week
throughout the academic year (the “clinical day”),
and three additional 1-week “miniclerkships”
toward the end of the year.
In the clinical day the students rotate in small
groups through five programs. In each program they
arc further divided into subgroups of three to live
students. These subgroups rotate within each pro
gram. between “stations” in which they serve for I
day.
The first program is growth and development.
I he stations here arc Maternal and Child Health
clinics, kindergartens in both allluent and under
privileged neighborhoods, as well as elementary and
junior high schools. In these stations, the students
learn to assess normal growth and development by
interviewing children of various ages, and their
mothers, teachers and counselors. They also observe
children in different settings and perform the
appropriate physical and psychological measure
ments. One additional day is spent in the pediatric
ward of the hospital and concerns the impact ol a
child’s chronic disease upon the lamily. 1 he
teachers, instructors and preceptors at all the sta
tions arc pediatricians, nurses, social workers and
psychologists, working either individually or in
teams.
The second program is prenatal care. 1 he stations
include community prenatal care clinics, family
planning centers, a course preparing young couples
for childbirth, as well as many home calls. Again, the
rotation of small subgroups enables the acquisition
of skills lor both assessing and counselling, includ
ing simple components of physical examination and
laboratory tests. The obstetrics program continues
in the miniclcrkship later in the year.
The third program lakes place in (he internal med
icine wards of the hospital and is devoted Io delect
ing the impact of hospitalization on the individual
and his or her family. The students try to ascertain
—from the point of view of the patient, the family
and the physicians—the direct cause ol the disrup
tion of the ambulatory maintenance. They have to
delineate a rehabilitation and follow-up program for
the patient. The students also acquire basic nursing
skills and further develop their proficiency in simple
diagnostic procedures.
1821
Voi 23. Nos. 9-10. Si HI MBI r O( loin r 19X7
I.ari y Ci ink ai Program ior Sii di nis
The fourth program is devoted to vocational reha
bilitation of discharged patients through reassign
week with a family practitioner in one of three differ
ent health care systems in various parts of the coun
try. Among these is a closed, protected kibbutz
community in which the nurse practitioner runs a
wide range of health services. The other two are
ment in their previous or new place of work.
Students learn to assess the physical status and fit
ness of adults, as well as the factors influencing
fitness. Again, physical examination and the opera
differently integrated hospital-community systems.
tion of equipment (ECG, spirometry) are further
The second miniclcrkship is in the hospital. Two
developed.
random patients are assigned to each student, who
follows them closely fora week from theiradmission
to the emergency ward until their discharge. One day
during this week is devoted to optional self
hospitalization, and a detailed analysis of the impact
The fifth program is geriatrics. The stations
include the geriatric department, the municipal
home lor the aged, community clubs for senior citi
zens, the geriatric social services and again, home
visits. In this program students acquire knowledge
of hospitalization upon various aspects of the
patients’s life is made. Finally, (he obstetric mini
clerkship includes participation in two deliveries,
of the aging process and the ability to assess the
physical, mental, social and f unctional status of the
elderly. They also further develop their nursing
skills. The teachers include physicians and various
careful follow-up of mothers and newborns, and two
home visits, before and after the discharge of the
allied professionals.
mother and baby from the hospital.
Concurrent with the five rotations are three longi
tudinal subprograms. The first, and the most
emphasized, is in communication skills. The stu
dents interview healthy and ill individuals, families
Wherever the students arc stationed along their
rotations, they apply knowledge and skills acquired
in the science courses simultaneously learned in the
classroom,
especially
biochemistry,
physiology,
and professionals. In each station they conduct
about one interview on every second clinical day in
the presence of their peers, the preceptor and some
epidemiology, biostatistics and behavioral sciences.
Simple diagnostic procedures such as blood counts,
times a behavioral scientist, and observe additional
aid measures are cither learned in the laboratory
interviews by peers. The interviews, relating to both
setting and applied in the clinical rotation, or vice
process and content, are carefully scrutinized by the
versa. Epidemiology and biostatistics help in gener
alizing patient problems.
spirometry, urine analysis. ECG recording and first
group and the instructors. A written summary of the
interview is submitted and corrected. In addition:
The ability to integrate other disciplines and to
each student is videotaped twice during the year, and
apply scientific knowledge to clinical cases is rein
the recording is analyzed privately with a social
forced by the Clinical Confrontation course. In this
scientist. At the beginning of the year the interview
course, students discuss in small groups a written
simulated patient problem, identify issues for
ees arc selected, and must be cooperative and
Hebrew speaking. Eater in the year, the students
further explorations, reconvene for exchange of
encounter less cooperative interviewees, as well as
talkative, silent, anxious and crying patients.
learned material, and gradually progress towards
solving the problem. During the process additional
information is provided, simulating changes in the
A second longitudinal subprogram is aimed at
sharpening the observational skills of the learners.
patient’s status, laboratory findings and the like.
Students report on their observations of patientsand
learn Io dillcrcntiatc between findingsand interpre
tations. objectivity and subjectivity. Small groups
Four 2-hour sessions arc devoted to each of the three
problems, and each is .summarized by a panel of
specialists involved in the case. The problems
selected for the 1st year arc childhood asthma,
Down's syndrome and an outbreak of gastroenteri
tis (33).
meet with hospitalized patients 10 times during the
year and report to those in the class who have not
seen the patients, yet must be able to perceive the
reported observations. The lack of “medical"
knowledge at this stage enables the students to be
Second year
unbiased by diagnoses and free of mind-sets.
In the third longitudinal subprogram, students
acquire first aid skills. This is the first phase of this
multiphasic emergency medicine curriculum, des
The 2nd-year ECP also consists of various compo
nents. the main one comprising six 1-weck mini
clerkships during the year in primary care, mental
health, nutrition, arteriosclerosis, infectious diseases
cribed elsewhere in this volume.
and cancer. Other components arc physical exami
nations. clinical confrontations and a public health
field project.
The primary care miniclcrkship is identical to that
The three l-wcek miniclerkships at the end of the
year include primary care, hospitalization and
obstetric programs. In the first, the students serve a
1831
• .L'JJHggHW
Israel J. Med. Sci
D. E. Benor
emphasis in this week is placed on the issue of death
in the 1st year, and provides each student with the
and dying.
opportunity to serve in another offered setting of the
Toward each of the last three miniclerkships, the
three However, in cor»traf-,t to the 1st year, the stu
students are engaged in intensive problem-based
dents systematically examine their patients, apply
self-learning activity. Written simulated case reports
ing the new skills that are acquired through the
for which each student learns one discipline in depth,
physical examination component of the 2nd-year
enable fruitful and lively group discussions. In addi
program. This includes 10 half-day sessions, also
tion, interdisciplinary seminars on the week’s
incorporating surface anatomy. The physical exami
themes are held every evening of the miniclerkships.
nation program evolves directly from the Ist-year
These may include selection of antibiotics, epidemi
observational skills course, attempting at this stage
ology of infections, carcinogenesis, basics of nutri
to achieve a systematic and thorough approach to
tion, etc. Knowledge gained from all basic science
examination, although not yet to attempt differen
courses, from molecular biology to pathology, as
tial diagnosis.
well as from psychology to medical ethics, is applied
The mental health miniclerkship deals specifically
in an integrated manner.
with simple reactive neuroses of the kind frequently
The 2nd-year ECP also includes the completion of
met by family practitioners. Students further
a public health field project by small groups. This
develop their communications skills, acquire psychi
project is based on the Ist-year courses in epidemiol
atric interviewing techniques, and become familiar
ogy,
biostatistics and research design, as well as on
with the scope and range of mental health services.
students
’ clinical experiences. Sometimes the stu
In the nutrition miniclerkship, small groups of
dents
select
the subject from a list, or it may be a class
students in various clinical settings learn how to
project
comparing,
for example, several aspects of
assess nutritional status, what people eat, and to
two
communities,
or,
more frequently, the problems
what extent patients comply with prescribed diets.
are
identified
by
the
students themselves through
Ethnic, cultural and sociological factors are consi
their
clinical
experiences
in the community. The stu
dered, and biochemical knowledge is applied.
dent
groups
gradually
develop
a detailed design and
The fourth miniclerkship stresses the concept of
protocol during two weekly sessions with a tutor,
natural history of a disease, using the model of arte
followed by data collection in the field. Later the
riosclerotic diseases. The students rotate in small
data are organized and analyzed, and the study is
groups through outpatient clinics for hypertension,
then presented to peers and faculty for feedback.
diabetes and peripheral vascular disease; they then
The hundred or so projects completed so far include,
move to internal medicine, coronary intensive care
for example, a comparative screening of growth and
and vascular surgery departments, and finally visit
development of children in various communities,
cardiac rehabilitation clinics.
prevalence of hypertension in two communitiesand
In the infectious diseases miniclerkship, the sta
its behavioral correlates, screening of kindergarten
tions are pediatric wards, neighborhood clinics and
children
for amblyopia, incidence of home accidents
preventive medicine laboratories and institutions. In
among
children
in various populations, the where
each station, the students interview acutely ill
abouts
of
patients
referred to hospital but not admit
patients, obtain the proper specimens for further
ted, suicide among adolescents, and anxiety among
investigation and prescribe, under supervision, the
hospitalized and nonhospitalized cardiac patients.
proper treatment. Knowledge and skills acquired in
The 2nd-year ECP also includes two I-day service
the science courses in pathology, microbiology,
periods in a mobile intensive care unit as a continua
virology, pharmacology and epidemiology are ap
tion of the Ist-year emergency care course. Finally,
plied. The efficiency of the treatment is assessed by
the Clinical Confrontation course continues. The
reexamining the same patients at the same sites
three patient problems dealt with in the 2nd-yeararc
toward the end of the week.
gout, immune deficiency and diabetes mellitus.
The 6th and last miniclerkship is devoted to
Tutored as in the 1st year, each case is analyzed by
cancer. Each student is assigned two patients, prefer
small groups in four sessions and summarized by
ably one who knows his or her diagnosis and one
interdisciplinary teams.
who does not. The stations include surgical and
medical wards, early detection clinicsand oncologi
cal institutes. Students also meet with volunteer
Third year
patients who have been cured of cancer and who are • Third year ECP covers the themes of emergency
care, the family and health education. Issues of
tutoring presently ill individuals. These tutors con
emergency care are incorporated into the classroom
vey to the learners their perceptions, expectations
studies of each of the integrated body systems. This
and feelings at the time of their illness. A major
[84]
Voi 23. Nos 9-10. Si ph mri r-Octobi r 1987
Fari y Ci inicai Program for Studi nts
theoretical knowledge is exercised in a 1-week
advanced life-support miniclerkship, which studies
the cardiovascular, respiratory and nephrological
systems. Several refresher sessions in first aid and
basic life-support skills precede the miniclerkship.
Monthly supervised evening shifts in surgical, medi
cal and pediatric emergency wards and in coronary,
respiratory and pediatric intensive care units follow
the miniclerkship.
The family program consists of a follow-up of a
family in which one member is chronically ill.
Biweekly meetings with the family are supplemented
by meetings with the family physician who is the
preceptor, and with social workers, psychologists
and psychiatrists, teachers and superintendents,
nurses and welfare workers and others, as approp
riate. The family dynamics and the impact of the
disease on everyday life are stressed. Communica
tion skills are further developed to include the art of
both interviewing a group and terminating longitu
dinal relationships.
The third track of health education is optional, yet
it attracts some 809? of the students. Each student is
assigned to two groups with whom he or she meets
weekly throughout the year to discuss health issues.
The groups are usually junior high school classes but
may also be young mothers meeting in a community
club, inmates in the local prison, illiterate adults in
their elementary education courses, etc. The issues
dealt with at the meetings range from general and
dental hygiene to sex education, and from normal
body f unction to tobacco, alcohol, and drug abuse.
In parallel, the students are engaged in additional
self-education. Weekly sessions deal with didactics .
of presentation as well as content-oriented sessions
on various health issues. The program was initiated
by the students, who also run and evaluate it with
help from faculty.
Finally, the 3rd-ycar ECP also includes simulated
patient problems within the framework of the clini
cal confrontations—such as cardiovascular, respira
tory, nephrological and endocrinological problems
in various combinations—and arc designed to pro
vide an opportunity to integrate knowledge across
systems and across disciplines. As in the previous
stages, each problem is summarized by a panel
discussion.
DISCUSSION
A complex, varied yet integrative ECP has been
presented. There is no doubt that the program meets
the requirements stated earlier; namely, it is compre
hensive, continuous and exposes the students to a
diversity of individuals and communities in a variety
of settings and situations. Nevertheless, a few ques
tions should be addressed: What exactly does this
program achieve? Is it really essential? Are there
perhaps simpler and cheaper ways to achieve the
same results? And further, is this ECP reproducible?
Can it be adapted to other institutions operating
under different conditions?
I believe that the ECP plays a majorand irreplace
able role in the professional growth of medical stu
dents, and that the graduates who have passed
through the program will be different from those
who have not. I urthcr, the program can be adapted
to many institutions.
The first advantage of ECP is the enhancement of
student motivation to learn. The freshman students
come to the profession to care for people and tocure
them. I hey did not intend to be engaged in tedious
learning of chemistry, physics and mathematics, nor
of biochemistry, histology and genetics. It is not the
cadaver on the dissection table of whom they
dreamed as their first patient. However, they accept
the importance of basic sciences if and when the
relevance to care and cure is both shown and felt. It
should be noted that relevance is not an intrinsic
quality of an external event. Rather, it is a psycho
logical construct which points to a congruence
between learner’s and teacher’s perceptions of the
educational experience (34). ECP provides the
opportunity to demonstrate how basic sciences fit
into real-life medicine, providing the basis for clini
cal solutions. The effect on learning motivation is
considerable and is well known to both students and
educators who have experienced ECP.
However, the effect of ECP on the professional
socialization of medical students reaches far beyond
the issue of motivation. The students’ initial desire to
care and cure (1. 35). sometimes called “healer’s
drive” (3), is traditionally channeled into the scien
tific approach from the start of their studies and
through an extensive period of the crucial, forma
tive years. This scientific approach is perceived by
the novice learner as a call for unequivocal answers
to the questions of causality, to be discovered by
tedious, objective, unemotional and painstaking
efforts (36). Ambiguity is tolerated as an unfortu
nate transitory phase until learning is completed or
until science further progresses to provide “the
truth.” Affect is totally deplored (36). The fact that
this is a false perception of science is irrelevant. The
students do not stay long enough in the scientific
milieu to outgrow this perception, which thus
becomes a factor in their professional growth.
Clinical reality is very different and is perceived so
even by the novice. It is willing to accept ambiguity
and to operate under uncertainty; it docs not require
reductionalism and allows multivariant causative
matrices, or may even ignore causality altogether.
185]
I
Israi i J. Mi d Sci
D. E. Benor
be reached in spite of incomplete or even conflicting
data. No simulation can compete with reality in
entangling organic,socioeconomical, psychological,
societal and environmental factors, bringing them
all into a matrix where they should be equally consi
dered in a “truly multidisciplinary context” (41). In
other words, although simulations may affect the
cognitive processes as ECP does, they have a lesser
effect on the socialization process because they lack
the experiential dimension. It is the confluent edu
cation” (12), in which cognitive and affective pro
37).
cesses are interwoven, which brings about the
The application of newly acquired knowledge to
change in personal growth (10). In fact, some
clinical situations within the framework of ECP ena
authors recommend that clinical experience precede
bles (he learners lo construct a comprehensive con
cognitive content learning in order to achieve the
ceptual frame by integrating across disciplines, both
desired educational effect (7, 42).
biomedical and psychosocial. This is very different
Acquiring communication skills, which atliactcd
from presentation ol integrated material by piopei
much attention in recent years (43), is an appropriate
sequencing ol the curriculum, because it is the
illustration. The period in which the students know
learner rather than the planner who is integrating.
little about symptoms and signs, syndromes and
The program thus becomes an “advanced organ
diseases, but empathize with people, is the best time
izer” (II) through active search for and discovery ol
to internalize habits ol obtaining inlormation
solutions to real problems (16, 38). Integration,
needed so badly for a good interview, yet so often
active learning and discovery are not ends in them
overlooked: Who is the person in front of you? What
selves. Nevertheless, they have been shown to
are her/his background, beliefs and values? How
improve recollection, to promote understanding and
does this person perceive his/her own condition?
to trigger high-level cognitive processes of problem
How does this condition affect her/his life? What are
solving. Education in which ECP is a central feature
his/her expectations, fears and hopes? What are
thus becomes a process in which questions are gener
her/his resources? Nevertheless, students in ECP do
ated and answers are sought, rather than the conven
relate to and learn of medical problems. It is the
tional process of providing answers to questions not
proportion between the narrow “medical” and the
yet asked.
wider health status that makes the difference.
Less crucial, yet worth mentioning, is the issue of
Similarly, learning observational skills at this
the joy of learning. Patient contacts, interdiscipli
early period demands that the students be able lo
nary approach to human problems and active prob
detect details without being distracted by diagnoses.
lem solving turn the learning into fun and the course
What kind of paleness is there? Is it whitish, blueish,
of studies into an enjoyable period rather than an
yellowish or gray, rather than is it anemia, cor pul
unfortunate but unavoidable preparation for hie.
monale, jaundiceor uremia. Moreover, the students
The effect of the joy of learning on the outcome of
arc expected to learn lo differentiate between objec
this learning in medical education has yet to be
tive observation and personal interpretations, and to
evaluated.
convey both in a way that enables the reader to
Could the same goals be achieved by a problem
differentiate between the two.
solving, problem-based approach, using written
Somewhat similar approaches lo teaching com
simulations in the classrooms and simulated or even
munication skills are seen in several programs else
real patients in the “clinical skill laboratory ? Some
where (24, 25, 43). Some were conducted within the
authors support this position, pointing to lavorablc
framework of psychiatric departments, some by
results in several innovative institutions (22, 39).
primary care departments and others by nonphysi
Without going into a detailed discussion, 1 agree that
cian experts; all have been reported to yield favora
some educational advantages may be achieved
ble results. However, it is possible that an isolated
equally by problem-based learning (40). However,
program will not have transferability to other disci
only real life, in which real people are looking for
plines and settingsand to future years. It is suggested
real solutions to real problems, can trigger such an
that the efficiency of the UCHSS communication
extent of personal involvement by the learner and
skills learning (44) is related to the fact that doctor
elicit maximal commitment. Only teal file provides
patient communication is taught in all the compo
such a variety of situations in which there are no
nents of the ECP, relating to real patients in the
right or wrong answers and in which solutions must
but it never deplores affectionate relationships.
Thus, the students who are exposed to ECP develop
different attitudes towards both science and clinical
medicine and to their mutual relationships. These
students may also later be spared the painful conflict
that often arises during the transition from preclinical to clinical phases. This conflict is resolved all too
frequently by cynicism and a further departure from
the initial drive to care for people, into what is often
mistakenly named “scientific medicine” (1,3,6, 35,
(861
Voi 23. Nos. 9-10. Sr pii mbi r-Oc tori r 1987
1
i
e
F.ariy CiiNrcAi Proc,ram j or Stiidi-nts
presence of physicians, usually the patients’doctors.
the public health projects and supplemented by
No transfer is required, only habit formation, which
information on health care planning. Most impor
is easier in the earliest phases of education.
tant, however, is the exposure of students to all these
So far, ECP has been discussed in general terms,
at the beginning of the socialization process and
regardless of the actual content of the program,
before a hospital-centered mind-set is created. Later,
provided that it exposes the freshman students to a
these students do not accept the existing services as
variety of situations in a real-life context. However,
an unchangeable factor.
the content may be so directed that additional, more
The educational activities in ECP follow the life
specific institutional goals may be achieved. UCHSS
cycle, which encompasses developmental processes
is committed to community health. The ECP des
and their interplay with emotional, mental and
cribed above enables the student to become inti
social dimensions of life. The students “discover”
mately familiar with a variety of communities, which
the multiplicity of elements that affect a child’s
differ from each other by ethnicity, socioeconomic
growth; they learn to perceive and appreciate the
variables, age distribution, occupation and geo
difference between middle-aged women with and
graphy. Learners serve in both formal and informal
without dependent children at home, and they
societal institutions, meet with professionals who
acquire a new insight into the issue of institutionali
are involved in maintaining health in its broadest
zation of the elderly. Most important, they accept
sense and visit homes and families. The students
these differences as part of the clinical reality rather
become aware of the impact of a disease on every
than irrelevant information imposed by behavioral
facet of life, and of the available personal and socie
scientists.
tal resources to cope with the ailment. The learning
Three dimensions have been mentioned above:
is gradual, with ever-growing levels of independent
the natural history of a disease, the life cycle and the
activity and responsibility.
available personal and societal resources forcoping.
ECP is partly organized around the well-known
Internalization of these by the learners in an early
model of the natural history of a disease, often
phase of their education enables them to consider
taught in medical
schools
but seldom
experienced
ctndpntc
nr-P
j
.
r-------------by
7
simultaneously all three dimensions, realizing that
t
ECr pr°V,deS the students with the oppordiseases present themselves differently, progress difnity to participate in primary and secondary prevferently and lead to different outcomes in each of the
entive activities, including health education; to take
small cubicles created by the three-dimensional
part in ambulatory care of chronically ill patients; to
model (Fig. 1). Each cubicle thus requires specific
witness the acute and sometimes heroic life-saving
management. As with the Rubik cube, students must
care in the hospital; and to be active in dcsigningand
spin the individual cubicles in order to achieve a
executing rehabilitations plans. The modern, glam
comprehensive solution.
orous hospital is thus perceived as but one short
Some difficulties in implementing ECP should be
phase along a long axis. It is necessary, yet some
addressed. The first is the need of central coordina
times implies a failure of proper care, which always
tion for integrating thedisciplinary components into
aims at keeping the patients in their families, com
a meaningful interdisciplinary sequence. Coordina
munity and work. Even the graduates who will later
tion is also needed because of the logistic complexity
select hospital careers will have regard for what has
of the program. Departmental chairpersons may
happened to their patients before hospitalization,
have difficulties in accepting such central control,
what will happen subsequently, and what the
not realizing that their autonomy to select contents,
patients feel and think about it. This proven long
to appoint teachers and to convey concepts is not
standing effect demonstrated by UCHSS graduates
threatened. On the contrary, the various clinical
(44, 45) may perhaps be attributed to the ECP.
disciplines gain additional curricular time in an ear
UCHSS students are raised to be change agents.
lier phase, while sharing the educational experiences
The institutional commitment to improve health
with other disciplines. Similarly, basic scientists who
care services requires a critical approach to the exist
are required to give up some curricular time in order
ing frames and models. ECP provides the elements
to make room for ECP cannot always realize that the
needed for such a challenge: the personal experien
learning of sciences may be greatly enhanced rather
ces in a variety of health care delivery systems; sensi
than cut back, these two difficulties require strong
tivity for health needs as these are perceived and
institutional leadership and a deep belief in ECP.
expressed by patients rather than by the medical
A more objective difficulty is the need for so many
establishment; awareness of resources; capability to
teaching sites and clinical preceptors simultane
work in broad, interdisciplinary teams; and finally,
ously. UCHSS has the advantage of controlling
proficiency in assessment of needs, achieved through
regional health services, as the Dean is also the
187]
.•sr»
-«
Israi 1 J. Mil) Sc I
D. I.. Binor
A
/ /' / / /iOBy
/
/
/
/
Com in uni IV lonnal
Community social
r*
• "Q
-Q
Nonintimate social
o
- 73
m
Intimate social
5
-n
m
tri
l amilial support
Personal strength
_____ .Mgi
[
NATURAL HISTORY OF A DISEASE
W'-‘
%
%
%
'%■
/
X .///
/ /
y </
\
&
%
Fig. 1. The disease cube—A
co in tn it n i t y-or ie n t ed a p proach to a disease entity.
requires no proofs). IICHSS is suggesting an innova
regional director of the health care-providing organ
tion that makes a dillerence. Will medical educalois
izations (46). However, many institutions have mu
accept the challenge?
tual relationships, both formal and informal, with the
health care delivery authorities. These may be used
for organizing 1 CT. Il is suggested that the willing
R| I-I KI NCIS
,
...
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versity Center lor Health Sciences. Ben-Gurion University
that leaching interferes with practice is greatly exag
of the Negev. Beer Sheva. Israel: an inlci ini repori. in: Kai/
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6.
more willing to participate in teacher-trainingactiviEdncSy.W-W.
7. I louts P and I lend) R Ji (1976). I caching bchas .oral modi
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delia. Kalama/oo. Ml.
i.
institutions may lake advantage of whatever facili
Nadclson CC. Noiman M'l and Poussaml Al (I
l ‘1'1>
X.
ties and professionals are available, instead ol look
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I dm 5?: 6K3-6K5.
9. Mel iaghie WC. Millci ( d . Sand AW and I eldet I V (I97S)
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“Compclcncv-bascd curriculum development tn medical
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It is often argued by traditionalist medical educa
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that innovation (as if the traditional approach
10.
II.
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Health Pol Educ I: 291-300.
THE FLUCTUATING
FORTUNES OF THE BEHAVIORAL
SCIENCES
AARON ANTONOVSKY
Department of the Sociology of Health. University Center for Health Sciences and Services, Ben-Gurion University
of I he Negev, Beer Sheva. Israel
Isr J Med Sci 23: 1022-1026, 1987
Key words: Beer Sheva Experiment; medical education; sociology of medicine; communications
In 1936, Dr. Henry E. Sigerist, some years after
leaving Leipzig to join the Johns Hopkins faculty,
addressing a conference of medical students (1),
said:
It was essential, the Commission argued (para 108),
that the medical student be aware:
why patients and families behave as they do in
situations of illness; of the social and cultural fac
tors which influence the patients’ expectations and
responses; of the problems for doctor, patieqt and
family in management of illness and handicap in the
community; of the social, ethnic, occupational and
psychological forces which can hinder prevention
and treatment; and of the difficulties of communica
tion and other problems which arise from estab
lished expectations about the way a person in a
defined situation will behave, particularly in
hospital.
I anticipate your question, “What shall we do?” My
answer is: study. Study history, political economy,
sociology! I know that your time is limited and that
the medical curriculum is exceedingly absorbing.
And yet, if you want to live and to act consciously
and intelligently, you have to have some knowledge
in the social sciences.v And finally you cannot
afford to be disinterested in sociology. The physi
cian is serving society, lie has to fit himself into a
given structure of society. He has to see patients
who come from all strata of society and has to treat
diseases that are quite often due to an environmen
tal influence... if we have troubles today, they are
due to a certain extent to the fact that our medical
ancestors of the last century directed all their efforts
to laboratory work, neglecting the social side of
medicine.
But such knowledge was only essential if a farreaching assumption, involving a fundamental con
ception of medicine, was made. Jefferys (3) put the
issue most directly:
Almost 40 years later, medical education through
out the Western world still largely disregarded Sigerist’s oft-repeated statement that medicine was also a
social science. Lip service was paid here and there.
But the 1965 Royal Commission on Medical Educa
tion (2) still saw as revolutionary its belief that soci
ology as well as psychology were disciplines as
essential Io medicine as were the biological sciences.
if the doctor ol the future is seen simply as one who
is concerned exclusively with the physiochemical
properties of man and his organs, then all he may be
required to learn while a medical student is enough
to enable him to display skills and sensitivity in his
relationships with patients and other health profes
sionals. [However] if the doctor of the future is to
take a wider responsibility for the range of human
problems which can undermine social functioning
and a sense of well-being, then his need to be well
grounded in the behavioral sciences is paramount.
Address for correspondence: Dr. A. Antonovsky. Department of
the Sociology of Health. University Center for Health Sciences
and Services. R^n-Gurion University of the Negev. FOB 653,
84105 Beer Sheva.
One point should be clear at the outset. The two
conceptions do not differ at all with respect to the
centrality of humane values—decency, honesty,
empathy, responsibility and so on—in the practice
of medicine. No proponent of the broader concep
tion can legitimately claim that the behavioral
[90]
Vol. 23, Nos 9-10, Sf.htmblr-Octorfr 1987
BniAVIORAI Sciincfs
scientist can teach students to behave decently. If
anyone can “teach” such behavior, it is the clinician
who is adopted as a role model by the student.
Having said this, however, it should be noted that
what the behavioral scientist can teach in this respect
is an understanding of the psychological, social and
cultural conditions that promote or impede such
physician behavior. But the true expertise of the
behavioral scientist is indeed in understanding the
range of human problems noted by Sigerist and
Jefferys.
As is amply clear in the introductory papers to this
volume, one might even say that the core of the Beer
Sheva Experiment was a commitment to the broader
conception of medicine. With respect to the behav
ioral sciences, this was expressed institutionally in a
number of ways. One of the first units to be estab
lished in the school was the Department of the Soci
ology of Health. Its small staff, consisting of two
medical sociologists, a medical anthropologist and a
political scientist, was to be enhanced by involving
other faculty members, particularly clinical psychol
ogists and social workers, as well as clinicians, in its
teaching responsibilities. The faculty bylaws pro
vided for a representative of the behavioral sciences
in the two major policy-making bodies, the Execu
tive Council and the Curriculum Committee. From
the very outset, behavioral scientists participated in
most of the committeesplanningone or another part
of the curriculum. The hours devoted to the behav
ioral sciences were never a source of contention.
There was a consensus that time allocation was to be
determined by the significance of what was to be
learned. Above all, the very powerful Dean and the
Associate Dean for curriculum, as well as the key
professors attracted to the school, were on our side.
Finally, and not coincidentally, the fact that the first
chairman of the Student Admissions Committee,
who was the first representative of the school met by
new students, was a sociologist conveyed the mes
sage that his was an important discipline.
The Beer Sheva Experiment at the outset, then,
seemed to provide promising opportunities for the
successful integration of the behavioral sciences into
the curriculum. Let us now turn to what was done,
what happened, and uhere things stand at present,
finally returning to the lessons to be learned.
an appendage to psychiatry, epidemiology or com
munity medicine, how is it to be fitted in? Tradi
tional medical schools have difficulty in answering
this question because their thinking is molded in
terms ol a triparlitc division of the curriculum into
basic sciences, medical science and clinical studies.
The behavioral sciences, relevant to all three parts of
medical training, cannot be fitted into this mold. The
Beer Sheva curriculum, based on the principles of
the spiral, is a much more hospitable framework.
Operationally, it follows that its teaching must be
conducted throughout the 6-ycar curriculum and
fitted in an appropriate manner into whatever else is
included each year.
Second, although .the behavioral sciences have
loosely meant psychology, social psychology, sociol
ogy and anthropology, each a different discipline
with its own concerns, traditions and questions, our
assumption was that it would be a mistake to engage
in disciplinary teaching to medical students. Instead,
we started out by seeking to specify “What are the
problems with which the graduate physicians of Beer
Sheva will be confronted?’’We would then address
ourselves to teaching skills, attitudes and knowledge
of our disciplines relevant to coping with these prob
lems. The assumption was that, in the Beer Sheva
curriculum, there is almost always a behavioral sci
ences “angle” to what is being studied. Thisdoes not
mean that organizationally the behavioral sciences
must always be part of another program. It does not
mean that the relevance should always be clear.
But clear to whom? We made the assumption—
unwarrantedly, as will be seen later—that what we,
the behavioral sciences, saw as relevant to the Beer
Sheva graduate practicing physician would also be
seen by our students and by our medical colleagues
as relevant.
Finally, we thought it crucial to have students
learn the key concepts with which we work and the
kinds of questions we ask, rather than the factsand
findings of empirical studies. While the data do sug
gest that a widower is in a high-risk category in the
first half year, it is far more important for the student
to learn that developmental transitions always pose
health problems.
THE CONCEPTUAL APPROACH
If the behavioral sciences constitute an independent
field that merits an autonomous place in the struc
ture and curriculum of a medical school*, and not as
♦This autonomy, as that ol all other fields, is qualified in
Beer Sheva, given the fundamental principle of vertical
and horizontal integration of the entire curriculum.
[91]
nr
THE EARLY YEARS
Had we had a long lead time, we might well have
worked out a total curriculum. As all who were with us
in the heady early years recall, we seldom were more
than a step ahead of the students. In 1974, we planned
for 1974-75, and most of our energies went into carry
ing out the plans. In 1975, we planned the second year
of studies, carrying a 2-year teaching load. By 1977-78,
we had a 3-year teaching curriculum.
Amonovsky
The first component of this curriculum was selfevident—the first-year program in Communication.
This flowed from the fundamental decision of the
school that clinical work was to be introduced at the
very outset of studies. There were many clinical skills
and areas of knowledge a first-year student could
learn, but at the very core, we all agreed, was talking
to the patient (or, rather, as we stressed, listening to a
person). The course was coordinated by behavioral
scientists, but psychologists, social workers and cli
nicians were all involved in the teaching conducted
in small groups. Over the years, there have been
various modifications of this program, but its essen
tials have remained the same.
A crucial problem may be noted. Few physicians
have even been trained in communication. They
record a history skillfully, germane to the particular
presenting problem, but have neither the skill, the
conceptual approach, nor the time to listen to the
person adequately, to establish a relationship that
would enable them to acquire rounded understand
ing. Our goal was to have the Beer Sheva student
learn to conduct an interview the way a family physi
cian—in the first encounter with the patient—
ideally should. On the other hand the behavioral
scientist, in the eyes of the student, is not a real
doctor, even though he is skilled in communication.
Sometimes this led to conflict: more often, the busy
clinician was glad to leave the teaching to the behav
ioral scientist. Over the years, a few physicians have
become skilled. In other cases, a physician and
behavioral scientist formed a team, complementing
each other, each learning from the other. Despite the
problem, this is one of the areas of success in the
curriculum. Reinforced by continued interviewing in
the 2nd and 3rd years, the Beer Sheva student, enter
ing his 4th-year clerkships, is far ahead of his peers
elsewhere.
Parallel to the life-cycle approach adopted in the
first-year clinical program, our first behavioral
science didactic course was the Normal Life Cycle.
Carrying on throughout the year, class lectures
traced the emotional, social and cognitive develop
mental lifelines, largely following an Eriksonian
model. In each session, there was some attempt id
locate developmental challenges in the context of
culture. I n a few sessions, physicians were brought in
to speak of the physiological lifeline as it interacted
with the other lifelines.
Though not taking a major active role in teaching,
behaviorial scientists were represented in the com
mittees planning the Ist-year clinical program (over
and above communication) and ecology projects.
Beer Sheva’s 2nd year has traditionally been the
most disciplinary. In keeping, the behavioral science
IsRAI I .1. Mil) S( I
input in the first years consisted of two didactic
courses. The first, called Society, Culture and Health,
aimed at equipping the student with basic concepts
in social anthropology. The examples given, the
problems posed and the exam questions were all
health and medicine oriented, whether the topic was
culture, ethnicity, family or social stratification. It
was. nonetheless, a course that required a leap of the
imagination. The second course was primarily an
introduction to basic principles of psychology:
intrapsychic processes, learning, perception and
cognition. Both of these were semester-long courses.
The overall 3rd-year program is based on organ
systems. No attempt was made to link the behavioral
sciences in any way to this program, though epide
miology was occasionally represented. On the other
hand, the 3rd-year clinical program was the primary
responsibility of the behavioral sciences: the Family
Program. In this project, each student, starling from
an index person with a chronic illness, maintained
ongoing contact with a family lor a period of 4 to 5
months. The goal, beyond deepening the communi
cation skills of the student, was to create an under
standing of the family as etiologic agent, as coper,
and as the bearer of the impact of illness. Each team
of students was tutored by a behavioral scientist
physician pair.
THE INTERIM PHASE
By the end of the 4th year (1977-78). a reassessment
was due. Clinicians responsible for the 4th- to 6thyear clerkships had not cxMlly come knocking at
our door for help. Our resources in any case were
stretched. (It should be noted that as scientists in an
academic department, we conducted a respectable
research program, over and above our teaching
responsibilities). The communication program was
going reasonably well. The family program was
more complicated. Going out into the community,
into homes, and developing an ongoing relationship
with a family was immensely anxiety provoking.
“What right do we have,” many students asked, “to
probe deeply when we are in no position to really
help?” For some students, the program boomerangcd. Others somehow glided through, learning
little but not becoming too upset. For still others, it
was a moving and maturing experience. Modifica
tions were subsequently introduced, but in principle
the program remained throughout the decade.
The didactic programs in the first 2 years, in con
trast, were problematic from the outset. Attendance
(not compulsory in Beer Sheva except for clinical or
lab studies) declined, often to less than half the class.
Few students read even the required reading. There
were no qualifying disciplinary exams. and one
192J
sB
Vol 23, Nos 9-10. Si I’ll MUI r Ooiobi r 19X7
Bl II W KiRM S(ll
could easily pass the integrative exam without the
behavioral sciences. The complexities, “soft" data
and competing theories ol the behavioral sciences, in
contrast to the seeming certainties of the natural
sciences, often led to the challenging “How do you
know?" Students, having been social beings forover
two decades, often manifested the alternative
responses: If something (hat was said accorded with
their experience they responded with. “So what’s
new?"; if not. (heir response was “It's not true." But
above all, the repeated question posed was that of
the irrelevance to becoming a doctor. The leap of the
imagination was indeed difficult.
These dissatisfactions led to a restructuring of the
program. Deciding on a considerably greater invest
ment of resources (al the cost of forgcltingaboul the
4th to 6th years), minicourses were instituted. The
group of 10 students participating in a 1st- or 2ndyear clinical program for 5 weeks met weekly with a
behavioral scientist, clinical psychologist or social
worker. Starting from a case history, the sessions
were devoted Io exploring how the concepts w'c use
(a dictionary ol over 200 concepts was compiled )a re
uselul in understanding (he clinical progiam. the
patient-doctor interaction, or the workings of the
health care system. We would, wc hoped, in this wav
solve the problem ol relevance while smuggling in
the conceptual tools of the behavioral sciences.
It was sadly amusing to hear, at the end of the 1st
year of minicourses. that they were too athcorctical.
In response, wc reinstituted, in briefer version, social
anthropology and psychology, f-or the next 5 wars
(I978-X3) (hen. the behavioral sciences input into the
curriculum consisted ol: Communication and mini
courses in Year I: brief courses in social anthropol
ogy and psychology and minicourses in Year 2: the
Family Program in Year 3: and occasional single
sessions in (he Introduction to Clerkships, primary
care and psychiatry clerkships in Years 4 and 5.
When the first class had reached its final year, wc
also took part in a full-time 2-wcek program. The
Physician and Society, in which competing para
digms. from the biomedical through the Marxist
institutional model, were analyzed.
AT Till: END OF A DECADE
Wc had had all (he possible advantages that should
have facilitated making the behavioral sciences a
resounding success. What should be added is (hat in
a survey of students and faculty al (he end of the
decade, a clear ma jority were very positive about the
importance ol the behavioral sciences in the medical
curriculum. Yet consensus was clear: in reality, the
dissatisfaction that had been with us throughout
was. il anything, sharper. 1 here was some anecdotal
(93 |
evidence that some upper level students and gradu
ates. thinking back, were beginning to sec that they
had indeed learned something that was important to
them as physicians. But there is no wavofdisregard
ing the cold fact of dissatisfaction—far from total or
universal, but nonetheless very real. What had gone
wrong?
I can. ol course, only seek to answer this question
with all the disadvantages and advantages of the
insider, as the key person throughout the decade
responsible for coordinating and carrying out the
teaching of behavioral sciences in Beer Shcva. Hope
fully. my training as a sociologist is of some help in
maintaining detachment. I could identify four
factors.
First, there is (he 'undeniable fact that ol the 10
behavioral scientists who have been directly
involved in the teaching over the years, the quality
has been variable. This is no less the case for the
clinical psychologists and social workers who haw
participated in teaching. One or two have been quite
good, particularly in some areas: one or two were
rather poor. Mos I have been icasonablv < < mipclt nt
worked very haid. picpaicd well—but didn’t can\
things oil. What has become quite clear is that a
microbiologist or clinical teacher can afford to be
reasonably competent: a behavioral scientist, (cach
ing “what everybody knows." must simply be wry.
wry good il he or she is to succeed. Such teachers are
rare, and seldom can be attracted to medical schools.
When to this is added the fact that in (he eyes of the
students they are not being taught by “real" doctors,
even the very good are handicapped.
Second, one cannot escape the reality of priority
setting by the student. Most acute in Beer Sheva's
second year, because of an overloaded schedule it is
endemic throughout. At the end of a decade, the
dean decreed a 15% cut in curriculum hours: the
problem of reading load is yet to be solved. The
best-meaning and motivated student, confronted by
an impossible load, sets priorities, and the first to be
cut is invariably preparation for. or attendance at.
behavioral sciences programs. Add to this the fact
that the papers important and fascinating to us are
oltcn seen by medical st udents as written in a foreign
language, devoid of hard facts, speculative and bor
ing. and lack of preparation for class becomes near
certain.
Third, students transmit messages. As the older
students moved into the advanced years, and their
clinician teachers were largely oblivious to (he need
to reinforce whatever may have been learned in the
earlier years, either through biinj’ing in bchavioial
scientists or themselves relating to behavioral
science issues, (he message was passed down: “You
ISRAI I J. Mil) S( I
A. Antonovsky
needn’t pay much attention to this.” Over the
vein is. 1 believe, at the core of our fluctuating
decade, we had little or no inlluence on the clini
cians, who remained by and large friendly but
unlearned. '! he fault is perhaps more ours than
theirs. The fact remains.
This third issue leads us to the fourth,an issue (hat
may well be the most fundamental one. In consider
fortunes.
ing it. I have often thought of the son who is de
scribed in the Passover Hagada as “he who doesn’t
know to ask.” (’lose analysis of the by-now quite
considerable literature about the bio-psychosocial
have done and what we have learned. With this
focus. 1 may well have sharpened and exaggerated
the shortcomings and frustrations, and underesti
mated I he successes. Many who have observed our
model reveals that what most authors really mean is
graduates have commented that, somehow, the
the psychology of the individual patient, and some
behavioral sciences have indeed rubbed off on them
LOOKING AHEAD
This issue of the ISRAI I JotiRNAI Ol Ml DICAI
S( il N< I s was not intended to be a celebration of
Beer Shcva. but a sharing with colleagues of what we
times family interaction. Clinicians liberated from
considerably. We prefer not to comfort ourselves,
confinement to the biomedical model may ask about
but to face the difficulties squarely. Al the time of
the patient’s anxiety or defense mechanisms, but
writing, we have just gone through a fundamental
they rarely have learned that there are questions to
ask beyond this. In contrast, the strategy upon which
reassessment of the behavioral sciences in the curric
the teaching of the behavioral sciences in Beer Shcva
had been based is far broader in concept.
would take us beyond the province of this volume.
Whatever happens in Beer Shcva. the fundamen
ulum. and have instituted changes. To discuss these
This conception has been spelled out elsewhere in
tal challenge confronting us and all our colleagues
detail (4). It encompasses societal and cultural fac
tors in etiology and coping with illness: the psychol
elsewhere is how we will respond to Sigerist’s chal
lenge with which this paper opened. We can retreat
ogy of the doctor as well as the patient, and the
organizational factors that shape their behavior: the
social organization ol health care systems: the rele
to biomedicine: we can modify this by including the
psychodynamics of the patient in the doctor’s oil ice:
or we can. with Sigcrist. see medicine as being also a
vance to medicine of alienation, social mobility, sub
social science. As I have indicated, this is far from
cultural norms, historical context, iatrogenesis, and
work stressors. Ami much more. But. as I have noted
above, it requires a leap of the imagination for the
being the only problem, but it may well be the heart
of the mailer.
student (and clinical teacher) to see how knowledge
and imdcistanding ol sm h matlvis wdl make
hi in/he i a be 11 ci docloi. Ol it icquiics lailh. sin. h as
that extended to biochemistry, that they arc indeed
relevant. And. perhaps, it requires superb teachers.
Il is much easier to equate the bchaviorial sciences
with the internal dynamics of the patient. The fact
Rl I I Rl NCI S
Roemer Ml (Id 111960). “Henix I Sigerisi on the socio logs
I
ol metliiiiie " MD I’nlilu nlions New Yoi k g V D
(|lh.S> ■■|6 |n>il <>| lire Ro\.il ( olilllii'.' ioll oil Me«ln .11
I iliu :ilion
( oiiini.Hid D6‘> llci M.i|es|\’s Stahonvi \
()llice. I ondon.
.IcIIcias M ( 1974) Social science and medical education in
3
Biitaiir .i socioloi'ical analysis ol ilicir relationship hu ./
4
that we have failed to educate the clinicians in this
| 941
Ih iihh s< m I s t*)
Antonoxskx A (1977). Rapports cnirc la pratique cl la
lormaiion mcdicalc I a contribution des sciences du comporicmcni A’ci A/< it Xiio w 97: ?37-247.
THE COMMUNITY-ORIENTED PRIMARY CARE CLERKSHIP
CARMI Z. MARGOLIS. NUR1T BARAK.
BASIL PORTER and KARL SINGER
Primary ( are Unit. Division of Health in the Community. University Center for Health Sciences and Services.
Ben-Gurion University of the Negev. Beer Sheva. Israel
/.vr ./ Med Sei 23: 1027-1034. 1987
Key words: Beer Sheva Experiment: medical education: primary care: clerkship
The authors feel that the Beer Sheva primary care
clerkship differs in two ways from those in general
evaluation. The process of developing a health
science curriculum backwatds from a performance
practice, family medicine, and community medicine
described elsewhere in this issue. First.it providesan
opportunity to teach a major medical school
clerkship whose goal is the preparation of students
specification has been described by Segall cl al. (2),
while Miller (3) and Simpson (4) described the
relationship between instructional objectives,
teaching methods and evaluation in a medical
to practice primary care in the same health service,
and often in the same regional service, in which they
context.
were trained. Second, in the practice setting of
Kupat Holim (Health Insurance Institution of the
General Federation of Labor), the clerkship has as a
major goal not only the teaching of primary care
clinical skills, but also community-oriented skills
(I),
such
as
community
data
collection
.Job description of the Israeli primary care
practitioner
Overaperiod of 4 months early in 1978.a 14-pcrson
team met weekly for 2 hours to write the job
description. The 14 team members comprised an
and
expanded clinic team that included physicians,
nurses, clinical psychologists, administrators and
others. Using nominal group process (5). team
community problem identification. Third, it is
possible in Beer Sheva to evaluate not only the
process of the primary care clerkship but also its
outcome. In this paper, we shall describe the
planning, implementation, and process evaluation
of the Beer Sheva community-oriented primary care
(COPC) clerkship, both as a case study of the
integration of COPC into a medical school
members closest to a particular subject area wrote
that part ol the performance specification, which
was then submitted for discussion and modification
until consensus was reached. All section headings of
the job description arc listed in Table I. Four
detailed examples follow (complete copies of the job
description and the clerkship objectives in English
curriculum, and in order to determine whether such
a clerkship indeed prepares and influences students
are available on request):
“1.1: While the physician is evaluating the situation
to practice COPC. Outcome evaluation will be
touched upon, but is outside the scope of this paper.
PLANNING
The clerkship was planned in the following lour
stages: final performance specification, instructional
objectives, clinical clerk's job description, and
Address lor correspondence: Dr. C. 7 Margolis. Primary Care
I 'mi. Division of I leahh in the ( ominunilv I Imversiiv ( eniri loi
Health Sciences and Sei vices. Beh-Ginion University of the
Negev. POB 653. 84105 Beer Sheva.
and identifying the problem, he should create a
rapport with the patient, relating particularly to
what is said ‘between the lines’."
“1.2: ...will determine the individual's status witliin
the family life cycle."
"1.3: I be physician will view himsell as a
professional with obligations toward the com
munity. and feel the need to help solve its problems.”
2.2. I he physician will be able to make diagnostic
and therapeutic decisions in the defined subdivisions
of all the most common problems in primary care."
|95|
C /. M AIU.OI IS I I Al
Israi i .1. Mid S< i
I able I. Outline oj tub description for the Israeli primary care
pra< titioncr
Ta b I c 2. Com m uni t) -orien I cd primar i • care clerkship: summary of
instructional objcctive.v1
Attitudes
I <>watd the individual
I I
I oward the family
1.2
1.3 Toward the communil\
I 4 I oward his work
I.
3.
4.
5.
6.
7.
Cognitive skills
2.1
Basic knowledge
2.2 Primary care knowledge
2.3 Cognitive skills in community medicine
8.
9.
10.
11.
12.
Ad ministration
3.1 Knowledge of health and welfare services
3.2 Definition of the primary care physician's
Instructional objectives
clerkship
following
goals
were
Table 3. Sclecteil clerkship instructional objectives and matching
tasks from the job description
defined:
knowledge of common organic and psychosocial
primaty care problems of children, adults, and
families: skills in community problem identification,
planning and follow-up; effective skills and attitudes
appropriate for the primary cate practitioner; and
skills and knowledge in clinic management.
Using Mager’s method (6), these goals were
further specified as 12 major instructional object
Inslniclional objective
1-3."
Data collection,
problem
identification,
planning and follow
Problem-oriented
recording
Approach to common and
uncommon problems
(2.2b cognitive skills)
5-8."
Altitudes while
gathering data,
identifying problems,
planning and follow
Attitudes toward the
individual and the family
(l .l: l.2b altitudes)
related to tasks in the job description. For example,
objective 5.0 states in part that, “when the student
patient,
messages;
with
up
he or she will demonstrate the
establish
special
impart
contact with the
attention to nonverbal
Approach to common and
uncommon problems
(2.2’ cognitive skills)
4."
and Table 3 shows how selected objectives are
following attitudes:
Task I’rom job description
up
ives, 4 of which were further specified in 17
subobjectives. Table 2 lists the 12 major objectives
collects data,
problem
1 This table presents the titles of the 12 sections of the set of
instructional objectives. Each section contains from I to 1 I
speciTic objectives, written in Mager’s (6) formal.
administrative functions
The
Data collection lioni patients and families
Problem dclinition in patients and families
Planning and follow-up
Problem-oriented recording
Altitudes while collecting data
Attitudes while identifying problems
Altitudes when developing a plan
Attitudes during problem follow-up
Community problems: data collection,
identification and planning
Attitudes towards one's work
Social institutions
Organization of the services
confidence;
define
the
9."
Community data
collection, problem
identification and
planning
Altitudes toward the
community (l.3b attitudes)
IO.a
Student’s attitudes
toward his work
Practitioner’s attitude toward
his work (1.4b altitudes)
visit;
attempt to understand the patient’s personal and
cultural perception of his illness: search for the
illness’ impact on the patient’s life and job; evaluate
the effect of the stage in the patient’s life cycle on his.
problems: define the stage of the patient's family life
cycle, e.g.. couuship. marriage, etc.; evaluate the
Numbers refer to those in Table 2.
b Numbers refer to those in Table I.
patient's economic, errfotional and social resources
and their relationship to family roles; define the
interactions between the patient, his illness and his
family (7).”
Clinical clerk’s job description
Once goals and objectives were defined, the
department chairman (C.Z.M.) and two other
prospective preceptors defined the clinical clerk’s
job. Supervised job performance and required
classroom learning sessions were chosen as the
clerkship teaching methods. Thus, the clerk’s job
included the following Five sorts of tasks: evaluating
clinic patients; community work: work during the
afternoon (when
the clinic is closed) including
evaluating a family in depth; small group teaching
sessions; and videotape sessions. Three of these tasks
were divided up into 12 subtasks. For example,
“evaluating a patient with a common problem
(clerkship objective 1.0)” required a “history,
physical examination and problem-oriented medical
record appropriate for the problem, either as defined
by a clinical algorithm (if available), or according to
the students’ judgment.” In order to learn
“community data collection (clerkship objective
1.1), the student must keep a separate log of all
patients that he examines, including data on
identity, age, sex, complaint, diagnosis and referral
(if any). Al the end of the clerkship, the student will
|96|
Vol 23. Nos. 9-10, Si pthmbi r-October 1987
Primary Carl Ci lrkship
summarize the data using simple descriptive
statistics.” To learn to collect data about and
identify family problems (clerkship objective 2.0),
“each pair of students is required to work up and
present to the clerkship one family in detail,
according to the method defined by Medalie(8). The
students must interview and examine all family
members and must make at least one home visit:
most of the workup will be done outside the clinic.”
must be coordinated. Thus, the clinic-based
clerkship is organized like a wheel, of which the
medical school department is the hub and the clinics
are the rim. The wheel will roll only if its
independent parts perform their independent
functions and cooperate with each other fully.
Central functions
The “Primary Care Clerkship Manual" was first
written in 1978 and has been revised in each
succeeding year. It includes the clerkship goals and
objectives, the student’s job description, the
procedures for evaluating both the student’s
performance and the ’clerkship, tables of
organization of community institutions in general
and Israeli community institutions in particular, lists
of common acute and chronic primary care
problems in children and adults in Israel, the UK
and the U.S., and a list of course textbooks.
Since preceptors, unlike hospital faculty, do not
work in an academic environment, teacher training
(9) for both new and experienced teachers precedes
the beginning of the clerkship each year. I he
training aims to clarify clerkship objectives and ad
ministrative arrangements, to provide practice at
specific teaching techniques, to clarify evaluation
methods, and to decrease the anxiety of the
practitioner who has never taught before. We have
trained teachers both in weekly short seminars over
a 4- to 6-week period and during day-long
workshops. Special topics covered have included use
and audit of problem-oriented records, teaching
tutoring skills using videotaped simulations of the
tutoring process, using a checklist to evaluate the
student’s management of anamnesis and physical
examination, teaching communication skills, and
use of computerized patient management problems
and clinical algorithms to teach workup of specific
problems.
Community Project
The community project was almost always
completed during the 6th-year rotation. Students
were given “project templates.” which consisted of
guidelines for performing projects on anemia in
children, identifying patients with hypertension,
preventing smoking, and screening for parasite
infestation in children. Guidelines included
definition of the project goal, objectives, methods
and identification of a data source that would
provide data suitable for studying the problem in
question. Students could study the problems
outlined in (he templates, or could choose a question
of interest to themselves and their clinical tutor,
which would then have to be approved by the
community project consultant. The consultant was
cither a clinician with epidemiology training or an
epidemiologist, who introduced the project on the
first clerkship day, was “on call” for questions, and
had at least one meeting with each student before he
presented his project on the last clerkship day.
Students were also required to submit the data from
the project to the clerkship coordinator.
IMPLEMENTATION
The clerkship was taught for 4 weeks in the 5th and 4
weeks in the 6th years, which arc similar to the 3rd
and 4th years in a U.S. medical school. The chief
difference between implementing a hospital
clerkship and a clinic or practice-based clerkship lies
in dif f ering organizational arrangements. Whereas a
hospital clerkship takes place within a single
department and can usually be monitored directly
every day by the responsible educational
administrator, even if students arc working in
several wards, a clinic-based clerkship always takes
place in several different clinics. Most of these arc at
some distance from the medical school, all arc
independent units, and none can be monitored
directly from a central office on an ongoing basis.
Implementing such a clerkship requires two
different sorts of managerial techniques. First,
central tasks to be performed by the medical school
department must be defined and executed. Second,
tasks to be carried out by preceptors and their teams
Matching students with clinics proved an
unanticipated problem that resulted from two
interrelated causes: varying distances of clinics from
the medical school, sometimes greater than 50 km.
and limited mobility of the student, who may have a
family and a job. Our solution was to provide
students with descriptions of all clinics in advance,
and to let them choose the clinics they prefer. The
clerkship coordinator spends about 4 days matching
students before each rotation. Even if the student
gets his/her preference, public transportation to
• some clinics is inconvenient, and the medical school
can afford to subsidize only public transportation.
Transportation problems severely limited our initial
objective of providing every student with one
rotation outside the Beer Shcva region.
f97|
—~ — - 'ii
■ m MMii—I
ISRAFl J. MFD SCI
C. Z. Margolis et al
On the introductory day, all students come to the
medical school for an orientation, including: a
discussion of the concepts of primary care and
family medicine; receiving and reading through the
entire syllabus manual together, including the
clerkship schedule; and reviewing criteria for doing
the family and community projects and
presentations. Day-release (when students are free
to attend group lectures at the medical school)
activities are held at the medical school weekly and
on the last clerkship day; they include discussions of
approaches to common clinic problems, practice at
small group communication skills, using videotapes
of student-patient interviews, family presentations,
community project presentations, and a final
examination consisting of multiple choice questions
and patient management problems. The teaching
process and student experience arc monitored by
one of five or six f ull-time or part-time members of
the Primary Care Unit who visit each clinic at least
once and frequently twice during each rotation. At
these visits, all clinic-based teaching and learning
activities are reviewed with the student and the
preceptor according to a checklist.
The preceptor’s other tasks include helping the
student to choose and prepare his family for
presentation in the clinic and helping him to choose
and prepare his community project. The preceptor
also facilitates the doctor-patient videotape session,
in which a communications expert from the Primary
Care Unit videotapes one or two student
interactions and reviews the tapes with the student
and his preceptor.
EVALUATION
Planning
We feel that much of the vagueness in
conceptualizing clerkship evaluation would be
dispelled by separating educational process from
outcomes, as has been done in evaluation of health
services (10). Outcome evaluations, consisting of
measures of primary care career choice and
measures of the quality of primary care practiced by
graduates, are ongoing and reflect a complex of
factors of which the clerkship is only one. Results by
date are limited by the small number of graduates.
Presentation of outcome evaluations would
therefore be both premature and outside the scope of
this paper. Our process evaluations are of the
following three types: cumulative evaluations(1 l)of
Peripheral tasks
achievement
of clerkship objectives; formative
The student spends all of his time in the community
evaluations;
and
evaluations by the students in the
clinic except for his weekly day-release activities.
form
of
debriefings
and written student evaluations.
The main task of the clinic and the preceptor is to
Evaluations
listed
in Table 4 were designed to
model the environment and role of the Israeli •
determine
whether
or not a student achieved the
primary care practitioner. The student is first
clerkship
objectives.
Our choice of evaluation
introduced to (he clinic, its staff and neighborhood,
sometimes by means of a walking tour guided by the
Table 4. Process evaluations of community-oriented primary care
clinic manager. For the first few days, the student
clerkship objectives
observes his preceptor. When the preceptor feels the
Clerkship objective evaluated
Type of evaluation
student is ready, the student is observed while seeing
Work habits: team
1. Summative
the preceptor’s patients. By the end of the 1st week,
1.1 Preceptor rating
work: doctor-patient relation
the student evaluates patients in his own room,
ship
discusses his observations and plan with the
preceptor, and then implements the plan they agree
Knowledge of common
1.2 Written and oral
upon. Experienced students may be allowed to
comprehension
primary care problem
management
discharge patients presenting with clearly defined
problems after only minimal checking by the
Ability to evaluate and present
1.3 Family presentation
a family
preceptor. If the follow-up visit is to take place
before the student leaves the clinic, he continues to
Ability to plan and execute a
1.4 Community project
clinic-based community
care for the patient. At the end of a clinic session, the
presentation
project
preceptor frequently reviews cases of special interest
with the student.
2. Formative
Data collection: use of medical
2.1 Record audit
Students are also expected to participate actively
reco rd
in all clinic conferences. These are held once or twice
history, perlormmg
performing
2.2 Review of
Taking history:
a week at midday and are of two types: either the
videotaped patient physical examination: attitudes
clinic staff meets about clinic and patient problems,
interviews
or patients are presented to one of the following
Community data collection
2.3 Patient log
consultants—social work, psychiatry, internal med
icine, pediatrics, or surgery.
1030
|98|
Vol. 23, Nos. 9-10, September-Octobfr 1987
Primary Care Clerkship
instruments was guided by the following principles:
abdominal pain). Faculty members have a complete
First, no instrument can evaluate all objectives, but
set of acceptable answers in front of them as they
an evaluation instrument can evaluate several
interview, thus minimizing haphazard or irrelevant
objectives at once. Second, an “overall” preceptor’s
questions. Scoring for correct answers is also defined
rating probably does not equal the sum of the
in writing, and each problem is given a maximum
preceptor’s ratings on specific scales, but has
grade of 50 points.
intrinsic value (12). Third, the student must pass
While students are evaluated using the above
each summative evaluation separately, and
techniques, the clerkship is evaluated by means of
evaluation of different areas will not be summed up
the debriefing session (17). This session is held at the
arithmetically. Fourth, the student’s final grade is to
end of each rotation by the Year Committee that has
be assigned on a pass/fail nominal scale by all
executive responsibility for managing the year, and
preceptors as a group, after reviewing all eval
the Curriculum Planning Unit. Students also
uations. As a rule, failure on any two evaluations led
evaluate their clinic preceptors and specific activities
to automatic failure and subsequent repetition of the
of the clerkship using questionnaires adopted from
clerkship. However, the preceptor's rating generally
Irby and Rakestraw fIS) and McKeachie (19).
weighed more heavily when the preceptor group
reviewed evaluations. In practice, if a student passed
EVALUATION RESULTS
the preceptor’s evaluation but failed other
Preceptor ratings
evaluations, he was given a passing grade that was
Fig. 1 shows that the average “overall” rating for
conditional upon successfully passing the failed
176 clerks in the first five cohorts was high (87.4% ±
evaluation. Fifth, three formative evaluations
6.3 mean ± so). Cohorts did not differ significantly
(11)—the students’ audited records (13), his
from one another. Analysis of the 19 ordinal scales
videotaped patient interviews (14) and his patient
gave similar results. The failure rate was 1/176
log—were used for feedback only.
(0.57%). This student repeated and passed the
The most important evaluation, the personal
clerkship with the next cohort. Eight students
rating, followed closely the pediatric house officer
(8/176, 4.5%) who passed all other evaluations and
rating form described by Margolis and Cook (12). It
were given borderline passing receptor ratings
rates the student overall on a 4-point ordinal scale
«70%) had their performance reviewed in detail in
(excellent to poor) and on 19specific 6-point ordinal
their presence by the department chairman and the
scales that evaluate the areas of empathy, work
preceptor.
habits, knowledge and clinical judgment, and
teamwork, most of which were clearly defined by
Written and ora! examinations
Shattuck (15) in 1906. Space for unstructured
Eig. 1 shows that the mean oral examination score
comments and critical incidents is also provided.
for the first five cohorts was 82.0± 8.5, and the mean
Preceptors fill out the evaluation forms and discuss
written examination score was 75.5 ± 5.7. Again.no
them with the students at the end of the clerkship.
significanl differences were dcmonslialed between
l amily projects are presented to the clerkship
cohorts. However, as shown in Fig. 1, mean written
group and are rated by at least two faculty members
examination scores were lower than mean oral
according to rating scales derived from Medalie (8)
examination scores, which were lower than mean
and Smilkstein (16). Community projects arc
preceptor ratings across all five cohorts; 14 of the 15
presented to the entire clerkship group and al least
possible differences were statistically significant (P
one of the community project tutors at the end of the
< 0.05) using the Student’s /-test. Standard
rotation. Grades are pass/fail, and the minimum
delations were greater for the oral examinations
criterion is that project data be submitted to the
than for either of the other evaluations, but the mean
project tutor for review.
oral examination scores approximated mean final
Written and oral comprehensive examinations are
grades most closely.
given just before the end of the final (6th) year to
determine knowledge of primary care problem
Family presentations
management. Written examinations consist of 100
All 176 students individually or in pairs, presented
items covering the range of common adult and
the
following elements of a family presentation
pediatric problems defined in the syllabus. Oral
successfully:
index patient’s history, physical
examinations consist of stuctured interviews by two
examination
and
problem list; three-generation
faculty members on one pediatric and one adult
family tree; major problems of family members;
management problem (e.g., a 41-year-old woman
intrafamily relationships; pertinent socioeconomic
with a headache; a 10-year-old boy with recurrent
and household family data; family support systems
[99]
1031
Israei J. Med Sci
C. Z. Margoi is 11 Al
IOOr
90-
<
LlJ
80-
70J______ I
COHORT-1
1
1
COHORT-2
KEY-a- Supervisor's rating
Oral examination
j________ |i
i
i
j_____ L
COHORT-4
COHORT-5
COHORT-3
—a— Written examination
—Final grade
ng. 1. Kaung ol the first live cohorts.
DISCUSSION
The process of defining
(i.e.. community, religion, etc.); family problem list
and management plan, and prognosis. A list of
a
performance-based
medical curriculum has been described in detail by
critical events in the family’s history was almost
always presented. Examples of family presentations
Segall et al. (2), whose work is based on a large
number of articles on job performance specifications
are given in Table 5.
in other fields (20). Precise job specification
determines the def inition of instructional objectives,
which in turn determine the choice of instructional
Community project presentations
All students but one successfully completed
community projects that included the following
elements: data analysis, conclusions and project
presentation. The one student who failed presented a
discursive and inconclusive description of his
clerkship experience at a distant community
hospital. Examples of projects are given in Table 6.
and evaluation methods. The relationship between
objectives, methods of instruction and methods of
evaluation was described in 1962 by Miller (3), and
was based on work by Tyler (21), Bloom (22), and
Mager
(6).
In
planning,
implementing
and
Table 6. Reprcscmalive community projecix
1 able 5. Representative Jamily presentations
I.
I he family of a 50-ycar-old man with ‘Tro/cn shoulder”
2.
who has slopped working.
The family ol an IX-month-old girl with
3.
4.
5.
6.
7.
X.
9.
lay-Sachs
disease.
1 he family of a 10-year-old girl with unconl rolled diabetes
mellilus.
The family of a dying 12-year-old boy.
The family of a 4-year-old girl never operated on for
congenital bilateral cataract.
The family of a 46-year-old obese woman.
The family ol a 21-year-old suicidal woman with
depression.
A family with familial dcalness.
The lamily ol a 14-ycar-old boy with Down's syndrome
and severe retardation.
11001
1.
2.
3.
4.
5.
6.
7.
K.
9.
10.
Hemoglobin survey in children under 2 years old.
Cholesterol levels in kibbutz members.
Stool parasites found in a pediatric clinic serving 5.(X)()
children.
Use of medications in the town of Nelivot (pop. X.5(X)).
Attitudes toward smoking in the town of Nelivot.
A survey in a kibbutz community of risk factors for heart
disease.
Transmission of tonsil'lis within a family in the
development town of Yeruham (pop. 7.000).
Demand for sick leave in the summer and in the winter in a
Jerusalem neighborhood clinic practice (practice pop.
10.000).
Common medical problems in a neighborhood clinic in
Beer Sheva practice (pop. 10.500).
Hospitalization rales in the winter anil summer months in
a neighborhood clinic in Bcershcva (practice pop. 9,000).
Voi 23. Nos. 9-10. Si-piembi:r-0(T0Bfr 1987
Primary Cari Ci i rkship
evaluating our clerkship, wc followed the method of
Segall et al. closely in order to arrive at a clinical
clerk's job description that bore a one-to-one
correspondence with the job description that we
envisioned for the Israeli primary care practitioner.
Our experience demonstrates that performance
based medical curriculum definition and imple
mentation is feasible, at least in our setting.
Although elements of this planning process have
been used in the past (23). we believe that ours is the
first published example of the completed process,
which was made possible by the merging of regional
health services with the medical school. We would
argue that the curriculum planning process used to
plan or replan clerkships should be performance
based in order to maximize the relevance of a
particular clerkship to the knowledge, skills and
attitudes used by practitioners.
Content of a clerkship planned using this method
will vary from setting to setting as the performance
specification varies. However, review of published
descriptions of family medicine, primary care and
'community medicine clerkships (24-26) shows that a
(
of sophistication, arc an example of the “spiral
curriculum” concept developed by Segall et al. (17)
that has guided curriculum development at our
medical school. This extensive preclinical
coursework can be viewed as preparation for the
clerkship. However, our clerkship could be taught as
described without these preparatory courses, albeit,
we assume, at a lower level of sophistication.
We believe that any medical school should
provide significant primary care experience,
especially if it aims to prepare specialists. Only in the
primary care setting will the student experience
strong emphasis on the patient, his family, and his
community, in contrast to the orientation towards
diseases of many specialty clerkships. Also, only in
the community will the future specialist perceive the
scope and limitations of the primary care environ
ment that will provide most of his referrals. Such a
clerkship may also provide one of the only
environments in which a senior physician has daily,
concentrated contact with the student that may
provide significant data regarding the student’s
noncognitive performance. Furthermore, although
minimal set of objectives for this type of clerkship
concepts developed within family and community
has emerged that includes at least the following three
medicine must be taught during a COPC clerkship,
types of objective: knowledge about a set of common
teachers do not have to be family practitioners, but,
problems seen in a clinic or practice; attitudes
may also be pediatricians, internists, or other
appropriate for primary care work; and skills for
physician role models, who are devoted to providing
gathering family data, defining family problems,, quality primary care.
and presenting families to a professional audience. A
At present, we can only speculate about the
fourth type of objective, first defined by Kark (1),
influence of the COPC clerkship on career choice.
describes skills at gathering community data,
The first five cohorts enjoyed the clerkship, but
defining community problems, and planning to
frequently had neither the appropriate role models
solve them. This sort of objective has not always
nor the appropriate work environment that would
been included in the primary care clerkship.
induce them to practice primary care. However, it is
However, community-oriented objectives are highly
reasonable to assume that our first two cohorts
relevant to the job of the Israeli primary care
comprised a relatively large percentage of students
practitioner. Moreover, both Mullen (27) and the
who were explorer or pioneer types, attracted by
policymaking bodies in American family and
difficult situations. For these students, a primary
community medicine (28) have suggested that
care clerkship that allowed them to experience
COPC should become the new standard for
primary care with all its problems may have
American primary care practice.
increased their motivation to change primary care.
Students at Ben-Gurion University have more
The clerkship showed them clearly that there was a
than the average preclinical coursework in
problem of specific dimensions needing change, and
epidemiology and communications skills (2). Thus,
that the faculty wanted to achieve change. Now that
when they begin their primary care clerkship,
the University Center-Kupat Holim partnership is
students have completed a 160-hour, 2-year course
beginning to effect change in the incentives of the
called Quantitative J'hinking. which includes
primary'care work environment, and an increasing
biostatistics, epidemiology, and project work at a
number of family medicine, pediatrics and internal
MPH (Master of Public Health)degree level. In their
medicine residents are choosing to work in primary
3rd. preclerkship year, many do a family project in
care settings, students will have appropriate models
which they present an oral and a written report on
who will encourage them to view these incentives
their evaluation of a family. These courses, which
positively. If these developments continue, wc may
prepare the student early in his training for concepts
now begin to hear students talk of the COPC
and content (hat will be taught later at a higher level
clerkship as a deciding factor in their career choice.
01253
rioi]
COMMUNITY HEALTH CELL
326, V Main, I Block
Koramc-ngala
Bangalore-560034
India
M'ffiasfflMF
'ws?- Wr
Israel J. Med. Sci
C. Z. Margolis et al
The authors thank Mrs. Z. Davidovich, the Primary Care
Unit administrator, and all the instructors who taught in
the clinics, without whose efforts this paper could not have
been written. In addition, special thanks go to Sheila
Warvshavsky for analyzing the evaluation data.
REFERENCES
1. Kark SL (1974). “The practice of community oriented pri
mary health care.” Appleton-Century-Crofts. New York.
2. Segall AJ. Vanderschmidt H. Burglass R and Frostman T
(1975). “Systematic course design.” John Wiley and Sons,
New York.
3. Miller G (1962). “Teaching and learning in medical school.”
Harvard University Press, Boston.
4. Simpson MA (1972). “Medical education: a critical ap
proach.” Butterworths, London.
5. Delbecq AL (1967). The management of decision making
within the firm: three strategies for three types of decision
making. Academy of Management J 10: 329-339.
6. Mager RF (1962). “Preparing instructional objectives.”
Lear Siegler Inc., Fearon Publishers, Belmont, CA.
7. Margolis CZ (1978). “Clerkship manual for the 5th and 6th
year primary care clerkship.” Ben-Gurion University of the
Negev, Beersheva, Israel.
8. Medalie J (1978). “Family Medicine.” Williams & Wilkins,
Baltimore.
9. Cormack J. Marinker M and Morrell P (1981). “Teaching
general practice.” Kluver Medical, London.
10. Starfield B (1973). Health services research: a working
model. N Engl J Med 289: 132-135.
ll. Scriven M (1967). The methodology of evaluation, in: Tyler
R et al. (Eds), “Perspectives of curriculum evaluation.”
AERA monograph series on curriculum evaluation, No.l.
Rand McNally, Chicago, p 39-83.
12. Margolis CZ and Cook CD (1976). Rating pediatric house
officer performance. Conn Med 40: 539-543.
13. Margolis CZ. Sheehan TJ and Stickley WT(1973). A graded
problem oriented record to evaluate clinical performance.
Pediatrics 51: 980.
14. Kagan N, Schauble Pand Resnikoff A(1969). Interpersonal
process recall. J Nerv Ment Dis 148: 365-374.
15. Shattuck FC (1907). The science and art of medicine in some
of their aspects. Boston Med Surg J 157: 63-67.
16. Smilkstein B (1975). The family in trouble: how to tell. J Fam
Pract 2: 19.
17. Segall AJ, Prywes M, Benor DE and Susskind O (1978).
“University Center for Health Sciences. Ben-Gurion
University of the Negev, Beersheva. Israel: an interim
perspective.” Public Health Papers No. 70. WHO,Geneva,
p 112-132.
18. Irby D and Rakestraw P (1981). Evaluating clinical teaching
in medicine. J Med Educ 56: 181-186.
19. McKeachie WJ (1979). Student ratings of faculty: a reprise.
Academe 65: 384-397.
20. Dunn WR, Hamilton DP and Harden RM (1985). Tech
niques of identifying competencies needed of doctors.
Medical Teacher 1: 15-25.
21. Tyler RW (1949). Basic principles of curriculum and instruc
tion. University of Chicago Press. Chicago.
22. Bloom BS (1956). "Taxonomy of educational objectives.
Handbook I: cognitive domain.” Longman, London.
23. Segall A, Barker VH, Cobbs et al. (1981). Development of a
competency-based approach to teaching preventive
medicine. Prev Med 10: 726-735.
24. McWhinney IR. Molineux JE, Henncn BKE and Gibson
GA (1977). The evolution and evaluation of a clinical
clerkship in family medicine. J Fam Pract 4: 1093-1099.
25. Buttery CMC and Moser DLA (1980). Combined family
and community medicine clerkship. J Fam Pract 11: 237244.
ex
26. Rabinowitz HK (1983). The precision phase: seven years
yearsexperience with a required family medicine clerkship for third
year medical students. Fam Med 15: 168-172.
27. Mullen F (1982). Community-oriented primary care. An
agenda for the ’80s. N Engl J Med 17: 1076-1078.
28. The Society for Teachers of Family Medicine (1983). “Inter
relationships between preventive/community medicine
and family medicine.” Kansas City, MO.
I
1034
H02J
PROBLEM-BASED CLINICAL CONFRONTATION MODULES
PLANNED AND CONDUCTED BY STUDENTS
MOSHE PHILLIP,' MIRIAM FRIEDMAN V and DAN BENOR
1 Division ol Pediatrics. Soroka Medical Center, and ■ Curriculum Unit, and ' Center for Medical I ducation.
University Center for Health Sciences and Services. Ben-Gurion University of the Negev. Beer Sheva. Israel
Isr J Med Sci 23: 1035-1037, 1987
Key words: Beer Sheva Experiment: medical education; clinical studies
Problem-based modules were introduced into the
basic science-structured curriculum during the first 3
years. These modules comprise a course entitled
Clinical Confrontation. The course attempts to teach
problem-solving skills, integration and to show the
students the relevance of the basic sciences by dis
cussing a clinical patient’s problem and using pre
viously acquired disciplinaryknowledgc.Thecour.se
is organized in small group tutorials by senior stu
dents who participate in the planning and writing of
the clinical problems and serve as the tutors of the
learning groups.
COURSE RATIONALE
A group of senior students felt insufficiently pre
pared for their clinical clerkship and were having
difficulties in integrating and applying basic science
and general knowledge to real-life cases. This prob
lem was identified during debriefing sessions (1)
when the students stressed the deficiency of an ear
lier course that was to remedy the insufficient inte
gration of basic and clinical knowledge and to
develop problem-solving skills.
The Clinical Confrontation Course shares many
features and advantages with similar courses, some
times called problem-based courses (2), case study
methods, and introductory courses. In most tradi
tional medical school curricula, the basic sciences
are distinctly separated from the clinical studies. The
basic sciences, which are studied during the early
part of the medical curriculum, are taught by basic
Address for Correspondence: Dr. M. Phillip. Division of Pediat
rics. Soroka Medical Center. POB 151. 84101 Beer Sheva
scientists who usually are not physicians. This dis
tinct separation appears to cause frustration among
the preclinical students. The students are unable to
grasp the relevance of the vast amount of basic
science studies to their future clinical work. Janet
Gale Grant (3) points out: “In clinical practice there
is no similar separation of subject and discipline
knowledge.’’ Furthermore, the student cannot per
ceive the connection between the various basic
science subjects which are learned. This mispercep
tion of relevancy by the students may diminish their
motivation to fully understand basic sciences (4).
Instead, the students invest their energies in rote
memorization of the material with one goal in
mind—to complete successfully this necessary but
irrelevant part of their medical studies.
The Clinical Confrontation Course intends to fill
this gap by modeling the relevancy of basic science
knowledge to the clinician's work. While grappling
with the clinical problem, the student learns at the
very early stages that basic science knowledge is
essential to understanding a clinical problem and
that within a specific patient context the basic
science interpretation of the clinical findings may
vary from one case to another.
In summary, the course objectives include:
1) development of problem-solving skills as they are
applied to clinical cases; 2) integration between the
different courses in the preclinical years; 3) raising
the motivation to better understand basic science;
and 4) fostering self-learning skills by enhancing
students’ curiosity (finding solutions for their case).
STUDENTS AS TEACHERS
It is not surprising that the initiative for a clinical
I 103]
Israel Journal of Medical Sciences. Vol. 23. 1987
1035
Israi 1 J. Mi l) Sci
M. Pun 1 IP I I Ai
confrontation course during the first years of the
curriculum came from the Beer Sheva students
themselves (as described above). The Beer Sheva
educational philosophy emphasizes the students’
active participation in the program. It was noted
that the senior students themselves might be the best
planners and facilitators of such a course. Some of
the senior students were acutely aware of these cur
ricular shortcomings and were particularly able to
identify the needs of the younger students. Further
more, they could improve the motivation of the
younger students by assuring them that the course is
indeed needed. By devoting their own time and
effort, senior students demonstrated the importance
of the course. Such motivation is apparently needed,
as Duban et al. (5) reported that although the impor
tance of such a course is acknowledged by most
medical schools, students and teachers often per
ceive its importance to be secondary and divorced
from the main curriculum. An additional problem of
extra teaching responsibilities was raised by Lambie
et al. (6) in their experience with a similar course at
Edinburgh. But the involved Beer Sheva senior stu
dents, most of whom were excellent academically,
gladly volunteered to teach the course. This course
also serves as the beginning of a process of recruit
ment and training of future teachers and educational
leaders.
During our 5-year experience with the course, we
have learned that the senior students act as nondisciplinary role models. The younger students may iden
tify more readily with the senior student who is still
engaged in the process of internalization and appli
cation of basic sciences to clinical cases than with the
specialist who may have already become insensitive
to such a process.
COURSE DESCRIPTION—METHOD AND
PROCEDURE
The course is given du ling the first 3 years |of the
6-year program (7)|. The 1st year's course is des
cribed as an example of the rest. The Ist-yearclass is
divided into 3 to 4 groups, each comprising about 12
to 15 students. Throughout the year, each group will
discuss three to lour clinical cases. The cases are
designed to match the appropriate knowledge level,
of the student at that time and are relevant to the
acquired knowledge at the different preclinical
courses. During the 1st year, the students grapple
with three clinical cases each in four 2-hour sessions
and one 4-hour summary session.
Prior to the first session, the clinical-case story is
distributed to the students. The students arc asked to
prepare a list pertaining to three aspects of the case:
problems, differential diagnosis (DD) and addi
tional information or tests needed to confirm the
DD. The tutor serves as a guide, discusses the case in
accordance with the three above-mentioned aspects,
and assigns projects in order to clarify questions that
were raised during the discussion.
The students are usually guided to look up the
relevant literature through a self-search, self-learn
process. Faculty members are also available as an
information source. The tutor has available the
results of diagnostic tests prepared in advance,
including X-rays, ECG, blood and urine tests, etc.
At the second session, a continuation of the case is
handed out to the students. Thisadditional informa
tion usually marks some significant development in
the clinical case discussed. Once again, the students
are asked to prepare a list pertaining to the three
above-mentioned aspects, but this time more infor
mation about the case is available. The remaining
sessions are handled in similar fashion. The assign
ments are given either to individual students or to
the group. The fifth session summarizes the case,
and usually a panel of relevant experts is invited to
this discussion. For example, the second case in the
Ist-year course deals with an epidemic of diarrhea in
children. The student is assigned to serve as a com
mittee member who investigates the outbreak of the
epidemic. In this clinical case, the student relates to
the individual patient as well as to the community.
When treating the individual patient, the student
learns how to use the knowledge acquired in the
physiology (body fluids), clinical (acid-base prob
lems), and life saving (treatment for severe dehydra
tion) studies in order to solve the clinical problem, as
well as to use the skills learned in communications
and behavioral sciences when dealing with the par
ents of a sick child ..While relating to the community,
the student uses the knowledge about epidemics
learned in the epidemiology course and practices this
knowledge in real life. He investigates both the var
ious services available in the community for such an
epidemic and the physician’s role in such cases.
Some difficulties were encountered during the 5
years of experience with this course. The first is that
the course competes for student’s time with the tight
and demanding curriculum. The reality thus dictates
a limited number of cases during each year, which
may be insufficient for some students. This disad
vantage is only partly compensated by continuing
the course in the 2nd and 3rd year of preclinical
studies. A second problem is that it becomes
extremely difficult to evaluate the course, as the
students' achievements may derive Irom diflerent
sources in the curriculum. The evaluation of the
course is at present at its starting point. However,
the course is favorably accepted by the students, as
| 104 I
It
I
I
Voi 23, Nos. 9-10, September-October 1987
Ci inicai Coni rontation Monm es
reflected by the large amount of time they are willing
to devote to it.
SUMMARY AND CONCLUSION
A course has been described which attempts to intro
duce clinical relevancy to the basic science knowl
edge. It has been demonstrated how senior students’
feedback about curricular shortcomings can be redi
rected to their constructive participation in the edu
cational process. The described Clinical Con
frontation course develops problem-solving skills
and self-learning habits in thelearners while they are
processing and rearranging prior knowledge. At the
same time, both the scientific base of medicine and
the internal logic of the disciplines arc preserved.
REFERENCES
I. Prywes M (1977). News f rom Israel. I he Beer Sheva
Experience. JAMA 238: 14.
2. Barrows HS (1976). Problem-based learning in medicine, in:
Clarke J and Leedham J (Eds), “Aspects of educational
technology 10: individualized learning.” Kogan, London.
3. Gale Grant J (1984). The integrated curriculum: ex
periences. achievements and problems. MedTeacherNo\. 6
no. I.
4. Elstein M and Forbes JA (1976). Southampton: the first
years of early medical contact. Rr Med J 2: 97-98.
5. Duban S. Mennin S. Waterman R, et al. (1982). leaching
clinical skills to pre-clinical medical students: integration
with basic science learning. Med Educ 16: 183-187.
6. Lambie AT. Maclean CM and McGuire RJ (1981). The
introduction of problem-based learning projects into a clin
ical correlation course in the first year of the Edinburgh
medical curriculum. Med Educ 15: 209-215.
7. Benor DE (1982). Interdisciplinary integration in medical
education: theory an^l method. Med Educ 16: 355-361.
Thamas Fulop
Director
Division of Health Manpower Development
WHO, Geneva
Lecture in Beer Sheva, 1975
“The Beer Sheva experiment is a very bold and farsighted
one which deserves attention and support from all con
cerned. It is unique in that it is based on the realization that
health services and health manpower development should
be changed in a synchronized way if results are to be
expected. The basic change is the education of future
doctors, built on the integrated and community-oriented
physicians who are ready to serve people instead of being
hospital and disease oriented. This would mean a very
important step forward in the history of health personnel
education.”
[105]
EMERGENCY CARE CURRICULUM OF THE BEER SHEVA
MEDICAL SCHOOL
I
EITAN LUNENFELD,1 MORDECHAI LEVIN2 and RACHEL LAZIN3
‘Department of Obstetrics and Gynecology.2Emergency Division, and 3Unit of Curriculum Development,
University Center for Health Sciences and Services, Ben-Gurion University ol the Negev, Beer Sheva. Israel
Isr J Med Sci 23: 1038-1040, 1987
Key words: Beer Sheva Experiment; medical education; emergency care; curriculum
When the Beer Sheva University Center for Health
Sciences and Services (UCHSS) was established in
1974 it received a dual mandate (1). The first was to
utilize academic resources in fostering the develop
ment of an integrated system for the delivery of
comprehensive regional health care. The second was
to educate a new type of physician who would have
the motivation and competencies to function effec
tively within this system. This latter commitment
implies that along with the basic elements of medical
education the primary care and emergency care
dimensions would be emphasized in a manner not
characteristic of other medical schools. A 6-year
competency-based curriculum reflects the goals of
the faculty. Basic sciences, clinical medicine with a
special emphasis on emergency medicine, and public
health constitute the principal areas of teaching.
Instruction in each area begins in the 1st year and
continues throughout the 6-year program. The com
plexity of problems and the level of simulation
increase progressively efs students advance through
the several phases of the curriculum. This spiral
concept of curriculum adopted in Beer Sheva is
based on the premise that learning and retention
occur more effectively when reinforced concurrently
across diverse components of the curriculum and
longitudinally over successive phases of the study
program. Furthermore, these concepts also meet the
need for introducing emergency medicine courses at
the undergraduate level (2-5) as summarized in the
Lancet (6) a decade ago: “The implication that one
Address for correspondence: Dr. E. Lunenfeld, Department of
Obstetrics and Gvnecofogy, Soroka Medical Center, POB 151,
84101 Beer Sheva.
1038
Israel Journal of Medical Sciences, Vol. 23, 1987
can graduate in medicine with distinction while
unable to avert disaster in practical clinical situa
tions is thought-provoking.”
DESCRIPTION OF THE EMERGENCY
MEDICINE CURRICULUM
Emergency medicine teaching—first 3 years
The duration of the first phase of the emergency
medicine teaching program is approximately 3
years. Formal courses and workshops are supple
mented by several clinical tracks which enable stu
dents to practice the basic skills in a clinical setting.
The basic clinical competencies taught at this stage
of the curriculum require minimal theoretical
background.
First-year Emergency Medicine Program. During the
1st year of medical studies a 54-hour first aid course
(18 sessions) is integrated into the basic physiology
course. The first aid course includes basic cardiopul
monary resuscitation (CPR), basic traumatology,
basic first aid in medical emergencies, and the princi
ples of dealing with multiple injuries and of triage.
The course is taught by medical students who had
been paramedical instructors during their army ser
vice. The students are trained using dummies for
basic life support, and they practice i.v. infusions as
well as bandaging and immobilization on each
other. A computerized simulator developed by the
School of Military Medicine of the Israeli Defense
Forces (IDF) Medical Corps is used as a teaching aid
and for practicing triage. The students’ knowledge
and practical skills are evaluated at the end of the
course, using a multiple-choice written examination
and simulating an accident with four wounded per-
(106]
i
I
Vol. 23, Nos 9-10, September-October 1987
Emergency Care Curriculum
sons. Passing the first aid course and examinations is
a prerequisite for 2nd-year medical studies. In addi
tion to the first aid course, the students are exposed
to the Emergency Room during their “clinical day”
described elsewhere in this volume. During this day
in internal medicine the students’ exposure to the
Emergency Room emphasizes the impact of the
acute and sometimes life-threatening situation on
the individual and his or her family. The students
learn the difficulties of communicating in this kind
of setting with special emphasis on the relationship
between the physician and the patient and family.
Second-year Emergency Medicine Program. Based on
the Ist-ycar first aid course the students arc exposed
to the Mobile Intensive Care Unit run by Magen
David Adorn (the Israeli equivalent of the Red
Cross) during the 2nd-year medical studies. This
exposure brings into reality the subjects taught dur
ing the 1st year and introduces the student to non
hospital emergency systems. The students are
required to submit a medical report on this expe
rience as a prerequisite for the 3rd-year medical
studies.
Third-year Emergency Medical Program. During the
3rd year, anatomy and physiology are taught
according to the body systems. Emergency medicine
is integrated with anatomy by teaching and practic
ing different emergency surgical, diagnostic and the
rapeutic procedures, such as thoracic drainage,
tracheostomy, abdominal tap, etc. on the cadavers.
These skills are taught by the senior surgeons in the
Emergency Room, and emphasis is given to the ana
tomic structures that are involved and at risk during
these procedures. This integration between emer
gency medicine and anatomy enables emergency
procedures to be introduced at this stage of training
and to be practiced in a classroom setting. Further
more, the students’ motivation in studying anatomy
is thereby enhanced.
Issues of emergency care are incorporated into the
classroom studies of each of the integrated body
systems. These issues include topics such as diabetic
ketoacidosis, hemolytic crisis, acute gastrointestinal
bleeding, etc. Following the cardiovascular, respira
tory and nephrological systems and based on the ■
theoretical knowledge learned in those systems, a
1-week advanced life-support workshop (32 hours)
is given. Preceding the advanced life-support course,
there are refresher sessions in first aid and basic
life-support skills. In addition panel discussions are
held concerning issues such as burns, shock and
multiple injuries. The students are evaluated by
means of a written and practical examination.
Supervised evening shifts in Surgical, Medical, and
Pediatric Intensive Care Units follow this workshop,
using the emergency medicine skills and experiences
booklet described in the following section.
The emergency medicine skills and experiences
booklet
During the 1st year the students are given a booklet,
“The skills and experience booklet,” which lists the
skills and experiences that the student must acquire
during the 6-year program. Some of the skills have to
be learned during the first 3 years—the early clinical
program—and are a prerequisite for the 4th year.
These skills and experiences involve mainly the
initial exposure to emergency situations. Another
section of the booklet has to be completed during the
4th year while the student acts as a clerk in medicine
and in pediatrics. During this year, the skills involve
exposure to emergency situations and procedures,
such as acute myocardial infarction, pulmonary
edema, severe dehydration, central venous catheteri
zation, nasogastric intubation, and urethral cathe
terization. Emphasis is placed not only on the
presence of the student during the emergency situa
tion, but also on the presence of the student during
the explanation given to the patient and his family
concerning the condition or procedure. In order to
be exposed to medical emergencies, the 4th-year
medical students have to complete at least five nights
on duty in the emergency room.
Emergency medicine teaching—later years
During the 5th and 6th years, the student is expected
to complete all of the functions described in the
booklet. During those years, the student acts as a
clerk in surgery, orthopedics, anesthesiology, pri
mary care, obstetrics and gynecology, medicine, and
psychiatry, and is exposed as well to the Respiratory
and Coronary Intensive Care Units. During these
years, the student has to participate in emergency
situations and procedures including resuscitation,
treatment of acute psychoses, drawing arterial
bloods, intubation, etc. During the different clerk
ships formal discussions are held concerning man
agement of emergency situations in the different
fields of medicine.
During their rotating internship in the 6th year
before the students arc expected to act as physicians,
a formal 1-week workshop (38 hours) in emergency
medicine is held. This workshop includes a review of
basic and advanced life support and discussions of
emergency situations in medicine, pediatrics, obstet
rics and gynecology, and traumatology, as well as a
practical simulation of emergency room treatment
of a mass injury.
U071
1039
Israel J. Med. Sci
E. Lunenffld IT Al
Participation in this workshop as well as comple
tion of the emergency medicine skills and experi
ences booklet is a prerequisite for starting the
internship.
DISCUSSION
It was clear that emergency medicine should be an
important issue in the curriculum of a new medical
school whose aim was to educate a physician with a
humanistic and a community approach (7). There
was also general agreement among the medical and
social science staffs of the new medical school that
emergency medicine should be included as a
required course and that the traditional way of
teaching emergency medicine was unsatisfactory.
The emergency medicine program described here is
based on the following hypotheses: 1) The commun
ity expects even a Ist-year medical student to be able
to cope with emergency situations better than a lay
man does. 2) Several skills such as communication
and basic paramedical skills are more readily
accepted and learned by undergraduate students
before they get too involved in the different clerk
ships. 3) The medical school should prepare the
medical student in a gradual and repetitive way to
cope both theoretically and practically with emer
gency situations, inside and outside the hospital,
before throwing him or her virtually unprepared
into the roles of medical clerk, intern, and practicing
physician.
Furthermore, the curriculum was based on the
basic principles of the new medical school, which
were: 1) clinical involvement of the student from the
1st year of the 6-year program; 2) teaching according
to the body systems and in an integrated and spiral
way; 3) involvement of medical students and young
graduates in creating the curriculum and teaching;
and 4) constant feedback mechanisms from stu
dents, teachers, and the medical and nonmedical
community in order to closely approximate the basic
aims of the medical school.
Based on these principles, the emergency medicine
curriculum was constructed and constantly im
proved. The curriculum described here is the latest
version and has been in effect for the last 3 years,. Its
aim was to spread and integrate the Emergency Med
icine Program into the 6-year medical school curricu
lum in a manner that would assure that emergency
medicine would not be neglected, thereby training
physicians to cope with emergency situations in the
field as well as in the hospital.
A program like the one described here can succeed
only in a medical school where the contribution of
emergency medicine-oriented physicians is wel
comed and taught in every field, system or clerkship
of the 6-year program. Although emergency medi
cine was taught in the UCHSS from the start and the
authors have always been deeply involved, the 6year Emergency Medicine Program has only been
established relatively recently. Full evaluation of
this program has thus heretofore been impossible. In
a preliminary study presented in this issue of the
Journal, Drs. M. Prywes and M. Friedman have
shown that the UCHSS interns received a signifi
cantly higher rating for technical skills than did
graduates of other medical schools in Israel. These
results are not specifically oriented towards emer
gency medicine skills, but are nevertheless encourag
ing and relevant. We are in the process ofevaluating
interns from the different medical schools, specifi
cally concerning knowledge and skills in emergency
medicine. Furthermore, we hope that with the help
of the School of Military Medicine of the IDF Medi
cal Corps we will be able to compare UCHSS gradu
ates with those of other medical schools, concerning
emergency issues taught and evaluated during the
medical officers’ course given by the IDF to almost
all Israeli physicians.
In conclusion, we have the impression that our
emergency medicine curriculum is on the right track;
we are getting substantiation of this view from the
community, the army, and Emergency Room direc
tors. as well as from our students, graduates and
staff. Emergency medicine, like every other curricu
lar component, should be thoroughly and objec
tively evaluated to determine whether it fulfills its
aims and goals.
REFERENCES
I. Segall A. Margalit C. Benor D. and Susskind O (1978). The
Beer Shcva Experiment in early clinical instruction. Kupat
Holim Yearbook 6: 37-44 (in Hebrew).
2. Brown CG. Sanders AB. Gurley HT. Stair TO. Morkovin V
and Jane AH (1984). Curriculum lor undergraduate educa
tion in emergency medicine. ./ Med Educ 59: 427-429.
3. Sanders AB. Criss E. Wilzke Dand Levitt MA(I986). Sur
vey of undergraduate emergency medical education in the
United States. Ann Emert’ Med 15: 1-5.
4. Sanders AB. Criss I' and Wit /ke D( 19X6). Core content sur
vey of undergraduate education in emergency medicine.
Ann Emerg Med 15: 6-11.
5. American College of Emergency Physicians (1987). Guide
lines for undergraduate education in emergency medicine.
Ann Emerg Med 16: 117-119.
6. Editorial (1972). Evaluation of medical curricula. Lancet
ii: 1014-1015.
7. Prywes M (1973). Merging medical education and medical
care. Hosp MedStafffAmerican Hospital Association), vol 2.
1108 I
i
I
LACUNAE IN THE EDUCATIONAL PROGRAM
S. GLICK
Dean. Universe Center tor Heahh Science........ Services. Ben-t iur.nn University nt the Negev. Beer Sheva, tsrael
hrJ'Med Sei 23: 1041-1043. 19K7
Key words: Beer Sheva Experiment; medical education; medical ethics; medical history
As a medical school with pretensions well beyond
our capabilities, with an overwhelming desire to
prove ourselves as not only innovative in many
areas, but at least as adequate in the classic medical
school roles, we often find that our appetites are
larger than our digestive capacity. The curriculum of
the medical school, with the added load of hours of
early clinical exposure, behavioral sciences, com
munity projects and the like, is already the most
extensive of all Israeli medical schools. And yet,
there remain numerous lacunae in the curricular
program that we would like to fill and present toom
students. The obvious gaps have resulted in part
because of a lack of staff in a particular area. In other
cases, sporadic attempts to teach the subjects have
been made in accordance with the time, personnel
and interest available during a particular semester.
These efforts have helped us formulate ideas in new
areas with the hope that these ideas can be put into
effect in future years. I will address just some of the
gaps in our curriculum.
MEDICAL ETHICS
It is generally agreed that the subject of medical
ethics is essential for a physician’s education. We
devoted much time and effort to planning an organ
ized course in medical ethics but have not had the
staff to fully activate the course.
1 he guidelines along which we organized the
course were as follows:
1) The course would not be given as a single short
Address for correspondence: Dr. S. Glick. University Center for
Health Sciences and Services. Ben-Gurion Univcrsitv of the
Negev. FOB 653. 84105 Beer Sheva.
course, subsequent to which ethics would not be
touched upon again. We did not want the student to
have the feeling that hc/she had “finished” the
course in ethics.
2) We would attempt to introduce the subjects under
discussion at the stage in the student’s education
when they become relevant to him/her. Thus, confi
dentiality might be taught in the 1st year when the
fledgling students in their first clinical encounter are
suddenly exposed to the intimate details of patients’
interpersonal relationships. Abortion might be dis
cussed relatively early when the student begins to
interview pregnant women. Truth telling could be
dealt with during the course on cancer in the 2nd
year, and so on.
3) No definitive solutions would be presented to
complicated ethical issues, but rather the students
would learn to define the issues in a case discussion
format, and they would be required to consult the
relevant literature and present different points of
view as expressed in these articles. Our students and
faculty represent a spectrum of often widely diver
gent philosophies and Weltanschauungen, and a con
sensus on “right” answers is not always possible.
An effective format that we found stimulatingand
thought provoking involved the assignment of sev
eral short cases illustrating the spectrum of the ethi
cal dilemmas on the subject under discussion
together with appropriate reading assignments. The
class was then divided into small groups to discuss
the problems, using their own insights and those
gained from their reading. Subsequently the groups
reassembled and heard several experts present their
views, followed by free discussion. This format was
. enjoyed and appreciated by students and faculty
alike. It is. however, quite costly in terms of faculty
r 109^
israi.i J. Mi d. Sc i
S. Gi ick
time and requires the importation of outside experts
from other cities in Israel and considerable logistical
manipulation for each teaching session.
Presently, ethics is taught largely in the 6th year as
part of the course The Physician in Society. Students,
rather than outside experts, present the varying
points of view based on individually assigned read
ing. and active class participation is encouraged.
This has been an effective and popular format. In
addition, in earlier years sessions on various topics
in medical ethics appear during different courses
rather than as part of a separate course in ethics.
Thus in the 2nd year during the clinical week on
cancer, several sessions are spent on the approach to
(he dying patient and on truth telling.
number of required hours in the sciences and the
overall study load.
In addition, our medical school has chosen to add
hours in early clinical exposure, community pro
jects, as well as behavioral sciences, leaving the stu
dent to stagger under an inordinately heavy work
load. Adding further hours in the humanities has
never been seriously considered, although the unfor
tunate lack of such broadening courses is frequently
lamented at faculty meetings. We are considering
simply setting a specific afternoon free on an ongo
ing basis and encouraging students to take their own
choice of courses in* other faculties of the University.
MIS( ELLANEOUS OTHER LACUNAE
Other areas in which there are clear gaps in the
curriculum
are those of human sexuality, forensic
HISTORY OF MEDICINE
medicine,
nuclear
medicine, alternative medicine,
For several years (during the introductory summer
and computer science. In a congested curriculum,
months preceding the first year), while an interested
courses without sufficient priority and an approp
faculty member was. available, we gave a short
riately strong faculty member to lobby for them and
course in the history of medicine. The course was
organize the teaching tend to be neglected.
given at that particular juncture in an attempt to
In some of these areas, the immediate future
provide the student entering upon a career in rnedi-’
would seem more optimistic. For example, this past
cine a historical perspective on the development of
year witnessed the creation of a Center for Jewish
medicine from ancient times to the present day—asa
Medical Ethics at the medical school. It is to be
function of the different cultures and eras. The
hoped that such a center with its focus 'will serve to
course was based on a focus of specific medical
catalyze
a better organized program in medical
personalities from different eras in medical history.
ethics.
We
have also begun a course in human sexu
The course was generally well received by the
ality
for
the
coming year, in addition, we are provid
students, but it was felt, ultimately, that offering the
ing
lice
hours
in the first years of medical school and
course at the outset of the students' education was
require
that
students
take courses in other faculties.
not ideal since they lacked the toolsand background
No
similar
prospects
are
on the horizon for some of
to properly appreciate medical history. The course
the
other
lacunae.
was eventually discontinued because ol the subse
We have taken one step this past year that may
quent unavailability of the faculty member who gave
make
it easier to introduce new courses in the future.
the course. We made another attempt to give a
Because
the inordinately large work load thrust
course in medical history asan elective in later years,
upon
the
students began to be counterproductive,
but poor student participation led to its
the
school
cut the class hours in the first 2 years of
discontinuation.
medical school by 15%. This precedent, if extended
and utilized intelligently, may permit curricular sup
HUMANITIES
(
plementation and augmentation in the future, in line1 he subject of the humanities in Israeli education in
with curricular development.
general and in medical education in particular is a
In considering the present gaps in our curriculum
sore point among educators who are used to the
and
others that have not been noted, the fundamen
American concept ol a broad university education
tal
issue
that needs to be confronted is the all-toofor the professions. Israeli university students,
common
tendency of each department to attempt to
beginning as they do after several years of military
teach
far
more detail in its area than is reasonable,
duty, arc of necessity very pragmatically oriented,
necessary,
or relevant. With the geometric increase
and they regard the university largely as a place to
in
scientific
knowledge, without a concomitant
receive an education that prepares them to cam a
increase
in
the
human mind’s capacity to absorb,
livelihood. Their major course of study is selected at
remember, and apply this knowledge, major changes
the start of university studies and almost all courses
in curricular concepts must be made with a signifi
are confined to the major course or to closely allied
cant reduction in the teaching of detail and greater
subjects. Medical school is no different, and proba
emphasis on broad concepts and an approach to
bly is even more restrictive, because of the large
1042
1110]
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Early Clinical program lor mudlms
Voi 23. Nos. 9-10, Sfptfmbfr-October 1987
Lacunal inthf Education Program
learning. In the coming years, if we succeed in'this
challenge, the question of specific gaps in the curric
ulum might then be addressed in a more comprehen
sive and imaginative manner.
to review, evaluate, plan, and execute curricular
changes in position or direction.
REFERENCES
1. Roemer Ml (Ed)(I960). “Henry E. Sigcrist on thesociology
of medicine.” MD Publications. New York, p 32-33.
2. (1968). Report of the Royal Commission on Medical
I ducation.” Cmnd 3569. Her Majesty’s Stationery Office.
I ondon.
3. Jeffreys M (1974). Social science and medical education in
Britain: a sociological analysis of their relationship. Int .1
Health Serv 4: 549.
4. Antonovsky A (1977). Rapports entre la pratique et la
formation medicale: le contribution des sciences du comportement. Rev Med Suisse 97: 237.
We are fortunate with regard to our organization,
which concentrates much of the decision-making
power about curriculum in the faculty’s Medical
I.ducation Unit. This central unit responsible to the
Curriculum Committee has been given considerable
authority for far-reaching curricular changes over
the special interest groups that characterize every
faculty. This organizational structure makes it easier
Ronald W. Richards
Center for Educational Development
University of Illinois, Chicago. IL
Preliminary Report on the Ben-Gurion University Center
for Health Sciences and Services, 1985
“A critical factor in the present and future viability of the
Beer Sheva medical program has been the visionary and
competent leadership at the helm. Moshe Prywes. the
founding dean, articulated the goal of integration of a
community-oriented system of medical education with the
health services of a developing region. He was masterful in
promoting the program and foreseeing potential obstruc
tions. A key tactic was the designation of Soroka Hospital
asa teachinghospital and the department chiefs as medical
school teachers to preclude severe contention between the
medical school and the regional hospital. Throughout this
period, quality of care and medical service were not sacri
ficed and Prywes espoused improved primary care.
Prywes’ leadership was followed by that of Lechaim
Naggan. Naggan’s commitment to the same ideals and
international stature as an epidemiologist facilitated a
smooth transition from the founding dean. His different
leadership style—one of process and attention to putting
systems and structure into place to support Prywes’
acclaimed ideals—is respected and he is seen as skillful and
convincing in his use of governance processes.
In the case of both leaders, their main source of power
has come and continues to proceed from the dual role as
head of the health servicesand the medical faculty. Both
see the control of the health services as the overriding
factor in matters vis-a-vis BGU and/or the Faculty of
Medicine.
The Beer Sheva Experiment has become institutional
ized and the justification for the program—the integration
of medical education and medical delivery—has been real
ized by the successful partnership between the school and
Kupat Holim. The medical program at BGU embodies a
philosophy of health care service as the overall mission
with medical education as the means to this end. Concom
itant with this mission is a growing agreement among
faculty to the community orientation and holistic
approach to patients. Faculty attrition and the recruit
ment of new. like-minded faculty has served to strengthen
this philosophy.
A combination of extraordinary leadership and esprit de
corps among students and faculty seems to contribute to
sustaining Beer Sheva’s viability, especially as shown in
the numbers of graduates who remain in the Negev to
practice.
The program’s present and potential for future
success is reflected in various areas: the fostering of
attitudinal values oriented toward the doctor/
patient relationship, teamwork, community and preven
tive health care, increased availability of primary care and
specialty physicians for the Negev region: the promotion
of regional policies toward Primary Health Care: and of
great importance, the integration of hospital care, ambula
tory care and community medicine. (Beer Sheva’s future
impact on increased numbers of primary care practitioners
may be more difficult to discern given an apparent
national trend for more medical school graduates to take
up primary care medicine due to limitations in speciality
positions and economic forces within the health care
system.)
Strengths of the program arc many. The congruence of
school goals with institutional objectives is supported by a
similar congruence of the goals/objecti ves with the eva luation system, admissions process and professional sociali
zation throughout the program. The actual presence of the
medical student in the community setting from the begin
ning of the program effectively communicates the impor
tance of the community-based orientation of the
program.”
1111]
T
1043
HEALTH SERVICES
A. General
HAS THE QUALITY OF THE HEALTH CARE PROCESS IN THE
NEGEV IMPROVED?
I.. NAGGAN
Division of Epidemiology. Soroka Medical Center and University Center for Health Sciences and Services. BenGurion University of the Negev. Beer Sheva. Israel
/at./ Med Sei 23: 1044-1046. I9K7
Key words: Beer Sheva Experiment: medical education: health care services: Negev. Israel: community medicine
The goals of the University Center for Health Sci
ences and Services (UCHSS) were, and still are. to
create an integrated health system that combines
preventive, curative and rehabilitative care as well as
primary, secondary and tertiary care, and to train
physicians and other health personnel who will be
prepared to work in such an integrated health sys
tem. In simple words, the aim is to improve the
quality of health care in the Negev, with an emphasis
on community health services. This emphasis stems
from the observation that while almost all medical
schools improve hospitals by converting them to
leaching hospitals, rarely do these benefits penetrate
the ambulatory health system, because traditionally,
most clinical teaching of medical students takes
place in hospitals. The changes that have occurred at
the Soroka Medical Center are described elsewhere
in this issue. This paper will address the effects on the
total system, emphasizing the impact on the organi
zation of pi imary care. The issues addressed include
the impact ol health (manpowcr development, academization of the community health professions,
organizational changes that succeeded and those
that failed, and a short description of the major
changes in the practice of primary care in the Negev.
HEALTH MANPOWER DEVELOPMENT
The selection processor medical students, the curric
ulum, which includes large components of social and
behavioral sciences and community medicine, as
well as the whole philosphy of the UCHSS facilitate
Address for correspondence: Dr. 1.. Naggan. Division of Epide
miology. Soroka Medical Center. BOB 151. 84101 Beer Sheva.
the training of community-oriented physicians.
Such physicians will not necessarily choose family
medicine as a career, but should be sensitive to the
total health problems of their patients and will hope
fully tend to function well in a health system that
combines tertiary and primary care. Evidence of this
orientation is seen in the 48% of our first four grad
uating classes who volunteered to serve in primary
care facilities for at least 1 year postinternship. Sixtythree percent (total n = 82) of these have chosen
either internal medicine (31%), pediatrics (19%) or
family practice (13%) for their residency, compared
with 53% of graduates (during 1980-84) in other
Israeli medical schools (total n = 555). The numbers
are too small, and it is too early to predict future
trends. But it seems clear that training received at the
medical school prepares our students to function
well in both tertiary and primary care systems. Sig
nificant as well is the fact that thus far 50% of our
graduates have remained in the Negev Kupat Holim
(Health Insurance Institute of the General Federa
tion of Labor) system, thus producing a cadre of
fresh, well-trained physicians in all our residency
programs.
The Recanati School for Community Health Pro
fessions trains nurses and physiotherapists in the
same manner, and its graduates function well in both
primary and tertiary care systems. There are special
programs to upgrade and expand the training and
skills of community nurses in the area of public
health and clinical assessment. Most teachers of the
medical school also teach at the Recanati School and
therefore the methods, curriculum, and conceptsare
the same.
Because of the emphasis on public health in the
[1121
1
L. Nagcan
Ishai i .1. Ml I). S< I
curriculum, the faculty has devoted significant man
physicians with faculty appointments far exceeds the
power and resources to the development of the Div
ision of Health in the Community. This effort served
total number of academic appointments in family
medicine in the other three medical schools in Israel
combined. The 33 faculty members in family prac
tice include 8 in (he north ol the country. Thus, it is
not only to attract high-caliber people to join us, but
also stimulated some of the local faculty to take
interest and do further training in the area of public
obvious that we have been a major driving force in
health. Thus, we encouraged and helped 10 faculty
llic acadcmization of community medicine and.
members (including 6 physicians) to obtain the
MPH (Master of Public Health) degree, and 2 to
more specifically, family medicine. This acadcmiza
tion adds prestige and increases the attractiveness of
obtain PhD degrees in health administration. This
training effort for public health in a medical school
faculty is unprecedented in Israel and in most
a career in family medicine and public health: we
hope to sec more good people attracted to this field,
winch has long been neglected in Israel. By doing so.
schools throughout the world.
the UCHSS contributes to the improvement of the
Residency training has become more academic, as
in most university teaching hospitals. In addition, a
special effort has been made to improve the quality
quality of community’medicine.
ORGANIZATIONAL CHANGES
and to expand the number ol family practice resi
dents. A National Center for Family Practice Resi
dency was established at the UCHSS. 'Ibis center
The concept of a medical center being responsible
for health care for a total area of the country has
been the foundation of the UCIISS philosophy.
Most medical schools adopt one or two small com
coordinates and overviews the academic activities of
family practice residents in Beer Sheva. Afula and
munities that arc usually used for demonstration
Haifa (constituting about 40% of the residents in the
projects or lor teaching community medicine. No
other center has taken upon itself the type of respon
sibility and commitment that the UCHSS has. The
Dean, being the Director of Health Services in the
country), and has promoted and improved the qual
ity of the teachers in family practice in both the
Negev and the north of Israel. Ninety-one residents
are now in training (32 in the Negev), and there are
already 37 specialists in family practice who gradu
Negev, has the obligation to deal with the problems
of the services on a routine basis. Thus, the academic
problems of teaching and research become inter
ated from this program (12 in the Negev). This is a
major contribution to the quality of primary care in
the Negev as well as to the country as a whole.
twined with service issues. Manpower and financial
resources from academic and health services serve to
strengthen each other and support programs that
otherwise could not be executed. This responsibility
Additional manpower training activities directed at
other community health professionals include spe
cial courses for primary clinic administrators, medi
cal secretaries, pharmacists and dentists.
is shared by the heads of the divisions; e.g.. the head
of pediatrics is not merely in charge of the hospital
pediatric wards but is responsible for the total child
health services in the Negev, which include Maternal
COMMUNITY MEDICINE AS AN
ACADEMIC DISCIPLINE
Most traditional medical schools pay only lip service
and Child Health clinics, primary pediatrics, and the
various consultative pediatric services. He allocates
pediatricians to work in the various hospital wards,
in the community primary pediatric clinics or in a
combination of both—a model that is becoming
to public health and community medicine by having
a small department and few resources for its pro
grams. The UCHSS from (he outset has emphasized
its intention and commitment with regard to public
more and more prevalent. The same pattern prevails
in obstetrics and gynecology, ophthalmology, otola
health by creating the following units: I)Epidemiol
ogy and Health Services Evaluation, 2) Sociology
of Health, 3) Administration and Health Economics,
and 4) Primary Care, which, together with the Occupa
tional Health Unit were integrated into the Division
Of Health in the Community. This Division pro
motes academic activities in the primary care system
in the same manner as done by the clinical divisions
in the hospital, or by the Basic Sciences Division in
its research
laboratories. There are 67 faculty
members with academic appointments in this divJs,on (out of 380 faculty, including clinicians) and
half
of these
--- ----—e arc family practitioners. The number of
ryngology and. to a much lesser extent, in internal
medicine (due to a severe shortage of internal medi
cine residents). Thus, without a formal organiza
tional
merging
between
the
hospital and
the
community health system, there has been a de facto
merging in many of the medical disciplines. This has
brought us closer to one of the most important goals
ol the UCHSS. namely, the merging of hospital and
community health care systems.
However, this is not enough, and the complete
administrative merging of the two systems under one
authority, which will include nursing, laboratory
(113]
Qi’aiiiyoi HiaiiiiCari intiii Nkiiv
Vol . 23. Nos 9-10. Si ni mbi R-OnoBi R 1987
care to the whole primary health system in the Negev.
The outreach programs, such as Community Health
Activists that has spread from Netivot to Yerucham,
Arad, Dimona and Beer Sheva, the oral rehydration
services and all other auxiliary facilities (single man
power organization, financial unification, etc.) is yet
to come, 'i his is our most significant shortcoming
and the most important goal for the next decade.
program in the Bedouin town of Rabat, and the reha
One goal toward which we have made absolutely
no progress is the merging of preventive and curative
services. The political implications of this union
were such that it was impractical to have expected it •
bilitation program of the handicapped in Yerucham,
are all additional and very excitingdevelopmenls in the
direction of the broader community involvement of
the health providers of the Negev.
to happen during the past decade. However, recently
the Ministry of Health has clearly stated its commit
ment to make significant progress in the merging of
to give the resources and responsibility for both to
CONCLUSIONS
This paper was limited to a review of the changes
that occurred in the organization of health services
Kupat Holim. T here is already a preliminary plan in
in the Negev and to the changes in the process of
which the Negev will be the natural experimental
area for this merger; thus, there is hope for change in
primary care delivery. The evaluation of outcome
indices is a broad and complex issue that is being
preventive and curative services under one roof, i.e..
the next decade.
tackled systematically by the Unit of Epidemiology
and Health Services Evaluation of the faculty. Issues
such as the efficiency of hypertension control in the
community, drug utilization in primary care, trends
in referrals to the hospital’s emergency ward, and
hospitalization patterns are being examined, as well
as the cost-efficiency estimates of the various experi
mental models of primary care. T hese important
CHANGES IN PRIMARY CARE PRACTICE
T he most significant contribution of the UCHSS in
the first decade of the health services in the Negev,
apart from its profound beneficial effects on the
teaching hospital, is certainly the revolution in pri
mary care. There are several papers in this issue that
describe in detail the various components of change
issues will be described and published in the years to
that have taken place, but it is important to stress the
come, since most of them demand long follow-up.
The answer to the question posed as the title of
total effect of these components. The fact that the
goal of the UCHSS was clearly defined as the
improvement of the quality of primary care, and that
a significant proportion of the teaching takes place
in primary care settings, made that commitment
this paper is definitely “yes!” In one decade very
significant strides have been made in the area of
manpower development, and training not only
community-oriented physiciansand nurses, bulalso
very visible. Teaching in primary care clinics had to
be created, and teachers had to be trained. A massive
effort of time and resources (namely, the Aguda
public health personnel who support and continue
to promote the community orientation of the
UCHSS. The faculty's role in community medicine
project, funded by the Joint Distribution Commit
and family practice has served to improve the levels
tee) was directed to changing no less than 13 primary
clinics in the Negev into teaching centers, with var
ious organizational and functional modalities that
of teaching and performance. There are signs that
research activity is starting to develop as a natural
sequence of this academization. T his too is a f eature
that provides assurance for the ongoing process of
serve as learning experiments to students, residents
quality of care and, thus, also on the quality of
health of the third of the Negev population that is
improvement in the quality ol primary care.
Organizational changes have enabled the merging
of hospital and community in various medical disci
plines. A formal organizational merging of the two
systems must come soon in order to consolidate the
served by these teaching clinics. The graduates have
become important change agents in this exciting
process. They have helped create modalities in which
there is utilization of nurses in triage, and where
achievements obtained so far and to continue to
progress and improve. Kupat Holim will soon have
to decide on several new organizational patterns for
primary health clinics. The present ones are a source
social workers, medical secretaries and other health
professionals are working together as a team (some
times for the first time) in primary care. T he family
residents are now taking over and adding their
expertise and have become a permanent feature in
this thrust to improve primary care. In the next
of considerable dissatisfaction to both providersand
consumers. These new modalities will have to satisfy
the academic standards of a university level ol prim
ary care, as well as the need to merge preventive and
curative services. The experience gained in the Negev
should prove very valuable when these decisions arc
decade, the goal should be to expand the improved
made early in the next decade.
and the Kupat Holim administration. These clinics,
in which the process of-care has improved drasti
cally, are bound to hdvc a beneficial effect on the
|H4|
1
THE BEER SHEVA EXPERIMENT—PAST, PRESENT AND FUTURE
The Hospital Management Viewpoint
Y. SHAPIRO.1 D. HAUBEN 2 and H. REUVENI 3
1 Directorate. Department ol Plastic Surgery and > Division of Pediatrics. Soroka Medical Center Ben-Gurion
University of the Negev. Beer Sheva. Israel
hrJMedSciiy. 1047-1050. 19K7
Key words: Beer Sheva Experiment; medical education; health care
services; regional hospital;
hospital management
In 1972 when the “Beer Sheva Experiment’’ became
a reality. Dr. Moshe Prywes defined the goals of the
University Center lor Health Sciencesand Services
(UCHSS): “It will respond to a double challenge: to
combine all health services in the region into one
integrated system in order to provide comprehensive
medical care lor the regional population; and to
merge this system with the system of medical educa
tion in trying to educate physicians who are aware of
the needs of the community and wish to work in both
community hospitals and primary care clinics” (1).
The concept can be summarized as a comprehen
sive medical system composed of integrated pri
mary, secondary and tertia’ry medical care and
community-oriented education—one academic
medical center with integration of medical care and
health services for one geographical region, the
Negev.
GEOGRAPHICAL AND DEMOGRAPHICAL
CHARACTERISTICS
The Soroka Medical Center is a regional hospital
whose catchment area includes half of the geogra
phical area of the state of Israel—the Negev—and
about 7.5% of the country’s population. The hospi
tal is located in the northern part of the Negev. To
reach the hospital, patients have to travel varying
distances, from I to 5 km within the town of Beer
Sheva, and 10 to 50 km from most regional settle
ments—up to 220 km from the southern part of the
Negev. The total Negev population of approxi
mately 300.000 comprises four main groups: I) the
urban population (110,000) that resides in the city of
Address for correspondence: Dr. Y. Shapiro. Directorate. Beilin
son Medical Center. POB 85. 49100 Pclah Tikva.
Beer Sheva itself; 2) the 55.0(X) Bedouin population,
many of whom still live in tents and huts, but
increasingly in permanent houses (some of the
Bedouins still partially use traditional tribal care,
with a dervish); 3) army populations that are in a
relatively self-contained system dispersed all over
the region of around 10.000 km2; and 4) residents
outside the urban area of Beer Sheva.
BEFORE 1973
The existing conditions for establishing the Beer
Sheva Experiment were: l)a population of 235.000
in one large developing region; 2) one general com
munity hospital with 585 beds and a good nonaca
demic nursing school owned and operated by Kupat
Hohm (Health Insurance Institution of the General
Federation of Labor); 3) 134 primary care clinics,
part of the Kupat Holim network, but with little
connection to the hospital; and 4)a young university
without a medical school.
Those who had the dream defined two other con
ditions (I). The first was the desire of the medical
staff of all the medical organizations in the region to
have a well-integrated framework. Later on, how
ever, this wish was not accepted by ail medical sec
tors, but only by a small group who wanted an
academic affiliation. Many others remained indiffer
ent to the changes. And the second was the trend of
the Ministry ol Health to integrate and to unify its
activities with those ol Kupat Holim. This goal was
not accomplished, however, and remained theoreti
cal. The two main problems of the medical services
were: I) the difficulty of recruiting skilled medical
manpower, especially physicians, for both the hospi
tal and the community; and 2) difficulties in man
power development.
1115]
Y. Shapiro et al.
Israel J. Med. Sci.
Despite the policy that attempted to offer the
Negev medical services as good as those in the center
of the country, the level of medical services in the
Negev remained inferior to those in the more devel
oped areas of Israel. The underdevelopment and less
attractive nature of the Negev, compared with the
center of the country, made the problem of recruit
ing “high-tech” personnel more difficult.
The main message of the Experiment to the physi
cians was “join us and see the academic world,” i.e.,
academic positions and academic privileges. This
message did not affect the rest of the staff.
FIRST DOZEN YEARS (1973-85)
According to the original concept, the Medical (’en
ter was founded through the union of the hospital
and the Faculty of Health Sciences on the same
campus, where the Dean of the faculty is also the
head of all the regional medical services. During the
last 12 years, the following main changes have been
accomplished:
1) The University Center for Health Sciences and
Services was established, comprising a medical
school and a school for community health pro
fessions.
2) The traditional Nursing School was changed from
a local nonacademic nursing school, belonging to
and serving the hospital, to an academic, indepen
dent school for community health professions com
prising nursing and physiotherapy tracks.
3) The community hospital became a teaching medi
cal center.
4) fhc medical center became the center of all the
medical services in the region; the involvement of the
hospital in the community was thus broadened and
deepened.
5) The Ministry of Health established a psychiatric
hospital of 170 beds, with an academic affiliation to
the medical school, but totally independent in all
other ways. In addition, a department of psychiatry
was opened at the Soroka,Medical Center.
6) Other medical services, such as Magen David
■ Adorn (the Israeli equivalent of the Red Cross),
declined to be absorbed into the Medical Center;
they preferred to remain independent and tried to
open their own medical rescue center.
The quantitative changes during the last 12 years
are summarized in Table 1. It can be seen that in
spite of a 29% growth in the population and its rising
age, the number of beds in the hospital increased by
20% only; the total number of hospitalization days
increased by 19% and the bed occupancy from 95 to
101%; thus the hospitalization system became more
efficient. The reduction in hospitalization days per
year from 872 days/1,000 population in 1974 to
824/1,000 in 1984 (5.5% reduction) supports the
assumption that the hospital became more ef ficient.
Organizational changes in the hospital resulting
from the Beer Sheva Experiment
1 he idea was stated in the principles of the Beer
Sheva Experiment (2) as follows: “Regionalization
of services, strengthening of primary care clinics and
community medicine, limitation of hospitalization
and changing the inner structure of hospitals, and
reform of medical education by increasing its rele
vance to the health needs of the population.” Most
of these goals have been fulfilled. The services have
been regionalized in full for pediatrics, gynecology
and internal medicine, i.e., the responsibility of the
chairman of a department includes total care of the
population—primary, secondary and tertiary care;
and partially regionalized for the other disciplines.
Primary care was strengthened by “integrative”
positions in internal medicine, surgery and pediat
rics. whereby board-certified physicians divided
their time between the hospital and the community.
The family physician residency program contributed
its share to strengthening the primary care system.
The inner structure of the hospital was changed as
follows: 1) In addition to the traditional medical
wards, five clinical divisions have been established:
internal medicine and allied disciplines (i.e., neurol
ogy. n c p h ro I ogy. ga s t roe n t e ro I ogy, ca rd i o 1 ogy, ge ri-
Table 1. Demographic changes in the Negev between 1974 and 1984 and their
reflection on hospitalization (excluding geriatrics)
I (Hal population
Bedouins
Total hospital days
Annual hospital days/1.000
population
Visits in outpatient clinics
Total no. of beds
Day care beds
Occupancy ((’/t )
Average duration
of hospitalization (days)
1974
1984
°7i change
235.000
37.000
204.973
872
296.(XH)
55.(X)O
243.783 (253.115“)
824 (855“)
26.0
48.6
19(23“)
146.453
585
256.706
704
47
101
75.3
20.3
95
6.3
6.3
5.9
-6.3
f
“'Total hospitalization including day care.
[1161
Voi 23. Nos. 9-10. Sim mbi r-Octobi-r 19X7
Tin Hospitai Manacj mi-ni Vii wpoint
J able 2. Manpower devclopmcni in the Soroka Medical ( enter and the community between IV7J and /9X-/
Hospital
I
Physicians (no.)
Nurses (Total no.)
RN (%)
Practical nurses (%)
Nursing aides (v/()
Nurse:physician
ratio
RN:physician ratio
Primary care
clinics (no.)
Monthly consultative
sessionsb (no.)
Community
1973
10X4
"t Change
1973
1984
^/t Change
133
401
34
54
12
313 + 39“
656
33
45
22
135 (165“)
65
119
199
30
69
I
208
300
18
62
0
75
51
3.01
1.02
2.10
0.71
1.67
0.50
1.44
0.55
134
I 19
40
269
573
’ Physicians in faculty teaching position.
The consultative sessions of secondary care are given by the hospital physicians in the community-clinics.
RN = registered nurse.
atric medicine, oncology, etc.): pediatrics: obstetrics
and gynecology: surgery (general surgery, ophthal
mology. ear. nose and throat, urology, orthopedic
surgery, neurosurgery and plastic surgery): and psy
chiatry. Other divisions arc in the planning or imple
mentation process. 2)4 enure in clinical specialties is
now granted only for entry into positions that
involve duties both in the hospital and the clinics. 3)
A pediatric ward of 25 beds was transformed into a
day care unit (8 beds) next to the pediatric emer
gency room. As a result, the occupancy in the other
two pediatric wards decreased by about 109?. and
the overall hospitalization days in the pediatric div
ision were reduced by 35%. Similar changes in the
other divisions arc being planned.
Present advantage to the hospital
The hospital benefits to a certain extent from the
Beer Shcva Experiment. By the creation of a teach
ing hospital, the whole area has become far more
appealing, from a professional point of view, result
ing in an increase of 135% in physicians in the hospi
tal and 75% in the community (Table 2). There are
adequate numbers of good candidates in most fields
Table 3. 1984 hospitalization rate hy discipline: comparison of
Nefjey region and national rates*
Negev
Israel
"A di He re nee
Totalb (excluding
824
geriatrics and psvchiatry)(5.9)
Internal mcdicine’’
171
(6.0)
General surgery1'
107
(6.9)
Pediatrics'
21 I
(6.2)
943
(5.8)
228
(6.5)
126
(5.9)
280
(4.9)
14
Hospitalization rate
ol medicine so that lhe management isablc to choose
the best for residency.
The resident who completes his or her training in
the hospital is drawn into community medicine and
is employed part-time by the hospital (about 3daysa
week) and part-time by the clinics in the community:
therefore, lhe hospital can continue to absorb new
young residents without discharging from the sys
tem those who completed their residency. Thus, the
recommendation of the WHO’s Executive Board
and the World Health Assembly to link health ser
vices and manpower deployment is realized (3). Asa
result, the primary care clinics in the community
receive highly trained doctors who by their ongoing
affiliation with the hospital, form a continuation of
care between the community and the hospital and
raise the standards of medical practice. These devel
opments improve the diagnostic and therapeutic
process and reduce unnecessary hospitalization. The
follow-up of patients is longitudinal and not limited
Io lhe hospital.
lhe annual number of hospitalization days per
year in the Negev is 824/1.000 population, excluding
psychiatry and geriatrics, and is lower than the
national average of 943/1.000 ( Table 3). (Unfortu
nately. age-adjusted rates are unavailable: however,
the exclusion of the geriatric patients makes this
comparison acceptable). 4 he same lower rates are
valid in almost every department of the hospital.
These low rates suggest that the Beer Sheva inte
grated medical system is the most effective in Israel.
33
18
33
The average hospitalization duration in days appears in
parenthesis.
In days/1.000 persons per year.
In days/1.000 children per year.
Goals not yet achieved
In spite of the significant achievements made during
lhe past 12 years, according to the original goals (I.
2. 4. 5). not all objectives have been attained.
Integration of all health services in the Negev. Prev
entive medicine and psychiatry services arc still
divided between Kupat Holim and the Ministry of
1117]
Y. Shapiro ft ai .
Israfi J. Mi d Sc i
Health. A major concern of the hospital is the sepa
and has no obligation to the hospital—in spite of the
fact that the hospital offers almost all of its facilities
ration of rescue services, a fact which impedes the
activity of intensive care mobile units and that of the
including teaching infrastructure to the nursing
school.
cardio-mobile ambulance in providing proper conti
nuity of treatment from the scene of the event to the
intensive coronary care unit.
A LOOK TO THE FUTURE
Furthermore, night-service emergency clinics are
still separated from the hospital and from the ambu
should be planned and implemented: I) Asa result
latory care clinics, resulting in two separate systems—
of the inconvenience of the large distances between
one, the emergency rooms of the hospital and the
other, Magen David Adorn. This dual system con-
the settlements and the hospital (up to 200 km) and
the need to retain the structure of one region, one
medical school, and one medical center, it is sug
From the point of view of the hospital, the following
ssumes essential Financial resources and reduces
optimal treatment.
Merger of hospital and community services. The
merger between the hospital and the auxiliary com
munity services, which include nursing, physiother
apy, occupational therapy, and social work as well
as laboratory services, are indispensable for continu
ous optimal medical treatment.
Full merger of health services with medical educa
tion. 1 his goal has almost been realized, since all
medical departments are affiliated to the Ben-
gested that the organization establish satellites of the
medical center, each satellite providing pediatric day
care (rehydration center), high-risk pregnancy day
care, general day care and “secondary” care medi
cine (regular consulting services, like ear. nose, and
throat, ophthalmology and others). These satellites
will be operated for the community by the hospital.
2) Operational autonomy of the Negev health ser
vices: This service should be governed by a regional
health council in which the Dean of the UCHSS will
Gurion University of the Negev. However, not all
be the chairman of the council. The council should
our clinical teachers are adequate role models with
define the comprehensive regional medical policy,
regard to integration in the community.
manage an independent medical budget, and hire or
Disadvantage of the Beer Sheva Experiment The
buy necessary medical services from outside the
main disadvantage of the Experiment is in the nurs
region. 3) Special attention should be paid to solving
ing sector, both in the hospital and in the commun
ity. An integrated medical service needs more
nursing manpower than does a traditional one.
of the shortage of nursing manpower: it should be
solved by the regional council as a regional solution
(i.e., regional nursing schools, regional scholarships,
Teamwork in the community needs highly qualified
special nursing educational programs for housekeep
nurses, namely registered nurses with special train
ing. This type of work is more attractive to most
nurses and, therefore, many registered nurses leave
ers, housing solutions, special financial aids, etc.).
Large organizations have a great deal of inertia.
the hospital for work in the community. In fact,
during (he years 1973 to 1984 the percentage of
registered nurses in the hospital dropped from 34^<
in 1973 to 33% in 1984. but increased from 30 to 38%
organization can the necessary changes be pro
duced. Such a process was created in 1973 by the
establishment of the Ben-Gurion medical school.
in the community. In the same period the percentage
of nursing aides in the hospital almost doubled
(from 12 to 21%), but remained 0 to 1^ in the
community. The overall nurse:physician ratio
decreased seriously in the hospital but not in the
major structural change, such as regional medical
autonomy.
community. Furthermore, the reduction in the ratio
of registered nurses to physicians in the hospital is
even more marked (Table 2).
Rl 11 Rl NCI s
I. Prvwes M (1973). “Merging medical education and medical
care " /tosp.Mcd XiaH fAmrricaii llospiialAsxociaiion). vol.
The
transformation
of the
previous
nursing
Only with the investment of significant energy in the
Further development can be stimulated by another
i
2.
school to an academic one with community medi
cine al til tides shifted the equilibrium toward the
3.
community with little compensation to the hospital.
Today, the hospital receives fewer graduate nurses
from its own school than in the past. Most nursing
4.
school students are moving outside the hospital and
5.
even to other regions, since the school is independent
[118|
Prvwes M (1979). The Beer Shevu experience in the promo
tion of health services and medical education: an interim
report. Ihncluah 94: 337-340 (in Hebrew).
(1977). “Report on consultation on health services and
manpower de\elopmenl. 6-X September 1976.”
HMD/77.1. WHO. Geneva.
Prvwes M (1977). 1 he Beer Sheva experience. JAMA 238
1571.
Prvwes M (1983). The Beer Sheva experience: inteeralion o
medical care and medical education. Isr J Med Sei 19
775-779.
DIVISION OF HEALTH IN THE COMMUNITY: DEVELOPMENT,
STRUCTURE AND FUNCTION
CARMI Z. MARGOLIS
Department of Heahh in the Community. University Center for Health Scienees and Services. Ren-Gurion
University ol the Negev. Beer Sheva. Israel
Isr J Med Sci 23: 1051-1055. 1987
Key words: Beer Sheva Experiment; medical education; health care services; Primary Care Unit
The founding Dean of the University Center for
Health Sciences and Services. Dr. Moshe Prywes.
initially established neither a department of general
practice nor a department of primary care, nor even
a. department of community or family medicine; he
maintained that primary care was to become every
one’s business. Therefore, the hospital chiefs of
service would be responsible for community as well
as hospital services. The head of the Pediatrics De
partment would be responsible for the health of all
Negev children, and the head of Internal Medicine
would be responsible for the health of Negev adults.
This strategy succeeded in motivating the heads of
the hospital departments to plan community care.
However, by 1977 it became apparent that sevenrl
forces were pressing for the establishment of an
academic locus for primary care within the medical
school. First, (he department heads were grappling
with many difficult hospital problems and had
neither the time nor the administrative support to
make major changes in community health services.
Second, the lew outstanding primary care prac
titioners who had been chosen to initiate primary
care leaching and change community services
perceived a need lor a power base outside the
hospital that could both balance the hospital power
base and work to effect these changes. Third, since
the organizational structure of the Kupat Ilolim
(Health Insurance Institution of the General Feder
Address lor correspondence: Dr. C. 7. Margolis. Department of
Health in the (ommtinily. University Centcf lor I Icaltli Sciences
and Services. Ben-Gurion University of the Negev. POB 653.
84105 Beer Sheva.
ation of Labor) continued to emphasize the
separation ol hospital and community clinics, only
an academic unit located near the district clinic
offices would be appropriate for effecting changes.
These were the main factors that brought the
^ary Care Unit (PCU) into being in September
The PCU was to assume responsibility for all
primary care teaching at all clinical levels, from
preclinical (including all early clinical teaching
programs during 1977-79). through clerkship and
residency teaching, including continuing medical
education for practicing physicians. However,
within a year of the founding of the PCU. as we
attempted to prepare the community clinics for their
first clerkship students, it became apparent that a
unit whose rcsponsibility.extcnded to clinical teach
ing alone would not have sufficient power either to
create a strong enough primary care curriculum or to
effect change in the clinics. Moreover, from the
perspective of research, it was felt that only close
coordination ol all the units involved with the
community could lead both to relevant studies on
health and disease in the community and to research
performed by practitioners. At a meeting of the
primary care and community medicine faculty. 19
central primary care problems were defined (Table
I). In July 1979. the Division of Health in the
Community (DHC) was formed in order to achieve
these teaching, service and research goals.
DHC BYLAWS
Bylaws were proposed by the DHC and ratified bv
the General Council of the University Center for
ni9]
ISRAI I J. Ml I) S( I
C. Z. Margoi is
DEPARTMENTAL STRUCTURE
Fig. 1 shows the organization of the DHC. While
each unit retains independence in internal budgetary
and personnel management and research, the Di
vision Council, which includes key health service
figuresand a representative from each major clinical
service, coordinates inlcrunit programs in service,
leaching and research .The council meets every 4 to 6
weeks, and the unit heads meet every 2 to 3 weeks.
Both groups are chaired by the head of the
department, who is responsible for managing the
DHC budget, for developing accommodations for
the Division, and for recommending academic
appointments. This departmental structure brings
together groups of specialists who usually work in
separate departments: primary care clinicians work
with community medicine, public health and be
havioral science specialists, and with primary care
clinicians from different specialties.
Table 1 ..List of problems (by priority) of the Planning Committee
of the Division of Health in the Community (DHC). 9 September
1978
1. Quality of care evaluation ol primary and preventive services,
including setting standards and evaluating community needs
2. Attracting primary care staff
3. Writing DHC bylaws
4 Coordinating X-ray and laboratory *• i vices wilh community
I ice) Is
5. Dclining primary care clinic models
6. Establishing continuous, comprehensive primary care, in
cluding developing night and holiday primary care services
7. Unifying health services (hospital-community, curativcprcvcnlive)
K. I stablishing a quality primary care medical record
9. Developing ambulatory and primary services as alternatives
to hospital (second and tertiary) ones
10. Motivating clinic staff to do research
11. Establishing an effective health education program
12. Designing effective continuing education courses for clinic
staff
13. Establishing priorities for developing quality clinics for ser
vice and teaching
14. Encouraging effective community representation in the health
services
15. Coordinating medical and nursing functions in the com
munity clinic
16. Providing sufficient specialty consultation
17. Improving community mental and dental health services
18. Planning health services for the Bedouin population, includ
ing a plan for follow-up of discharged Bedouin children (by
request of the Division of Pediatrics)
19. Decreasing unnecessary surgical referrals to the Emergency
Room (by request of the Division of Surgery)
Health Sciences and Services to govern situations
involving the DHC’s overlapping functions in the
hospital and the community, its relationship to other
clinical divisions, and the relationship between its
academic and clinical units (see below). The main
reasons lor establishing the DHC were a common
interest of member units in community health
services and in research performed in the com
munity, and a strong interest in merging clinical and
primary care—including family medicine—with
teaching in epidemiology, sociology of health,
medical economics, medical care administration and
occupational health. I hc DI IC had four tasks: 1) to
help plan and coordinate community health ser
vices, community-based teaching and community
research—including running several model services,
planning, implementing and evaluating primary
care clinical and community medicine teaching, and
coordinating and supervising community-based
research; 2) to define, together with community
representatives, community health problems, and to
plan and implement programs for solving them; 3) to
develop connections between hospital and
community services in service, teaching and
research; and 4) to establish connections with
community health institutions, as well as
community welfare teaching and research
institutions in Israel and abroad.
DEPARTMENTAL PROGRAMS
Service
The central goal of the DHC is to upgrade a group of
Kupat Holim community clinics to provide high
quality primary care. This process began with
defining community health problems even before
the DHC was established (see Table 1) and con
tinued with intensive efforts in three major areas:
developing quality community clinics, establishing
the Bedouin Mobile Care Unit and related projects,
and establishing quality residency training in family
medicine and in community pediatrics and internal
medicine.
The Clinic Development Committee was
established in September 1979 in order to coordinate
planning and implementation of changes in
community clinics (1). At the same time, significant
funding was obtained from the World Joint
Distribution Committee (JDC) through the Israel
JDC for the specific purpose of advancing health
and social services in the Negev. The first 2 years of
this 5-year project, known as Phase 1, were spent
developing one urban clinic (Massada clinic in Beer
Sheva) and one development town clinic (Ofakim
clinic)—models of quality community medical care
(2). The limited success of Phase I was due to local
difficulties with program management, com
munication problems between Beer Sheva and
the Israel JDC in Jerusalem, and lack of an effective
mechanism for allowing project personnel to
function within Kupat Holim. During the following
3 years, known as Phase II, the program was expand
ed to include the Graduates Program for primary
care, which constitutes a major DHC effort and is
described in detail in several other papers in this
1120]
!■
t
Vol.. 23. NOS. 9-10. SFP1 EMBER-OCTOBER 1987
Division of Health in the Community
]
< >1 fi« <■ ill |hr ('li;iitni:in
5 unit chairmen
Rtprescnladvcs of major clinical departments (pediatrics,
psychiatry, etc.)
Medical directors of Kupat Holim and Ministry of Health
(KHM)
Director. J DC project
[
Nursing directors of the KI IM
I Inisinn Coiiiicil
Administrative directors of KHM
Representatives of Rccanati Nursing School
Chief. Kupai Holim social work
Representative. Kupat Holim community clinic chiefs
I’niiiaiy
Care
Unit
I amih
Medicine
Program
Community
Pediatrics
Program
I
I
I
;in<l Ht-.-ilih
Services
Evalualion
Unit
Sot i< ilog v
in Hcalih
Unit
Hcalih Service'.
Administration
and Economics
Unit
Ind list i ial
Medicine
Unit
Coinmiiniiy
Internal Medicine
Program
Fig. I. Structure of the Division of Health in the Community. Kupat Holim = Health Insurance Institution
of the General Federation ol labor; JDC = Joint Distribution Committee: JDC project = Association for
Advancement of Medical and Social Services in the Negev.
issue. During the first 3 years of this process, the
regularly visit a child with a failure to thrive, in order
Clinic Development Committee met over40 times to
plan and review the progress of these projects. Phase
to help with feeding and to check its weight, or will
enable an adult burn patient to return to his tent
earlier by providing frequent dressing changes.
Arabic-speaking staff includes a Bedouin com
munity worker-driver, an experienced registered
II is seen as a success by participants, by Kupat
Holim and faculty managers, and by the
communities that have benefited from improved
individual patient and family care (3).
In May 1984, the Israel JDC Negev project
continued past its original 5-year mandate into the
unanticipated Phase III (4), which aims to support
the development of specific community projects,
and is also described elsewhere in this issue.
In August 1985, the DHC was defined as having
responsibility over the quality of care in 13 teaching
nurse with special training in public health, and a
communitiy nutritionist. The nutritionist, a locally
trained paramedic, started the second Unit service:
predischarge nutritional counseling for Bedouin
mothers in the pediatric ward. A third service
provides nutritional and nursing counseling to new
mothers in the obstetric ward. During the past year,
staff have begun to strengthen the interaction
clinics. 5 in Beer Sheva, and 8 in development
between the Kupat Holim community Bedouin
towns—Nehora, Sederot, Netivot. Ofakim. Rabat.
Arad, Dimona. and Yerucham. This definition was
clinics and the hospital, as well as the connection
between community clinics’ staff and their patients
not meant to permanently exclude other clinics fronl
joining the DHC. Rather, it is felt that these 13
clinics arc now functioning generally at a relatively
high level of care. Other clinics that will reach this
at home.
level will subsequently be candidates for inclusion in
the DHC.
Another major DHC project is the Bedouin
Mobile Care Unit that provides outreach services to
the Bedouin population. Initially funded privately
with running expenses provided by Kupat Holim.
the Unit provides follow-up services for children and
adults living in the desert. For example, the staff will
Teaching
The major teaching effort was initially invested in
the community-oriented primary care clerkship (5).
However, with the establishment in August 1979 of
the Kupat Holim Ben-Gurion University National
Institute for Residency Training in primary care and
family medicine (NIRT), and the concomitant
designation by Kupat Holim of 175 salaries for
family medicine residency training, strong emphasis
was placed on developing postgraduate primary care
(121]
C. Z. Marcioi is
Israi-i J. Mid Sci
programs. To significantly upgrade the quality of
gram in primary care internal medicine are only
the family medicine residency, the following steps
barely visible today.
were taken: 1) Admissions policy and procedures
Teaching programs in the basic sciences of com
were made explicit and standardized. 2) A required
munity medicine and primary care—epidemiology,
day-release course in family and community
health services research, behavioral and social
medicine was designed, implemented and evaluated.
sciences—are described elsewhere in this issue.
This course was taught for a 7-hour day/week, 9
months/year over 3 years, and included units in
Research
communication skills, Balint-type group work,
Bringing together the units of the DHC has led to
counseling for common psychosocial problems,
increased coordination of their research efforts.
epidemiology, medical sociology and other critical
Thus, the evaluation of the Israel J DC pro ject was
areas in which the residents had little or no training.
performed by members of the Epidemiology-Health
The course was accredited as compulsory in 1981 by
Services Evaluation, Primary Care and Medical
the Scientific Council of the Israel Medical As
Administration Units. The Epidemiology Unit also
sociation. Within a year, the same course held at the
helped members of the PCU and Medical Sociology
northern branch of the NIRT in Haifa and Afula was
Unit in major research on health, disease and culture
also accredited, followed by the accreditation of
in the Bedouin population. The Medical Sociology
similar courses in Jerusalem and Tel Aviv, and thus
Unit is now spearheading major collaborative geri
a major change was effected in the family medicine
atrics research. At the same time, preserving the
residency training in Israel. Recently, emphasis has
independence of member units has allowed each to
been placed on designing an appropriate evaluation
develop its own research themes. The Medical Soci
of resident performance, insuring structural stan
ology Unit has concentrated on stress research. The
dards for family medicine training clinics, and
Health Services Administration Unit has empha
improving the quality of supervision by tutors.
sized research on the cost-effectiveness of the medical
Two other innovative continuing medical
staff and medical economics. The Epidemiology
Unit has completed studies on local diseases such as
education courses are the continuing medical
viral hepatitis, and the PCU has explored research in
education course for medical school graduates
clinical education, including studies on medical deci
participating in the Graduates Program described
sion making and medical record audit.
elsewhere in this issue and the clinical scholar
Two enduring DHC forums for presenting
program. This newest DHC teaching program is
research have been established: at the research collo
designed to provide promising new specialists in
quium, investigators present research planned or in
family medicine, pediatrics orinternal medicine with
progress io a critical audience; al the monlhly
a year’s I raining in general academic medicine. The
research meeting, visiting or resident researchers
program, which started in February 1985, with a
present completed work in detail. Recently, renewed
family practitioner scholar, is made up of three
effort is being invested in a research activity that was
units. The scholar 1) provides supervised weekly
initiated by the PCU and Epidemiology Units in
consultation to medical graduates practicing in two
community clinics; 2) takes 1- to 4-month tutorials . 1977, and which solicits and supports practitioner
research. To this end, a community research meeting
in clinical epidemiology, medical sociology, medical
for community practitioners was begun a few
care administration and medical education; and
months ago. In summary, when compared with any
3) completes a supervised independent research
of the other medical school divisions, the DHC has
project.
‘
accomplished a large amount of quality research, as
A program in community pediatrics for pediatric
measured by the number of published papers or by
residents is being planned jointly with the Division
research dollars earned.
of Pediatrics. The program will include course work
similar to that taught to iamily medicine residents
and pediatric community clinic case presentations.
DISCUSSION
Many of the achievements, described above, in
Full implementation of this program will occur only
after the new. nationally required community pedi
upgrading Kupat Holim clinics are now being
atrics curriculum is implemented. Although Dr. R.
repeated in other clinics, but all too frequently some
Boehm did pioneering work in developing a com
of the original achievements have at the same time
been eroded. Thus, finding a permanent home in the
munity internal medicine clinic in Yerucham that
was integrated into the Division of Internal Medi
Kupat Holim services for the Bedouin Mobile Care
unit that functions in and out of the hospital has
cine at the M 'ieal Center, this model has not yet
grated sharply against the rigid definitions that
spread to other clinics, and the beginnings of a pro-
|122|
r< >
Vol. 23, Nos 9-10, September-October 1987
Division of Hi ai hi in the Commijnii y
require a Kupat Holim unit to be either hospital or
clinic based. Our effort to implement a community
problem-oriented record has collided repeatedly
with an attempt to institutionalize nationally a less
costly, inadequate, abbreviated, problem-oriented
record. Decisions on the organization of a develop
ment town clinic may be taken out of local team
hands because of ostensibly more important consid
erations appreciated only by central administrators
in Tel Aviv. At the same time, it is well known that
highly competent physicians must function profes
sionally with a large amount of independence if they
are to pursue fulfilling careers not only as hospital
chiefs of services but as clinic directors or practition
ers. Can Kupat Holim decentralize? Can community
Kupat Holim clinics gain professional and even eco
nomic independence so that physicians are chal
lenged to work in them? These questions define
limitations to the goal of upgrading the clinics. We
do not yet know if these limitations are
surmountable.
If in the teaching and research game the outlook is
brighter, this is because wc have made the rules for
playing on our home court. Yet, limitations do exist.
We have not yet attracted or trained a sufficient
number of quality teachers to allow for development
of programs in depth. BeerSheva is formany only an
empty desert, rather than a challengingly empty
desert. Even for those who see the challenge, if one is
the only specialist in an area, there is no room in all
that emptiness for a discussion among colleagues.
Built-in mechanisms for change may themselves
constitute a limitation. Changes that are too rapid in
unsettled but fundamentally sound programs for
teaching family dynamics and clinical judgment to
students, and fortcaching the medical graduatesand
family medicine residency course, have sometimes
wasted effort and achievements already gained.
National inertia has seriously hampered local devel
opment of important programs. Development of
both pediatric and internal medicine primary care
will have to await national support in the form of
required residency tracksand speciality examination
requirements. This last limitation, however, may be
legitimate albeit extremely frustrating. Our medical
social forces are only a microcosmic model of larger
Israeli social forces. Thus, like the individual kibbutznik, an Israeli medical school maynotbeable to
proceed with a plan that does not have general sup
port. On the other hand, even in a socialist society,
much progress may be made by means of small,
rather than large groups, that allow individual
expression within a framework. In Israel, the kib
butz seems to I unction effectively as an independent
unit. In the hospital, a ward seems to warrant inde
pendence. Outside the hospital, it is essential that
recognition be given to the community clinic as the
appropriate independent organizational unit.
ri:i IRI NCI S
1.
2.
3.
4.
5.
1123]
Eldar R. Roncn Dand MargolisCZ(1984). Development of
city health services by an academic department. World
Hospitals 6: 41-42.
Margolis CZ (1981). “The Negev project in primary health
care, two year interim report.'’ Association for Advance
ment ol I lealth and Social Services in the Negev, BeerSheva.
Schein M (1982). “ The Negev project in primary health care.
Progress report.” Association for Advancement of Health
and Social Services in the Negev. Beer Shcva.
Porter B (1984). “Proposal for the continuation of the Negev
project for primary health care in the Negev.” Association
for Advancement of Health and Social Services in the Negev.
Beer Sheva.
Margolis CZ. Barak N. Porter B and Singer K (l987).Thecommunily-orienlcd primary care clerkship. Isr./ Med Sei
23: 1027-1034.
Ttv***' -
ADMINISTRATION OF THE BEN-GURION UNIVERSITY CENTER
for health sciences and services
DAVID SINGER
Administration. Ben-Gurion University of the Negev. Beer Sheva. Israel
Isr J Med Sei 23: 1056-1061. 1987
Key words: Beer Sheva Experiment: medical education; administration
Before leaving the World Health Organization to
join the staff of the Ben-Gurion University, which
was to establish the Center lor Health Sciences and
Services. Prol. Newell, an epidemiologist of internaDirector of the Division of Strengthening of Health
Services. Prof.Newell, an epidemiologist of interna
tional renown and a scholar in the field of health
services administration, explained the reasons for
WHO’s enthusiastic support of the ideas underlying
what was later termed “The Beer Sheba Expe
rience.
We shall support you,’’ he said, “because
your project is not based on a piecemeal approach
towards change and development. What you intend
to do may constitute a revolution in the field of
health care and medical education which could have
a vital impact on progress of medicine, not only in
Israel, but all over the world.’’
This conversation worried me, because I was
aware of the difficulty often encountered in the actu
alization of great ideas in the reality of large organi
zations with bureaucratic restraints. I was reminded
of this problem again by the late Mr. V. Palgi, who in
1973 held the position of Chief of Personnel in
Kupat Holim (Health Insurance Institution of the
General Federation of L^bbr). He warned me pres
ciently: “Kupat Holim has been in existence for
more than 50 years and is very set in its ways. It is
extremely difficult to introduce changes, and espe
cially if they are proposed by, and require collabora
tion with, outside organizations.” Over the years, I
had to remember this warning time and again.
For implementing any program, four vital com
ponents are required: The underlying ideas and con
cepts, the people to execute them, the necessary
financial resources, and the requisite administrative
Address for correspondence: Dr. D. Singer. Administration. BenGurion University of the Negev. P.O. Box 653.84105 Beer Sheva.
structure. These components are of course interre
lated. and the insufficiency of any one of them will
endanger the proper utilization of the others. Novel
and challenging ideas often attract outstanding staff;
however, the best employees will not be able to
function without financial resources, and both per
sonnel and funds will be wasted unless supported by
a suitable administrative framework.
I shall describe and evaluate the administrative
stucture that was designed to implement the ideas
underlying the Beer Sheva Experiment. Evaluation,
of course, also involves an analysis of the progress
made toward the realization of the aim of the
program.
•
THE HEALTH INSTITUTIONS OF THE
NEGEV
The basic concept was to create a comprehensive
regional health services delivery system, which
would be composed of the existing health service
institutions and the University Center for Health
Sciences and Services, to be established within the
Ben-Gurion University of the Negev. This system
was to comprise all organizations providing prim
ary, secondary and tertiary health care, as well as
those in charge of public health and preventive
medicine.
In 1973, the following institutions existed in the
Negev: 1) The Soroka Medical Center, a Kupat
Holim general hospital of about 650 beds situated in
Beer Sheva. led by a medical director and an admin
istrative director. 2) The regional primary health
services organization of Kupat Holim, led by a medi
cal director and an administrative director, which
was responsible for all community clinics in the
Negev, both in towns and rural settlements. Both
these organizations reported directly and separately
to Kupat Holim Headquarters in Tel Aviv.
(124]
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i
Vol 23. Nos. 9-10, Si pti mbi r-Octobi r 1987
Administration
3) Josephthal Medical Center in Eilat, a 150-bed
general Kupat Hol ini hospital, led by a medical
director. It was not included in the Negev District of
Kupat Holim, but related directly to Tel Aviv.
4) The Regional Organization of the Ministry of
Health headed by a medical director who reported
directly to the head office in Jerusalem. It fulfilled all
public health functions and was responsible for the
network of Maternal and Child Health clinicsand of
a mental health clinic.
In 1977 the Mental Health Center, a government
psychiatric hospital, was opened in Beer Sheva. It
was headed by a medical director and an administra
tive director who reported directly to the Ministry of
Health in Jerusalem. The existing mental health
clinic was incorporated into the center.
There were additional institutions which had
never been officially included: firstly, the Barzilai
Medical Center, a general hospital in Ashkelon, and
secondly, the various other health insurance institu
tions existing in the Negev. As for the Barzilai Medi
cal Center, there has from time to time been pressure
by the Ministry of Health to include it officially
within the University Center. So far, no official steps
have been taken in this direction. However, over the
years, groups of medical students have done part of
their clinical training there, mainly in pediatrics and
psychiatry. Inclusion of the smaller health insurance
institutions, which havea relatively limited member
ship in the Negev, has, to my knowledge, never been
seriously considered.
There existed, therefore, a tripartite pattern. Two
sectors. Kupat Holim and the Ministry of Health,
had been in existence for many years. They had
developed a tradition of mutual distrust and even
animosity on the national level, though probably
less so in the Negev. The University Center for
Health Sciences and Services, which was created in
1973. had no such tradition, and since it was estab
lished under the banner of integration with the
health services (the slogan of Moshe Prywes was:
“Whoever teaches should serve and whoever serves
should teach’'), it can be said to have always been a
centrifugal force.
In fact, the pattern was even more complex. Kupat
Holim in the Negev has never been a monolithic
body. The hospital and the primary health network
constituted two quite independent entities which,
although cooperating in the professional field, had
completely separate budgets, administrative struc
tures and staffing.
Jo bring about a measure of coordination and
cooperation among these manifold components was
the aim of the Beer Sheva Experiment. I shall give a
brief outline of the organizational tools and methods
designed and used and how these contributed tc
achieving the basic objectives.
THE FORMAL ORGANIZATION
When Prywes and Haim Doron (Head of Kupat
Holim) conceived the basic concepts of their plan for
the Negev, they gave much thought to the adminis
trative framework. Early in 1973, the main features
had already been worked out and implemented long
before they were formally set down in writing.
In 1975 the administrative framework was for
mally defined within the framework of the “Agree
ment between the University and Kupat Holim for
the Establishment of the University Centerfor Health
Sciences and Health Services in the Negev." The
Agreement had thus far been signed only by the
University and Kupat Holim and related mainly to
the relationship between these two organizations.
However, it mentioned specifically that “... this
agreement will become tripartite, and the Ministry
of Health will assume the obligationsand conditions
contained in it, with changes and amendments as the
case may require.’’ So far, this has not happened;
however, the present text involves the Ministry by
including its representatives in some of the commit
tees established and by stating that its medical insti
tutions and facilities in the Negev be incorporated in
the Center for its use.
The aim of the Agreement is defined as “combin
ing all health services and medical education’’ and
“to coordinate and integrate all health services.”
However, side by side with this very comprehensive
aim, the Agreement contains a number of provisions
that delineate and limit the concept of integration
and show what was really intended. These main such
provisions state:
1) The management of the medical institutions
will remain in the hands of officials of Kupat
Holim, and the management of the Center in
the hands of the University authorities.
2) There will be no staff from the Center, and
Kupat Holim and University personnel will
continue to be employed by the respective
institutions.
3) There will be no common budget, but “any
expenditure...will be made only in the frame
work of the...budgets of each of the parties.”
4) There will be no property held by the Center,
but any facilities “placed by one party at the
disposal of the Center for use. wilLremain the
exclusive property of said party...”
In fact, the process of integration has been vested
in the following bodies: the Supreme Coordinating
Committee, the Committee for Health Services, the
Committees of the Center for Health Sciences and
[125]
ii
D. Singer
Israel J. Med Sci
Services, and the Dean of the Center/Directorof the
Regional Health Services
Supreme Coordinating Committee
This committee, which was supposed “to function as
the highest authority of the Center,” is composed of
persons belonging to the highest echelon of the Uni
versity and Kupat Holim directorates and includes
also the Director General of the Ministry of Health.
Its functions include the formulation of overall pol
icy and long-range plans for the integration of the
components of the Center, for the curriculum of the
Center and for the regional health services. It even
has some vague budgetary tasks—to recommend
budget proposalsand changes to the directorates of
the parties.
Committee of Health Services
This committee was clearly considered to be the
most important administrative body of the Center.
It was to be composed of the directors of the health
service institutions of the Negev, both of Kupat
Holim and the Ministry, and of one delegate of the
Center. The Dean/Director of the region acts as its
chairman.
Its functions are defined as follows: “...to take
charge of the management, coordination, promo
tion and improvement of the medical services pro
vided to... the general population of the Negev.” It
will “coordinate between the medical institution and
the Faculty” and “act towards the integration of
medical services and medical education.” In other
words, it should be in charge of implementing the
aims and principles for which the Center was estab
lished, but in conformity with the regulations of
Kupat Holim, the Ministry of Health and the
University.
University Center for Health Sciences
and Services
The Agreement provides fpr coordination and inte
gration between the Ceriter and the health service
institutions by giving membership in the Faculty
Council to senior academic staff of Kupat Holim
and the Ministry, both on the national and regional
level. The Faculty Committee includes the Medical
Director of Kupat Holim in the Negev as well as the
Medical Director ol the Kupat Holim headquarters,
who, however, has not attended any of its meetings
during the last 12 years. No representation of the
Ministry was provided for.
The main provisions for coordination between the
faculty and the health service institutions are con
tained in a section of the Agreement—“Duties of the
Representatives”—that states the staff members of
the faculty and of the service institutions who serve
on any ol the committees or governing bodies must,
inter alia, ensure that the medical curriculum be
oriented towards community medicine, that the
principle of “those who serve, teach and those who
teach, serve” be implemented and that there be “full
cooperation, continuous joint action, flow of infor
mation and assistance in manpower and facilities
between the Faculty and medical institutions.”
Dean of the Center and Director of the region
One of the major and determining features of the
Beer Sheva Experiment is the “personal union” of
the Dean and the Director of all regional health
services in one person. His functions a re not spelled
out in detail, but his status is defined as f ollows: “He
will be responsible to each party for its sphere of
competence... by virtue of his appointment by said
party. He will also be responsible for the advance
ment of cooperation between the parties.”
The positions of a Dean and of a Regional Direc
tor are normally established within the hierarchy of
the University and Kupat Holim. However, no equi
valent position exists in the formal regional structure
of the Ministry, and his status is based on a letter
appointing him as head of the Negev region of the
Ministry without, however, defining his functions
and authorities in any detail.
ACTUAL FUNCTIONS OF THE SYSTEM
hi the following, 1 shall give a brief description of
how the various component parts of the system have
operated over the years.
Supreme Coordinating Committee
This committee has met frequently on an ad hoc
basis to handle specific problems, and has generally
included the Director General of the Ministry of
Health.
Committee of Health Services
This committee was initially considered as the key
instrument for achieving the aims of the Beer Sheva
Experiment. It should be noted that the Agreement
states that “The Center will be managedby Commit
tees,” and the committee was clearly intended not to
function merely as an advisory group, but as an
executive body that could take decisions binding on
the constituent organizations, at least on the
regional level.
Space does not permit a detailed description of the
activities of the Committee during the first years of
its existence, but a few examples with more general
implications will provide a general idea.
The Agreement states that “The establishment.
1126)
t
Vol. 23, Nos. 9-10, Septfmblr-Octobfr 1987
Administration
development, expansion, enlargement... of an insti
tution in the Negev... will be effected after coordina
tion with the parties.” Therefore, any plan to
establish or abolish any departments, units or other
facilities in health services institutions was discussed
and had to be approved by the Committee. Any
recommendations as to medical appoHtments, pro
motions or granting of permanent status had to be
approved by the Committee before being submitted
to Kupat Holim headquarters, which had also
agreed not to appoint to a senior positic n in Beer
Sheva any candidate who was not endor ed by the
Committee. In this way, the Committee was used as
an instrument to achieve an increasing measure of
decentralization, which is a prerequisite for any suc
cessful pattern of regionalization.
During the first years of its existence, the Commit
tee enjoyed a great measure of authority, and its
resolutions often carried more weight and influence
than decisions by any individual institution. In this
way, the Committee, through its resolutions, put
pressure on the various bodies concerned regarding
such issues as increasing the number of interns in the
hospital, obtaining development budgets for addi
tional building activities, etc. In addition, the Com
mittee constituted a forum where the senior regional
executives met, aired their ideas, solved differences
of opinion and decided on measures of coordination
and integration.
During recent years, the activities of the Health
Services Committee have been drastically reduced.
Between September 1973 and September 1978, 58
meetings took place, i.e., an average .Cone session
per month. Since 1983 the number oi meetings has
been reduced to three and four per year, and the
Committee no longer concerned itself with such
matters as appointments of staff, establishment of
medical units, etc., but with issues of lesser
magnitude.
It would seem that the Committee for Health
Services no longer serves as a coordinating or execu
tive instrument and has been allowed to lose most of
its influence and status. The precise reasons for this
development are not entirely clear; perhaps not all
those concerned continued to believe in the impor
tance of this committee, and the deteriorating rela
tionship between Kupat Holim and the Ministry
might also have been a contributing factor. Alte rnatively, more efficient and direct means of communi
cation between the local administration and the
governing bodies may have pre-empted some of the
functions of the Committee.
Dean of the Center and Director of the region
It is hard to evaluate the impact of the merger Dean/
Director on the development of the Beer Sheva
Experiment, since much of the influence that the
incumbent exercises is of an informal nature and
does not find its expression in written protocols, nor
has it immediate and overt consequences.
A prerequisite for the exercise of any authority is
to be well informed. It took several years until the
Dean/Director was recognized by Kupat Holim as
being entitled to receive all significant documenta
tion, at least in the form of copies of correspondence.
At present he is consulted on any major regional
problem, and probably few, if any, significant deci
sions are made on the regional level without his
involvement. On the other hand, the Dean/Director
is concerned only minimally with the day-to-day
administration of t^e hospital or the region; for
instance, he does not participate in the regular meet
ings of the hospital management and he is clearly
much more involved in the detailed administration
of the Center than of the Kupat Holim institutions.
With regard to the Ministry, his involvement is much
more limited.
The personal inclinations, interests and priorities
of the incumbent determine to a considerable extent
his impact on the regional health services establish
ment. Moshe Prywes, the founding Dean, was
greatly concerned with the quality of the senior staff
and devoted much time and effort to recruiting out
standing physicians to leading and senior positions
in the hospital. He also tended to spend considerable
time visiting various medical units and establishing
informal relationships with their staff so that he was
generally well informed about the situation and
could solve problems before they acquired grave
proportions.
An important facet is the relationship between the
Dean/Director and Kupat Holim headquarters,
especially in view of the fact that Kupat Holim is an
extremely centralized organization whose headquar
ters wields great authority on all aspects of regional
activities, lhe Dean/Director has access to, and
deals with, the highest levels of Kupat Holim. He is
involved both in policy decisions as well as in impor
tant executive matters concerning the Negev region.
However, his actual influence will, to a considerable
extent, depend on his personal relationshipsand the
status he is able to establish for himself. It certainly
requires a very forceful personality to succeed in
obtaining the resources and securing the organiza
tional arrangements that the special features of the
Beer Sheva Experiment demand.
It is fair to say that the position of Dean/Director
is now well established, at least regarding the Center
and Kupat Holim (but not with regard to the Minis
try of Health), and it has justified many of the initial
[127]
D. Singer
Israel J. Med. Sci.
expectations. The limitations on his authority and
influence are, to a considerable extent, a function of
the strongly centralized organizational pattern of
Kupat Holim, and this problem will be solved only if
and when existing proposals for decentralization,
which have been recommended by a number of
investigatory committees, will be implemented.
University regulations do, of course, also impose
certain restrictions, but in general, a Dean of a
Faculty enjoys a considerable measure of indepen
dence, which is rooted in the traditional concept of
academic freedom.
APPRAISAL AND EVALUATION
To what extent has the Beer Sheva Experiment suc
ceeded in achieving its defined aims to “coordinate
and integrate all health services” and to “integrate
medical services and medical education?”
Integration of health service organizations:
Kupat Holim—Ministry of Health
Integration of the regional Kupat Holim services
with those of the Ministry of Health has hardly
progressed. Preventive and curative services are still
far apart and very few organizational changes have
occurred. The reasons are many and varied, extend
back over many years, and are not relevant to the
present discussion. In recent months, with the incen
tive of severe budgetary restrictions, renewed move
ment towards integrating preventive and curative
services are in the offing.
There has been one positive deviation from this
rather discouraging situation. In psychiatry, a pat
tern of close cooperation exists between the related
services of Kupat Holim and the Ministry in the
Negev. The Ministry maintains a psychiatric hospi
tal as well as a mental health clinic in Beer Sheva,
while Soroka Medical Center has a psychiatric
department and a psychiatric outpatient clinic. Both
organizations maintain ambulatory psychiatric ser
vices in towns throughout the Negev, and all these
institutions and their activities are now very effec
tively coordinated.
Interestingly, the administrative tool through
which this integration was achieved was not men
tioned in the Agreement, but was created by the Cen
ter itself and constitutes one of its important
achievements—establishment of the supradepartmental transinstitutional Divisions as the basic units
on which the organizational pattern of the Center is
built. Dr. Falik, the first head of the Psychiatric
Division and a strong supporter of the concept of
integration of services, succeeded in utilizing this
tool for creating a closely knit regional Psychiatry
Division composed of the mental health staff of both
the Ministry and Kupat Holim. Professionally and
scientifically, there is much cooperation and organi
zational agreements have been reached concerning
the satisfactory division of the ambulatory psychiat
ric services in the Negev between the two
institutions.
Integration of health service organizations—
hospital and region
The need for close collaboration between the hospi
tal and the primary health network hasT>een recog
nized from the beginning, and it was anticipated that
the “personal union” of the Dean/Regional Direc
tor in charge of all Kupat Holim institutions as well
as the Health Services Committee would constitute
important unifying forces. However, Kupat Holim
apparently had intended to go even further and to
work towards a model of complete integration.
Attempts were made to achieve this aim from the
top. For several years and until 1984, the medical
director of the hospital also occupied the position of
medical director of the region. In addition, in the late
1970s, an attempt was made to create a similar per
sonal union in the area of administration, and one
regional administrator was appointed for both the
hospital and the ambulatory services organization.
Neither of these experiments succeeded.
From the formal and administrative point of view,
the relationship between the hospital and the pri
mary health network is hardly any closer than it was
10 years ago, but there has been a new commitment
on the part of Kupat Holim authorities to change
this in the near future. On the other hand, much
professional coordination carried out by the Div
isions exists and is growing. The chief of the Pediat
ric Division is responsible for the pediatric services
both in the hospital and in the clinics, and the same
applies for gynecology, orthopedic surgery, and
other departments. Another important development
that has occurred in this respect is the arrangement
according to which each clinic is affiliated to a par
ticular department in the hospital for hospitalization
of its patients. In this way, a permanent professional
relationship between the clinics in the region and the
hospital has been created which should lead towards
closer integration of the services.
Another factor that tended to strengthen the rela
tionship between hospital departments and primary
health clinics is the presence of graduates of the Beer
Sheva medical school in both institutions. Of every
graduating class, a number of young physicians
volunteer for 1 year’s service in clinics in the Negev.
Having completed their clerkships and often also
their internship in the Beer Sheva hospital, they
obviously have close connections with their former
[128]
Vol 23, Nos. 9-10. Si ph mhi r-Ociobi r 1987
Administration
teachers and with their classmates in specialty train
ing at the hospital.
This personal relationship strengthens thecooperation between the clinics and the hospital. Hopeully. as more graduates from the school and family
medicine residents from lhe school’s training pro
gram accept permanent employment in Negev clin
ics. these relationships will be strengthened.
Cooperation between the faculty and health
services organizations
Integration between the health sck"
... sciences and the
health services has advanced
greatly and can be
considered quite <i success. Although the formal
arrangements, such as the personal union of Dean/
Director, have contributed to this development, one
can observe here also a process of natural evolution.
Most of the staff of the faculty arc employed by the
hospital: they teach not only clinical subjects, but
also a part of the basic medical sciences such as
pathology, physiology, biochemistry, etc. Gradu
ally. they took over many of the most important
funchons of the faculty by becoming active members
ol the Faculty Committee, the Research Committee
lhe Library Committee and the Curriculum Com
mittee. When the Dean appointed a number of
assistant deans for such areas as student affairs,
recruitment and promotion, etc,, most of them were
clinicians. All department chiefs hold academic
appointments, as does the Medical Director of the
hospital. The Pharmacology and Virology Units of
the faculty perform the clinical tests, and there are
close connections between the Immunology Unit
and the Immunological Laboratory at the hospital.
As a result of these developments, a great part of
the medical staff has become integrated, in the sense
that they lend to look al siluations and problems
equally from (he point of view of the hospital and
from that ol the Center which was one of the princi
pal aims of the Beer Sheva Experiment.
On the organizational level, a similar develop
ment can be observed. A numberofcommon institu
tions have been established-such as the central
medical library, the animal house, an electron mic
roscope unit and a medical computing unit-whieh
serve teachers, students and the health staff of the
region. More and more, medical equipment is pur
chased jointly out of Center and Kupat Holim funds'
fellowships for postgraduate clinical training funded
by the university are annually awarded to voung
physicians. A visiting professors program, financed
out ol donation funds to lhe Center brings annually
about 10 eminent consultants, most of them clini
cians. from the most prestigious medical institutions
to spend several weeks here at the Center. Every year
lhe Research Committee of the Center distributes
research grants, which are financed out of the Uni
versity budget, to investigators, most of whom
belong to the hospital staff.
The relationship with lhe primary helath organi
zation ol Kupat Holim is less close. One of the
reasons might be that only a small (but growing)
number of the primary health physicians hold acadcmic appointments, and there is, therefore less
involvement in the life of the Center. On the other
hand, the “Graduates Program.'' which is described
elsewhere in this publication, has involved a great
measure of cooperation and coordination and cer
tainly contributed towlirds the integrative process.
The relationships between the Regional Organiza
tion ol the Ministry and the faculty arc satisfactory,
although not as close as with lhe Kupat Holim insti
tutions. Students are taught in the psychiatric hospi
tal and m the maternal and child clinics: theyare also
taught in a few departments of the Ministry’s Barzilai Medical Center in Ashkelon, where some of the
teachers hold academic appointments in the Center
The Ministry’s Medical Director of lhe region held a
number ol faculty positions, including most recently
the important function of Head of the Students’
Selection Committee. However, there is practically
no administrative cooperation and very little in
volvement of the Center in the public health field
CONCLUSION
In this paper. I have attempted to show the extent to
which the Beer Sheva Experiment has succeeded in
estabhshmg in the Negev a comprehensive regional
health services delivery system, to be composed ol
the existing health service instil inions and lhe Cen
ter. As observed, there has been little progress
towards the mtegration of the two main health
organizations, that of the Ministry of Health and
that of Kupat Hohm. with the exception of lhe area
of psychiatry where, by means of the newlv estabhshed dmsional structure, a great measure of pro
fessional cooperation has been achieved. Little
administrative integration between the hospital and
the pnmary health care del,very svstem has taken
place in spite of several attempts made during recent
hesc attempts arc presently being renewed.
lhe integration between health sciences and
health services has been much more successful and
as had an important impact on the quality of health
care in the Negev. This is probably the special contribut.on which the Beer Sheva Experiment has made
towards creating new concepts and principles of
health services delivery and towards showing a wav
of realizing and implementing these concepts.
'
1129]
THE CHALLENGE:
CHILD HEALTH
IN THE NEGEV
I
l
RAFAEL GORODISCHER
Division of Pediatrics, Soroka Medical Center and University Center for Health Sciences and Services, Ben-Gurion
University of the Negev. Beer Sheva. Israel
IsrJ Med Sci 23: 1062-1064, 1987
Key words: Beer Sheva Experiment; medical education: health care services; pediatrics
i
provided by pediatricians and general practitioners
The inauguration of the Ben-Gurion University of
who had been trained in different countries, result
the Negev Center for Health Sciences and Services in
ing in a serious lack of uniformity in the standards of
1974 provided an opportune time to initiate changes
these physicians. In addition, the structure of the
in the stucture as well as in the content of health care
system
contributed to the gap between the two levels
delivery to the children in the Negev. Community
of
medical
care (hospital vs. community clinics). The
orientation and integration of medical services,
vast
majority
of the pediatric population had access
which were central objectives of the medical school
to
a
health
care
system through a well-developed and
(1,2), were viewed as proper solutions to the gener
highly
centralized
network of clinics, but its medical
ally recognized deficiencies in the provision of medi
care
was
fragmented
and often duplicated in differ
cal care to the children in the area.
ent
institutions
[the
therapeutic clinics of Kupat
The population Of the Negev is young and ethni
Holim
(Health
Insurance
Institution of the General
cally heterogeneous (3). Over one-third of the popu
Federation
of
Labor)
and
the preventive Maternal
lation is 14 years old or younger; approximately
and Child Health clinics of the Ministry of Health].
one-third of infants are born to Bedouin families and
Just as the clinic pediatricians practicing in the com
two-thirds to Jewish (mostly Sephardic) families.
munity did not participate in the care of the hospital
The commonest causes of hospitalization are gas
ized child, so too the hospital pediatrician had no
trointestinal and respiratory infections for Bedouin
responsibility for the care of the child within the
and Jewish children, respectively (4). In the Negev,
community clinics (except for routine examinations
as in the country as a whole, there is no lack of
of the well child and/or pediatric consultations in
physicians; the number of pediatricians per 1,000
clinics of certain kibbutzim and development
children in Israel has been estimated as 0.9 (5).
towns).
It is distressing for patients as well as for health
As part of the overall goal of the new medical
care personnel to d^aT with two discordant and
school,
it was anticipated that some of its students
uncoordinated levels of pediatric practice—in the
would
seek
careers in the ambulatory setting and be
hospital on the one hand, and in primary clinics in
interested
in
the delivery of health care to children.
the community on the other. While hospital services
In
view
of
the
community orientation and the lack of
have been academically oriented with a tendency to
adequate
role
models for the student, it was expected
progressive specialization, no major changes in the
that
hospital
pediatricians would increase their
traditional and uniform pattern of community clin
degree
of
involvement
in community clinics. This
ics could be foreseen prior to the establishment of
focus
implied
a
change
in their attitudes towards
the medical school in Beer Sheva (6). The medical
professional
values
and
day-to-day
practice. In addi
services for the sick child outside the hospital were
tion, it was hoped that some pediatric residents in
the teaching hospital of the medical school, the Sor
oka Medical Center, would depart from the tradi
Address for correspondence: Dr. R. Gorodischer, Department ol
tional choice pattern of a hospital career and would
Pediatrics A, Soroka Medical Center, POB 151, 84101 Beer
choose to work chiefly as primary care pediatricians
Sheva.
[130]
Vol. 23, Nos. 9-10, September-October 1987
Child Health in the Negev
and as consultants to community clinics. It was not
service and at the Maternal and Child Health clinic
certain whether these ambitious plans were achievI he goal has been the establishment of model pedi
able.
atric
commumty clinics that would favorably affect
Fundamental changes took place in the hospital
patient
care. We have shown that such a clinic results
pedmtric services during the first decade of the medi
m
much
more effective use of hospital emergency
cal school. Some, such as the integration of the
room
facilities
when compared with clinics using the
existing three pediatric wards (departments) into the
traditional
referral
pattern (8).
Division of Pediatrics, were initiated by the medical
Hospital
pediatric
residents participate in primary
school. This integration led to a more logical and
care
activities;
all
of
them
rotate through a primary
functional structure both for patient care and for
care
pediatric
clinic
in
the
community
under faculty
teaching at all levels. One cardinal concept of the
supervision
(as
part
of
their
residency
training pro
Division of Pediatrics was its responsibility not only
gram).
In
addition,
several
have
volunteered
to
for hospital care, but for the health care of all the
in
terrupt
their
formal
residency
training
for
a
period
children m the Negev, including community pediat
° upto I year in order to serve in communityclinics.
ric services. Pediatric admissions to the hospital
caching pediatrics to medical students is carried
were regionalized, and clinics within the community
out
within this atmosphere (9). Already during the
were linked to each of the departments in the Div
early prechnical years, the student is exposed to
ision. Other innovations in the hospital represented
aspects of physical as well as psychomotor, social
a trend seen m the whole country: emphasis on
and
mental development. This part of the curricuambulatory hospital services at the expense of inpa
urn
functions
chiefly in day care centers, community
tient beds (16 specialty and follow-up pediatric clin
clinics and schools. The traditional pediatric clerk
ics and a Day Hospital Unit were opened) In
ship during the 4th year of medical school (involving
addition, a general Pediatric Intensive Care Unit, a
mostly
hospital inpatients) still exists. However we
Premature and Special Care Nursery, and (for the
have
added
(beginning 1985-86) mandatory clerk
first time in this country) an Adolescent Unit were
ships
in
hospital
ambulatory pediatrics and in com
established.
munity
pediatric
clinics during the 6th year of
Inspired by the philosophy of the medical school,
medical school. The curriculum thus provides an
a significant number of Western-and Israeli-trained
ongoing exposure to child care with special emphasis
hospital-linked pediatricians accepted the challenge
on
preventive and ambulatory aspects of pediatrics.
of delivering primary care and consulting in com
In
Beer Sheva, as in other academic settings, clini
munity clinics, particularly in poorly developed
cal research 1S carried out in the various pediatric
towns such as Ofakim, Yerucham, Mitzpe Ramon
subspecialities, but with a major focus on the most
and the Bedouin town of Rabat. The head of one of
characteristic
pathology seen in the Negev
the hospital pediatric wards (who had been the first
Lookmg
back
on the first decade it is apparent
pediatrician in a Beer Sheva hospital—Dr. Wilhel
that the tasks undertaken have been directed toward
mina Cohen) chose to take a position in the primary
e implementation of the initial objectives. Yet one
clinic of the socioeconomically deprived town of
of the mam drawbacks has been the lack of success in
Ofakim after retiring from her hospital position.
establishing solid educational models for the provi
Today, no less than 10 pediatricians who have com
sion
of primary care to children. One pediatric com
pleted the residency program at the Soroka Medical
munity
clinic, after major progress in becoming an
Center have tmxed primary care clinic/hospital
academic
focus of excellence, failed to withstand the
duties, and several of them hold academic appoint
political pressures after its leader gave up his super
ments and teach medical students both at the hospi
visory position (10). That experience in particular
tal and at them clinics. The Division of Pediatrics
makes it dear that basic alterations in the organiza
grants hospital rights and duties to some of them
tion of the services sanctioned and encouraged by
with the intention of bridging the gap between the
the
highest level of our centralized system (and not
hospital and the community-based children’s clinics
only
motivation of the clinic physician) are neces
( )■ Simultaneously, hospital-based pediatricians
sary
to
bring about the needed transformation of the
have expanded their consultative and well-baby ser
community clinics.
vices in the community clinics. Preventive and thera
It seems that full implementation of the planned
peutic primary care services are still provided by
changes of the structure of medical services in the
separate organizations. However, in four communi
Negev under the direction of the Dean of the medical
ties an experimental program exists whereby the
school
(including a more autonomous and unified
i entical hospnal-linked primary care physician
admimstration)
may be necessary for the definite
provides care both at the Kupat Holim therapeutic
establishment ol high-level hospital- and medical
c
[131]
Israel J. Med. Sci.
R. Gorodischer
school-linked primary care clinics as well as for a
much more substantial involvement of the Division
of Pediatrics in the Community.
Several issues have not yet been adequately
addressed. Assuring both quality patient care and
continuing education of health care personnel in
community clinics is central to the success of the
entire project. There are obvious advantages to the
provision of medical care by organizations (such as
Kupat Holim and the Ministry of Health) rather
than by individual physicians. However, a potential
drawback is the absence of a physician who is prim
arily and continuously responsible for the child and
implements his/her total care. This need is para
mount for disabled and chronically ill children (11).
This question, as well as how to develop an optimal
patient-doctor relationship within such a system,
remains largely unanswered.
Plans exist for the involvement of all hospital
based pediatricians in the community clinics. How
ever, in view of the need for advanced specialization
in certain fields of pediatrics, the degree and nature
of their participation in the care of the patient out
side the hospital need to be more clearly defined.
The objectives of the Division of Pediatrics
include not only the provision of services of high
quality to individual patients within the hospital
setting and in the primary care clinics, but also the
effective handling of neglected areas of child health
within the community. These areas include assess
ment of the state of health of different pediatric
populations in the Negev. Also included are the
design and mobilization of strategies to deal with the
shortcomings found. The concept of communityoriented primary care (12, 13) poses a challenge to
the pediatrician who may find in it a source of inspi
ration to improve the health of children as well as to
design educational and research objectives.
This article describes endeavours of many dedicated
people of the Division of Pediatrics and of the University
Center for Health Sciences in Beer Sheva with whom the
author has had the privilege of sharing these intellectually
challenging and fulfilling experiences. Conversations with
distinguished visiting faculty from abroad have
enlightened the perspective of the community-oriented
role of the Division of Pediatrics.
The author acknowledges the helpful comments and
suggestions of Dr. Shimon W. Moses and Dr. Stanley C.
1
Uretzky in the preparation of this manuscript.
REFERENCES
1 Prywes M (1972). Merging medical care and medical educa
tion. Harefuah 83: 309-312 (in Hebrew).
2. Prywes M (1977). The Beer-Sheva experience. JAMA
238: 1571.
3. (1985). “Statistical Abstract of Israel 1984-85.” Central
Bureau of Statistics, Jerusalem, p 38 and 98.
4. Nathanel M (1983). Analysis of some demographic medical
and socioeconomic characteristics of children admitted to
the Soroka Medical Center in 1978. MD thesis, Tel Aviv
University, Tel Aviv.
5. Barnoon S (1985). Demand forecast for ambulatory pediat
rics. Report, Division of Health Economics and
Administration, Faculty of Health Sciences, Ben-Gurion
University of the Negev. Beer Sheva, Israel, p 40.
6. Gorodischer R (1974). Pediatrics in a development town.
The Family Physician 4: 40-51 (in Hebrew).
7. Gorodischer R (1985). Primary pediatrics: goals in the
Negev. Harefuah 108: 365-366 (in Hebrew).
8. Porter B. Cohen W. Kobliner M and Goldsmith J (1981).
Differences in the use of emergency room and
ca re pediatric
hospitalization in relation to primary care
services. Isr J Med Sci 17:119-121.
9. Segall A, Prywes M, Benor DE and Susskind O( 1978). Uni
versity Center for the Health Sciences, Ben-Gurion
University of the Negev, Beer Sheva, Israel: an interim
perspective. Public Health Papers No. 70. WHO, Geneva, p
112-132.
10. Porter B and Margolis C( 1987). Pioneering and settlement
in health services: a case study. Isr J Med Sci 23: 000-000.
11. Battle CV (1972). The role of the pediatrician as ombuds
man in the medical care of the young handicapped child.
Pediatrics 50: 916-922.
12. Kark SL (1974). Epidemiology and community medicine.
Section 5. “Community medicine and primary health
care.” Appleton-Century-Crofts, New York, p 317-463.
13. Mullan FV (1982). Community-oriented primary care. N
Engl J Med 307: 1076-1078.
(
[1321
e
PSYCHIATRY AND PRIMARY CARE
B. MAOZ
Isr\J Med Sci 23: 1065-1067, 1987
Key words: Beer Sheva Experiment; medical education; health
When we established the Psychiatric Division of.the
University Center for Health Sciences and Services
in Beer Sheva in 1978, we immediately had to face a
serious problem, namely, how to teach simultane
ously: 1) the theory and practice of major psychiatric
diseases, such as the organic-brain syndromes and
the lunctional psychoses; 2) current daily psychopa
thology, such as neuroses, personality disorders and
transient adjustment reactions to stress situations;
and 3) the psychosocial aspects of disease in general.
We had to emphasize all three abovementioned sub
categories, as well as the preventive and communityrelated aspects, on the one hand, and the clinical,
therapeutic and practical approach, on the other
—including basic principles of individual, family
and group therapy.
It was finally decided that the clerkship in psychia
try (5 weeks during the 5th year) would be dedicated
mainly to “major” psychiatry, whereas the other
two subjects (“2” and “3”>-we hoped at the time—
would be taught in the framework of the other clini
cal clerkships. During the clerkship in psychiatry,
students would also have opportunities to observe
various activities of the psychiatric outpatient clin
ics, including their outreach program. In addition,
they would join psychiatric consultants during their
consultations in the different departments of the gen
eral hospital and in the community primary care
(CPC) clinics.
It has been shown by several investigators (1,2)
that most people who have minor (nonpsychotic)
mental and emotional disorders never reach the
mental health services. Those who do seek profession
al help within the framework of the health services
Address for correspondence. Dr. B. Maoz. Department of Psychi
atry. Soroka Medical Center. POB 151. 84101 Beer Sheva.
care services; psychiatry
usually turn to general primary health care, i.e., that
provided by the general practitioner or the family
physician and his/her team. It was therefore obvious
to us that medical students should receive their train
ing in current, daily psychopathology during the
clerkships in primary medicine. Moreover, the post
graduate training in this area should be an integral
part of the residency program of family medicine.
We planned to teach the third subject (psychoso
cial aspects of diseases) during psychiatric
consultation-haison programs to be carried out in
various clinical departments of our general univer
sity hospital.
Now, 10 years after the foundation of the Center
and 7 years after the establishment of the Psychiatric
Division, we can point to some successes and also a
number of failures and problems that have emerged
during the implementation process. In the first part
of this paper, I would like to discuss especially the
collaboration between the Psychiatric Division and
the Division of Health in the Community, in which
the Departments of Primary Medicine and Family
Medicine arc located. The second part will describe
some of the basic problems that arose in teaching
psychosocial aspects of diseases.
COLLABORATION WITH THE DIVISION OK
HEALTH IN THE COMMUNITY
During the first of the two clerkships in primary
medicine (which used to be in the 5th year and was
recently moved to the 4th), students were spread
over 10 teaching CPC clinics in the Negev—usually
two to three students per clinic. It was our goal that
during their clerkship they would meet the psychiat
ric consultant of the CPC clinic on several occasions
m order to discuss with him/her some patients or
families with psychosocial problems. In order to
ri33]
Israi i J. Mi d. Sci
B. Maoz
vant to the general practitioner, an introduction to
implement this plan, the Psychiatric Division devel
psychotherapeutic interventions, and counselling in
oped a consultation-liaison program in the abovedifferent areas. During the final academic year we
mentioned 10 teaching CPC clinics: consultations of
try to introduce methods of learning in small groups,
l>/2 hours were held every 2 to 3 weeks during the
with the seminars focusing on the case presentation.
entire year, not only during the primary medicine
The
“Balint groups” are discussion groups of 10
clerkship. The same consultants (psychiatrists, clini
residents
with two leaders, a psychiatrist and a clini
cal psychologists or psychiatric social workers)
cal
psychologist.
In these groups, which function for
always visited the same clinic and the general practi
2
years,
the
topics
discussed include: “the doctor
tioner in charge of the clinic organized and chaired
patient
relationship,
patients with mental disorders
the meeting and was responsible for the agenda.
(who
approach
general
practitioners), and emotion
With the creation of a position for social worker in
al
problems
of
the
physicians
(residents) themselves
primary medicine (3, 4), the social workers of the
(which
appear
in
their
relations
with patients, col
CPC clinics also began to play an important role at
leagues
and
hospital
administrators).
Special atten
these educational meetings. At each meeting, not
tion
is
paid
in
the
Balint
groups
to
development
of
more than two patients (families or problems) were
the
professional
identity
of
the
family
physician.
discussed. Sometimes the patient (or family) was
The family presentations are essentially a continua
presented and interviewed by the consultant in the
tion at a higher level of those described above.
presence of the staff and the students. Usually after
Besides (his regular residency program, 1-day work
the case presentation some practical and some rele
shops
are organized covering special subjects close
vant general theoretical points were discussed, mak
to
psychiatry,
such as: the use of hypnotic methods
ing it an experience from which the student could
in
general
medicine,
health problems of new immi
learn how to handle similar problems. Every student
grants
from
Ethiopia,
etc.
(or pair of students) had to present a family to
The Psychiatric Division has made an enduring
his/her (their) peers and faculty members during the
effort to participate in the residency program of
clerkship. It was intended that while preparing this
family medicine. We feel that this contribution has
presentation, the students would consult the psychi
been a success. Our goal is to increase the general
atric consultant of the CPC clinic, and that the con
practitioner’s sensitivity to mental health problems,
sultant would participate as a discussant in the
to improve his/her ability to detect and define these
presentation.
problems,
to devise a reasonable treatment plan that
Over the years it was difficult to fully implement
could
include
a well-reasoned referral to the mental
the abovementioned program, mainly because of or
health
services,
and to follow up patients. We are
ganizational problems and the shortage of teach
now planning a critical evaluation of this education
ing personnel in the Psychiatric Division (e.g., the
al program and its results in daily practice. 1 believe
clerkships in psychiatry and in primary medicine
that we have achieved many of these goals. Our
often took place at the same time in two parallel
positive experience with family medicine residents
groups). In spite of these difficulties and our irregu
has encouraged us to intensify our participation in
lar participation in the clerkship of primary medi
the undergraduate clerkships of primary medicine,
cine, we were able to demonstrate to the students
which can be seen as an introduction to family
that psychiatry is an organic part of the comprehen
medicine.
sive approach" that forms the basis of general pri
mary medicine and family medicine.
PSYCHOSOCIAL ASPECTS OF DISEASES
As this paper deals mainly with the undergraduate
With respect to the teaching of the psychosocial
education of medical students, I shall mention only
aspects of diseases, we have to admit that the rela
briefly some highlights of our activities in the post
tionships between psychiatry and the general depart
graduate program in family medicine (which takes4
ments of the hospital are much more complicated
years). During their clinical residencies, residents in
than those with primary medicine.
family medicine spend 1 day a week in theoretical
Clinical clerkships begin in Beer Sheva in the 4th
training, which includes psychiatry and the behavior
year.
Before that, during the 2nd and 3rd years
al sciences. Our training of residents in family medi
behavioral
sciences and communication skills are
cine is given in three areas: 1) theoretical seminars,
taught. Parallel with this teaching, the Psychiatric^
2) “Balint groups”; and 3) participation in the fam
Division is responsible for two courses: 1) Introduce
ily presentation of the residents. The theoretical
lion io Psychopathology, and 2) Clinical Days during
seminars deal with such subjects as: the individual
which the students encounter a patient from the|
and family life cycle-related chapters of psychopa
mental health clinics for the first time.
(
thology and psychosomatic medicine that are rele
1134]
Psychiatry and Primary Cari
Vol 23. Nos 9-10. SFPrrMRi r Octobfr 1987
consultation-liaison
program at least in the
This teaching of behavioral sciences, psychopa<
, as we have done in
departments
of
medicine.
thology and mental health used to be interrupted
1
primary
care
clinics.
We
want
the medical students
between the 3rd year and the psychiatric clerkship in
(and faculty members) to perceive us and psychiatry
the 5th year, but this gap was eradicated during the
in general as an integral part of the general health
1985-86 academic years by the introduction of active
services
and to take into account the psychosocial
programs in the 3rd and 4th years. It is our impres
aspects
of
each patient in attempting to understand
sion that during this period a dichotomy between
the
genesis
and course of a disease. These
“soma” and “psyche” develops in the minds of most
psychosocial aspects may also play an important
of our students. It thus becomes more and more
role in the construction of a reasonable treatment
difficult to preserve the basic integrated and compre
plan.
hensive approach of our faculty during these two
It should be emphasized that until May 1984, the
critical years (3rd and 4th). Two examples illustrat
psychiatric
service in the general hospital operated
ing this development follow. First, some years ago
as
an
outpatient
clinic. In 1984 a small psychiatric
the first clerkship in internal medicine, which lasts 3
impatient
department
was established, which
months, included 1 hour (!) for a “psychosomatic
enhanced
our
status
in
the
general hospital. It served
case presentation”—this instead of emphasizing the
as
a
base
for
our
consultative
service and enabled us
bio-psychosocial approach in all diseases. Second, in
to
hospitalize
patients
with
mixed medical and
the introductory course to Obstetrics and Gynecol
psychiatric
problems.
ogy, 1 hour (!) is reserved for all psychosomatic
aspects of this important domain.
SUMMARY
In collaborating with other members of the
Besides the traditional clerkship in psychiatry, the
faculty who also became aware of this
Psychiatric Division has tried to develop the
compartmentalized thinking, which almost
psychosomatic and psychosocial dimensions of
separates psychiatry and behavioral sciences from
other clinical divisions. This effort was rather
“real” medicine, we have tried to overcome this in
successful in primary medicine in the community,
different ways. Members of the Psychiatric Division
especially in family medicine. However, it seemed to
have begun to participate in the introductory
be quite problematic in various departments of the
program to the internal medicine and pediatrics
general hospital, where we have only partly achieved
clerkships. In one of the internal medicine
the realization of the bio-psychosocial model in
departments a psychiatrist and a clinical
medicine.
psychologist conduct regular psychosocial
conferences with students and residents; in another
department of medicine a senior psychiatrist
participates regularly in the rounds.
REFERENCES
. .
....
■
The implementation of such projects has always
I. Goldberg D and Huxley P (1980). “Mental illness in the
community. The pathway to psychiatric care.” Tavistock.
been difficult, and we have had to overcome much
London, p 11.
resistance. Indeed, they have often collapsed after a
2. Ormel J and Giel R (1983). Omvang en behandelmg van
trial of 1 or 2 years. This is not surprising, as it is well
psychischc stoornissen in de praktyk van de huisarts.
Tvdxchritt voor fwchiairir 25: 688 709.
known from the literature (5)(and from my personal
Association for the Advancement ol Health and Wdlare
3.
experience) that it is difficult to integrate the
Services in cooperation with the Epidemiology and Health
Services Assessment Unit (1983). ”T rcaimcnt ol psychoso
attitudes and ways of thinking ol
“medical
cial problems in community care clinics. Center lor
practitioner” and the “psychological practitioner”;
Health Studies. Ben Gurion University ol the Negev. Beer
they are often basically contradictory, e.g., the
Shcva (in Hebrew).
•
• .
4. Gross A and Gross J (1982). “The first 12 months ol social
medical practitioner is mainly goal oriented, while
work activity in Kupat llolim community clinics. A report
the psychological practitioner is more process
on service utilization. Nov. 1. 1981—October 31. 1982
The Association for the Advancement of Health and Wel
oriented. Nevertheless, it has been shown that it is
fare Services of the Negev (in Hebrew).
possible to unify both models in one person. We feel
5. Brown HN and Zilberg NE (1982). Difficulties in the inte
gration of psychological and medical practices. Am J Psy
that if we had enough professional personnel we
chiatry 132: 1576-1580.
would be able to organize a regular psychiatric
CIV LI"-
[135]
.L
GERIATRICS IN THE FRAMEWORK OF UNIVERSITY-BASED
COMMUNITY MEDICINE
D. GALINSKY
Department of Geriatrics, University Center for Health Sciences and Services, Ben-Gurion University of the Negev.
Beer Sheva, Israel
Isr J Med Sci 23: 1068-1070, 1987
Key words: Beer Shcva I'.xpcrimcnl: medical education; geriatrics; hccdth care services
The elderly population in Israel is rapidly increasing
both in absolute terms and in proportion to the
general population (1). The aged in the Negev have
special characteristics, related mostly to theirdiverse
cultural backgrounds and behavior, and many of
their medical and social problems are probably
related to their cultural background (2). The
geriatric services in the Negev were developed with
special consideration of these characteristics. The
main goal of these services is to keep the elderly in
their own environment wherever possible. The
strategies used by the Geriatrics Department of the
Soroka Medical Center in terms of services, teaching
and research have been described (3). The geriatric
service in the Negev was launched in. 1974 with
coordination of the various institutions involved in
the delivery of services for the aged—Kupat Holim
(Health Insurance Institution of the General
Federation of Labor), the Ministry of Health, the
Association for the Welfare of the Aged and the
municipality of Beer Sheva.
Kupat Holim operates the Geriatrics Department
for patients in acute condition and for rehabilitation
at the Soroka Medical ^Center (headquarters of all
the services). The Hoihe Care Unit (HCU) and the
consultation clinic are a part of the Department of
Geriatrics. The Ministry of Health operates the
Department of Gerontopsychiatry and part of the
preventive program together with the HCU, and is
responsible for the provision of medical appliances
for the handicapped. The Association for the
Welfare of the Aged (a volunteer organization)
operates the Home for the Aged (long-term care)
Address for correspondence: Dr. D. Galinsky. Department of
Geriatrics, University Center for Health Sciences and Services.
Ben-Gurion University of the Negev, FOB 653,84105 Beer Sheva.
and also some of the community services such as
“meals on wheels.” The municipality of Beer Sheva,
through the Department of Welfare, operates the
clubs for the aged and also “meals on wheels.” Other
organizations involved are Matav (domestic aides),
the pensioners and volunteers, and the National
Insurance (BituachLeumi). All the above institutions
work in an interlinked and complementary fashion.
Patients are referred for geriatric consultation either
by family physicians or by hospital departments.
After a thorough evaluation, the patient is placed in
the most suitable setting in accord with his or her
needs. Staff meetings with representatives of the
various institutions are held regularly, thus allowing
an ongoing assessment of patients by a multi
disciplinary team and flexible shifting to other
services in order to meet new demands.
TEACHING PROGRAM
With the opening of the medical school in 1974, a
comprehensive curriculum in geriatric medicine was
developed both for the medical school and for the
Recanati School of Community Health Professions
(4, 5). Teaching takes place in the departments, the
home for the aged, clubs for the elderly, homes of the
patients, etc. All the instructors—physicians, nurses,
physiotherapists, occupational therapistsand social
workers— are involved in the services for the elderly.
In the medical school, the 1st year is devoted to
teaching basic skills in communication, observation
and nursing. At the same time, the principle of conti
nuity of care and the multidisciplinary approach to
the geriatric patient is emphasized. The student
spends 6 days in geriatric settings, interviewing
patients and participating in their care. The 2nd and
3rd years of study present a few topics in geriatrics
—these include lectures on the physiology of aging
[136]
I
I
I
■»
Vol. 23. Nos. 9-10. Septfmblr-Octobf r 1987
Geriatrics
within the course in biology and a few lessons on the
at the Soroka Medical Center and acts as a consul
physical examination of the elderly patient. In the
tant for the family physician in the management of
4th year of study, within the framework of a medical
homebound and bedridden patients (7). This unit
clerkship, different issues on aging are addressed,
has strong links with all the medical and social
and in 1985, a new, separate clerkship in clinical
agents in the community. It carries out programs of
aspects of the elderly was introduced. In the primary
prevention, such as detection of high-risk subgroups
care clerkship in the 5th and 6th years, the plan is to
or vaccination against influenza. Eighty-three per
continue the students’ exposure to the problems of
cent of the family physicians in Beer Sheva interact
the elderly by involving them in the activities of the
actively with the HCU; this cooperation was the
HCU. Here emphasis is placed on the special needs
result of (he HCU’s deliberate policy of including the
of (he homebound and bedridden patients in the
family physicians in home care at all stages, while in
community.
no way seeking to usurp their functions. It is likely
The Recanati School of Community Health Pro
that this close cooperation will result in the primary
fessions has a course in communication for the 1stcare team acquiring extra skills in geriatrics. An
year nursing students which is similar to that for the
overall estimation of the cost of care for the geriatric
Ist-year medical students. In addition, at the end of
patients in Beer Sheva showed that it is among the
this course, geriatric nursing is taught intensively.
lowest in the country (8).
During the 2nd year al the School of Physiother
Effective integration of geriatric services with the
apy, 2 or the 7 months of clinical exposure are
community works fairly well in Beer Sheva; how
devoted to work with the elderly in different geriatric
ever, coping with the elderly in other areas of the
and rehabilitation hospitals. In the 4th year, a pro
Negev, far from the main city, requires a different
ject in geriatrics is a prerequisite for the bachelor’s
approach. These areas do not have adequate social
degree. In addition, in the 2nd year, nurses and
services for the aged, and the primary care team is
physiotherapists are given a course in geriatrics,
not easily reached by the consultants. A regional
including biology, normal aging, basic clinics and
system of services with a geriatric nurse having a key
pharmacology for the aged. Permanent courses in
role might be an adequate answer in this situation
geriatrics are given to family physicians, community
(9).
nurses, domestic aides, directors of centers for the
The curriculum for the medical school and the
aged, volunteers, pensioners, public health activists
Recanati School is unique in its extent and concern
and high school students.
for the comprehensive care of the elderly (4. 5). The
The development of the geriatric services in the
aim of the teaching program is to deal with the need
Negev has fulfilled two basic principles in geriatric
for: 1) community-oriented continuity of care; 2) a
medicine. 1) a hospital-community continuity of
multi-disciplinary team approach; 3) a comprehen
care, and 2) permanent assessment by a comprehen
sive clinical approach toward the elderly; and
sive multidisciplinary team. The fact that the
4) transforming geriatric medicine into an attractive
Department of Acute Care, the Gerontopsychiatrics
field of specialization. These four points have been
Department and the HCU on the one hand and the
extensively considered elsewhere (5). The concept
Long-Term Care Unit on the other hand are under
that teaching takes place wherever the elderly get
the same direction, presented a unique opportunity
services and that teachers a re those involved with the
to use the various geriatric services in a rational way.
delivery of services, is in accord with these aimsand
I his system has several advantages: patients a re eas
is in the spirit of the Beer Sheva credo: “To teach is
ily placed in the most suitable setting for treatment; a
to serve, to serve is to teach’’ (10). A study carried
common problem for geriatric patients is their need
out in order to assess students’ attitudes toward the
for transfer to other services with the resultant
elderly, prior to and after exposure to the Ist-year
delays and unnecessary occupancy of beds needed
curriculum in geriatrics, showed that positive atti
for other patients. Waiting listsand delays have been
tudes were reinforced (4).
significantly reduced in the Negev (6). A regular
In spite of the above achievements, a few prob
schedule of staff meetings and informal contacts
lems should be emphasized. The gap between the
among the different teams enhance this trend.
preclinical and clinical years is evident, especially
Another important advantage is that these teams
when students become much more interested in
have the same level of knowledge, acquired through
pathophysiology, than in the social problems
permanent ongoing teaching programs, which
accompanying the multiple pathology of the aged.
ensures a uniformly high level of care for the patients
Part of the problem is probably related to the nega
wherever they are placed.
tive role models in terms of attitudes to which stu
The HCU is attached to the Geriatric Department
dents are exposed in the clinical years. The positive
[137]
Israel J. Med. Sci.
D. Galinsky
role models, it is hoped, will be found when gradu
ates of Beer Sheva begin to infiltrate the health care
system. An initial move in this direction is currently
under way—graduates specializing in family medi
cine are demanding more training in geriatrics, and
several graduates are interested in specializing in
geriatric medicine. The decision of the faculty to
establish an independent clerkship in geriatrics in
the 4th year, and the requirement for a special
seminar in geriatrics prior to qualifying for the
bachelor’s degree at the School of Physiotherapy at
the Recanati School are consistent with this policy.
The research is also community oriented and deals
with the special problems of the elderly in the Negev.
Two studies were carried out in order to ascertain
the medical and social needs of the elderly in Beer
Sheva (2, 11). The conclusions were applied in order
to raise the awareness of family doctors, medical
students and other medical agents in the community
to these problems. This informalion.also permitted
us to plan services and research areas for the future
more effectively. One such area is the research on
Vitamin D levels in the elderly. Our current conclu
sion is that the low level of vitamin D metabolites in
the healthy elderly in the Negev is probably one of
the reasons for the large number of elderly patients
with.hip fractures (12-14). A multidisciplinary team
comprised of geriatricians, orthopedists, nephrolo
gists, radiologists, biochemists and epidemiologists
intends to link findings of the research in the com
munity (2), such as falls, loss of vision, poor housing,
etc., with those of the laboratories. The goal is the
development of a comprehensive research program
aimed at the prevention of bone disorders in the
elderly.
In summary, a community-oriented approach in
medicine is most effective to fulfill the requirements
for the proper development of geriatrics in terms of
service, teaching and research. Undoubtedly, the
program presented in this paper is stimulated by the
philosophy developed at the University Center for
Health Sciencesand Services at the Ben-Gurion Uni
versity of the Negev.
■
REFERENCES
1. Davies AM (1979). Demography, morbidity and mortality
in Israel: changes over 30 years. Isr J Med Sci 15: 959-964.
2. Galinsky D, Pilpel D, Naggan L, Weitzman S and
Schneiderman K (1985). “The Jewish elderly in Beer Sheva.
Social and medical characteristics.” Brookdale Institute of
Gerontology and Adult Development, Jerusalem.
3. Galinsky D (1984). Geriatric services in the Negev region.
The Family Physician 12: 144-148 (in Hebrew).
4. Galinsky D, Cohen R, Schneirman C, Gelper Y and Nir Z
(1983). A program in undergraduate geriatric education:
the Beer Sheva experiment. Med Educ 17: I(X)-I64.
5. Galinsky D (1985). Ten years’ experience teaching geriatric
medicine. Isr J Med Sci 21: 249-253.
6. Galinsky D, Kudish M and Ovnat A (1977). Functional
assessment in evaluating a geriatric unit. HarefuahW 346348 (in Hebrew).
7. Galinsky D, Schneiderman K and Lowenthal MN (1983). A
home-care unit: geriatrically oriented and hospital based
with the active involvement of the family physician. Isr J
Med Sci 19: 841-844.
8. Ginsburg GM (1985). Balance of care in services to the
elderly in Israel. Isr J Med Sci 21: 230-237.
9. Gardiner R (1975). The identification of the medical and
social needs of the elderly in the community: a pilot survey.
Age Aging 4: 181-187.
10. Prywes M (1983). The Beer Sheva experience: integration of
medical care and medical education. Isr J Med Sci 19:
775-779.
11. Galinsky D. Herschkoren H. Kaplan M and Alyagon R
(1978). The need for a new approach to neglected elderly
patients. Geriatrics 33: 103-110.
12. Berlyne GM. Ben Ari J, Kushelevsky A et al. (1975). The
etiology of senile osteoporosis: secondary hyperparathyroi
dism due to renal failure. Q J Med 175: 505-521.
13. Galinsky D. Oren A. Zvili I. Yankowitz N. Lowenthal MN
and Shany S (1982). Disturbance of 24-25 dehydroxyvi
tamin D in healthy elderly, in: Menczel J. Robin G and
Makin M (Eds), “Osteoporosis.” John Wiley & Sons. New
York, p 55-60.
14. Meller Y. Kestenbaum RS. Shany S et al. (1985). Para
thormone. calcitonin and vitamin D metabolites during
normal fracture healing in geriatric patients. Clin Orihop
I99-: 272-279.
1
1138 J
HEALTH SERVICES B. Special Community Programs
THE GRADUATES (BOGRIM) PROJECT—MY EXPERIENCE IN NETIVOT
ASHER ELHAYANY
Division of Health in the Community, University Center for Health Sciences and Services. Ben-Gurion University
of the Negev, Beer Sheva, Israel
hr J Med Sei 2y 1071-1074, 1987
»
Key words: Beer Sheva Experiment: medical education; graduates; Netivot, Israel
Established in 1974, the University Center for
Health Sciences and Services at the Ben-Gurion Uni
versity of the Negev was founded on the principle of
merging medical education with medical care
toward improving the health of the population. The
goals are described in the introductory paper of this
issue (1). Educated on these principles, a small group
of my classmates from the first class of this school
was disappointed to see, during the 6 years they
spent in school, that the primary health services
remained inadequate and relatively unchanged. We
were therefore concerned lest the lofty aspirations of
our school would remain as ideas only.
Accordingly, we decided to volunteer to serve for
a period of time in primary care clinics and to intro
duce changes that would enable us to practice and
teach primary care at the same level taught in the
medical school. We were afraid that without such a
step, much that we were taught would remain a
beautiful but impractical and inapplicable theory.
Our group grew rapidly and our enthusiasm spread
to most of the class, until finally, 18 of the first 30
graduates joined what wc called the Graduates
(Bogrim in Hebrew) Project.
We began in October 1977, by trying to define our
aims and goals as well as the problems facing us. I
will describe these in relation to education, service
and research, and then illustrate the changes
wrought by the Project in each of these areas.
EDUCATION
The quality of the education we received at medical
Address for correspondence: Dr. A. Elhayany. Division of Health
in the Community, University Center for Health Sciences and
Services. Ben-Gurion University of the Negev. FOB 653. 84105
Beer Sheva
school in primary care was considerably lower than
that given on the wards of the hospital, both quantit
atively and qualitatively. The exposure to primary
care medicine consisted of 2 months of clerkship—1
month during the 5th year and another in the 6th
year. We considered this inadequate, especially in a
school whose major emphasis is on primary care
medicine, and felt that additional months in family
medicine should be added. We were concerned that
while in all fields of hospital medicine there existed
appropriate role model personalities, such individu
als did not exist in family medicine. A leader-role
model contributes much to the attractiveness of a
hospital residency as compared with one in family
medicine. We were worried by the fact that during
our years of study, the Dean and the faculty had
been unable to recruit even one permanent leading
physician in the field of family medicine, but appar
ently had had fewer problems in attracting
renowned physician educators in the various fields
of hospital medicine.
Postgraduate medical education for primary care
physicians barely existed. Although such education
had been proposed by Dr. Moshe Prywes 10 years
earlier (2), no effective steps had been taken in this
direction. Wc were afraid that after a few years in
primary care clinics, without ongoing education, wc
would become obsolete and unprofessional.
We were troubled by the low motivation of the
graduates toward a future in primary care. We
thought that encouragement in this direction should
begin at an earlier stage of the spiral (3) and not in
the 5th year, when the student’s wishes and object
ives are often already established.
We were faced with the further problem that the
faculty had not decided which model it wished to
encourage—primary care medicine (i.e., internal
1139]
t
A IIHAYANY
ISRAI I J. Ml I) S( I
►
medicine/pediatrics) or family medicine. Some of us
seminars was held on the subject of psychosexual
►
saw this question simply as a semantic one, but
others felt that the school had to decide and
problems, and a successful workshop was carried
out to teach ambulatory surgical management of
problems commonly encountered in primary care.
We arranged a system of consultations in the clin
ics by visiting specialists on a regular basis. The
►
announce its intentions clearly, and then carry them
out in the field.
We found that while a tremendous investment had
been made in changing the teaching system and in
building a new model of a medical school, little had
been invested beyond the hospital and the faculty to
change working models or to prepare suitable clinics
in which the graduates could apply the advanced
teachings ol the school. The promises that we would
be our own role models, the “doctors of the future,”
in a new model of medical care would be shattered in
the light ol the sad reality of the clinics and their
heavy work load.
meetings allowed the medical staff in the clinics to
present a limited number of cases that were usually
followed by an in-depth discussion of the problem.
In addition to providing solutions for difficult cases,
these consultations provided an invaluable and
excellent teaching experience. However, we found
that the specialists lacked orientation in community
health and needed some training in the field of fam
ily medicine before they went out to work as consul
The Project's impact on education
specific health problems they confronted in the com
The difficulties faced in the clinics were foreseen,
munity. We felt that a year of service in primary care
clinics should be a part of the training of all gradu
met at the clinic.
ates. It was unanimously agreed that this year was
invaluable and crucial to our development as physi
cians in any specialty area.
The graduates became models to medical students
and to the staff at the clinics. For the first time, the
students encountered an organized, well-func
tioning team, consisting of a physician, nurse and
medical secretary. They saw a model of a young
physician trying to apply what he or she had learned
in a different field of “battle” and not doing badly
for all that. But we felt that the school too had to
help its graduates survive in the clinics in order to
reinforce the model.
The Graduates’ clinics served as teaching centers,
not only for medical students from Ben-Gurion Uni
versity and from abroad, but also for student nurses
from the Recanati Nursing School and the social
work students from the new Department for Social
Work at Ben-Gurion University. Unfortunately,
most clinics still lack adequate space to accommo
date all these students* this problem will have to be
solved so that the students can benefit optimaHy
from the time spent in (he primary care setting.
In order to allow the medical graduates to keep
abreast of medical advances, half a day each week is
set aside for continuing education. Part of the morn
ing might be spent attending a ward round, visiting
hospitalized patients, consulting with specialists or
reading in the library. The rest of the morning con
sists of a formal program (4), including case and
family presentations, a journal club and seminars
concerning relevant subjects presented by senior
I
r
>
r
r
&
tants in primary care clinics. Their residencies had
not prepared (hem adequately for dealing with the
and we found that the good training we received in
the school did enable us to deal adequately with
many of the medical and administrative problems
k
We were unable to combine successfully curative
medicine with preventive medicine, and this prob
lem will have to be dealt with in the future. We
lacked sufficient interaction with the emergency
j-oom, which was our natural point of contact with
the hospital. We thought it would be worthwhile to
create a framework of weekly meetings between
primary care physicians and the emergency room
team to discuss-hospital referrals. Such meetings
could be ol mutual benefit, resulting in improved
communication and medical service to the emer
gency room consumers from the communities.
Each clinic received a library stocked with basic
modern text books applicable to primary care, and
two medical journals of its choice. This modern
literature is of great benefit to the staff of the clinics,
enabling them to keep up with recent developments.
SERVICE
Dr.
Haim
Doron, National Director of Kupat
Holim (Health Insurance Institution of the General
Federation of Labor) recently stated that the Gradu
ates in the Negev had revolutionized primary care in
their area. To illustrate this “revolution,” I will des
cribe some of my personal experience in the Netivot
Clinic where I served for 3 years, 2 of them as direc
tor of the clinic.
When Drs. Orkinand Pazand I joined (he project,
faculty members. These meetings, which also pro
vide an opportunity for an exchange of ideas by a
we looked for a clinic with particularly difficult
problems, where it would be possible to affect signif
icant changes within a short period of time. The
peer group, are very popular. In addition, a series of
following is a partial list of the problems we faced
[140|
►
E
Voi 23. Nos. 9-10, September-October 1987
Graduates (Bogrim) Project
prior to starting our year of service in Netivot:
1) lack of suitable equipment; 2) lack of teamwork;
3) absence of or poorly maintained medical records;
4) overwhelming physician work load; 5) poor care
of the elderly population; 6) inefficient laboratory
services; 7) absence of on-site specialty consultation:
8) lack of cooperation between the clinic, local social
services and the local municipal council; 9) lack of a
communality of identity between the graduates and
the physicians already in the clinic (not from the
Graduates Project)', 10) inefficient clinic administra
tion (e.g., missing files, poor relationship with par
ents, unnecessary bureaucracy); 11) insufficient
support services (e.g.. X-ray. physiotherapy);
12) absence of night services; 13) no overall preven
tive health service; 14) inefficient psychosocial servi
ces; 15) poor telephone communications inside and
outside the clinic; 16) no academic supervision; and
17) no health education program.
Within 2 years of work in Netivot, we saw tre
mendous changes and many of these problems had
actually been solved. Vital equipment was provided,
including an electrocardiograph, ophthalmoscope,
anoscope, incubator, and first aid and resuscitation
kits. The clinic was reorganized into live medical
units (doctor-nurse), and we have had progressively
close teamwork and excellent cooperation on the
part of the nurses. More than a 1000 new problemoriented medical records have been opened. More
than 50% of the old files have been transferred to the
new format, and the problem of missing files has
been considerably reduced. The quality and
organization of medical records have thus improved
tremendously. One of the outstanding achievements
has been the transfer to an uninterrupted work day
(in contrast to the split shift system) and the
introduction of an appointment system, while still
permitting the treatment of urgent cases referred by
the nurse. These changes significantly decrease the
work load of the physicians, providing prompt
service to the patient as well as free time for staff
meetings and preventive medical care. Since the
switch to the new system of work, we have been able
to initiate home visits to our elderly patients: a
doctor-nurse team visits three to four times a week,
and each patient is thus checked once or twice a
month. A laboratory technician was hired, with
dramatic improvement in the quality of results and a
reduction in public dissatisfaction.
The greatest achievement, in our opinion, has
been the infusion of the staff with enthusiasm and
motivation. There has been a resultant reduction in
absenteeism and increased cooperation and
attendance of personnel at staff meetings; (he nurses'
knowledge and quality of care have improved
beyond recognition, and they have been trained to
practice triage. Simultaneously, there has been an
improvement in their self-image and in their image
in the eyes of the population, who no longer consider
them merely as “ointment spreaders and injectors of
penicillin.” We have included the first nursing
graduate from the Recanati School of Nursing in our
team, and consider this a great step forward.
A well-organized consultation system exists, with
specialists in most disciplines visiting the clinic on a
regular basis, thus providing on-the-spot service and
reducing the number of patients having to travel
long distances to speciality clinics. Moreover, the
gap (hat had existed between (he family physician
and the consultant ^as narrowing. During (his 2year period, a welcome development has been the
growing cooperation between the clinic, the social
service, (he psychological service, the Maternal and
Child Health clinics and the local authorities, up to
the point of mutual involvement of the clinic in the
town s affairs and vice versa. The local welfare
service has provided a part-time social worker for
the sole purpose of working with the clinic staff. The
veteran physicians cooperated fully in the new
program and participated enthusiastically in all its
activities. The backup and paramedical services, as
well as the counselling and consultation services, a re
allocated equally among all the physicians.
Specialists visiting the clinic today comment on the
remarkable improvement in the quality of care
provided by these doctors compared with their
performance prior to the Project.
Two medical secretaries were added to the staff,
resulting in tremendous improvement in admin
istration. Added benefits have been the reduction of
the doctors work load and fewer unnecessary
bureaucratic demands. Regarding priorities for Xray appointments, we received specific allocation of
particular days and number of X-rays; thus, wc were
able to shorten the waiting period and obtain greater
control over this vital service for the benefit of the
patients. We organized a 24-hour emergency
medical service staffed fully by the Netivot doctors.
We have partially solved the problem of the poor
psychosocial service, through the services of the
part-time social worker who is part of the core staff.
For the first time, a physiotherapy service is
functioning in Netivot; the local council provides
and maintains the premises, the Neighborhood
Rehabilitation Project provides the equipment, and
the Agudaja joint endeavour between Kupat Holim
and the Israel Joint Distribution Committee (JDC)]
finances the salary of the physiotherapist.
Altera long struggle, wc were event ually provided
with an internal telephone exchange and automatic
[141]
Israel J. Med. Sci
A. Elhayany
dialling, enormously relieving our telephone
communication problem. We have introduced
regular staff meetings (two to three a week), devoted
to administrative and professional discussions,
consultations, presentations and other academic
activities for the staff. We have developed a wide
range of health education activities for the pop
ulation, initially through lectures and presentations,
and more recently through education of health
activists who are part of the community. We are thus
fulfilling one of our principal goals, which was to
develop the community’s involvement and self
responsibility in dealing with its own health needs
(5).
RESEARCH
Before commencing the Project, we defined the areas
of our research: First, we wanted to define what a
family physician should know in order to do a
satisfactory job in the community. Such inf ormation
was nonexistent in Israel prior to our Project.
Second, we wanted to examine whether there is any
difference between the type of physician who
graduated from Beer Sheva and graduates of other
schools in Israel. Third, we wished to find time, in
spite of the heavy patient load, for research in the
clinics. In reality, we were too busy with the day-today work to find time for such research, and only in
one clinic was research conducted [Ben-Yair
Clinic—Drs. E. Lunenfeld (6) and A. Katzspent one
morning every week in research and in preventive
medicine. During this time, they provided prenatal
care, and Dr. Lunenfeld completed an effective
screening program for risk factors in primary care
clinics.] In subsequent years, following the great
improvement in the quality of medical service in the
clinics, the graduates devoted more time to research,
resulting in programs of ongoing evaluation and
research in the specific fields of community
medicine.
CONCLUSIONS
The graduates’ personal experience in the clinics has
been extremely positive. All graduates who have
participated to date have described the Project as an
invaluable continuation of their medical education
and a sound preparation for their continuing
careers.
The Graduates Project has more than justified its
initial expectations. Models of high-quality, com
prehensive health care have been established in
several areas of the Negev. New graduates of the
Beer Sheva Experiment have joined with other
health workers in a unique experiment of interacting
with existing services toward the common goal of
improving them. During the past 2 years, family
medicine residents have taken over some of the
positions previously held by the graduates, and it is
hoped that they will become established as highquality, committed physicians in permanent
positions in these clinics. This involvement of the
residents in family medicine in the Graduates Project
is crucial to its long-term success, since it is these
residents who can provide the role model that was so
lacking in the clinics as well as the continuity of care
that is so important in a primary care setting.
REFERENCES
I. Prywes M (1987). Coexistence—the rationale of the Beer
Sheva Experiment. Isr ./ Med Sci 23: 945-957.
2. Prywes M (1971). Reform of postgraduate medical
training—a need of the time. Harefuah 80: 323-328 (in
Hebrew).
3. Segall A, Prywes M. Bcnor DE and Susskind D (1978).
University Center for Health Sciences and Services, BenGurion University of the Negev: an interim perspective.
Public Health Papers. No. 70. WHO. Geneva, p 112-132.
4. Schein M (1982). The Negev Project in primary health
care—progress report. Ben-Gurion University of the
Negev. Beer Sheva. Appendix Bl.
5. I lermoni D. Mankouta D. Sivan A. Colander Y and Porter
B (1987). Community Health Activists Program: a new
model of community health involvement. Isr J Med Sci 23:
1084-1087.
6. Lunenfeld E (1987). Screening for risk factors in primary
care clinics. The Family Physician (in Hebrew). In press.
!
I
I
[142]
i
J
COMMUNITY-ORIENTED PRIMARY CARE PROVIDED BY INTERNISTS
AND PEDIATRICIANS — THE EXAMPLE OF YERUCHAM
RAPHAEL BOEHM
Division of Internal Medicine, Soroka Medical Center and University Center of Health Sciences and Services, Ben-Gurion
University of the Negev. Beer Sheva. Israel
. ’ IsrJ MedSciiy 1075-1078, 1987
Key words: Beer Sheva Experiment; medical education; health care services; Yerucham, Israel
Primary health care in Israel is traditionally divided
into preventive care, pravided by the Ministry of
Health through the Maternal and Child Health
(MCH) clinics, and curative care, provided by Kupat
Holim (Health Insurance Institution of the General
Federation of Labor) clinics (1). In addition to the
separation of preventive and curative care, there is
also a dissociation between primary care and hospi
tal medicine. The more than 1,250 Kupat Holim
clinics in the country vary considerably in the range
of services provided, from fully staffed clinics with
many paramedical services to small clinics with a
nurse and a physician who visits periodically. Rural
areas present a worldwide problem in terms of med
ical manpower, and Israel is no exception (2). Devel
opment towns in Israel present similar problems in
terms of medical manpower, even though they are
primarily urban settlements (3). Perhaps they can
best be compared to urban slums in Western
countries.
Most of the development towns in Israel were
established in the 1950s and 1960s to accommodate
the large waves of immigrants and to disperse the
population. One symptom of the problems in the
development towns used to be the large turnover of
teachers and physicians. Yerucham, the first devel
opment town in the Negev—the southern, desert
part of Israel—was established in 1951. Surrounded
by desert, it is located some 40 km southeast of Beer
Sheva, the nearest large city. The first immigrants
came from Rumania. They were followed by immi
grants from North Africa (mainly Morocco and
Tunisia) and a decade later by immigrants from
India (Bene Israel) and Iran. The present population
Address for correspondence: Dr. R. Boehm, Division of Internal
Medicine, Soroka Medical Center. FOB 151,84101 Beer Sheva.
[143]
of Yerucham is about 6,500. There is an MCH clinic in
the community, and all curative care is provided by
the Kupat Holim clinic, there being no other facili
ties in the community. There is a first aid station,
which is an ambulance service. For many years, as in
other development towns, the clinic suffered from a
turnover in medical personnel (especially physi
cians), leaving the community with inadequate med
ical care. This chronic situation was acutely
exacerbated in 1978 when Yerucham had no physi
cian at all. At this critical juncture, a group of resi
dents of the Department of Medicine at the Soroka
Medical Center volunteered to step into the breach
as a rescue operation. Their involvement was guided
by health care needs as perceived by the community
and by the prevailing philosophy of the Ben-Gurion
University medical school in Beer Sheva. It was clear
even without formal study that availability, i.e., hav
ing a physician in the clinic, was the first priority for
everyone.
EVOLUTION OF THE SYSTEM
Phase I: Running a clinic by rotating residents
A group of six residents in Internal Medicine were
recruited. Each resident agreed initially to serve for 2
months a year as a primary care physician in Yerucham. In addition, each resident agreed to spend one
half-day a week in the clinic throughout the year,
during which he would be available to a subgroup of
the population who would be under his continuous
care by appointment only. The attending physicians
agreed to consult on a rotational basis as needed.
This plan had one strength—availability. There was
always a physician in the community. The plan also
had one serious weakness—lack of continuity. We
tried to overcome this by the intensity of the involve
ment on the part of the physicians, by the half-day a
MW
R. Boehm
Israel J. Med. Sci
week of clinic service and by the development and
obsessive maintenance of problem-oriented medical
records, as well as by delegating responsibilities to
the nurses and newly hired medical secretary. Our
experience with this plan showed that residents kept
their commitment for 2 months, and all but one
repeated at least one 2-month session in the second
year of the project. On the other hand, almost no one
was able to consistently keep up his commitment to
half a day a week because of ward duties and person
nel shortages. We concluded that an extended period
of rotation was preferable, but we continued the
original organizational plan because that was the
best we could do.
Phase II: Applying epidemiological methods to
community-oriented primary care (4)
About 2 years after starting the project in Yerucham,
I had the opportunity to conduct a community sur
vey that was designed to objectively assess the medi
cal needs of the community. This was done while
Phase I was still continuing. A systematic random
sample of the people over age 31 years enrolled in
Kupat Holim was selected; 212 people, representing
little more than 2A of the sample, participated. Each
one of them was interviewed and underwent a full
medical examination plus simple tests such as hemo
globin, blood glucose, and ECG. The results were
not reported in the literature, but they enabled us to
plan our further work in the community. We found a
poor community with 11.1% of the population sup
ported by welfare. Large families were common with
59.3% having five or more children, and 16.7% of
the men < 65 were unemployed. We found that
23.5% were hypertensive (half of them not pre
viously identified as such), 6.6% had diabetes, 8.4%
ischemic heart disease, 5.6% pulmonary disease,and
6.1% congenital or valvular heart disease. We also
found that alcohol abuse was a problem in the com
munity. We compared the medical records of those
examined with those who did not come for examina
tion and found no significant differences. We con
cluded therefore that our findings were rep
resentative of the population as a whole. As a direct
result of this study, we were able to convince Kupat
Holim as well as the Department of Social Welfare
to hire a social worker who would have a joint posi
tion in both institutions and would try to solve as
many social problems as possible.
Phase 111: Prc'onged rotation and integration of
services
After almost 3 years in the community all of the
residents who had initially started the project ended
their residencies and continued in internal medicine
subspecialities. We extended the rotation period to 1
year of service in the community and found enough
physicians who were willing to commit themselves
for 1 year. Some were new immigrants, but most
were graduates of the Ben-Gurion University Center
for Health Sciences and Services (as part of the
Graduates Program). The commitment of a physi
cian in the community was for 1 year of service. This
included night duties, so that the community would
be covered by a physician 24 hours a day, including
weekends. About half of the physicians so far have
extended their initial commitment to a second year.
The clinic was divided into four teams, with each
team consisting of an attending physician and a
resident. One team is pediatric and is responsible for
children aged 0 to 10 years; the other three are
primary care medicine teams.
Simultaneously, we tried to integrate services. I
served in a part-time capacity as both the attending
physician internist and medical director of the clinic,
and at the same time part-time as an attending physi
cian in the hospital’s Department of Medicine,
where patients from the community were hospital
ized. I also served as a medical consultant for
patients from the community on other hospital
wards. In the community itself, my task was to teach
and consult with other physicians and to provide a
sense of continuity for the population.
In addition to the physicians’ role, many services
were available in the clinic—pharmacy, laboratory,
physical therapy, as well as those provided by a
social worker, dietician and medical secretary. We
had a number of consultants who were all attending
physicians in the medical center in Beer Sheva. Their
specialities included obstetrics and gynecology, ear,
nose and throat, dermatology, orthopedics, cardiol
ogy, psychiatry, and pediatrics. The pediatric at
tending physician was simultaneously the physician
in charge of the MCH clinic in Yerucham, which is a
unique situation, existing in only a few clinics in
Israel—since there is usually total separation of prev
entive and curative services. There was also a dental
clinic staffed by a dentist and assistants. All the
physicians had joint appointments in the medical
center and in the clinic (see Fig. 1 for interaction).
THE CLINIC AS A MODEL FOR
COMMUNITY-ORIENTED PRIMARY CARE
Primary health care is expected to provide most of
the preventive and curative services to the popula
tion. It can be individual, family oriented, commun
ity oriented (5) or all of these (6). Patients’ priorities
and satisfaction can be assessed by a number of
attributes. These criteria vary in relative importance
[144]
Vol 23, Nos. 9-10, Sfptfmrer-Octorfr 1987
Primary Care in Yf.rucham
SOROKA MEDICAL CENTER
OB-GYN
ENT
MEDICINE
PEDIATRICS
DERMATOLOGY CARDIOLOGY ORTHOPEDICS
\
x.
xX
'x
X
n
i
•i
\
■!—yr
I ____ _
I
I
._______ yfruham
MCHC
SOCIAL
WELFARE DEPT.
CLINIC
y A PEDIATRIC
INT MED 1
X / /[resident
RESIDENT
/>'//
/
/
COMMUNITY
CENTER
OLD AGED
DAY CARE
!
I
I
I
I
I
I
HOME CARE
I
I
HOME DIALYSIS J
/
PSYCHIATRY
I
2
3
I
I
I
DENTAL
CLINIC
I
I
MEDICAL
f
LABORATORY
PHYSIOTHERAPY
i:
I:
DIETICIAN
i-
r
PHARMACY
___________i- ________
MAGEN DAVID ADOM I
SOCIAL WORKER
FIRST AID STATION
MEDICAL SECRETARY
Fig. I. Relationship
r • •
• of- Soroka
Medical Center, the University Center for HeaIth Sciences and Services
and the’ allied u
health
Services.
“"'*uc
..... —■ WMCHC
",T:C= Maternal and Child Health clinic:
Joint appointment;
— = consultative service; •
radio communication (24 hours).
in different studies, but almost invariably they
include the following: continuity of care, compre
hensiveness, compassion, expertise, availability,
affordability and coordination (7, 8).
If wc examine the existing program in Yerucham
according to the guidelines for community-oriented
primary care as outlined by Kark and Kark (5) or by
Fletcher et al. (8), we may see that many criteria are
met. The population is composed of the entire com
munity, and its geographic situation is very well
defined. We were able to conduct a preliminary
epidemiological study to identify the main prob
lems. Subsequent studies were concerned with
control of hypertension, and these subjects are contin
uously monitored with the help of the Department
of Epidemiology and Health Sciences Evaluation of
the Ben-Gurion University. The clinic is accessible
and within walking distance foreveryone in the com
munity. We extended the hours of the clinic, and we
have 24-hour coverage for emergencies [at least two
successful resuscitations have been performed in the
community, confirming the observation that the
most important influence on outcome is the availa
bility of trained personnel (9)]. Physicians, as well
as other medical staff, are involved in community
programs. All community committees that deal with
the aged, the disabled, alcoholics and other groups
include a member of the medical staff. Continuity of
care over the years is assured by retaining the same
attending physician. Continuity of care between
community and hospital is through (he involvement
of the clinic physicians in the hospital care of their
patients. All appointments and referrals to a special
ist are done through the clinic’s office and approved
by the primary care physician. The care is compre
hensive, and in terms of major facilities the clinic
lacks only a local X-ray facility. However, some
have suggested that local availability of X-ray facili
ties often results in considerable overuse and
reliance on substandard and outdated equipment, in
contrast to referral to the medical center.
CONCLUSIONS
This presentation describes the development of the
current state of the Yerucham clinic, that now serves
as a teaching clinic for the Ben-Gurion University
[145]
Israel J. Med. Sci
R. Boehm
Center for Health Sciences and Services. The
personnel are involved in a continuous effort to
improve the services provided by the clinic. Our
model, in which attending staff have dual
responsibilities and joint appointments while
residents assume the everyday responsibilities,
provided reasonable availability and compre
hensiveness. Although it suffered from a certain lack
of continuity due to physician turnover, the model
continues to assure quality of care. One of its major
strengths is that most of the changes were achieved
with relatively minor investments, making it replica
ble in other clinics.
In the future, solutions to two problems are
urgently needed: 1) the complete integration of
Kupal Holim and MCH clinics, where the obstacle is
political rather than ideological, and 2) recognition
by the Scientific Council of the Israel Medical
Association that work in the community health
center is part of a residency program—not only in
family medicine, but also in internal medicine,
pediatrics and other specialities.
REFERENCES
1. Modan B (1982). Current status of health services in Israel.
Jsr J Med Sci 18: 337-344.
2. Rober M (1978). Strategies for increasing rural medical
manpower in five industrialized countries. Public Health
Rep 93: 142-146.
3. Arnoff MJ (1973). Development towns in Israel, in: Durlis
and Chertkoff (Eds), “Israel social structure and change.”
E.P. Dutton, New York, p 27-47.
4. Abramson JH (1983). Training for community-oriented
primary care. Isr J Med Sci 19: 764-767.
5. Kark SL and Kark E (1983). An alternative strategy in
community health care: community-oriented primary
health care. Isr J Med Sci 19: 707-713.
6. Epstein I (1983). Family and community medicine: com
plementary components of primal y health care. 1st I Med
Sci 19: 719-722.
7. Hulka BS. Kupper LL and Daly MR (1975). Correlates of
satisfaction and dissatisfaction with medical care: com
munity perspective. Med Care 8: 458-463.
x IlvUhvi KII. O’Mallcv MS and l aip IA(l9Xt) Padcnls’
priorities lor medical care. Med Care 21: 234-242.
9. Systkowski PA, D’Agostino RB. Belanger A.I. Bettencourt
KS and Stokes J 111 (1984). Testing a model that evaluates
options for rural emergency medical services development.
Med Care 22: 202-215.
(
I
| >46 ]
PIONEERING AND SETTLEMENT IN HEALTH SERVICES:
A CASE STUDY
BASIL PORTER and CARMI Z. MARGOLIS
Dtvistons ol Pediatrics and Health in the Community, and Association for the Advancement of Health and Social
Servtccs tn the Negev. University Center for Health Sciences and Services. Ben-Gurion University of the Negev
Beer Sheva, Israel
b
'
I
Ixr ./ Med Sei 23: 1079-10X3, 19X7
KfJSS*”
""'d“""ita*
In 1974, the newly formed University Center for
directly adjacent to the KH curative centers; a dif
Health Sciences and Services of the Ben-Gurion
ferent staff of nurses and physicians provided servi
University ol the Negev initiated a project to create a
ces in each type of facility.
1 he aims of the new ambulatory pediatric project
community pediatric teaching clinic in Ofakim, a
development town in the northwestern Negev. In
were as follows: I) to provide high-quality pediatric
care in a clinic staffed with university-affiliated pedi
atricians; 2) to establish a setting for undergraduate
keeping with the stated goals of the institution—
merging medical care and medical education
(1)—the Division of Pediatrics at the Center under
and postgraduate pediatric training; 3) to establish
an effective and efficient liaison between the hospital
took the development of the project together with
the local Kupat Holim (KH)authority(Health Insu
and the community; 4) to integrate preventive and
curative services and provide comprehensive prim
rance Institution of the General Federation of
Labor), which was responsible for all curative servi
ary care for the child and family; and 5) to provide a
setting for the implementation of research in areas
related to ambulatory pediatrics.
Studies carried out in Ofakim have demonstrated
ces in the town, and the Ministry of Health (MH),
which was responsible for preventive services. Pedi
atric training in Israel is almost entirely hospital
based. It was hoped that the Ofakim experiment
the importance of such a project lor research in
ambulatory pediatrics. In the clinical area, this
included a study of the reliability of the middle car
could become a model ol a community pediatric
setting where trainees could gain experience in prob
lems not seen in the hospital, with appropriate
examination in an ambulatory setting (2). Two stud
ies relating to pediatric health services were carried
academic supervision. Before (he academic person
nel of the Health Sciences C’enler entered Ofakim,
services had followed a standard model typical of
out: one stressed the importance of the pediatric
record for acute compared with chronic problems
(3). and the second used emergency room utilization
most communities in Israel. KH. the major prepaid
health insurance body in Israel, provided curative
health services for 909? of the population through
and hospitalizations as markers for measuring the
effects of improved ambulatory pediatric services.
two geographically separate clinics: pediatricians in
these clinics saw children up to age 12 years. MH
1 he study showed that for the experimental clinic in
Ofakim. compared with another traditional care
provided antenatal and well-baby services at Mater
nal and Child Health (MHC) clinics, and to a lesser
degree services for mental health and chronic
illnesses through two family health centers situated
Address lor correspondence: Dr. 0 Porter. Division of Pediat
rics. University Center for Health Sciences and Services. Ben-
Gurion University of the Negev. POB 653. X4IO5 Beer Sheva.
model (4), there were 50% fewer referrals to the
pediatric emergency room, with a significant
increase in the percentage of these referrals requiring
hospitalization—indicating that the changes intro
duced indeed influenced the quality of health care
delivery.
The implementation of the other aims has been
lengthy and complicated. Though the aims of pro-
I 147|
■-sum
Israel J. Med. Sci.
B. Porter andC. Z. Margolis
viding quality care, setting up a training base and
establishing liaison with the hospital have been prob
-lematic, change in the service environment to allow
for comprehensive child care has proved to be the
biggest obstacle to success. This area is the major
focus of this paper.
PIONEERING THE MODEL
The director of the pediatric service (B.P.) was
appointed jointly by the director of the Department of
Pediatrics at the Health Sciences Center, the regional
KH directorand the regional MH director. Two main
avenues were open to the director of the clinic to bring
about desired changes. First, he could work for
change from within the service system in his capacity
as director of the pediatric service; and second, he
could use the new academic connection as leverage to
press for change from without. Since the Dean ol the
medical school also functioned as regional director of
all health services, and the Chairman of the Division
of Pediatrics in the hospital was responsible for the
health of the pediatric community of the whole Negev
area, Ofakim became the first testing ground for these
new community health service functions of the medi
cal school.
Following the introduction of a senior faculty pedi
atrician and a pediatric resident into the clinic in 1974.
all subsequent changes in the clinic were made in an
effort to create a unified team to provide comprehen
sive care; i.e.. attention to all health needs of the child
by a single health team. From 1974. major organiza
tional changes were made in order to achieve this goal,
which involved changes in physical setting, role
changes for existing personnel and addition of new
personnel. Every change was preceded by a drawnout process of negotiation complicated by the bureau
cratic structure of health services in Israel. Change
had to be negotiated within the clinic itself and with
the regional supervising authorities, and certain issues
required intervention of the national controlling
body. The goal of integration of services further com
plicated the process fyeCause all levels of decision
making—local, regional and national—in both health
service organizations had to be involved.
At the local level, i.e., within the clinic setting itself,
any change depended on the ability of the clinic direc
tor to persuade other clinic personnel. A minor modi
fication of nursing roles or clerical procedures would
be attempted this way. Clinic personnel were undei no
obligation to implement a change suggested by the
new director; lines of authority within the system are
drawn strictly within professional groupings in both
the preventive and curative services. For example, the
exact working conditions and obligations of nursing
staff are specified in agreements drawn up at the
national level and are implemented at the local clinic
by the nursing supervisor of the regional office. Thus
the director has no formal authority in the clinic as a
“horizontal” director of a multidisciplinary team.
The regional level, therefore, had to be involved for
any type of decision requiring more than local good
will. Changes in work schedule or hiring and firing of
personnel required intervention of the regional super
visors. Although regional nursing and clerical direc
tors could theoretically authorize change within their
sectors, in practice most issues involving conflict
between the sectors necessitated the intervention of
the regional medical director.
In order to improve coordination both between the
professional groupings and between the two insti
tutions (MH and KH), the Combined Services Com
mittee (CSC) was created in 1975. Members included
representatives of all professional groupings within
the preventive and curative services, the clinic pediat
ric director and the Chairman of the Division of Pedi
atrics. This body represented the first major effort to
involve the academic and service components in the
change process in primary care; specifically, this body
was required to help implement horizontal change in a
clinic setting. This committee subsequently became
the operative arm of the Division of Health in the
Community, which was established within the Health
Sciences Center. At CSC meetings a “problem list”
would be presented by the clinic director—problems
that had not been solved through regular channels.
For example, in 1976 the pediatric director persuaded
the regional medical directors of both institutions to
have the MH (preventive) nurses take on curative as
well as preventive pediatric care. However, as control
of nursing supplies remained with the KH nursing
supervisor, friction rapidly developed, with the MH
nurses resenting dependence on this new authority
figure. Amalgamation of preventive and curative ser
vices in the KH facility in 1977 produced further
tensions: selection of rooms, record storage, tele
phone access and even tea break arrangements, which
had previously been the responsibility of the MH
regional nursing supervisor, were now dependent on
non-Ministry personnel. These issues, each seemingly
trivial, cumulatively became a major demoralizing
and dividing force. Intervention of the CSC in all such
issues facilitated appropriate definition and delega
tion of tasks across institutional lines.
An additional factor that abetted change was the
recognition of the Ofakim setting for part of the pedi
atric residency training in 1975. Prior to this, no prim
ary care setting in Israel had been granted such status,
except for an optional period in the MHCclinics. This
recognition forced the service-providing organization
to upgrade certain aspects of service, e.g., to improve
[148|
Vol 23. Nos. 9-10. Si pti mbf r-Octobi r 1987
Pioneering and Settlement in Hi ai th Services
accessibility to radiological services and widen the
scope and availability of laboratory services.
Important questions throughout this process of
change have been: Are these changes creating a setting
that will be seen as an attractive alternative career
pathway by future pediatricians? And secondly, will
these changes ensure long-term improvement in the
overall primary care delivery system?
PROBLEM OF SETTLEMENT
The title of this paper contains the terms “pioneering”
and “settlement.” Pioneering is defined in Webster’s
dictionary as “to open or prepare for others to fol
low.” In this case it was hoped that the Ofakirn experi
ment would be a pioneering model for ambulatory
pediatric services in Israel. As such, the Olakim pedi
atric experiment has helped show pediatric trainees
the changing context of pediatrics in which the hospial
has a diminished role. The longitudinal management
of children in the context of their families, and man
agement of the child both in health and when ill, are
new experiences made possible by the integration of
preventive and curative roles. In addition, the role of
the resident in following the patient in hospital has
helped improve relations between the hospital and the
community. Consultation by other pediatric faculty
take on curative tasks, as discussed above, established
a precedent for subsequent demands for increased
salary and status change on a national level.
At the national level of KH and MH, the Ofakim
experiment received at best post facto approval for
changes negotiated at the regional level. No meeting
ever look place between the (wo institutions regarding
the planning and implementation of change. In other
words, there was no formal institutional policy regard
ing change in the status quo of ideological and func
tional separation of the curative and preventive
services.
The regional level was crucial for implementing any
changes in the system. Within the KH curative servi
ces, the regional physician, nursing and administra
tive personnel supported the Ofakim pediatric direc
tor. A hotline to these functionaries was used to
mobilize support rapidly for even minor changes that
were frequently not welcomed within the clinic itself.
In time they conveyed to the clinic staff that they were
delegating decision making on certain issues to the
pediatric director. Within the MH, responsibilities of
the Ofakim pediatric director and the MH regional
office were never fully defined. This lack of clarity
precluded of
both
the possibility
of readily changing the
functions
Minist^
pe^nne^d
m Ofakim. and the presentation of cases from the
Ofakim clinic at pediatric department meetings have
done much to improve the understanding and
academic credibility of ambulatory pediatrics.
However, the numerous organizational changes
over a 10-year period, though some were planned as
part of a process of evaluation and innovation essen
tial to any pioneering effort, have not led to (rue
“settlement” of ambulatory pediatrics. The Ofakim
pediatric experiment has not yet established itself as a
truly viable model for child health care. Three main
factors have been responsible for failure of settlement
(i.e., failure to consolidate): lack of commitment to
change from within the service sector, conflict of inter
est between service providers and the academic set
ting, and insufficient commitment of the
predominantly hospital-based academic medical cen
ter to the development of primary care models.
Given the rigid hierarchical structure of health ser
vices in Israel, change from within is always prob
lematic. Vertical control of all sectors—physician,
nursing and clerical—from the national to local levels
determines all aspects of work including a detailed job
description, work hours and salary. Labor unions
vigilantly protect all such details within labor agree
ments. Consequently, people within the system who
do agree to change may risk antagonizing some level
in the hierarchy, with ripple effects to the related labor
unions. For example, the agreement by MH nurses to
-----of
r child
. ............................
tion
health services.
The signs of failure of settlement have been most
obvious at the local clinic level. Local personnel were
not involved in any of the planning of the Ofakim
experiment, but they were expected to implement deci
sions made at the regional level by their respective
supervisors, and to cooperate with the pediatric direc
tor. Most changes in the service demanded more work
from these personnel. Each change in the work rou
tine required that the clerical staff spend more time in
explanation to patients and in patient scheduling,
which necessitated increased demand for telephone
services.
Integration of curative and preventive services dis
located work routines and norms. Thus, for example,
the workers responsible for providing tea to the addi
tional MH staff protested the additional burden
involved and required regional approval for increased
funding for tea and sugar! The pharmacist com
plained of increased demands by the pediatric resi
dents on rotation to alter norms not within his
control, such as the frequency of prescription renew
als for medications used by chronically ill patients.
For the MH nurses, adoption of curative tasks was a
major change in their routines. Whereas their tradi
tional role allowed them to exercise control electively
when a child appeared for immunization or consulta
tion. they were now exposed to the problems of a
socialized medical system with large numbers of
[149]
B. Pori i r and C. Z. Margoiis
ISRAI I J. Ml D S( I
patients brought in randomly by anxious parents.
Tasks such as triage, wound dressing or administra
tion of antibiotic injections had not been practiced for
many years. Such problems, together with a feeling of
divided loyalties between the regional supervisorsand
the local pediatric director, resulted in a sense of alie
nation and anger within the newly integrated
environment.
departmental meetings were not suff icient to establish
Ofakim as a true priority of the pediatric division.
Success of such a program relies heavily on accep
tance by pediatric trainees, who in turn are heavily
influenced by faculty attitudes and practices.
CONCLUSIONS
From a descriptive hindsight review of this kind we
For the pediatricians involved in the experiment,
present suggestions for others embarking on the diffi
cult task of integrating the academic and service com
new experience. Despite similar professional group
ponents of primary care. There are few reliable
ings in both the clinic and hospital ward setting
guidebooks to guide the uninitiated, other than empir
(physician, nurse, clerical), the department head was
ical efforts of this type.
always the clearly defined authority for problem solv
Within the service, a lesson learned from the Ofa
ing on the ward. In the clinic and at the regional level,
even a strict “physician” task, such as the decision
regarding the number of patients to be seen in a ses
kim experience has been the importance of both plan
sion. was in fact not under the pediatrician's control.
stages without local personnel, and expecting them to
The system demanded that all patients requesting to
then unquestioningly carry out those decisions, invites
obstruction. As in all organizations, power is precious
to all; most changes will threaten someone’s power
base, neutralizing some if not all of the possible effect
of the change. Local personnel will often have greater
and clerical staff to share the burden. Nurses and
clerks could leave the clinic at hours stipulated in their
wage contracts, with the physician having to control
patient How, see all patients, and lock the clinic upon
leaving! The impact of such situations on the percep
tion of pediatric residents concerning their future
ning and implementing change in consultation with
the local workers in the field. Planning changes at all
understanding of the problems than outsiders, and
they can thus contribute significantly to theirsolution.
At the other end of the hierarchy, the higher level
planners must be active in ongoing reinforcement and
roles was negative, to say the least. The result was
rapid development ol “burnout.” With difficuli
patient loads, little energy was left lor problem solving
settlement of the program. Most changes in the system
will require repeated cycles of evaluation, replanning
and implementation; nothing is more demoralizing to
at the local and regional levels.
Conflict between service providers and the academ
the local team than seeing that, in addition to their not
ic setting also impeded change. The Ofakim exper
system, decisions once taken are not appropriately
implemented.
iment constantly “used” the academic backing of
either the division chiefs or the Dean himself to press
participating in decisions concerning their roles in the
for change. Constant pressure from these outsiders on
Another important function of high-level policymaking within the health service is the allocation and
the service providers caused antagonism at both local
and regional levels. A frequent reply to requests to
will incur additional costs. Policymakers must be pre
prioritizing of funding. Good teaching service models
upgrade was: “We cannot create two levels of
care—Ofakim and the rest.” Academic recognition of
Ofakim provided no benefits for many personnel in
the system—only mori work.
one hand, and being unwilling to pad and reinforce
services in any way on the other hand.
Finally, there was the problem of adequate academ
ic commitment to the development of primary care
lem of commitment at the practical as well as the
models. Much of the impetus for initiating the Ofakim
experiment had come from within the pediatric div
ision of the university hospital. The division chief was
always available and actively supportive of the local
conceptual level has already been mentioned. In addi
tion, the Ofakim experience has helped to highlight
the need for reviewing the content of pediatric train
ing in order to increase its relevance to primary care
team. Nevertheless, the Ofakim experiment was not
needs. No resident failed to comment on his inadequa
cies in the fields of child development and behavior,
family intervention and epidemiology, to name a few.
seen by many pediatric faculty as an important div
isional and institutional priority. With heavy service
loads on the pediatric wards, Ofakim was seen by
some as draining manpower from the division. Spo
radic visits by senior pediatric consultants or the occa
sional
presentation
of
cases
from
Ofakim
at
>
I
the organizational power structure of the clinic was a
see the pediatrician on a given day must be seen,
irrespective of the availability of supporting nursing
I
pared to walk the tightrope between setting up expen
sive and therefore nonreplicable model services on the
Regarding the role of the medical school, the prob
A final conclusion relates to the problem of “burn
out.” Within a socialized health system such as exists
in Israel, demands on health personnel, particularly
the physicians, are unremitting. Little attention has
1150]
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Voi 23. Nos. 9-10, Septi mber-Octorfp 1987
PlONFERINCi AND SETTLEMENT IN HEALTH SERVICES
been paid to this problem, which would seem to be a
logical one for service and academic people to tackle
are essential tor consolidation of the changes that can
move a pioneering effort to one of true settlement.
together through continuing education, group dynam
ics and active support activities by supervisors.
This paper has attempted to explore some of the
problems inherent in bringing a pioneering effort to
REFERENCES
I. Prywes M (1977). The Beer Sheva experience. JAMA
238: 1571.
2. Margolis C. Porter B. Barnoon S and Pilpel D (1979).
Reliability of the middle ear examination. IsrJMedSci 1523-28.
3. Margolis C and Porter B (1978). Problem acuteness and
medical record utility. Am J Dis Child 132: 1115-1116.
4. Porter B. Cohen W, Koblincr M and Goldsmith J (1981).
Differences in the use of emergency room and hospitaliza
tion in relation to primary care pediatric services. IsrJMed
Sci 17: 119-121.
settlement in a health service. Briefly stated, the Ofakim experiment was one of the first major attempts of
an Israeli medical school to show the community
setting as an alternative locus to the hospital for high-
quality health care delivery and training. Consulta
tion and coordination at all levels within both the
academic and health service provider organizations
)
Eli Ginzburg
A. Barton Professor Emeritus of Economics, and Direc
tor. Conservation of Human Resources
Columbia University, New York
Moshe Prywes Distinguished Lecturer, 1986
“I offer the following tentative reactions to your farreaching reforms of medical education at Ben-Gurion
University:
You have had marked success in selecting and educat
ing medical students who are interested more in treat
ing individuals than diseases. The goal of ‘sensitizing’
students to deal with ailing individuals has been
achieved.
You have gone further and taught your students to
recognize and deal with sick individuals |... | within the
community of which the patient is a part. That is a
significant accomplishment.
You have convinced at least some of your students
that family practice and primary care in a clinical sys
tem arc respectable alternative models to practicing
acute care in a hospital setting. That is an important
advance.
I am less clear about the impact of your highly
successful reforms on residency and postresidency
practice patterns. Considerably more time must pass
before these questions can be definitively answered. It
is clear at this still early stage of the experiment that
your reforms have had a significant impact on your
own student body at Ben-Gurion as well as on the three
other medical schools in Israel. Moreover, your
reforms have provided an important model for a
number of third-world nations.
MEDICAL SERVICES IN THE NEGEV
This is how I read the record of the impacts of the new
medical school at Ben-Gurion University on the level of
medical services in the Negev:
It seems incontrovertible that the establishment of the
medical school alone made possible the expansion and
improvement of Soroka Medical Center into a major
regional hospital with a broad array of sophisticated
services.
The placement of students, residents, and faculty (parttime) throughout the Negev surely contributed to the
improvement in the range and quality of medical care
in the clinics of the region. The largest gains were the
expansion of specialists and subspecialist
consultations.
The .IDC (American Joint Distribution Committee)
clinic demonstration which was aimed at new team
approaches with an emphasis on family practice, on
strengthening administrative procedures (appoint
ments for patients), and on more attention to patient
education (use of a telephone to obtain advice) appears
Irom preliminary evaluations to have accomplished
many, or most, of its objectives.
Nevertheless, since this is an era of constrained resour
ces, the demonstration was not able to alter the extant
clinic system which continues to be plagued by heavy
patient loads, less than fully engaged physicians, and
bureaucratic procedures that weigh heavily on both
patients and providers.”
community health CELL
326, V Main, I Block
Koramongala
Bangalort-560034
India
1151J
COMMUNITY HEALTH ACTIVISTS PROGRAM: A NEW MODEL
OF COMMUNITY HEALTH INVOLVEMENT
D. HERMONI,1,2,5 D. MANKOUTA,*,2 A. SIVAN,1,2 Y. COLANDER1,2 and
B. PORTER2,3,4
1 Kupat Holim (Health Insurance Institution of the General Federation of Labor), Netivot. and Divisions of
2Health in the Community and ’ Pediatrics, and 4 Association for the Advancement of Health and Social Services in
. the Negev, University Center for Health Sciences and Services, Ben-Gurion University of the Negev, Beer Sheva.
and 5 Department of Pediatrics. Lady Davis Carmel Hospital, Haifa, Israel
Isr J Med Sci 23: 1084-1087, 1987
Key words: Beer Sheva Experiment; medical education; health care services; Community Health
Activists Program: Netivot, Israel
In 1981,,new graduates of the University Center for
Health Sciences and Services at the Ben-Gurion Uni
versity of the Negev were placed as family physicians
in the only clinic serving a population of 8,000 in the
development town of Netivot in southern Israel. The
clinic belongs to a national prepaid health insurance
scheme, Kupat Holim (Health Insurance Institution
of the General Federation of Labor), which provides
primary care services for approximately 80% of the
population of Israel. Patients are allocated on a
geographic basis to a particular physician. This com
munity placement of graduate physicians was pan of
a program to raise the level of primary care services
in the Negev region, the area served by the
community-oriented Ben-Gurion Medical School
(1). Important changes in clinic function were intro
duced during the initial 2 years of the program, with
improvements in patient scheduling, support servi
ces and patient records (2).
The third group of physicians entering the pro
gram (about 40% of all graduates signed for a 1- or
2-year period of service in the clinic), following their
initial period of adjustment in the clinic, indicated a
desire to extend their role into the community. This
paper describes the Community Health Activists Pro
gram introduced in this clinic, which has subse
quently served as a prototype for similar programs
Address for correspondence: Dr. B. Porter, Division of
Pediatrics, University Center for Health Sciences and
Services, Ben-Gurion University of the Negev, POB 653,
84105 Beer Sheva.
in the area. While examples of community participa
tion in health affairs have been described (3), the
nature and scope.of this program seem to have uni
que elements.
AIMS OF THE PROGRAM
The initial aims of the program were: 1) to improve
communications between the community and clinic
staff; 2) to improve patient satisfaction regarding
health services; 3) to improve community under
standing of the health system in general, and of the
clinic functions in particular; 4) to reduce overuse of
clinic services by improving patient knowledge
regarding when to seek medical help; and 5) to move
the focus of responsibility for health from the physi
cian to the individual, the family and the commun
ity, in keeping with the declaration of the 1978
Alma-Ata International Conference on Primary
Health Care (4).
Role of the Activists in the community
The Activists were required to function as resource
persons concerning issues of health and illness in the
community—an intermediary role between citizens
and medical personnel. In addition, they were
expected to be involved in specific projects relating
to health issues in the community.
METHOD OE IMPLEMEN1ATION
Involvement of community organizations
The program was planned to include maximal involvemcni of all community organizations; this invol
[152]
Vol. 23, Nos. 9-10, September-October 1987
Community Health Activists Program
vement would include active participation in the
program in addition to granting passive support.
The organizations involved included: the commun
ity center, fhe local emergency medical service,
Kupat Holim, the Ministry ol Health family preven
tion health service, the town council, the local rab
binical authority, the social welfare department and
Project Renewal—an international philanthropic
program aimed at improving the quality of life in
underserved areas in Israel.
Community responsibility
The program stressed the responsibility of the com
munity itself in health matters. In a community
where passive acceptance was the norm, with the
doctor being omnipotent in all health-related deci
sions, the Activists program emphasized the role of
the individual in deciding matters of policy and
implementation of health services in the community.
Training the Activists was a means of pointing the
health services toward consideration of the needs,
and it stressed a realistic goal-oriented approach.
Creation of a clear framework for activity
An atmosphere of earnestness was an important
initial goal for the course organizers; the course had
to be seen as a serious commitment, and not as an
unusual source of evening entertainment. Achieving
this atmosphere included a number of steps: 1)
Admissions Committee: all wishing to participate in
the program were required to be interviewed by a
committee comprising two organizers of the pro
gram. Candidates regarded as not taking the pro
gram as a serious commitment, or who for any
reason would not be able to participate fully in all
course activities, were excluded. 2) A nominal fee
was required, more as an indication of commitment
than for any financial reasons. 3) All participants
signed a form declaring their intention to attend the
full 3-month course and-to continue community
activity within the course framework for a period of
6 months following completion of the course; 4)
Written examinations (multiple-choice format) were
part of each session. 5) The family physician was
used as an ongoing connection between participants
in the course from his practice area and the course
organizers. The physicians themselves were each
committed to recruiting 20 participants from their
practices. 6) Punctuality was rigidly enforced. 7) For
those with poor literary skills, aides were available at
the sessions to help with the writing or translating of
material.
Course content
The course was structured around 12 weekly evening
meetings. Each evening covered a topic seen by the
participants as important for their future activist
role in the community. Topics included: structure of
health services, child health problems, first aid and
cardiopulmonary resuscitation, use and abuse of
drugs, problems of the elderly, and medicine and
Jewish tradition. Members of the community were
involved in the selection of course topics.
At the beginning of the course the participants
were divided into groups of X to 10 people, these
groups remaining constant throughout the course.
Though some of this subdivision was arbitrary,
social and religious factors were important. For
example, the men attending the local Yeshiva (center
for Orthodox Jewisfi studies) together comprised
one group; this was done in order to respect their
religious sensitivities concerning mixing socially
with women, and to enable them to develop their
particular field of interest—the relationship of tradi
tional Jewish teachings and modern medicine.
The first part of each evening started with a pre
test, with the group discussing a question related to
the talk that would follow. For example, in the area
of child health, groups would receive short vignettes
of common pediatric problems, such as: a 6-month
old baby has a fever of 38.5 C, frequent loose stools,
and vomitingall foods. The group would discussand
present their opinions as to what treatment should
be given, when medical help should be sought, and
what the probable diagnosis is. Following the pres
entation of each group’s summary, the main lecture
was presented. The preceding group problem discus
sions actively involved the participants in the educa
tional format and helped the lecturer in f ocusing his
presentation. When possible, the pretest questions
were prepared by the lecturer himself.
In addition to the weekly topic, help was given to
participants in the choice of specific community pro
jects that they would implement as part of their
practical work in the community at the end of the
didactic part of the course. Some of the projects
involved practical application of the learned mate
rial. e.g., practicing resuscitation procedures on
models, or demonstration of first aid techniques.
The group leader would present a general plan of a
project, a progress report, and specific time commit
ments for implementation of the project. The train
ing team was available to advise the learners and to
help translate their ideas into a practical format for
implementation and ongoing evaluation.
EVALUATION
Evaluation of the success and impact of the project
involves short- and long-term measures. Short-term
measures include: participation and dropout during
1153]
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ISKAI-I J. Ml D SCI
I). Ill RMONI I I Al
the course, the number of new community projects
initiated, “spread” of the program to other com
munities, and satisfaction of the participants.
Participation
To dale, of a total of 173 participants who began the
two courses in Netivot, 148 have completed all
course requirements (85%).
Initiation of specific community projects
As part of their commitment to the program. Acti
vists are expected to implement projects in the com
munity after their training period. Following are
examples of such projects: early detection of hyper
tension, early detection of breast cancer, establish
ment of a local branch of (he Israel Diabetes
Association, an assessment of the health needs of the
community, a needs assessment for the aged, a
household survey for excessive drug storage, and
initiation of a preventive dental health program.
Spread of the program to other towns
Similar courses were started by physicians partici
pating in the graduate program in two towns with
characteristics similar to Netivot, and three further
clinics not staffed by physicians in the Graduate Pro
gram have since run courses using the same model.
Satisfaction of participants
The low degree of attrition from the program, the
number of community projects initiated, the
intensity of involvement in the sessions themselves,
and the eagerness to organize end-of-course parties
all indicate high levels of satisfaction. Apart from
minor changes in course content for the second
course, no requests were made for change in format,
with graduates of the first course taking full
responsibility for the planning and implementation
of the second course. In addition, the personal
participation of all clinic staff members (including
nursing, clerical, and pharmacy personnel) in the
initial course indicated (very high staff satisfaction
with the program.
Public recognition of the program
The
program
was
granted
an
award
for
distinguished volunteerism by the President of Israel
at a national ceremony in 1985. This highly regarded
award is an indication of the significance attached to
the work of the Activists and of the high regard in
which the program is held.
DISCUSSION
The Community Health Activists Program was not
initiated as a simple attempt to improve health
education in the community. For many years prior
to the inclusion of the Netivot Clinic within the
Project for Improvement of Health and Social
Services in the Negev, the community had been
served by poorly trained physicians, and there was
much dissatisfaction. The first years of the project,
while bringing well-trained graduates of a
progressive community-oriented medical school to
the town, were still accompanied by voices of
suspicion and dissatisfaction. Some community
members claimed that the project used newly
graduated physicians to “experiment” on the
population; there was also a demand that
pediatricians have primary responsibility for the
children, instead of the family practice model used in
the clinic. A system introduced by the graduates to
schedule appointments for patients instead of seeing
them on a first come first served basis was seen by
some as an effort by the new physicians to give
themselves an easy time!
The Activists program was seen by the organizers
as a way to improve the relationship between the
community and its health providers. 'Hie group of
young physicians saw that despite the changes in
basic structure and function of health services that
had been introduced by previous physicians in the
program, there had been no real input from or
dialogue with the community itself. They rapidly
perceived that a traditional physician-patient health
education model was not sufficient, and that families
and communities must have a greater role in
deciding on their health priorities. Course
organization followed the principles laid down by
Standard and Kaplun (5). where the emphasis of
health education is shifted “from a focus on
particular behaviors, to one that takes into account
the general life-style of a person—which in turn is
influenced by that of the family, community and
country.”
Though not systematically evaluated by the team
organizers, it was fell strongly that no single
component of the Activists progam was responsible
for its acceptability; rather, a combination of factors
seemed to contribute to the creation of a viable and
replicable “package.” This package included a
careful
definition
of
the
commitment
of
the
providers and participants, involvement of all
health-related community bodies and. probably
most important, stressing and supporting the role of
each individual as a critical link in a community
effort.
In analyzing the success of the program, attention
must be paid to the milieu in which the program was
carried out. Little opportunity exists in a community
such as Netivot for self-expression other than
[154]
Community Health Activists Program
Vol 23. Nos. 9-10, September-October 1987
concerning religious or political affairs. In addition,
apart from the general conservative nature of the
community, there are many subgroupings based on
sex, age, ethnic background or specific religious
affiliations, to name only a few. The program
organizers were challenged to present a framework
that could appeal to all groups and would enable
them to express their wishes actively within it. In a
setting where passivity characterized the re
lationship to services, this transference of mastery
to the community indicated a significant change in
behavior.
Considering the initial evaluation, the ongoing
activity of the course and the community projects
indicate important continuing motivation of the
community to succeed. Ongoing evaluation will
concentrate on outcome measures, such as changes
in health status and health-related behavior.
Descriptions in the literature have documented the
impact of education programs on health behavior,
such as the one carried out to reduce physician visits
for the common cold in a family practice setting in
Columbia, MO, USA (6); however, there is little
evidence regarding the replicability of such a
program to the community described in this paper.
Impressive health outcomes have been described, for
example, in a health education program via
intermediary “Care groups’’ in a developing
community in Gazankulu in Southern Africa (7),
with an impressive reduction in the prevalence of
cholera after introduction of the program. However,
changes of such magnitude are far more difficult to
achieve in a community such as Netivot, which has a
more Westernized health status. More sophisticated
monitoring of the behavior of patients with chronic
diseases, such as diabetes and hypertension, is under
way, and other outcome measures will require
development in the future.
REFERENCES
I Prywcs M (1983). I he Beet Sheva Experience: integral ion ol
medical care and medical education. !sr J Med Sei 19: 775779.
2. Porter BA (1984). Interim report—The Association for the
Advancement of Health and Social Services in the Negev.
Internal publication. Ben-Gurion University of the Negev.
Beer Sheva.
3. Pritchard PMM (1975). Community participation in
primary health care. Br Med J 3: 583-584.
4. (1978). Final report of International Conference on Primary
Health Care, Alma-Ata. USSR.
5. Standard K and Kaplun A (1983). Health education: new
tasks, new approaches. WHO Chron 37: 61-64.
6. Roberts CR. Imrey PB. Turner JD. Hosokawa MC and
Alster .IM (1983). Reducing physician visits for colds
through consumer education. JAMA 250: 1986-1989.
7. Karlsson EL (1983). Care groups and primary healthcare in
rural areas. Isr J Med Sci 19: 731-733.
[155]
r
THE NEGEV PRIMARY CARE PROJECT: PRACTICAL
CONTINUATION OF THE BEER SHEVA EXPERIMENT IN
MEDICAL EDUCATION
BASH.PORTER
Divisions of Pediatrics and Health in the Community, and Association for the Advancement of Health and Social
Services in the Negev. University Center for Health Sciences and Services. Ben-Gurion University of the Negev,
Beer Sheva. Israel
Isr J Med Sci 23: 1088-1092, 1987
Key words: Beer Sheva Experiment; medical education; health care services; model clinics;
Graduates’ Program
The University Center for Health Sciences and Ser
vices (UCHSS) of the Ben-Gurion University of the
Negev has attempted to change the orientation of
both medical education and the provision of health
services in Israel. Much of this innovation has come
about through involvement of the medical school
curriculum in the community, using primary care
clinics, schools, old-age homes and other
community-based organizations as appropriate set
tings for more relevant medical education. This edu
cational reform was seen as part of a broader
program for closing the gaps between medical edu
cation and the delivery of health care, as described
by Prywes (1). The original goals of the UCHSS at
Ben-Gurion University stressed, firstly, utilizing
academic resources to develop a comprehensive
community health care program for the region, and
secondly, educating a new type of health worker
with the motivation and competencies to function
effectively in the system. This paper describes a pro
ject established to implement the institutional goals
of the UCHSS.
THE PROJECT
In 1979, with the aim of improving primary health
care in the region, the UCHSS entered into a colla
borative experiment together with the major health
provider in the area, Kupat Holim (Health Insu-
Address for correspondence: Dr. B. Porter, Division of Pediat
rics. University Center for Health Sciences and Services, BenGurion University of the Negev. POB 653. 84105 Beer Sheva.
rance Institution of the General Federation of
Labor), and a philanthropic organization, the Joint
Distribution Committee (JDC). The JDC agreed to
finance positions not provided by Kupat Holim,
such as social workers, health educationists and
medical secretaries, as well as improved on-site
laboratory and record-keeping facilities. These were
felt to be the essential components of a good health
service, which could influence the Beer Sheva gradu
ate in choosing between a hospital-based career or
one in primary care. During medical school expo
sure in primary care settings, the students had identi
fied sources of frustration relating to primary care
practice: namely, distance of clinics from the medi
cal center, long waits for laboratory and X-ray tests,
poor quality records, no on-site availability of refer
ence material, and—most important—the lack of
peer support.
The general objectives of the project were:
1) To develop, demonstrate and evaluate compre
hensive systems of delivery of health and social servi
ces in varied community settings in the Negev, based
on better utilization and upgrading of existing
services;
2) To develop the health and social manpower neces
sary for the establishment and future expansion of
these programs;
3) To use new models of primary health and social
welfare services as a basis for the future education of
professionals in multiple health disciplines, focused
on community and primary health care;
4) To utilize the knowledge gained in the successful
models for the future development of national policy
I
i
156]
I
Vol. 23. Nos 9-10, Sfptfmbfr-Octobf.r 1987
Thf Nfgfv Primary Carf Projfct
with respect to education of health and social wel
fare professionals and delivery of health services in
Israel.
The project would provide the resources f or devel
oping a number of high-quality community labora
tories aimed at improving primary care delivery and
attracting new graduates. It would also redirect
resources from the hospital to the community, and
would hopefully address some pressing health care
issues, such as excessive hospitalization rales and
overutilization of hospital services, overutilization
of primary care services, patient and provider dissa
tisfaction and physician “burnout.”
During the 6 years of the project's existence, there
have been four stages of development; each stage
grew out of a continuing process of evaluation, rein
statement of priorities and reevaluation.
Stage 1: Establishment of model clinics
This stage involved the upgrading of four clinics in
order to create a small number of “ideal” primary
care settings that would attract the new type of
physician graduate. This upgrading involved prim
arily the addition of personnel as mentioned above.
A medical social worker was introduced as a core
member of the primary care team to help manage a
wide range of psychosocial problems presenting in
the primary care setting. Previously, social workers
had been available only through the local welfare
agency, with emphasis more on their role in provid
ing economic assistance than in health promotion.
Medical secretaries were introduced to improve
direct clerical support to the physician. Tra
ditionally, the role of clerical staff centered on fee
collection and general clinic organization, with no
specific definition of a role in directly assisting the
physician. The new role included patient reschedul
ing, communication with hospitalsand laboratories,
and chart conversion to a problem-oriented format.
Improved local laboratory facilities involved provi
sion of a laboratory technician and basic laboratory
equipment in each clinic, as well as improving the
speed at which other tests could be performed and
their results provided to the clinic. Clinic libraries
included basic textbooks and two journals relevant
to primary care. Improvement of the record-keeping
system involved supplying an improved format for
records, which would be larger and more durable
than traditional records, and training the secretaries
in maintenance of problem-oriented records.
Stage 2: The Graduates Program
Following evaluation of the first stage after 2 years
of the project, a decision was made to introduce
graduates of the medical school into lOclinics. It was
realized that a focus on the quality of physician
manpower was needed. In the absence of sufficient
primary care role models among the existing medical
staff in the clinics, it was hoped that by using these
graduates as more active agents of change, the
desired changes in the system would occur more
rapidly. The graduates were thus offered the oppor
tunity to put into practice some of the ideals to which
they had been exposed for 6 years and to play a key
role in a health care “revolution.” In addition to the
changes in the clinics mentioned above, the gradu
ates were promised attention to their academic needs
through a weekly continuing education program
and regular on-site consultation by hospital subspe
cialists. To make the program attractive in more
practical terms, the graduates were offered a stipend
for medical studies and preferential acceptance to
residency programs, particularly family practice,
upon completion of a year of service within the
project.
The continuing education program was concen
trated in a single day per week, with different activi
ties. Firstly, lectures and seminar activities relating
to common problems from their primary care expe
rience were conducted with faculty members. Thus
topics extensively covered in their undergraduate
experience, such as diabetes, hypertension or depres
sion, would be presented with an emphasis on the
management of these problems in primary care set
tings. Secondly, interviewing skills would be
reviewed through discussion of tapes from on-site
encounters in their clinics. Thirdly, some of the
groups requested intensive work in a group format
to help them deal with their problems as individuals
and as a group in these primary care settings. These
sessions included a psychologist with extensive expe
rience in group dynamics and the project director, a
senior pediatric faculty member who had spent
many years as a primary care physician in similar
settings to those in which the graduates were work
ing. Fourthly, time would be spent in subspecialty
outpatient clinics, such as dermatology or orthoped
ics, areas in which the graduates felt deficient.
Lastly, an important component of this day was a
session devoted to discussion of specific problems
related to the physicians functioning in the system.
At this session the project director could list prob
lems requiring his intervention at higher levels
within the system, such as poor-quality administra
tive help or an excessive patient load. In addition,
the opportunity to sec the problems as common to
all the clinics seemed to help the physicians in their
adjustment to the world of primary care. A more
detailed account of this program appears elsewhere
in this issue (2).
[157]
Israi I J. Mi l) Sei
B. Porti r
Stage 3: Community outreach
Two years after the introduction of graduates into
the clinics, a number of specific community-oriented
projects were selected to direct the emphasis of
health care from the clinic to the community. Exam
ples included a Community Health Activists program
described in detail elsewhere in this issue (3), an oral
rehydration program and a program for rehabilita
tion of handicapped adults in the community.
Stage 4: Consolidation of primary care clinic models
This stage of the program centered on lessons
learned concerning problems of process in health
care delivery. Whereas in the early years of the pro
gram the emphasis was on structure, of both person
nel and facilities, now more emphasis could be
placed on the functioning of the clinic. Unforseen
professional and political conflicts had reached
some resolution. I hese included the conflict be
tween physicians and administrators over the re
sponsibility for supervision of the medical
secretaries, and between nurses and health educa
tionists over responsibility for health education.
An important addition to the project at this stage
was support for community-oriented research.
Energy and resources could now be directed to needs
of the community, instead of to needs of the clinic
setting alone, through research projects initiated by
the clinic teams in collaboration with medical school
faculty.
EVALUATION
Evaluation of the Negev project has focused on the
two principal goals of the project, which arc inti-
mately associated with the institutional goals of the
UCHSS: improving the level of primary health servi
ces and training a physician who will both be able,
and want to practice primary care. Though a period
of 6 years is still early to definitively determine the
impact of various aspects of the program, it does
allow for some conclusions. Even before describing
the lessons learned, the dynamic environment in
which the experiment took place must be stressed. In
1979 few could foresee the crises awaiting medical
care in Israel—i.e., the general economic crisis
straining resources throughout the system, and a
surplus of physicians within the system. Thus, ser
vice by a graduate in a development town clinic in
1981 was a true pioneering act due to lack of man
power in these areas, whereas today many positions
in primary care in Israel might have multiple
applicants.
Impact of the project on the health services
\ list of changes implemented in all the project
clinics is presented in Table I. Though some of these
changes might have taken place spontaneously,
there is little doubt that the “mass” effect of the
project was a significant force. For example, institu
tion of a scheduled appointment system for patients
had been virtually unknown in these clinics. Follow
ing the overnight decision of a group of graduates in
one of the clinics to introduce scheduling of patients,
the snowball effect was rapid. In a highly centralized
health system such as Kupat Holim, where changes
of any sort often require a long period to filter
through the system, the ability of the graduates to
expedite the process was impressive. This effect was
Table I. Impact of Ben-Gurion University medical graduates on primary health services in the Negev
Area
Before
After
Teamwork
Doc t or-nurse
Doctor-nurse, medical secretary, social worker,
nutritionist, health educator
Triage
None ,
Effective use of nurses for triage
<
Work hours
Split shills
Uninterrupted, sometimes 24 hours
Scheduling system
Walk-in basis
Appointment system
Academic
activities
None
Journal club, case consultation with visiting experts
Communication
with hospital
Minimal
Active consul la I ion by phone and improved How of
patients
Quality of
care
Mediocre standards
Reduced rate of unnecessary referrals, belter evaluation of
patients in primary setting
Satisfaction
Low for patients
and doctors
High satisfaction of patients, graduates and providers
Outreach
programs
None
Lectures in the community. Community Health Activists
Program
I 158|
Vol 23. Nos. 9-10. Si PTf MBI r-Octobi r 1987
I
Tur Negev Primary Care Project
most notable in those clinics where the staff was
comprised mainly of graduates; in clinics where
most of the personnel were unchanged, the process
of change was much slower. Another area of signifi
cant impact was on the hospital-community rela
tionship. The new graduates demanded a new type
of relationship between the hospital and the com
munity physician. They did not accept inadequate
responses to their referrals to the emergency or out
patient departments, failure to send a letter back to
I he referring physician, oi “take over” of the patient
by a subspccialty clinic.
The area of outreach programs deserves special
mention. A Community Health Activists program,
which was initiated by three graduates working in a
piojecl clinic, aimed al shilling the locus of responsi
bility for health from the provider to the community
and at improving liaison between providers and con
sumers. In a community where passivity had charac
terized health behavior, this move towards health
activism was a new phenomenon. This program has
subsequently been adopted by clinics in a number of
towns in the Negev and throughout Israel (3). Other
outreach programs have related directly to perceived
health needs. In Rabat, an urban Bedouin commun
ity. an intensive program to encourage early oral
rehydration lor infantile gastroenteritis was intro
duced. A health worker with no formal medical
training was attached to the health team to specifi
cally instruct mothers in the preparation and admin
istration of the oral rchydration solution (ORS),
including follow-up for weighing and reintroduction
of the regular diet. A 90% compliance rate for return
visits was one of the preliminary results of this pro
gram. In addition, the program further generated a
demand for educating families about gastroenteritis
within the community, and doctors and nurses gave
lectures in all the high schools on the subject. The
success of the program resulted in the local council
hiring an experienced health educationist todevelop
a program directed at the mother in her home within
the community.
In another town, in response to a need perceived
by the graduate physicians and the social worker, a
program for the rehabilitation of adults with a wide
variety of handicaps was established in the form of a
shpltProd
b u
cl
\----------------- -dJ™
” 2^; rS.ULSe^ently- Si?nifica"'
decreases in demands (or health services from this
population were reported.
Impact of the project on the educational process
Of the first four graduating classes of the UCHSS, 55
(49%) volunteered lor the program. As part of an indepth evaluation of this specific aspect of the Negev
project, 25 participants were interviewed to assess
their reasons for entering the project, and the impact
of the project on their careers. The results showed
that graduates participated in the project for several
reasons: 1) they wanted a longer exposure to primary
care than was provided by their medical education in
order to make a more informed choice of future
specialization; 2) they wanted to test their skills by
working independently before beginning formal
specialization; 3) they felt a sense of obligation to the
medical school and its special mission of community
service; and (lor a minority) 4) they saw the project
as a means of securing residency placement.
At the end of the service in the project, most
graduates indicated their desire to be involved
somehow in primajy care in their future careers;
many ol them have chosen internal medicine and
pediatrics as their specialies, with a clear demand of
those responsible for medical education to increase
the primary care content in these fields. Regarding
family practice, of 11 graduates who have entered
the field since inception of the medical school, 10
had participated in the project; at the same time,
family practice was still seen as having to prove itself
as a fulfilling, full-time career goal.
The project has also provided valuable feedback
for planners of the undergraduate curriculum in
primary care. The specific undergraduate course
material taught in subspccialty areas, such as
dermatology and orthopedics, was frequently found
not to be relevant to the types of problems
presenting in primary care settings. Moreover,
health services administration, interviewing
technique and family therapy are just a few of the
other topics either missing or understressed in
training. “Burnout” has been fell by many
participants in the program, with implications for
both the academic and service sectors.
CONCLUSIONS
The JDC project combined health service providers
and an academic setting in a unique experiment to
change the health care delivery system. Despite
demands to reduce spiralling hospital costs,
transferring the focus of health care from the
hospital to the community cannot take place
overn^ht- The project, as an extension of an
inno''ative curricula oriented toward the needs of
the community, has provided information regarding
additional unmet needs lor the potential primary
care physician. At the same time, the project has
shown that, in a complex, centralized system such as
Kupat Holim, change is not simply a question of
additional funds for extra staff. While the Beer
Sheva medical school graduates have clearly
demonstrated their ability to have a strong impact
[1591
B. PORI I R
Israi i J. Med Sci
on the system, the system is adapting slowly to
REFERENCES
1. Prywes M (1977). The Beer Sheva experience. JAMA 238:
satisfy their needs for continuing careers in primary
care. The redirection of a system of medical
education and health service provision from a
technological hospital base to a community-based,
holistic approach continues to present a challenge to
all those interested in primary health care.
John R. Evans
Chairman
Allelix, Inc.. Mississauga, Ontario. Canada
Moshe Prywes Distinguished Lecturer. 1985
“In an educational experiment, evaluation is necessary to
identify strengths and weaknesses and to permit sensible
evolution of the program. The process is frustrating,
however, since what is important is difficult to measure
and what is measurable is usually not important. Three
foci of evaluation might be considered for Beer Sheva. The
first concerns the general professional competence of
graduates, measured usually by a qualifying examination
and by acceptance into residency training programs. The
graduates from Beer Sheva have been accepted by
hospitals in other centers and their performance, assessed
by supervisors in these institutions, has not revealed
deficiencies. Additional evidence will come in the future
from the performance of Beer Sheva graduates in national
specialty examinations. The first level of evaluation,
therefore, indicates that the opportunity for Beer Sheva
graduates to pursue their medical career has not been
jeopardized by their educational experience.
The second focus of evaluation should address the
unique competence of Beer Sheva graduates in relation to
the distinctive objectives of the program. Characteristics
to assess include: orientation of career to primary health
care and community medicine; sensitivity to social, cultu
ral and familial factors in health; skills in the management
of people and health resources: communication skills;
ability to critically appraise evidence; and self-directed
continuing education. In regard to some of these charac
2.
3.
Elhayany A (1987). The Graduates (bogrim} Project—
my experience in Netivot. Ixr J Med Sci 23: 1071-1074.
Ilvnnoni I). Maiikouta I). Sivan A.Colander Y and Porter
B (1987). Community Health Activists Program: a new
model ol community health involvement, isr J Med Sd23:
1084-1087.
teristics. it may be difficult to sort out the relative impor
tance of the type of student admitted and the educational
process al ter admission. There is already evidence that the
Beer Sheva objectives have left their mark on the first four
classes of graduates. Hospital staff in other centers note
better-developed interpersonal skills in Beer Sheva gradu
ates. for example. Great significance must be attached to
the decision of more than half the graduates to volunteer
for community care in the Negev, some even for 2 years.
The students are key change agents in the organization
of health services in the Negev. When it comes to advocat
ing the goals and programs at Beer Sheva. it may not be
too unlike my experience as Dean al McMaster: 1 was not
very successful, and the faculty were only moderately suc
cessful. It was the students that ended up really establish
ing a name for the program. They did it with the
accreditation team al the beginning, and they have done it
at the hospitals where their special skills have been recog
nized. That, to me. illustrates why the investment in the
students is so extremely important.
The third focus of evaluation should assess the success
of the faculty’s programs’in improving health standards in
the Negev. Although it is still early, the role of Beer Sheva
graduates in reorganizing established services to be more
responsive to patient needsand supportive of practitioners
is already a matter of record. Other contributions are the
new programs to train community health activists, the
postgraduate training of family physicians to staff Negev
clinics, and the health services’ research projects. There is
every reason to believe that these improvements in the
process will result in measurable improvements in health
standards of the people of the Negev region.”
[160]
!
I
!
AN INTERIM SUMMARY
THE BEN-GURION UNIVERSITY GRADUATE PROFILE:
AN EVALUATION STUDY
MOSHE PRYWES ',2 and MIRIAM FRIEDMAN 2
'Founding Dean and Chairman? Center for Medical Education. University Center for Health Sciences and
Services. Ben-Gurion University of the Negev, Beer Sheva, Israel
I
Isr J Med Sci 23: 1093-1101. 1987
Key words: Beer Sheva Experiment; medical education; evaluation
The establishment of the Ben-Gurion University
ates in order to elucidate whether BGU is fulfilling
Center for Health Sciences and Services (BGU) was
its committment to its basic objectives. The purpose
approved by the Council for Higher Education and
of this article is to present a preliminary report on
by the Government of Israel in 1973 on the basis of
the first five classes of BGU graduates, their career
its well-defined objectives: to develop an integrated
choices, self-ratings and supervisors' evaluation
system for preventive, curative and rehabilitative
compared with those of other medical schools in
care to the population of a specific region, the
Israel and to discuss the overall plan for evaluation
Negev; to merge this integrated health care system
of the BGU graduate. This report is the first of a
with the University Center for Health Sciences under
series of evaluation studies that will attempt to iden
a single authority; and to educate a physician capa
tify the profile of the BGU graduate, to define the
ble and motivated to serve in an integrated hospital
standards of knowledge and skills in comparison
and community health care system (1,2). The inten
with those of graduates of other medical schools in
tion was not necessarily to train general practition
Israel, and finally, to determine the extent to which
ers or family physicians, but rather to provide all
BGU graduates have fulfilled the school’s objectives
graduates with an orientation to comprehensive
and are different from other medical school gradu
medicine. It was expected that even specialists with
ates in their professional attitudes.
such training would be better consultants to primary
Recent literature contains only a few similar com
care physicians, while graduates who choose prim
prehensive evaluation projects performed by other
ary care or family medicine would be better prepared
medical schools. Case Western Reserve Medical
for such a practice (1).
School in Cleveland, OH. USA (3), McMaster Medi
Since the establishment of the medical school in
cal School in Hamilton, Ontario, Canada (4). the
1974, candidate selection, curriculum planning and
University of New Mexico Medical School in Albu
implementation, and the learning environment have
querque. NM, USA (5), Medical School of Maas
been geared toward achievement of these goals, as
tricht, Netherlands (6) and the University of
described in this issue of the ISRAEL JOURNAL OF
Newcastle, Australia (7) have reported similar ongo
Medical Sciences. The idea was to apply special
ing evaluation projects of theirgraduates. Duetothe
selection and training methods that would epitomize
paucity of such comparative studies, little is known
the delicate balance of science and humanism in the
of the effectiveness of programs emphasizing new
practice of medicine.
approaches to teaching medicine (8).
•In 1982, one of the authors (M.P.) established the
Center for Medical Education, which undertook as
GRADUATES OF ISRAELI MEDICAL
its major project the evaluation of the BGU gradu
SCHOOLS
Graduates of the BGU medical school
Address for correspondence: Dr.M. Friedman, Center for Medi
Of a total of 175 graduates from the first five classes,
cal Education, University Center for Health Sciences and Servi
1981-85, 105 (60%) have started their residency
ces, Ben-Gurion University of the Negev, 84120 Beer Sheva.
training, 29 (17%) serve in the army, 18 (10%) are as
[161]
Israi i J. Mid Sci
M. Prywfs andM. Friedman
per yearwhoenter the Joint project. Excluding those
in the army, 26 of the 146 BGU graduates (17.8%)
are presently in community clinics (10 in the Joint
project, 5 in primary care clinics and 1 1 in family
medicine residencies) vs. 39 of 1,044 (3.7%) from the
other medical schools.
yet undecided regarding their specialty choice, 10
(6%) are enrolled in the special project of 1-year,
voluntary, postgraduate primary care service in the
community (the Joint Project), 8 (5%) went abroad
for residency training and 5 (3%) postponed their
residency training and are working in various com
munity clinics.
Graduates of the other three medical schools in Israel
The BGU graduates of the 1981-85 classes were
compared with graduates of the 1980-84 classes ol
the other three medical schools in Israel—in Tel
Aviv (Sackier School of Medicine), Jerusalem
(Hebrew University-Hadassah Medical School),and
Haifa (Faculty of Medicine, Technion—Israel Insti
tute of Technology). Of a total of 1,236 graduates,
732 (59%) have started their residency training, 192
(16%) servein thearmy, 146(12%)arenot practicing
medicine or are undecided about their future plans,
137 (11%) were not located, 27 (2%) went abroad for
specialty training, and 2 died. Information concern
ing 1985 classes was not available at the time of the
study.
CAREER CHOICE
In total, the study relates to 1,411 graduates from all
four Israeli medical schools. The distribution by
school and graduation year is presented in Table 1.
The career choice of the 113 of the 175 BGU gradu
ates (1981 -85) who have started their residency train
ing compared with the 589 of the 732 graduates of
the three other medical schools who have officially
declared the specialty choice (1980-84) are listed in
Table 2. Career choices of BGU graduates were
similar to those of the graduates of the other medical
schools in Israel with, small differences in internal
medicine, surgery, gynecology and family medicine.
(Actually, while the numbers are too small for any
statistical analysis, 10% of the BGU graduates haveselected family medicine vs. 7% for the other gradu
ates—a 43% difference in favor of BGU.) In addi
tion to the 10% of th^ BGU graduates who chose
family medicine, there are about 10 BGU graduates
Table 1. Distribution of Israeli medical school graduates by school
and year of graduation
School
Year
Jerusalem Tel Aviv Haifa
1980
1981
1982
1983
1984
1985
81
104
72
78
71
125
I 14
107
112
102
71
41
56
53
49
Total 406
560
270
Beer Sheva Total
30
28
32
43
42
277
289
263
275
265
42
175
1,411
One-year postgraduate work in primary care—the
Joint project
The Joint project was initiated in 1981 by the medi
cal school and is partially supported by the Israel or
American Joint Distribution Committee (9). Its pur
pose is 1) to expose BGU graduates to 1 year of
primary care practice in the community and to
expand their performance in the social dimension of
medical practice before making their career choice,
and 2) to introduce BGU graduates as “change
agents” for improving the medical care in the Negev
region. Sixty-three (42%) of the 150 graduates,
excluding those in army service, of the 1981-85
classes volunteered to serve for 1 year or more in a
primary care clinic, mainly in the Negev region
(Table 3). The 19 graduates of the first class (1981)
chose to join the Joint project. Thereafter, while the
absolute number of graduates who joined the project
remained unchanged, the percentage has fallen
steadily.
Table 2. Career choice distribution
BGU graduates
(1981-85)
Other medical
school graduates
(1980-84)
No.
Career choice
No.
%
Total in residency
Internal medicine’
Pediatrics
Surgery6
Gynecology and obstetrics
Family medicine
Psychiatry
Other
113
33
22
19
15
11
4
9
100
29
19
17
13
10
4
8
589 100
189 32
106 18
121 21
66 10
39
7
5
27
7
41
Total not yet in residency
Israel Defense Forces
Primary care clinics
Joint project
Do not practice.
undecided, unknown or
not registered
62
29
5
10
100
47
8
16
647 100
192 30
5
I
18
29
450
Total no. of graduates
175
a
%
69
1,236 —
Internal medicine includes: cardiology, neurology, oncology.
hematology, endocrinology, gerontology, nephrology, pulmonol
ogy, rheumatology, and gastroenterology.
b Surgery includes: ophthalmology, orthopedics, ear. nose and
throat, urology, plastic surgery, and neurosurgery.
BGU = Ben-Gurion University Center for Health Sciences and
Services.
[162]
I
J'
Vol. 23, Nos. 9-10, September-October 1987
Graduate Profile Evaluation
Residency location
Residency locations of BGU graduates and the other
Israeli graduates are presented in Table 4. More than
Table 3. Ben-Gurion University graduates in the 1-Year Joint
project in primary care by year of graduation
Graduation
year
Graduates in
Joint project
N^
%
All graduates*
(no.)
1981
1982
1983
1984
1985
19
13
10
12
9
65
59
34
35
25
29
22
29
34
36
Total
63
42
150
* Excluding those doing military service.
half the Tel Aviv and Haifa graduates (72 and 69%
respectively) chose to remain in hospitals affiliated
to their medical schools, compared with smaller per
centages of Jerusalem and BGU graduates (44 and
41% respectively). It may be noted that 95% of BGU
graduates are originally from other parts of Israel,
an “out of town’’ percentage far higher than that of
any other school, and that as many as 41% chose the
Soroka Medical Center in Beer Sheva as their resid
ency location. This suggests the attraction of the
graduate to his/her university hospital. Ninety-three
percent of BGU graduates were accepted as resi
dents in large and medium-size university hospitals,
compared with 75% of the other Israeli graduates.
The remaining 7% of BGU graduates and 25% of the
graduates of the other three medical schools work in
small hospitals, mainly nonuniversity hospitals.
Table 4. Residency location ofgraduatesfrom Ben-Gurion University (1981-85) and other Israeli medical schools
(1980-84)
Medical school
Jerusalem
Tel Aviv
Haifa
%
Hospital
No.
%
No.
Jerusalem
Hadassah
Bikur Holim
Shaare Zedek
90
20
18
31
7
6
6
1
4
2
3
I
1
Subtotal
128
44
11
3
4
13
26
4
18
2
5
9
1
6
1
9
35
3
12
1
34
45
17
51
26
7
31
14
31
10
12
5
14
7
2
9
4
9
110
38
256
6
3
2
15
7
4
7
2
Tel Aviv area
Ichilov
Beilinson
Edith Wolfson
Chaim Sheba
Assaf Harofeh
Serlin Maternity
Meir General
Kaplan
Golda (Hasharon)
Subtotal
Haifa and north
Rambam
16
Lady Davis Carmel
9
Haifa (Rothschild)
5
Hillel-Jaffe
Western Galilee Regional 5
Central Fmck
I
Rebecca Sicff
I
Government
Poriya Government
Subtotal
Beer Sheva and south
Soroka
Barzilai
Yoseftal
3
No.
Beer Sheva
%
No.
2
8
7
1
1
2
9
8
6
15
1
7
2
4
8
5
5
6
3
3
4
8
1
I
13
1
1
5
6
1
7
I
I
12
1
1
5
6
1
72
47
27
37
35
I
22
14
15
4
4
10
6
7
5
40
24
26
6
7
17
6
7
14
4
2
I
2
4
3
3
69
16
16
43
41
43
41
105
100
1
4
1
I
2
I
I
37
13
55
15
122
10
3
15
7
4
1
.2
1
Subtotal
10
3
22
6
2
I
All psychiatric
5
2
15
4
2
I
288
100
359
100
177
100
Total
%
[163]
¥
M. Prywes andM. Friedman
Israel .1. Med Sci
RETROSPECTIVE CURRICULUM
EVALUATION
Retrospective curriculum evaluation was performed
using a questionnaire consisting of 15 characteristics
of the BGU curriculum that were expanded with the
help of Dr. Betty Mawardi of Case Western Reserve
University (10), based on a 7-point scale: 1 = very
important to 7 = not important. The graduates were
asked to indicate retrospectively to what extent the
curricular characteristics are important to them
today in view of their experience. The retrospective
evaluation form was given to a sample (see below in
Interview of Graduates as an Evaluation Method),
comprising 76 BGU graduates from the first four
classes, excluding those in the army and those
abroad, and responses were received from 66 of
those originally approached (Table 5). The same list
of 15 characteristics was given to a control group (n
— 20) from the other three medical schools. Table 5
lists the rank order of importance assigned by the
BGU graduates and the control group to each one of
the 15 most important curricular characteristics.
The five most important characteristics of the pro
gram, as perceived by the BGU graduates, are in
order of importance: openness to new information,
problem-solving skills, openness to change and criti
cism, integration of knowledge, and early clinical
exposure. Other medical school or graduates arc
similar in their order of ranking preference except
for early clinical exposure and community orienta-
Table 5. Order oj importance assigned to 15 curriculum character
istics by graduates from Ben-Gurion University (BGU) and a con
trol group ofgraduatesfrom the three other Israeli medical schools
Rank order"
Conlrol
BGU
group
(n = 66) (n
20)
1
2
3
4
5
2
3
I
5
9
Curriculum characteristics
Openness to new information
Development of problem-solving skills
Openness to change and criticism
Integration of knowledge
Early clinical exposure
7
K
4
6
K
Sell-learning
Interpersonal com inimical ion
Integration of medical education and
medical care
9
10
14
15
Community orientation
11
12
12
13
14
15
7
II
Development of “change agent”
attitude
Development of research skills
Participation in curricu'um planning
leadership
Medical administration
6
’ I
Co mm u n i t y i n vol ve me n 1
10
13
most important.
lion and involvement, which are ranked higher by
BGU graduates.
EVALUATION IN INTERNSHIP PERIOD
Self-evaluation
The internship program is a 1-year, rotating, com
pulsory program during the 7th year of the under
graduate curriculum. An Internship Self-Evaluation
Survey was carried out using a 27-itcm questionnaire
related to quality of training, reasons for selection of
hospitals, supervisors and staff attitudes, work load,
scientific and academic activities, development of
technical skills, degree of responsibility, intern's role
as teacher, and intern’s professional self-image.~The
graduates of all four medical schools in Israel who
had their rotating internship programs during 198283, 1983-84 and 1984-85 were asked to participate in
this survey. The response rate was 528 (66%) of the
803 approached during the 3 years of the survey. The
first report on the internship program of 1982-83
was published in Hebrew in Harefuah (11). Several
questions drawn from the self-evaluation question
naire are relevant to the BGU graduate profile.
Results of the internship survey indicate that dur
ing the internship years 1982-83, 1983-84 and 198485, an average of 909r of the BGU interns were
offered a residency position at the hospital in which
they interned, compared with an average of 80, 73,
and 72% of interns from other schools. Fifty percent
of BGU graduates were involved in teaching activi
ties as shown in the 3-year survey, compared with an
average of 26% of the other medical school interns.
The professional self-image of the interns was inves
tigated by the question: “How do you see your per
formance in comparison to other Israeli medical
interns during the internship program in relation to
knowledge, skills, behavior and patient relation
ship?” The results are presented in Table 6. The
pattern of responses to this question seems to remain
consistent in the 3 years of the internship surveys.
Jerusalem interns feel better prepared in the area of
“knowledge” (average of 54% compared with an
average of 17.5% of other interns). BGU and Jerusa
lem interns, compared with other medical school
interns, feel similarly better prepared in technical
skills. As lor behavior, BGU interns feel better con
cerning their behavior (average of 42% compared
with an average of 21% of other interns). Similarly,
BGU graduates feel strongly that their relationship
to patients is better than that of the other graduates
(average of 60% compared with an average of 24%).
It is interesting to note that the lower percentages of
the “better” perception in patient relationship and
behavior reported by the interns from other schools
support the validity of the BGU intern’s professional
1164]
9
I
Vol 23. Nos 9-10. Sf pti MRI r-Octobi R 1987
Graduate Profile Evai uation
self-image with regard to behavior and patient
relationship.
10-point scale from 1 — low performance to 10 =
high performance. During the years 1981-84, 15
BGU, 12 Jerusalem and 19 Tel Aviv graduates who
took their rotating internship in this hospital were
randomly chosen forevaluation. Mean and standard
deviations of ratings are presented along with F
values of the analysis of variance (ANOVA) (Table 7).
Table 7 summarizes the results obtained from the
pilot study. The mean rating indicated that supervi
sors were using a restricted range of the scale, using
only numbers 10, 9 and 8 (8, 11,12). The direction of
average rating of knowledge revealed that the BGU
graduates were rated equally competent, although in
the internship self-evaluation the BGU graduates
may have underestirtiated their knowledge ability
compared with that of their peers. Concerning tech
nical skills, the BGU intern ratings were signif icantly
Supervisor evaluation of interns
Based on the self-evaluation results, it was interest
ing to investigate how supervisors view the interns
from the four medical schools on the same four
aspects. A comparative pilot study of supervisors’
evaluation of interns was conducted ata large hospi
tal in Tel Aviv. This hospital was selected because it
maintains a regular program of intern evaluation on
an ongoing basis. The evaluation form consisted of
five areas of competence: knowledge, skills, staff
relationship, patient relationship, and attitude to
work. Each intern was evaluated by five or six super
visors from various clinical departments. In each
area of competence, interns were evaluated on a
Table 6. Response regarding professional self-image among Israeli interns during thile years
1983-85 (%)
Medical
school
Knowledge
Skills
Less
Better
Less
Better
48
50
64
2
9
11
19
15
5
Jerusalem
82- 83
83- 84
84- 85
Tel Aviv
82-83
83-84
84-85
8
4
4
Haifa
82-83
83- 84
84- 85
Beer Sheva
82-83
83-84
84- 85
2
28
33
20
7
3
II
Behavior
Patient relationship
Less
Better
Less
Better
43
50
48
17
21
26
4
2
14
20
29
24
28
22
14
28
25
3
6
6
29
24
34
22
35
37
25
24
17
3
28
24
20
48
47
54
21
—
—
—
48
47
32
70
53
57
Less or
( better
‘
means that the interns rated their knowledge, skills, behavior, and patient
relationships as being not as good (less) or better than thaT of interns in the other1 Israel'i
medical schools.
I
f
IwW98^84 rV'eValua,i°^ (>J ,srac,i interns durin8 rotating internship at one large hospital in Te!
1
I
1
Medical school5
Knowledge
Skills
Staff relationship
Patient relationship
Attitude to work
7
S
1.
f
d
s
J
a r-
.
Jerusalem
(n = 12)
Tel Aviv
(n= 19)
Beer Sheva
(n = 15)
ANOVA
Mean
sd
Mean
5SD
Mean
SD
F
8.7
8.86
9.15
9.17
9.00
0.74
0.62
0.53
0.58
0.71
8.9
8.97
9.26
9.22
9.22
0.74
0.66
0.60
0.62
0.67
9.04
9.17
9.39
9.37
9.35
0.81
0.82
0.60
1.91
0.85
NS
3.11c
NS
NS
NS
.
‘ Each intern was evaluated by 6 to 8 supervisors from a pool of 30 supervisors.
b The medical school in Haifa is not included due to a
small sample of interns.
c‘ P
D—
nc
=n
0.05.
ANOVA
analysis of variance.
■ 0651
▼
▼
Israel J. Med. Sc.
M. PrywesandM. Friedman
higher than those of graduates of the other medical
schools. Similarly, in the categories of staff relation
ship and attitude to work the ratings indicated some
what higher means for the BGU interns. When all
ratings were compiled across areas of competence a
one-way ANOVA indicated a significant difference
among the three groups’ global mean performance
(F = 3.43; P = 0.05), where the BGU mean was
significantly higher than those of Jerusalem and Tel
Aviv interns. The restricted range of the rating
requires the development of an evaluation measure
that will differentiate between competent and less
competent interns. The Center for Medical Educa
tion has developed a unified intern evaluation form
that is currently being used for all interns in the
country during the year I9K5-K6. Behavioral descrip
tions were anchored to the rating scales, thus creat
ing a broader range. The same analysis will be
performed for all interns once the data from the new
evaluation form are obtained.
SUPERVISOR EVALUATION OF RESIDENTS
An evaluation form was sent to heads of depart
ments in which 105 BGU residents are trained. The
supervisors were asked to evaluate the BGU resi
dents’ clinical performance in relation to other
Israeli residents in the same department. Five areas
of clinical competence were rated: knowledge, skills,
relationship to patients, behavior, and relationship
to staff. For each area the resident was evaluated as
Table 8. Supervisors' overall performance rulings of Ben-Gurion
University residents at Soroka Medical Center and al other Israeli
hospitals
Soroka
Others
Ratings
No.
W<
No.
%
Excellent
Very Good
Good
Average
Adequate
Inadequate
8
10
7
29
35
25
4
7
8
23
8
3
1
19
52
18
7
2
2
Total
28
44
100
1
2
100
1
<
better, worse or equal to other Israeli residents. The
supervisors also indicated an overall rating of per
formance on a scale: excellent, very good, good,
average, adequate, or inadequate. Of the 105 BGU
residents, 72 (69%) evaluations were returned. Rat
ings were summarized separately for the Soroka
residents and for those at the other Israeli hospitals.
The distribution of overall performance rating, as
shown in Table 8, indicates a somewhat higher per
centage of “excellent” rating at Soroka and a signifi
cantly higher percentage of “very good” rating of
residents at other Israeli hospitals. The distribution
of “better,” “worse” and “equal” ratings on the five
areas of clinical performance (Table 9) indicates a
consistent tendency of BGU residents to receive
higher percentages of “better” ratings in the catego
ries of relationship to patients and behavior com
pared with the knowledge and skill rating,
irrespective of the hospital. However, at Soroka (the
graduates’ “home” hospital) these ratings are even
higher (71 and 60% compared with 44 and 34%). An
•additional study that will include residents of other
schools is being planned to validate this survey.
INTERVIEWS OF GRADUATES AS AN
EVALUATION METHOD
An extensive interview was adopted from Dr. Betty
Mawardi of Case Western Reserve University Medi
cal School, as an important evaluation tool for gen
erating a comparative graduate profile (10).
Mawardi had employed a hedonergonism approach
in the development of the interview. The hedonergo
nism theory includes the cognitive factors as well as
perception, development and motivation aspects
that one efnploys in finding satisfaction at work. The
interview provides insight into aspects such as:
“What provides long-term satisfaction to the perspn
who chooses to spend his life in a medical career?
Why does he select this way of life? What does he
gain and what does he give up through his choice?
How does the doctor exercise control over the prob
lems he seeks to solve and what are the ways he
Table 9. Distribution of supervisors' ratings in five areas of clinical performance of Ben-Gurion University residents at
Soroka Medical Center and at other Israeli hospitals
Other Israeli hospitals
Soroka Medical Center
Knowledge
Skills
Relationship
with patient
Behavior
Relationship
with staff
Better
Less
Equal
Better
Less
l:qual
No.
%
No.
%
No.
%
No.
%
No.
%
No.
%
13
16
46
57
6
3
21
11
9
9
32
32
31
29
73
68
4
4
10
10
8
10
17
22
7
9
25
32
1
2
4
7
20
17
71
60
19
22
46
51
4
6
10
15
18
15
44
34
14
50
14
50
27
63
5
12
II
24
[166]
Vol. 23. Nos. 9-10. September-October 1987
Graduate Profii f Evai uation
chooses to solve them? How does his career affect his
total life style?”
Mawardi’s interview questions were adjusted to
the BGU medical school objectives. The questions
address issues such as professional philosophy,
methods of practice, professional attitudes and
values, and evaluation of the medical school curricu
lum and its goals. The interview consists of 120
questions and an average interview takes about 2,/2
hours. The interviews are recorded and transcribed.
Coding categories for each question are currently
being developed. All the interview questions will be
coded, based on the question categories.
Of the 100 BGU graduates selected for the inter
view study, 80 have already been interviewed. Con
trol groups of the three study categories from the
three other medical schools have been identified (see
below in Studies in Progress). Trained interviewers
in the Jerusalem, Tel Aviv and Haifa regions have
already started interviewing the control group. Of 80
graduates in the control group, 30 have already been
interviewed. As part of a series, the details of each
study segment will be published as soon as it is
completed.
DISCUSSION
The present study has shown that a significant
number of BGU graduates have volunteered, before
starting their residency training, for 1 year of prim
ary care practice, mainly in settlements in the Negev
region. This unique route has had major impact on
the organization of the clinics in the Negev, as des
cribed in Ref. 12. However, there is concern about
the steady decrease in the percentage of each class
that volunteers for the Joint project. The causes for
the decrease are manifold and are under analysis. (A
reverse in this decrease has just occurred in the pres
ent graduate year—almost 50% expressed an inter
est in the program.) Only 10% of the graduates have
chosen family medicine as their future profession.
While the percentage of BGU graduates who chose
family medicine is slightly higher than (hat at (he
other schools, we would have hoped for a much
higher percentage. We are investigating the factors
involved in the career choices, including the possibil
ity that given the existing organizational problems in
primary care clinics, the increased exposure to them
during medical school may paradoxically discour
age students from choosing a career in family
medicine.
Another important trend that we have noticed is
that of an alternate route to primary care. Of the
BGU'graduates, 48%, compared with 50% of the
other graduates, chose internal medicine or pediat
rics, which in Israel are traditionally hospital-based
specialties. However, a significant number of these
future BGU internists and pediatricians have
declared their stated aim ol becoming primary care
internists or pediatricians. This trend represents a
break with the Israeli norm and may signify an
attempt by these graduates to enter primary care
under conditions that to them promise a higher level
of such care.
In other specialization choices, BGU graduates do
not differ from others. A higher percentage of BGU
graduates (93%) participates in residency programs
in large and medium-size hospitals compared with
other Israeli graduates (75%). These findings may
suggest that BGU graduates seek to work or are
more readily accepted in large academic centers.
Their greater interest in teaching may support this
trend. When the clinical reasoning ability of BGU
senior students was compared with that of Hadassah
Medical School students, no significant differences
were obtained, but BGU students tended to score
higher on treatment and additional information
skills (13).
On supervisor evaluation of BGU graduates at a
single large hospital, the BGU interns were invaria
bly rated at least as high as those from Jerusalem and
Tel Aviv, with the higher global rating and the
higher rating in skills achieving statistical signifi
cance. The self-evaluation questionnaire indicated
that in comparison with graduates of the other
schools, many more BGU graduates feel superior in
the areas of patient relationships, behavior, and
skills to graduates of other schools. With respect to
knowledge, the BGU graduates were more modest in
their self-evaluation than were two of the three other
schools. Interestingly enough, in no area did a BGU
graduate consider him/herself less skilled than
his/her colleagues. The supervisors’ evaluation con- t
firms the previous findings of a higher percentage of
better patient relationships among the BGU gradu
ates than among others, which may be due to the
supportive medical school environment at Soroka
Medical Center that reinforces this type of behavior.
One may conclude from these preliminary data
that, in spite of the experimental nature of the pro
gram, the BGU graduate emerges with basic knowl
edge and skills no less than those of conventional
programs. There are suggestions that in some impor
tant areas the BGU graduate may actually be super
ior. In retrospective evaluation of the BGU
curriculum, openness to new information, problem
solving, and openness to change were rated as the
most important characteristics of the program.
These findings suggest that the BGU graduates
believe that responsibility for the continuous learn
ing of physicians lies within the graduates them-
[167]
. ^.1
M. PRYWI-S AND M. I'RII DMAN
IsKAi-i J. Mi d Sc i
selves, which coincides with the self-learning
objective of the school. They recognize the dynamic
aspects of the medical profession, which is manif
ested by openness to both new information and
change. Development of problem-solving skillsand
early clinical exposure are viewed as important prep
aration for the physician’s work.
Studies in progress
The specific objective of the school was to educate a
physician with a balanced comprehensive approach
to both professional knowledge and social responsi
bility. Therefore, the professional behavioral aspects
of our graduate’s performance and his/her sensitiv
ity to the human side of the doctor-patient relation
ship has been regarded as one of the most important
aspects to be evaluated. The difficulty of objectively
evaluating attitudes, values, beliefs, and behavior of
doctors in different social environments is well
known. Evans (14) said recently in Beer Sheva that
what is measurable is not important and what is
important is not measurable. The few reports pub
lished in this field relate mainly to career develop
ment, career satisfaction, learning styles, problem
solving, and self-evaluation of medical students,
with limited comparative studies (3-5). The conti
nuation of our evaluation study will focus on four
main questions:
Are selection attributes separable from the influ
ence of school or health settings? Differences among
study categories—students accepted at BGU and
stayed, accepted at BGU and went elsewhere,
rejected at BGU and went elsewhere, and a random
sample who did not apply at BGU—may provide
some insight as to the effects of selection methods on
the type and quality of practice of the graduates.
Once the admission effect is separated, the role of the
school and of the health delivery system in shaping
the young physician may be better understood.
Selection methods should be evaluated not only by
the academic achievements„of the student while in
school but also by his/her success as a physician. It is
thus quite difficult to evaluate adequately the admis
sion processes. Four cohorts from all four medical
schools in the country that graduated during the
years 1981-84 comprise the study population. Geoff
Norman (15) from McMaster University, Hamilton,
Canada, assisted us in selecting the methods most
appropriate to address the many facets of the com
prehensive physician.
Is the BGU graduate’s professional knowledge ade
quate, higher or lower than his/her colleagues at other
medical schools? As it was shown, the knowledge of
the BGU interns is rated equal to that of the other
Israeli interns by their supervisors, but this evalua-
tion is quite subjective. This calls for continuous
research during the resident years. Resources of
objective data will include national and interna
tional professional examinations and comparative
supervisor evaluation of residents.
Did the graduate meet the specific educational
objectives defined by the program? The original
objectives of the medical school reflected certain
humanistic, social, and professional values. The cur
riculum was designed to transmit these values to the
graduates. Thirteen years later we ask: are the basic
values of the school retained by graduates? During
the course of 13 years, the curriculum underwent a
few changes and several courses were redesigned: are
the basic values and philosophy of the school still
retained? Since BGU graduates are scattered all over
the country and work at different hospitals, research
findings may throw light on the question of the
extinction rate of BGU values either as a function of
different health care systems or as a function of time
in their professional progress in the residency years.
The open-ended interview will identify the existing
or changing values of our graduates as they grapple
with issues of professional development.
Are the differences identified through the interviews
also manifested in clinical performance? \ perfor
mance study will be conducted on a random sample
of graduates to ascertain whether the basic philo
sophy of medicine as expressed by the different study
categories is also manifested in actual practice.
Furthermore, along with careful documentation of
graduates’ individual activity, their impact on
improving the health services in the region is contin
uously assessed.
CONCLUSIONS
This article reports various educational outcomes of
a community-oriented medical school compared
with traditional schools. The reported studies relate
to career choice, residency location, retrospective
evaluation of the curriculum, clinical reasoning
competence, internship, self-, supervisor, and resi
dent evaluation, interview of graduates, and volun
tary projects. The studies in progress will ultimately
provide an evaluation of an innovative medical
school unique in its comprehensive approach. The
present study and future studies will assist in
improving the quality of medical education both in
innovative and traditional medical schools.
In conclusion, it may be said quite safely that
while the BGU graduates are as good as those from
other medical schools, they still differ (on the basis
of our limited available data) in their behavior. They
are much more responsive to human aspects of med
ical practice, i.e., in the care of patients and their
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Vol. 23, Nos. 9-10, Sfptembeb-October 1987
Graduate Profile Evaluation
families and in their respect of and collaboration
with all health team members and colleagues in any
of the medical institutions in which they work.
6.
Verwunen M (1982). The evaluation system at the Medical
School of
Assessment and Evaluation in Higher
7.
The encouragement and financial help of the WHO Div
ision of Health Manpower Development, Geneva, Swit
zerland, is acknowledged.
8.
Newbie DI and Clarke R (1987). A comparison of the ap
proaches to learning of students in a traditional and an
innovative medical school. Med Educ (In press).
Siu A, Mayer-Oakes A and Brook R(1985). Innovations in
medical curricula, templates for change? Health Affairs 4:
60-71.
Porter B (1987). The Negev primary care project: practical
continuation of the Beer Sheva Experiment in medical
education. Isr./ Med Sci 23: 1088-1092.
Mawardi B (1979). “Physicians
and theirr careers.” Uni
------- ---------versity Microfilms International, Ann Arbor. MI.
Friedman M. Hyam E. Prywes M and Maresh A (1985).
Evaluation of 1982-83 internship program by graduates of
four medical schools in Israel. Harefuah 108: 402-405 (in
Hebrew.)
Elhayany A (1987). The Graduates (Bogrim) project—my
experience in Netivot. Isr J Med Sci 23: 1071-1074.
Friedman M (1987) The development and orientation of
information processing employed by medical students and
its relationship to clinical reasoning. Unpublished thesis.
The Hebrew University of Jerusalem, Jerusalem.
Evans J (1985). The Moshe Prywes lecture in medical edu
cation. Medical education—the search for international
eminence and local relevance. Isr J Med Sci 21: 557-563.
Norman G (1985). Evaluation of graduates of BGU medical
school. Report submitted to the Center for Medical Educa
tion, Beer Sheva.
1.
2.
3.
4.
5.
REFERENCES
Prywes M (1973). Merging medical education and medical
care. Hospital Medical Staff (American Hospital Associa
tion), Vol. 2.
Segall A J, Prywes M, Benor D and Susskind D (1978).
“University Center for Health Services, Ben-Gurion Uni
versity of the Negev: an interim perspective.” Public Health
Papers no. 70, WHO. Geneva, p 112-132.
Mawardi B (1980). The Case Western revised medical’edu
cation program: a long term evaluation by graduates. Paper
presented at the AERA Meeting, Boston.
Woodward CA and Ferrier BM (1983). The content of the
medical curriculum at McMaster University: graduates
evaluation of their preparation for post-graduate training.
Med Educ 17: 54-6().
Kaufman A (1985). “Implementing problem-based medical
education." Springer Publishing Co., New York.
fl69]
9.
10.
11.
12.
13.
14.
15.
AND NOW: WHAT ABOUT THE FUTURE?
MOSHE PRYWES
Founding Dean and Chairman. Center for Medical Education. University Center for Health Sciences and Services.
Ben-Gurion University of the Negev. Beer Sheva. Israel
hr J Med Sci 23: 1102-1105, 1987
Key words: Beer Sheva Experiment; medical education; future
A new science, futurology, has come into being.
Conferences and symposia, books and reports on
futurology have become part of the current scene.
This approach of the year 2000 makes this science
even more meaningful. Besides marking the end of a
millenium, what will happen in 2000 may directly
concern many of us who are here today and will
certainly affect our students and the world in which
they will practice medicine. While contemporary
scientific knowledge provides a basis upon which to
forecast the future of technology, the future progress
of science is almost unpredictable. If we knew more
about the science of tomorrow, we probably would
have it here today. Yet forecasting, unlike planning,
does not seek to actively influence the future directly
and it lakes into account the entire spectrum of
possible options, both objective and subjective.
Thus, intuition, vision, and extravagant ideas must
not be ruled out since, as in the past, they may spark
off genuine breakthroughs.
Medical education is a sociocultural complex of
values and interrelationships, and only partially a
scientific discipline. Hence, when dealing with medi
cal education as a mission-oriented endeavor, due
consideration has to be given to the human and
social implications of the scientific and technologi
cal revolution. Finally, one cannot ignore the politi
cal elements and processes that affect every nation’s
way of life, or the public opinion of consumers that
serves as the feedback channel for its decision
making bodies. As a result, the art of prediction in
health care and health education is conceptually and
technically complex.
Address for correspondence: Dr. M. Prywes, Center for Medical
Education. University Center for Health Sciences and Services,
Ben-Gurion University of the Negev, 84120 Beer Sheva
When asking ourselves what is desirable in our age
of change and choice, we had better take another
look at existing values. Thus, while becoming futu
rologists, we should not forsake history, past and
present.
The 13 years of the existence of the University
Center for Health Sciences (UCHS), also called
“The Beer Sheva Experiment,” is a far too short
period of time on which to base a forecast for its
future. We feel that we are on the “right track,” since
today some 60 medical schools all over the world in
both developing and developed countries have fol
lowed in our footsteps. Moreover, some 10 old, wellestablished schools—led by Harvard Medical
School—started in 1985 a new, parallel track (“The
New Pathway”), which is philosophically based on
the principles of Beer Sheva (1).
Fifteen years ago, in 1972,1 was invited to deliver
the closing address of the Fourth World Conference
on Medical Education in Copenhagen, entitled: “A
Look to the Future” (2). I made 10 predictions for
the direction in which change will probably move in
the future. It may be worthwhile to mention them
and compare them with the reality of 1987 in Beer
Sheva and in the world of medical education:
1) Viewing medical educations a social endeavor to
serve growing national health needs is the first fore
seeable challenge. Therefore, medical education will
inevitably become more involved in shaping better
health care for all. This involvement will increas
ingly impose on the academic medical center a new
responsibility—the search for new models of health
care.
2) The second challenge, a direct outcome of the
first, will be to seek new, realistic approaches in
relationships between academic and health service
sectors. Since one system cannot survive without the
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And Now: What About the Future?
other, both must contribute to better communica
tions and understanding.
3) The third foreseeable change will be the extension
of medical schools’ educational responsibility
beyond the traditional undergraduate level. This
expansion will encompass a few directions: First, it
will move upwards into graduate, postgraduate,and
continuing education. Second, it will move within
the university setting, developing an ever-growing
interaction with other academic disciplines: the nat
ural, behavioral, and social sciences, and the engi
neering and computer sciences. Third, we shall
witness the transformation of the traditional medi
cal school into a regional multischool medical cen
ter, providing education not only for physicians but
also for a multitude of health professions, both aca
demic and vocational.
4)A few basic changes will occur in the future medi
cal curriculum. Firstly, the uniform curriculum
structure will slowly but steadily lose its sanctified
position. More and more medical schools will aban
don it in favor of an increasingly flexible program
that is adaptable to the needs of individual students.
This will probably include different designs, like
“core” and “elective” courses, multiple tracks in un
dergraduate education, different rates of student
advancement—all leading to less rigorous frame
works and rules. Secondly, we shall witness a trend
to erase the existing lines of demarcation between
the traditional basic science disciplines and depart
ments. In a parallel fashion, the teaching of sequen
tially arranged disciplines*wi11 disappear, and a more
integrated system will come into being. Thirdly, the
strict schedule of long laboratory hours, identical
and obligatory for all students, will become more
liberal, and more of the basic sciences will be taught
in relation to patient problems. This will enhance
also a better integration of behavioral sciences
within the medical curriculum. Consequently, fun
damental biological, behavioral, and social concepts
will become more essential to the understanding of
health and disease. In addition, a growing number of
scientifically trained clinicians will participate in
basic science teaching. Fourthly, in the clinical cur
riculum, more attention will be given to education in
ambulatory care (primary, comprehensive care) and
to work in community hospitals. This will mean
much more cooperation or integrated relationships,
through affiliation, between medical schools,
regional and community hospitals, and community
health centers and clinics. As a result, one might
expect from tomorrow’s doctors a renewed concern
for humane considerations and a new balance
between the elements of individual and community
health needs.
5) As for new teaching techniques, they will continue
to attract some of the teachers and students. They
will, however, contribute effectively so long as they
succeed in enhancing the self-learning process that
must ultimately become the leading objective of any
educational program. Evaluation of medical educa
tion will continue to be improved by the design of
new and more scientifically based techniques and
systems.
6) Much of the leadership in curriculum changes,
introduction of new teaching techniques, prepara
tion of teachers to teach, and evaluation of educa
tional programs will become the responsibility of
departments of medical education, which will be
established in an increasing number of medical
schools the world aver.
7) Student participation will evolve into a deeper,
more intellectual, and more mature factor in the
shaping of the social and academic systems of medi
cal education institutions. One outcome of the cam
pus riots at the end of the 1960s, which we are
already witnessing, is a kind of sublimation of feel
ings and relationships within the teacher-student
community, where each group has discovered that it
has a lot to learn from the other. The main challenge
will be to give our students the feeling that the medi
cal school belongs also to them, and that they,
equally, belong to it.
8) Medicine will always progress along parallel lines
with science and technology, and thus will become
more and more specialized. This in turn will call for
strong safeguards in the future to preserve the essen
tial nature of medicine as a science and an art. In this
context—and keeping in mind medicine’s humane
and social obligations—problems of medical ethics
and morals will become one of o,ur foremost
preoccupations.
9) Medical education will become in the future more
global, international and regional. Waysand means
will be found leading to equivalence of medical
diplomas and licensing procedures, closer coopera
tion of national and regional medical education
associations, and better exchange of experience
among them. Ultimately we shall probably all
become members of a World Federation of Medical
Education.
10) Freedom, experimentation, flexibility and diver
sity will forever remain the key forces conditioning
medical education’s progress and molding its future.
Since medical education is a dynamic process deal
ing with living people, it can never achieve a static
balance and stop there. Therefore, the surest fore
cast for the future is that tomorrow’s doctors will
speak again and again about “educating tomorrow’s
doctors.”
[1711
Israi I J. Mi l). Sci
M. Pry wks
All this I said in September 1972, when I already •
had in my mind the basic principles of the Beer
Sheva Experiment. For me it wasn’t a dream. It was
rather a deep, almost religious belief in the rightness
of the ideas which inspired me. These ideas seem
rather simple today. Everything we now take for
granted once seemed revolutionary. Often the sim
plest things or thoughts may become a vision. A vision
may sound quite often unrealistic or utopic or even
absurd. Still, a vision is realized when there is a deep
feeling of social commitment—a feeling of a mission
to fulfill. Medical education is a mission-oriented
endeavor. It is not composed of programs, tech
niques or systems. It is a composition of values.
These were my convictions which, in the words of
Norman Cousins, are potent when they are shared.
Until then, they are merely a form of daydream. It
was the good fortune of the Beer Sheva ideology that
enough crazy people were willing to make an Experi
ment out of it. The man who realizes he is a fool isn’t
as foolish as he thinks.
Where do we go from now?
1) We have to reinforce the existing achievements in
all fields of our activities, in education and in health
care. In the main endeavor to link medical education
and medical care, we have not yet achieved a com
plete merging. This is our ultimate objective. In
addition, we are compelled to achieve more auto
nomy at the regional level.
2) Israel may pretend that it didn’t wait for year 2000
to achieve WHO’s slogan “Health for All in the year
2000,” as we have in Israel free access to health
services for all—but this is not yet the whole story, if
one keeps in mind the quality of life and freedom
from disease. Beer Sheva will have to work it out.
3) Promoting primary care is still an unfinished busi
ness. Beer Sheva, which raised primary care and
family medicine to equal partners in medical prac
tice and education, will become more deeply
involved in faculty development in this field.
4) We are committed lo make community-based
medicine more attractive and more intellectually ful
filling for the many young graduates who now enter
this field of practice.
5) The impact of the Beer Sheva Experiment on
educational and health service institutions in the
country will increase in the future. We, as good
leaders; will have to give up ownership of our ideas.
This will be done with the help of our graduates who
will act as change agents in all the institutions they
work in.
6) Our close links with so many friends overseas
—members of 'mr foreign Visiting Faculty, visiting
students from all over, the Network of Community-
Oriented Educational Institutions for Health Scien
ces, the Association of Medical Education in Europe
(AMEE), the Association of Medical Deans in
Europe (AMDE), World Federation of Medical
Education (WFME), and, last but not least, the
WHO regional offices and headquarters—will
become stronger and more intimate. We shall enter
with more vigor into collaborative programs and
enterprises.
7) We shall have to increase our efforts to convince
the Ministry of Health to join the UCHS not only
locally, but as full-fledged partners in our
institution.
8) We shall do our utmost to keep the “social sys
tem,” the atmosphere, of our institution friendly,
informal and honest. We shall continue to keep it
fun to be a student at Beer Sheva.
9) A greater effort in the field of research—basic,
clinical and epidemiological—will have to be made
despite the upcoming financial limitations.
10) We shall continue our evaluation studies, keep
ing in mind that comprehensive evaluation proce
dures can stifle essential creativity and flexibi 1 ity. In
comparative studies (as expressed by Donald
Richards of Chicago), one is trying to say he is doing
the same old things better; but in fact one creates
something new.
11) Good leaders are scarce, and our concern for
successors will always be with us. “Good leaders
know their success depends on what happens after
they are gone,” to quote Richards again.
While looking to the future of Beer Sheva, I
remember the story about Winston Churchill. As is
well known, he liked French brandy and he enjoyed
it quite frequently. When he was appointed Prime
Minister, he continued for a while to work out of his
office at the Admiralty, which had rooms with rather
high ceilings. One day, a delegation of ladies from
the Salvation Army came to visit him requesting him
to limit his drinking habits and give a better example
to the younger generation. They said: “If we filled up
this room with the boxes of brandy you drank, they
would probably fill it up at least halfway.” Sir Win
ston looked up, then looked down, and said: “So
much to do, so little done.”
There is a lot still to be done in Beer Sheva. We are
still traveling, and it is sometimes better to travel
than to arrive.
In his opening speech as Chairman of the newly
established National Medical Board of Kupat Holim
(Health Insurance Institution of the General Federa
tion of Labor), our Dean, Shimon Glick,said that he
is sceptically optimistic. An “oxymoron” is the jar
ring juxtaposition of opposites, usually an adjective
[172]
Vol 23, Nos. 9-10, Si rn mbi r O<tobi-r 1987
And Now: What About the Future'*
headed one iway (cruel) modifying a nobn headed the
other (kindness).
I am a terminal optimist.
REFERENCES
1
N?cdcd:a "cwway to train doctors. Harvard
Magazine May-June, p 32-33
2. Prywes M (1972). A look (o the future. BrJ MedF.duc & 264ZOo.
I
EXCERPTS FROM THE REPORT OF THE
ACADEMIC REVIEW COMMITTEE OF THE
BEN-GURION UNIVERSITY—1986
Ephraim Friedman, Chairman
Former Dean
Albert Einstein School of Medicine, New York
Director
Massachusetts Eye and Ear Infirmary, Boston
Sasha Englard
Professor of Biochemistry
Albert Einstein School of Medicine, New York
John Stoecklc
Professor of Medicine
Harvard University Medical School, Cambridge
i
Nathan Trainin
Professor of Immunology
The Weizmann Institute of Science, Rehovot
II
In 1986, the Ben-Gurion University of the Negev
conducted an academic review of all its faculties. Each
faculty was reviewed by a subcommittee of the Academic
Review Committee. The subcommittee for the medical
faculty reviewed written reports from every department of
the faculty and spent several days in on-site visits. A brief
summary of their major findings follows:
The overall impression of the subcommittee was that the
Ben-Gurion University medical school, in a short period
of time, “has become a world class medical school,
respected for its innovative education and quality of
service.” It is, indeed, clearly “the jewel in the crown” of
the Ben-Gurion University.
The report found “no serious concern about the quality
orquantity of medical education offered. Plans are already
underway to fill the few remaining curricular gaps, and the
school’s compulsive curricular self-examination has
produced a finely honed continuously revolving
curriculum. The tension between the basic sciences,
clinical, and primary care perspectives are universal,
normal and healthy. No evidence was found that the
curriculum is slanted. The students are well prepared for
further training in their selected disciplines. The school is
well renowned for its curricular innovation. Although the
process is centralized within the administration, the
faculty and students participate rather fully in curricular
planning and evaluation."
“The admission process works. The students are by and
large able. The constant scrutiny of their growth and
performance is exemplary.”
“Although uneven, the clinical and basic science faculty
are composed by and large of teachers and investigators of
high caliber.”
The committee felt that “despite its meteoric rise” and
the excellence of the quality and the quantity of medical
education offered, “the Faculty of Health Sciences was in
serious jeopardy” because of inadequate resources,
inordinate teaching and clinical load, and scarcity of
research funds, even of seed money. The committee
recommended major efforts on the part of the University
and Kupat Holim [Health Insurance Institution of the
General Federation of Labor] to support the faculty’s
efforts in philanthropy and obtaining research grants. The
committee also emphasized the need for decentralization
and regionalization in order to develop successfully first
class primary care facilities in the region.
Other recommendations included greater recognition
and identity for the basic sciences, the development of a
comprehensive organizational structure for the surgical
department, and external evaluation of the effectiveness of
the graduates of medical school and the creation of an
advisory board to the medical school.
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