A Look Inside Medical Education in Israel - Dr. Peter Gilbey and Dr. Yair Blumberg of Bar-Ilan University, Azrieli Faculty of Medicine

Shiv Gaglani: Hi, I'm Shiv Gaglani, and today I'm delighted to welcome two faculty members from the medical school at Israel's second-largest academic institution, Bar-Ilan University. Dr. Peter Gilbey is an otolaryngologist and chair of the Department of Research and Innovation in Medical Education. And Dr. Yair Blumberg is a clinical exercise physiologist in cardiology and Physiology Coordinator at the school. I had the privilege to meet up with Yair when I was in Jerusalem earlier this summer and was really impressed with everything I learned from him about Bar-Ilan, as well as the medical education system in Israel as a whole. I'm looking forward to learning more from both Peter and Yair about the school and its approach to training the next generation of healthcare professionals. So, Peter and Yair, thanks so much for taking the time to be with us today.

Dr. Peter Gilbey: You're very welcome.

Dr. Yair Blumberg: Our pleasure, thank you so much.

Shiv Gaglani: Let’s start with what we normally do which is to ask our guests to tell us about their backgrounds, what gets them interested in medicine, then medical education and leadership. So, Peter, can we start with you giving us some career highlights and then go over to you, Yair?

Dr. Peter Gilbey: Yes, well, I've been a physician for many years and my interest in medical education is about a decade old, I think. With the formation of this medical school, I found myself more and more involved and interested in medical education. I had the opportunity to spend six months at the Stanford Medical School -- that was almost ten years ago -- and I then did a master's degree in Medical Education at the University of Dundee in Scotland. I think it's fair to say that currently medical education is my main interest and my main challenge. 

Shiv Gaglani: That's great and actually, on that note, when you were at Dundee, did you overlap at all with Ron Harden? 

Dr. Peter Gilbey: I've been taught by him and we actually saw him recently at the AMEE conference we've just attended in Europe. I understand he's retiring or at least stepping down as chairman of AMEE so it's a new period, but he's untiring, you know.

Shiv Gaglani: I mentioned him because we had him on the podcast before AMEE to talk about AMEE and obviously, we had teammates there. I mentioned to him what Catherine DeAngelis, who is a professor at Johns Hopkins Professor Emeritus, told me. When we were just starting Osmosis, I went to her for some advice, and I asked her, "When are you going to retire? Are you retired?" and she said, "Shiv honey, I never tired the first time, so how can I re-tire?" She's known as the first female Editor-in-Chief of JAMA. So, people like her and Ron Harden are obviously very impressive. 

So, Yair, let's go to you. I already know you quite well, having met up with you in Jerusalem, but for our audience's sake, what got you interested in medical education?

Dr. Yair Blumberg: So, I'm not a physician, I'm a Ph.D. in exercise physiology and physiology. I did my Ph.D. at Bar-Ilan, with this faculty, the Azrieli Faculty of Medicine. I was one of the first PhDs who finished the program. During my Ph.D., I was caught into education and teaching. I started with anatomy, and then moved to general physiology and cardiac physiology. Eventually, I ended up staying and developing, with Peter, a few new models of teaching and medical education. So, this is how I got through to medical education.

Shiv Gaglani: That's wonderful. So, let's actually dive in. First, let's talk about the school, Bar-Ilan and Azrieli Faculty of Medicine, and then maybe zoom out and talk about the Israeli medical education system as a whole. Peter, back to you. Can you talk to us a bit about the school, its founding, how many students you train and those kinds of metrics?

Dr. Peter Gilbey: We are the fifth Israeli medical school to be established. There are now six. That's for a population which I think is now around nine million people. Our faculty was established in 2011, so that was about eleven years ago. Traditionally, medical education in Israel has been a six-year study program. It hasn't been an American model graduate entry system but a six-year program, similar to the European or the British system, especially. But we opened with a four-year graduate entry program and there are currently I believe, three, four-year programs in Israel, and we've actually just applied to the Council of Higher Education -- which is the professional body of the Ministry of Education -- we've just applied for a six-year program, which is something we want to expand into. Yair and I are both working together on that. 

We currently have about 150 students per year and we are of course, hoping to expand that because we have a problem here in Israel in that we have very many foreign medical graduates -- I think something like 60% of our physicians are trained elsewhere -- and this is a number we're aiming to bring down. In general, we have a physician shortage as in many other places in the world, but we also have a shortage of high-quality homegrown Israeli physicians, which we'd like more of so we are participating in that national effort. So, that's us more or less.

Shiv Gaglani: Yes, that makes sense, and actually, maybe Yair do you want to add anything to that overall picture before we go into kind of what specific innovations you both have implemented for your curriculum? 

Dr. Yair Blumberg: Not much. The only thing is there is a bit of story of not enough physicians, especially in our district in Israel, which is also unique, and in the faculty, and what the faculty are doing.

Dr. Peter Gilbey: I could just say one more small word about that. This may sound funny to an American, or to a Canadian, but we are a peripheral medical school meaning that we are two or two-and-a-half hours drive away from the center of the country. In other places that would be considered completely central, but we are in the periphery of the country. We have a hard time attracting students to the Galilee, to the area we're in, and this is an area which has significant health disparities, which is part of our school's mission. 

We have significantly fewer physicians and nurses per capita in the north and in the far south of Israel, when compared to the center of Israel. In Tel Aviv -- where I imagine you've been -- you can find five physicians per one thousand population. We're hovering around or two-point-one physicians per one thousand population, so it's significantly less. And the health outcomes in the north are also less than they are in the center of the country. So, that's one of our main missions, which we're not yet successful enough in doing.

Shiv Gaglani: That's fascinating, and actually, it's really interesting to think that even though Israel is a much smaller country than the U.S., some of these issues are still popping up where there are disparities in healthcare and health outcomes just based on the zip code or the area you're born in. We've had several guests on our podcast including my friend, Ted Wendel who runs A.T.  Still University. One of their main missions is improving the number of physicians who train and then stay in more rural areas. 

Actually, that could be a good segue. Because of these disparities, there's a lot of changes in the curriculums in the U.S. focused on social determinants of health, diversity, equity, inclusion, and telehealth, which hopefully because of COVID and whatnot, can be a potential solution for some of this access to healthcare, at least part-time types of healthcare. So, what are some innovations you all have been focused on at Bar-Ilan? I know both of you have spearheaded many of them and changes to the curriculum. Maybe we can start with you, Yair, talking about that and then hand it off to Peter.

Dr. Yair Blumberg: Lead by Peter, we're trying to develop new approaches to education. In the last few years, we started a bit of flipped class, which we're using Osmosis for. We're doing a lot of studies on point-of-care ultrasound, trying to implant it in a very early stage in medical education. We're also trying to develop more of an internet-based learning and self-learning and use the basis that people have been taught alone, and trying to practice it in the university itself.

Dr. Peter Gilbey: I just wanted to get back to the question of social accountability and social determinants of health. As I said, we haven't been successful enough in retaining our graduates in our rural area, and many other places have had the same challenges in Canada, in Australia, in Japan, in Norway…there's a great deal of international experience on this. It seems today that the best way to retain physicians in a peripheral social or economic or geographic periphery of any country is to recruit these people from that area. That seems to work much better than giving any kinds of monetary incentives. So, if you take the best local people and you train them, they will stay in the area. This has been proved time and time again. So, we're trying to move in that direction.

The solution starts in the admissions process. Then you have issues of equal opportunity, and is this discriminatory against people coming from the center of the country because there are obviously much fewer spaces in medical school than there are people wanting to enter medical school? These are complex issues that we are dealing in. So, get the rural people to keep the rural physicians in the rural area. That's number one. 

The other thing is to involve them in the community from a very early stage. You know, our first preclinical course is a public health course exactly for that reason, because we want to be accountable to the community that we operate in. We get the students into the community and to health organizations in the community. We have a very unique program within public health called GAO, which basically involves students in the transition from hospital care to community care. Actually, we get students to accompany patients -- especially patients with low health literacy -- in the transition from hospital to community and actually to translate their discharge letter, which is sometimes unintelligible to people. It's written by a doctor for a doctor and people don't really understand what it's all about, and they're not compliant with their medications or they don't understand what's required of them. 

So, we're getting students involved in that interface and this gets them heavily involved in the community, hopefully, to build a true commitment to the community. And we have a unique community. We have all kinds of people. We have a very large Arab-speaking population, we have an ultra-religious Jewish population, a rural population, urban population…we have all kinds, so that's what we're trying to do.

Shiv Gaglani: I love that. Those themes are really important and certainly are aligned with what we're seeing in the macro healthcare environment where we have to do a better job of providing healthcare, as you said, in the community, or even at home, and then also involving patients through concepts like shared decision-making. The whole literacy aspect is something we believe very strongly in. A lot of what we do at Osmosis clearly focuses on health literacy and getting patients to understand why they need to take their entire antibiotic regimen, or how to do peritoneal at-home dialysis is another example of content we've made. So, it's great to hear those are two of the focus areas. 

While we're on some of those areas, do you do anything about interprofessional education? How care coordination happens between the physicians you're training, the nurses…I don't know if there are physician assistants in Israel, but I'd love to hear about scope of practice and interprofessional education.

Dr. Peter Gilbey: The State of Israel and the Ministry of Health are working on the development of a physician assistant program. This is something that we need to move towards. If it's nurse practitioners, or physician assistants, you know, with the physician shortage, and with a growing population, these are going to be some of the solutions. We're not there yet, but we are definitely moving in that direction. In terms of interprofessional education, we'd like to be there, but we're not there enough. We do have some joint training with the nursing school for our clinical skills course, and we even have nursing students or nurses, assessing and grading our students in OSCEs, for clinical skills. So, you'll find a nursing student grading a medical student on their basic skills -- taking a blood pressure or pulse or a temperature or whatever -- which I think is great, because I grew up in a different world. I'm the oldest person by far here, I think, and it was all "do as the doctor says.”  We're moving away from that absolutely and we believe in a multi-disciplinary, multi-professional environment of mutual respect and we definitely need to do more there.

Shiv Gaglani: That's awesome. Whenever I go get my blood checked, I prefer to get it done from a phlebotomist or a nurse and then a physician just because of the cycles, the iterative process of that. 

So, speaking of procedures, something Yair and I spoke about in Jerusalem -- which I'd love to turn to you, Yair, to talk about here -- is your focus on trying to get students trained to use handheld ultrasound as part of the diagnostic exams. I know we talked about developing content around that potentially. We've had people on the podcast -- including Eric Topol, Dan Craft and Marios Lukas -- who've said the stethoscope is dead. Just a couple of weeks ago, we had on Dr. Oleg Turcotte from Hopkins. He's Ukrainian citizen as well, and he partnered with an ultrasound company and went to Ukraine multiple times. I think they may be there right now trying to build up healthcare capacity by in part using handheld ultrasounds to do acute and chronic care. So, can you talk to us a bit about that passion of yours and where you see that space evolving?

Dr. Yair Blumberg: Okay. We realized as a new faculty there are a lot of new technologies that are not well established in medical education. In other universities around the world and in Israel, we saw that the point-of-care ultrasound may be one of the major tools that the future physician is going to use, and we decided as a strategic teaching method to try to teach the student to use the ultrasound from basically the first day of medical school. Starting with anatomy courses and every section that they're seeing, we are incorporating ultrasound. Then when they're entering the clinical stages, we're keeping making the students use ultrasound. It's something that we're trying to build and do it throughout all four years. But there are a lot of challenges. What are the hazards? What can we achieve by teaching this method? What are our limitations? So, there are a lot of questions that we're trying to develop, but we think that's one of the most important tools.

Shiv Gaglani: Yes, definitely. Certainly, this is something that I'm hearing from other schools, but I think you guys are pretty far ahead as far as what I've seen in terms of that particular technology. I also wanted to turn it back to you, Peter, to talk about the issue of med school burnout and moral injury, which I know is a huge area of discussion, especially post-COVID. What's the situation like? We can train more people in place, we can train more people to become clinicians, but if they're only lasting for five, ten, fifteen years or even less, it's a leaky bucket. What are some of the possible solutions you're seeing, and how are you addressing it at your school?

Dr. Peter Gilbey: That's a really big issue and I've done some research on medical student burnout, and there is research on that. It started, of course, with research on physician burnout, and we know that over 50% of American physicians are burnt out, depending, of course, on how you define that.  The numbers are the same with medical students and it's amazing, because it's from very early stages of their studies, because we ask a lot of them. I think there may be generational issues here as well. I think that maybe people are more minded to what's called work-life balance today than we were back in the day. We have to cater to that.

So, yes, a great many medical students are feeling burnt out and we definitely need to address that. The first stage was to actually map that out in Israel, and it seems that we do have a problem. This is yet to be published, but I hope it will be, and the question is, what do you do about it? There's literature on that as well. I mean, do you keep the same continual repetitive stress going all the time, but give people a mindfulness workshop or a similar sort of personal intervention? That doesn't seem to be doing the trick. There seems to be a need for institutional systemic interventions here in order to decrease the workload, perhaps, or make the conditions more hospitable for physicians. 

I'm an ENT surgeon, as you said, and it wasn't acceptable to admit weakness in the face of surgical complications, or death of patients. These are very serious issues, and there was nothing. People are talking about this more and more today, so that goes to physician burnout. We have to be there for our physicians, for our younger physicians, for our older physicians. We have to be able to talk about these difficulties, and we have to make working conditions more acceptable. Carrying on the same way, but just having a couple of hours of mindfulness workshops, is not going to solve the problem. I believe we're moving in that direction. 

We have a big issue here in the country now in Israel involving work hours. We grew up working thirty, thirty-two or more hours consistently. That's obviously unacceptable and today's residents are saying, ‘no more.’ They're currently allowed to work twenty-six hours. They're on call, they come in the morning, and they work until the following morning, and they hand over the department to two other physicians and they go home. That's twenty-six hours. It was a big political strike now, by the residents saying, “You know, this is unacceptable. We cannot work twenty-six hours. Pilots are not allowed to pilot a plane for twenty-six hours. Drivers aren't allowed to drive a lorry for twenty-six hours. Why should we be allowed to operate on patients and make life and death decisions after a night without sleep?” So, this is happening now and it's a big issue. It's in the news. Things are moving, I think, in the right direction so that will also be part of the solution.

Shiv Gaglani: It's a very complicated issue, for sure and it's good to hear things are turning in the right direction. When I was in med school at Hopkins, one of the mentors we had is Peter Pronovost, who does a lot of patient safety research. One of the things his lab published was that the more times there are handoffs -- the same patient is being handed off multiple times because we have shorter shifts -- the more potential chance there is for error, because people don't fully understand the patient as when they admitted them, or things like that. That’s versus a handoff of a plane or a bus. The plane or bus is not a human, so they should react the same way in the same conditions. There's more standardization, but it's obviously complex, because as you said, you're delirious after twenty, twenty-four hours, especially in a high taxing environment. So, it will be interesting to see how it goes and we'd love to see your research, once it's published as well. 

My favorite question is, we have an audience of 2.5 million healthcare students around the world. You have trained thousands of them or more, actually, over the course of your career. I'm sure you get asked to give advice to these students pretty regularly, and so for our audience, we'd love to get your advice about meeting their challenges of the COVID pandemic and beyond, and progressing in their career. So, Yair, can we start with you?

Dr. Yair Blumberg: Wow, it's a good question. I think that the best thing that I could give in advice is keep the curiosity all the time. Be curious about this profession, because it changes a lot, and you have to be very curious and very updated all the time.

Shiv Gaglani: I was just talking to a urologist and surgeon named David Canes, who was also on the podcast recently. Going back to your point, Peter, about burnout…part of the reason he felt burnout was he was just kind of doing repetitive stuff every day. So, he started learning how to do software and building up websites for patient literacy. His curiosity, as Yair mentioned, kind of saved him. He said, "Look, I fell in love with the profession again, because I started using that curiosity to solve other problems.” So, it's great advice. Peter, how about you? What's your advice to the audience?

Dr. Peter Gilbey: Much the same. I would say keep the passion alive. I mean, learn something new, be curious, be devoted, and I would add teaching as a cure for burnout. I would say not only be interested in your chosen profession, and keep up to date, innovate, and research, but I would say be passionate about teaching. We don't have enough people who are passionate about teaching and teaching is an excellent cure for physician burnout or anybody else's burnout. Anybody involved in teaching can find great joy in that teaching. 

We need people to be self-directed learners, but we also need excellent teachers and faculty development. I know we're at the end of our time, but that's a big issue, and we have great challenges all over the world in faculty development. We need to build up our teaching force. Maybe Osmosis can do some work in that direction. I'd love to see some faculty development content on Osmosis, because teaching is such an important skill for our students, for our residents, and for our practicing physicians. Everyone needs to know how to do it and we don't become excellent teachers just by finishing medical school. There's stuff to be learned there, you know.

Shiv Gaglani: Despite the whole "see one, do one, teach one," there needs to be a little bit more to get someone to be a good teacher…

Dr. Peter Gilbey: Shiv, that's almost as obsolete as the stethoscope.

Shiv Gaglani: Exactly. Actually, on that point, we do have some faculty development content I'd love to share with you and would love your advice in a separate conversation about what else you're seeing. But one plug I'll put it in is we just launched this week the second Raise the Line Faculty Awards to recognize some of the greatest teachers around the world.  Obviously, you two have the passion and curiosity and dedication to medical education, so I'm sure you both will get nominations. But we'd love to see people at Bar-Ilan and in Israel getting nominated as well. So, that's a plug to our audience listening to this as well.

Is there anything else that I didn't ask you about that you want to get across to our audience about you, Bar-Ilan, Israel, medical education or anything else that you'd like to get across?

Dr. Peter Gilbey: Well, I'd like to say a couple of words about the use of Osmosis, because we are talking about Osmosis. I’d just like to say that an interesting challenge for us is to move away from just giving it to the students and saying, "Use this with this…whatever you want to do" and actually making this part of the curriculum. Whether it's the preclinical curriculum or the clinical curriculum, we need to convince teachers to use Osmosis and similar tools as an integral part of their teaching, and we're not there yet. 

This touches on faculty development, which actually is connected to point-of-care ultrasound, because it's a bottom-up thing, you know?  The whole thing is all student-led, because we have older faculty who have not grown up with ultrasound, and they have to be convinced to use point-of-care ultrasound. They've been convinced by the students. We have all the teachers, all the faculty who have known nothing else but traditional bedside teaching, or frontal teaching by lecturers, and we're saying ‘here are these wonderful tools use them.’  It's an uphill battle. It's a struggle. We have to work in that direction.  The students are our partners in that because it comes from them. They want these tools and the pressure from the students will eventually convince the faculty to integrate Osmosis and other tools perhaps, into their teaching. So, it's a very interesting time.

Shiv Gaglani: We've definitely seen that sort of pull. There's 5% or 10% of the faculty who, like you, are going to these conferences, are listening to the webinars, are publishing research on medical education, who are adopting these tools and putting them into practice. But then there's a lot of other faculty who, as we know, they're focused on their research, they're focused on clinical duties, they're are focused on other things, and for good reason. That's how they're paid, or that's how they're incentivized. So, finding ways to get them passionate about this as well and make it easy for them is definitely an area of focus of ours. So, thanks for that insight. Yair, final word? Anything we didn't ask about that you wanted to share?

Dr. Yair Blumberg 

No, actually. Peter said it all.  

Shiv Gaglani: Awesome. Well, I really appreciate the opportunity to speak with both of you and the partnership we have with you and your faculty and students at Bar-Ilan University, and most importantly, the work that you do to raise the line and strengthen our healthcare systems. Thanks for taking the time to be with us today.

Dr. Peter Gilbey: Thank you. Thank you very much.

Dr. Yair Blumberg: Thank you so much, pleasure seeing you again.

Shiv Gaglani: Likewise - and with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to Raise the Line. We're all in this together. Take care.