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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.

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.

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).

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.

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.

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.

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

The Holocaust is presently part of the universal human identity in the 21st century, as well as a component of Jewish and Israeli identity. Contemplating the role of medicine in the Holocaust is crucial for health professionals' identity formation. This paper narrates the story of the Bergen-Belsen concentration camp, the events preceding its liberation and the months that followed in universal, Jewish, medical and personal dimensions. A British book (After Daybreak by S.Shepard, Shocken Books, 2005) addresses the Bergen-Belsen Liberation on 15.4.45 and focuses on the medical relief operation mounted by the British. It tells the story, among others, of 96 volunteer medical students flown in from London to assist in the survivors' care. I have also heard the tales of Bergen-Belsen in those days from my late father who was there and was fortunately Liberated by the same British soldiers. My mother too stayed in Bergen-Belsen and left two months prior to liberation. By the end of May 1945 the British soldiers had left, the camp was transformed into a refugee camp, and it became a transit camp for preparation for Aliya and immigration. In 1948 my mother's younger sisters spent time there on their way to joining a kibbutz in Palestine. This is how I found myself caught in the duality of seeing, in my mind's eye, the picture portrayed by the book, the gaze of the camp's liberators and healers, as well as imagining myself in the shoes of my family members in the same place and time. This article conveys the dual gaze: the medicaL, that the health professionals present on the one hand, and the personal outlook--on the other hand.

Background: Adequate premises, equipment and organization of care are prerequisites for good primary care. The lack of a generally accepted systematic framework for practice management contributes to clinical outcome variations as well as inequalities in health care delivery., Objective: To validate, localize and assess an internationally validated method for practice assessment in primary care in Israel., Methods: The international tool contained 6 domains, 171 indicators and 470 items in 32 different aspects of primary health care provision. The instrument was translated into Hebrew. The major assessment in Israel was performed in 30 practices of Clalit Health Services by practice visits of 2 independent observers who completed check lists, structured interviews with the management staff of the clinic, work satisfaction questionnaires of the clinic staff and satisfaction questionnaires to patients at 30 clinics. The data was processed and analysed by SPSS. Frequency distribution and descriptive statistics were computed for all questions. Factor and reliability analysis were used to reduce the remaining items to a reduced number of indicators., Outcomes: From the initial 171 indicators and 470 items, we have managed to downsize the process of evaluation to a feasible size of 57 indicators and 142 items which have been proved as discriminating between the practices on an international level. The Israeli assessment downsized the number of locally discriminating indicators to 50., Conclusions/recommendations: The resulting set of indicators is good and valid for improving the organization and management of general practices. On a national Israeli level there is need for further validation, which will include all the Israeli providers.

Background: The decline in the number of medical students who choose a residency in family medicine may cause a shortage of family physicians. The choice of a medical career is a complex process influenced by many interwoven factors., Objectives: To find out the level of interest in a residency in family medicine among medical students in one faculty of medicine in Israel (Technion) and to identify the factors related to family medicine preference., Methods: A self administered questionnaire was distributed to medical students at the Technion. The students were asked to indicate their career choices and to rank the importance of 30 statements with regard to their choice. Factor analysis was performed to examine similar variables. A logistic regression was performed to examine the variables that predict family medicine choice., Results: Of 496 students, 358 (72%) completed the questionnaire; 5.6% chose family medicine as a first residency option, and 24.9% chose it as one of their 3 first options. Research findings show that gender (female), marital status (non-single), religion (Jewish) and lack of previous health-related experience, predicted family medicine choice. The students that chose family medicine were more concerned with medical lifestyle, patients' population characteristics and societal commitment., Conclusions: The number of students that prefer a residency in family medicine is low. Several factors predict family medicine preference. Correct identification of these factors could enable interventions to increase the number of students choosing family medicine. The current study should be continued at the Technion and should also be carried out in other faculties.

The purpose of clinical practice guidelines is to delineate an evidence-based common approach to a prevalent medical problem. Guidelines for Chronic Low Back Pain (CLBP) care were never published in Israel previously, contrary to the Acute Low Back Pain (ALBP) guidelinges. This year, such guidelines are disseminated sponsored by the IMA. In the present paper a summary of the new CLBP care guideline is reported. To each recommendation an evidence level is attached, enabling the practitioner to examine his deliberations against the existing evidence. The guidelines are adapted from a recent European multidisciplinary document and will stay valid with periodic updating. Clinical practice guidelines are not intended to replace careful clinical judgment and personal acquaintance with the patient in. They may support decisions by bringing a summary of the existing evidence in the domain.

Physicians in Nazi Germany were among the first to join the Nazi party and the SS, and were considered passionate and active supporters of the regime. Their actions included development and implementation of the racial theory thus legitimizing the development of the Nazi genocide plan, leadership and execution of the sterilization and euthanasia programs as well as atrocious human experimentation. Nazi law allowed the use of humans and their remains in research institutions. One of the physicians whose involvement in the Nazi regime was particularly significant was Eduard Pernkopf. He was the head of the Anatomy Institute at the University of Vienna, and later became the president of the university. Pernkopf was a member of the Nazi party, promoted the idea of "racial hygiene", and in 1938, "purified" the university from all Jews. In Pernkopfs atlas of anatomy, the illustrators expressed their sympathy to Nazism by adding Nazi symbols to their illustrations. In light of the demand stated by the "Yad Vashem" Institute, the sources of the atlas were investigated. The report, which was published in 1998, determined that Pernkopfs Anatomy Institute received almost 1400 corpses from the Gestapo's execution chambers. Copies of Pernkopfs atlas, accidentally exposed at the Rappaport School of Medicine in the Technion, led to dilemmas concerning similar works with a common background. The books initiated a wide debate in Israel and abroad, regarding ethical aspects of using information originated in Nazi crimes. Moreover, these findings are evidence of the evil to which science and medicine can give rise, when they are captured as an unshakable authority.

Physician health is a matter of interest for patients' physicians and their teams, managers and policy-makers. It has an impact on public health, physician impairment, patient safety, resource allocation and malpractice litigation. International medical literature, unlike Israel publications, is extensively preoccupied with the domain. Based on 2 MD thesis dissertations, Ministry of Health data and a literature search, the present review addresses many issues. It deals with: physicians' physical and mental health internationally and in Israel, prevention and health promotion, burn-out, the professional lifespan and career, health services utilization, legal and administrative aspects, boundaries, physicians' characteristics and vulnerability, interpersonal relations, care provided by physicians, physicians as patients and finally the impaired physician. International recommendations as well as a proposal for a local action plan are presented.

The purpose of clinical practice guidelines is to delineate an evidence-based common approach to a prevalent medical problem. A decade ago, Guidelines for Acute Low Back Pain (ALBP) care were published in Israel. This year, updated and upgraded guidelines were disseminated, sponsored by the IMA. In the present paper a summary of the new ALBP is reported, as well as a comparison with the prior 1996 guidelines. An evidence tag is attached to each recommendation, enabling the practitioner to examine his deliberations against the existing evidence. The guidelines are adapted from a recent European multidisciplinary document and will remain valid with periodic updating. Clinical practice guidelines are not intended to replace your careful clinical judgment and personal acquaintance with the patient in front of you. They may support your decisions by bringing you a summary of the existing evidence in the domain.

Background: In recent years, the Israel Defense Forces IDF developed special training programs for junior military physicians at the beginning of their service and CME courses for senior military physicians. The Objective Structured Clinical Examination (OSCE) is a well established assessment tool in medical education that can be of vast use in military training programs for primary care physicians., Aim: To evaluate the OSCE as an assessment tool of military primary care physicians., Methods: Forty-one military primary care physicians completed a 10-station OSCE. The clinical scenario choices were based on the most prevalent problems in the annual statistics of the Israeli Medical Corps between the years 1988-1998. Each station consisted of two parts: a doctor-SP (standardized patient) encounter and a written exercise. Both parts were evaluated by checklists designed and validated by a committee of OSCE experts and senior military physicians., Results: The overall reliability of the exam was alpha = .88. The examinees highly valued the relevance of the scenarios to their every day practice (4.38 out of 5.0) and the reliability of the standardized patients (4.0 out of 5.0). A total of 92% request feedback on their performance., Conclusions: This pilot study found the OSCE to be a feasible, valid and reliable tool that can serve to assess the capability of physicians to deal with major issues in military primary health care. The OSCE can also play a major role in structured feedback provided to these physicians.

Number needed to treat--NNT--is a bridging tool between statistical results from clinical trials and the physician daily work. This number represents the number of patients we need to treat with the experimental therapy in order to prevent one of them from developing the bad outcome. The concept is a useful measure of the clinical effort our patient and we must expend in order to help them avoid bad outcomes to their illness. For example, the NNT for antibiotic treatment of otitis media is 8, which means that we have to treat eight children with antibiotic and only one out of the eight will benefit the treatment. In a medical world that uses the Evidence Based Medicine as essential tool, we believe that the NNT is an important tool and very efficient for choosing the best treatment method.