For doctors, a simulating experience
Yorai Lahav-Hertzano is an impressive 18-year-old. This year he graduated from a leading Tel Aviv high school with a high average. His chairmanship of the city's Student Council for the past three years earned him a certificate of appreciation from the school for social excellence. As a highly motivated youngster, Lahav-Hertzano wants to serve in a quality unit in the Israel Defense Forces, and he will soon begin his service in an elite unit. However, he was disappointed after his initial encounters with the military framework, in the form of the medical staff at the National Induction Center.
"I was examined by two physicians when I was in 11th grade," he says. "The first physician was very tough. I have no expectations of conducting a deep conversation with a professional whose job is no more than to give me a brief check to determine my medical profile. Still, I expected a little more empathy from someone engaged in medicine. It was important for me to clarify a certain medical matter, about which I did not get an answer." According to Lahav-Hertzano, "The second physician who examined me was attentive, asked where I wanted to serve, and took an interest in the state of my health, and so made me more positive and open toward the army."
To the head of medical classification in the IDF, Lieutenant Colonel Arnon Ofek, it is important the physicians of the induction centers under his command resemble more the caring physician described by Lahav-Hertzano than the physician who left him with a bad taste in his mouth. Accordingly, he organized, together with the Medical Instruction Center at Sheba Medical Center, Tel Hashomer, a course for physicians to improve their proficiency in making personal contact with the draftees. At the height of the hard fighting on the northern border, the first group, consisting of 12 physicians from induction centers arrived at Sheba for a practical workshop. This was the follow-up to a theoretical workshop, which was held a few weeks earlier.
Tens of thousands of high-school graduates who will be conscripted in August were exposed to physicians who don't have this special training. However, Dr. Ofek says, "The theoretical and practical course physicians will henceforth undergo is part of a comprehensive program put together with experts on adolescent medicine at Sheba." Ofek says, "The success of the training program will be tested by the young people who go through the induction centers in the form of feedback questionnaires. Afterward we will process the questionnaires and take lessons from them. The professional research, which will be the end of the process, will point to the optimal way to integrate the IDF's needs with maximum attention to the young people, who are going through a sensitive and tempestuous period of their lives - adolescence.
The practical workshop took place in a unique setting - Meser, the Israel Center for Medical Simulation, which was established by Amitai Ziv, deputy director of Sheba Medical Center, five years ago. Meser is a virtual hospital for training medical teams, including teams from abroad and medical students in situations that simulate real cases, in order to reduce human errors. Thus a student can train on a "patient" in the form of a sophisticated $200,000 medical mannequin that emits cries if the physician is not gentle enough. The mannequin also simulates symptoms resulting from a mistaken dosage of medicines.
The workshop for the 12 army physicians also included meetings with actors, who had been trained to represent a high-school student. Dr. Dan Harduf, one of Israel's leading experts in adolescent medicine who helped put together the training plan for the medical physicians, explains, "As part of his training, a physician who takes part in the course does not know which character the actor is playing. The physician has to find out about the youngster and how to deal with his medical problem."
A team of medical experts monitors the interaction between the actor and the physician from behind a glass window. The encounter is also documented on video. "Later," Harduf explains, "the physician will receive dual feedback about the way he performed. One encounter takes place with the actor, who describes to the physician the person and professional impression he left him with, and the information remains their secret. The second feedback takes the form of an open debriefing. All the physicians who took part in the workshop viewed the videotaped encounter, together with the team of instructors. We analyze the situation and find out where the physician could have done things differently."
Captain Yael Ben-Ami, who completed her medical studies two years ago, has been a physician at an induction center for the past eight months. In the role game she encountered a colorful youngster, very liberated in the body language he projected at "his doctor." The conversation with him revealed him to be a sexual hedonist who consumes a great deal of alcohol. The "urine test" the actor provided - a routine element in the pre-draft classification process - turned up an inflammation of "the urinary tract.
Dr. Ben-Ami asked the actor if he used contraceptives, and after getting a negative reply explained to him the importance of protected sex. "An inflammation like this, which can develop in the wake of random sexual encounters, does not lower the medical profile," Ben-Ami says. "Still, I explained to the youngster that if he did not get the inflammation treated in time, his medical profile would be lowered."
Ben-Ami displays candor when analyzing her performance in the encounter. "I don't think my empathy needs improving," she says. "I forge good human contact with the young people I classify." Her senior commander, Lieutenant Colonel Ofek, nods his head in affirmation. "However," the young physician adds, "I am embarrassed when I have to ask intimate questions that are a breach of privacy. I feel it is a sensitive point, to ask a boy or girl about whether they had sexual relations."
The workshop for the physicians of induction centers is held under laboratory conditions that are very different from what actually goes on in the centers. Ben-Ami says she examines 40 to 50 high-school students "in a situation lacking in privacy. Sometimes there are four youngsters in the room at the same time." The physicians who took part in the role game had to discover, for example, that the "anemia" a fragile young woman displayed stemmed from an irregular menstrual period, and that the diverse "medical problems" displayed by another actor were probably the result of a human fear of combat service. What emerged from the workshop is that an attentive physician will send such a youngster, after a thorough conversation, to a mental health officer before deciding on his medical profile.
Ofek, who has been in his present post for the past two years, says the special training to be undergone by 80 physicians from induction centers - 20 of them in regular service, the rest in the reserves - "is, I believe, essential as part of the education of army physicians to excellence." It is also likely that Dr. Ziv established the Center for Medical Simulation in the wake of his military service.
Ziv, a former combat pilot, says the idea for the center came to him in his first years of study. "I thought to myself," he says, "that air force pilots are well trained to do their job thanks to countless simulations. It seemed to me natural to combine the pilots" simulations with the world of medicine." About 10 years after completing his specialization in child and adolescent medicine, Ziv established the world's first center for medical simulations, which is a role model for leading medical centers in the United States, Canada and Brazil.