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

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

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

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

Competency and confidence in ECG interpretation among medical students.

Objectives: To assess competency and confidence in ECG interpretation in medical students across years of medical school and evaluate the associations of various factors, a curriculum change, and student confidence with ECG competency. Methods: Four hundred and fourteen (414) third- to sixth-year medical students participated in this cross-sectional study conducted in 2019 in the Hebrew University of Jerusalem, Israel. A voluntary response sample of participants answered a validated, web-based questionnaire, composed of eight ECG strips. Participants were also asked about confidence and sources for ECG education and exposure. Competency and confidence across medical school years were compared using the ANOVA and chi-square tests. Results: Competency was low overall (mean score, SD (standard deviation) 3.23±1.81 out of 8), and higher in sixth-year students compared to third-, fourth- and fifth-year students (4.37±1.69 vs. 2.90±1.82, 2.90±1.54, 2.50±1.56, respectively, F(3,337)=24.425, p<0.0001). There was no difference between students before and after the curriculum change. Work experience in medicine was associated with competency (odds ratio (OR), 7.97; 95% confidence interval (CI), 4.03-15.77, p<0.0001). The reported confidence level was low (median 2 out of 5) and was found to be correlated with the total score achieved (r(332)=0.5, p<0.0001). Conclusions: Student competency was shown to be insufficient throughout medical school. Competency and confidence in ECG interpretation seem to be significantly improved by increased and repetitive exposure to ECG. Thus, strategies to facilitate better ECG skills should involve an extended focus on ECG in the undergraduate and graduate curricula and include competency-based educational programs.

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

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

From the "what" to the "how": Teaching integrative medicine-related skills to medical students during COVID-19.

OBJECTIVE: To examine the impact of an integrative medicine (IM) course on self-perceived IM-related communication and research skills. METHODS: A 3-day mandatory "hybrid" (online and in-person) IM course was held within COVID-19 restrictions for 161 pre-clerkship medical students, with workshops facilitated by mentor healthcare professionals (IM and non-IM) and student-directed tasks. Self-perceived levels of 6 IM-related skills were scored (from 1 to 5) for history-taking; communicating with patients with "alternative" health-beliefs; referral to IM consultations; assessing risks/benefits; and working with non-medical IM practitioners. RESULTS: 137 students (85.1%) completed pre-/post-course questionnaires, with overall scores improving from pre-course (1.98 ± 0.92) to post-course (3.31 ± 0.63; p < 0.0001), for the entire group and student subgroups (with vs. without prior IM experience). Multivariate analysis found no association between age, gender, primary language or prior experience with IM and improvement in skill scores. CONCLUSIONS: The IM course increased self-perceived skill levels, reflecting the course curriculum and workshops. Further research needs to explore the application of these skills during clinical training. PRACTICE IMPLICATIONS: Teaching medical students about IM in a course comprising communication and research skills was shown to be feasible and effective. The application of IM-related skills needs to be evaluated during the clinical clerkship.

Empathy and boundary turbulence in cancer communication.

OBJECTIVES: To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent. METHODS: Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations. RESULTS: We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories-transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered. CONCLUSIONS: Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication "boundary turbulence." Patients may benefit from physicians' improved use of empathy and boundary management.

[EXPERTISE IN MEDICINE].

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

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

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

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

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

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

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

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

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

The Holocaust, medicine and becoming a physician: the crucial role of education.

Learning about the abandonment of moral principles of healthcare professionals and scientists, their societies and academic institutions, to a murderous ideology yields fundamental concerns and global implications for present and future healthcare professionals' education and practice. Medicine's worst-case scenario raises deeply disturbing yet essential questions in the here and now: Could the Holocaust, one of the greatest evils ever perpetrated on humankind, have occurred without the complicity of physicians, their societies, and the scientific profession community? How did healers become killers? Can it happen again?We reflect here on those queries through the lens of the Second International Scholars Workshop on Medicine during the Holocaust and Beyond held in the Galilee, Israel on May 7-11, 2017 and derive contemporary global lessons for the healthcare professions. Following a brief historical background, implications of the history of medicine in the Holocaust are drawn including 1) awareness that the combination of hierarchy, obedience, and power constitutes a risk factor for abuse of power in medicine and 2) learning and teaching about medicine in the Holocaust and beyond is a powerful platform for supporting professional identity formation. As such, this history ideally can help "equip" learners with a moral compass for navigating the future of medical practice and inherent ethical challenges such as prejudice, assisted reproduction, resource allocation, obtaining valid informed consent, end of life care, and challenges of genomics and technology expansion. Curriculum modules are available and studies on impact on students' attitudes and behavior are emerging.The conference culminated with the launch of the Galilee Declaration, composed and signed by an international, inter-professional community of historians, healthcare professions educators, and ethicists. The Declaration included herein ( http://english.wgalil.ac.il/category/Declaration ) calls for curricula on history of healthcare professions in the Holocaust and its implications to be included in all healthcare professions education.