TEACHING

I had three goals for the department: clinical service, research and teaching. Apart from two years in Rhodesia, my entire life had been spent in teaching hospitals. Teaching and education was a pivotal and fundamental building block of my presence in the teaching hospital.

In 1973, I found myself running the introductory course in cardiology to the 4^th year students and undertook the brunt of the teaching, first in English and then in broken Hebrew.

I had brought English and South African clinical bedside medicine to a country which was based on European and American tradition and instrumentation with an emphasis on special tests, with little associated physical examination. I introduced the basics of physical examination to my residents in the out-patients and to the departments of internal medicine. The impact was great and soon Prof. Eliakim and all his staff would join me on the grand rounds. I applied myself to the students using the basic system of careful history taking, meticulous physical examination, precise analysis of the ECG, x-ray interpretation and only then analysis of the laboratory tests, echocardiography, and finally cardiac catheterization and angiography.  All of these were integrated into the final clinical diagnosis for correct prognosis, treatment and management. This logical approach upset my clinical and surgical counterparts and it took some years for them to slip seamlessly into this clinical pattern.

I had to undertake most of the teaching myself and although the teaching staff expanded gradually, I continued to provide the major portion of the teaching thrust.  We soon had elective students in the final year, and since they came in small groups of 6 students, this meant that every day we had students for 6 – 8 hours for 8 months of the year.

This was a heavy burden, since I became very active in the cath lab, operating room, and wards.

We had inadequate teaching space, as the students were squashed into our small seminar room and at one stage, I was given a small laboratory the pharmacology building to give seminars. It was very inconvenient, but it gave me good, physical exercise. In later years, Penchas would joke and say that Gotsman had brought the 3^rd heart sound and the cardiac catheter to Jerusalem.

We produced teaching pamphlets for the students using the power points presentations, but I had the feeling that they liked to have all their information pre-digested like porridge for breakfast.

We attracted many foreign students who came to Jerusalem for elective periods, and I took them under my wing. They were great fun. They were enthusiastic, very intelligent, and were well-educated, and I created a very special personal relationship with them. I took them into my private clinic, and between the patients and a white teaching board and colored pens, we were able to create a very personal teaching relationship. When I met them in later years, it was clear that this period had made a great impression on them.

The modern approach frowns on formal lectures to large classes, but I still believe that a well-prepared and organized lecture, given slowly without any time constraints, provides the student with a framework for understanding and digesting the material. Seminars of six to eight students provide intimate and personal eyeball contact with the students but this requires repetition of the material and is time consuming. I enjoyed these seminars, for which I not only produced outlines and power point presentations, but also used the white board and colored pens. I was a little disappointed by the students, who would simply listen passively and try to understand the material, but they rarely asked questions or took down notes. Ward rounds and bedside teaching was always very exciting. It provided intimate interaction with the patients, resulting in a close patient-student-teacher interaction. It was easy to determine the pace of the teaching and to appreciate how well the students understood the subject. I used the Socratic method of question and answer. Once again, a group of six students was too large, and I often divided large groups into two small sub groups. Often, I crowded too much material into a discussion on a single patient.

I had my own techniques of careful history taking, based on years of clinical practice: Unhurried, detailed, and comprehensive. Physical examination followed a precise pathway so as not to omit significant details, electro-cardiography gave a careful insight into the electrical and anatomical aberrations of the heart, detailed analysis of the echocardiogram, careful interpretation of the silhouette of the heart, and nature of the lung fields on x-ray, and then interpretation of the special tests. Differential diagnosis today is a lost art, but then it was an accurate diagnosis, often of multi-organ disease, knowledge of the prognosis and trajectory of the patient, and finally, an understanding of the physiological and pharmacological basis of treatment.  If the patient needed an intervention, the procedure would be discussed together with its advantages and disadvantages.

I had a perfect control of both English and Hebrew. My single disadvantage was impatience with the students, who often would not concentrate on the discussion, and the nurses, whose activities sometimes interfered with the flow of teaching.

As we received more space and moved the department to the eighth floor, I built a large teaching room using the most modern teaching methods with computers, overhead projectors, and we had discussions of recent research and simple seminars to introduce new material into our clinical practice.

Many years later I would meet my former students who are now heads of the army medicine, directors of hospitals, and leaders in different departments. They would always joke about the precise teaching methods and how much they had enjoyed studying cardiology as undergraduate students.

Teaching was my greatest investment in medicine in Israel and I had the opportunity to influence at least 50% of the students who passed through the Hebrew University.

Space and Expansion – Growth in the Hospital 

A university department of cardiology has to be well-balanced. Its primary function is patient care, but it is also responsible for teaching students and post-graduates. It should also encourage research to introduce all the latest technologies and innovations. The fundamental principles of organization are no different than that of a large business, which must be built on sound economic principles. Its final goal is patient health.

To proceed, it needs patients, persuading them that the department is excellent and better than others in the country, so that there is a continuous supply and input into the department.

Adequate space is essential to build a factory or a supermarket, and similarly, a medical department needs sufficient space – wards to hospitalise the patients, large outpatient clinics to care for the clients, offices to house the doctors, secretaries, nurses, technicians and research staff, and storage space for equipment and records.

Inadequate staffing prevents optimal production and patient care and creates inefficient work, backlogs, and waiting lists. In the hospital, insufficient or uncoordinated staff hampers an efficient patient flow. Outpatient clinics have to be optimal for services provided; insufficient nurses or technicians create long waiting lists; and the patients find other clinics or hospitals. Inadequate or insufficient equipment can create bottlenecks.

Funding  fees from the sick funds and private patients and charitable donations has to be maximised with income covering the costs, and leaving a small profit; while capital has to be carefully allocated to provide the most modern and efficient machinery or equipment.

I soon realised that my major function was to navigate the department through this maze of precise coordination.

Space is always a problem. When I arrived in 1973, all the available space in the hospital had been allocated, including the new oncology block and later the mother and child pavilion.

The echocardiography service, which started from scratch, occupied one room in the basement, and as we acquired more machines, we needed more space we were allocated space in the gastroenterology department on the fourth floor, and we converted it into the echocardiography department with two examination rooms and an animal research surgical laboratory. The area was far from the catheterization laboratory in the basement and the patient ward on the eighth floor. The rooms were not renovated; they were physically far from my center of work; and so, the area was not part of my daily route.

The next improvement was a new ward of six beds on the third floor. This had been part of the physiotherapy department, which had moved most of its activity to Mt. Scopus. The rooms were renovated with clean, white paint, spacious windows opening into the atrium of the hospital building and with completely new fittings. We now had more monitored beds to hospitalize our growing in-patient service in a shiny, modern ward. I felt rejuvenated, and we recruited new staff of young nurses. For the first time we had a really modern department.

Two years later, the administration decided that the bone marrow transplantation service was earning more than cardiology, and we were moved to the fourth floor, but shared less-renovated space with the emergency room short-term hospitalization ward. This was a hybrid of two different services, overseen by the same nursing staff. It was airy and spacious, but the patients were always mixed up.

Phase three of the expansion started 15 years later and we acquired the dermatology department inpatient wards, which transferred from the eighth to the fifth floor.  This consisted of half a wing of the hospital but it was ideal to move my office from the basement to the 8^th floor.  Fortunately, Prof. Penchas, the hospital director, was behind the move, and we had a good donor from New York.  The ward space had to be renovated completely and we built a new office for myself with a secretarial suite and a large room for Yonathan Hasin, two new large catheter suites, a control room, radiological facilities, a six bedded recovery room, kitchen and a small waiting space for the patients and their families.

There was more office space, and I moved my own office to the eighth floor. We had also continued with the extra beds on the third floor and then another ward on the fourth floor.

The catheterization suite and the radiological facilities were superb.  General Electric gave us a very good deal.  I ordered a L-Y gantry and with a biplane configuration and they added the equipment for the second room—a single plane at half price.  These new rooms gave us sterling service as we did 10 to 12 cases a day of which half were follow up angioplasties.  The machines were reliable with very little down time. 

The recovery room was a G-d send.  We now had extra beds to house the catheterized patients overnight and this solved our extreme bed shortage. 

The dermatology outpatient department occupied the transverse wing on the eighth floor and two years later moved to renovated space on the fifth floor.  This was our opportunity to provide more office space for the doctors and a new echocardiographic department, bringing it up from the basement.  There was a small conflict between myself and Prof., Stern, the hospital director.  He wanted to convert it into an outpatient clinic while I saw it as an outlet for my overcrowded doctors who had no personal office space.  The administration decided to use it as alternative space while they were renovating the ENT department so the building was delayed for two years.  It made me very sad as the corridor was half empty in the mornings when they held their public clinics and only filled in the afternoon when the seniors had their private practice.

I sat with the architects and with minimal structural changes we built a corridor of physician's offices, a conference room and a well organized echocardiographic suite and stress testing laboratory.  A new wind of change blew through the department and for the first time the physicians had their own comfortable personal offices. 

The echocardiographic suite was comfortable and the corridor waiting room was full with patients.

This overall expansion program took 25 years. I felt that it was 20 years too long. We always had too many patients, too many procedures, too few doctors and in adequate space. Yet this was the reason that I had come to Israel and despite the lack of coordination by the hospital directorate we developed the busiest and best  cardiovascular department in the country. The patients flowed from every direction: Nahariya and the Kibbutzim in the north, Haifa and its suburbs, Nazareth, Afula, Rehovot, Ashkelon and Beer Sheva. Less than half the patients came from Jerusalem. After I retired the situation reversed and now 90% of patients come from the Jerusalem conurbation.

It is not only the space that counted, but the vision, drive, passion, enthusiasm, team spirit and hard work that created success.

     

The Cardiac Revolution at Hadassah

The Cardiac Revolution at Hadassah

The Inheritance

Cardiology at Hadassah Hospital in 1973 was a very small operation, which functioned as a mere “service” to the more established departments. Cardiac patients were hospitalized in the Internal Medicine wards and treated by the Internists. Cardiology provided specialized services for consultations, ECG, arrhythmia monitoring, cardiac catheterization, pacemaker implantations and an outpatient clinic. The only beds that Cardiology had at its disposal were the four beds in a Intensive Cardiac Care Unit (ICCU), meant for the more severe cases and acute infarctions.

The cardiac diagnostic service was located on the second basement floor of the hospital along a corridor connecting the hospital and the medical school. The unit was located on one side of the corridor and the hematology department on the opposite side.

Since the corridor was the main thoroughfare from the medical school to the hospital and immediately adjacent to the main dining room, this created a continuous flow of human traffic in each direction and a very friendly, busy, market-like public environment. I soon became friendly with the hospital staff as they passed to and fro, but it was far too busy, and this disturbed our patients who used the corridor as their waiting room.

The unit was small. It had a conference room with a miniscule bookcase and library, a resident and secretarial offices. My office was three by three meters, opened into the main corridor and had no windows. The catheterization lab was also small (three by six meters) with very simple equipment, including a Philips patient table and a ceiling-suspended C-arm, which rotated in three planes. The X-ray generator was an old Westinghouse unit held together by a criss-cross of insulating tape to cover the exposed wires. There was a modern Arriflex 36-millimeter camera and a closed circuit television system. The Elema recording system worked with an ink-jet recorder. The lab could barely contain the equipment, the operators and the technician, and there were no nurses to attend to the patients.

We had three technicians, including Yaakov Fischer and Shmuel Raz. The cath lab investigated three patients a week. The techs worked in the experimental labs for the rest of the week.

There were two experimental labs: one directed by Prof. Braun which investigated isolated perfused rat hearts (the Langendorf preparation). They examined the effect of scorpion venom, which was toxic to the heart, and the ameliorating effect of beta blockers. The second lab was a dog lab dealing with electrophysiology.

The small ICCU was located on the eighth floor; it had four beds surrounded by curtains and a small monitoring station. The director of this unit, Prof. Rogel (Rosenberg), had a tastefully decorated, airy, adjacent office with a view of the hospital courtyard.

Full Throttle

My first priority was to improve my rudimentary Hebrew, so I attended a full-time Ulpan. After a month, I left the Ulpan and started activities at Hadassah.  

Time was short. It became apparent that the medical hiatus at Hadassah, without a new chief in charge had created a vacuum, which was being filled by the other senior staff. The department needed a new, fresh, active and dynamic chairman. I needed to start work and rev up the department.

The department had two senior associate professors, both born in Hungary. They had survived the Holocaust, and after the war had trained in Hadassah. Prof. Shlomo Rogel was the elder and ran the ICCU. Prof. Shlomo Stern was in charge of the cath lab and had an interest in 24-hour ECG monitoring and silent ischaemia. Danny Tzivoni was the senior registrar with Prof. Stern while Danny David worked with Rogel in the ICCU on the eighth floor.

I started working in the outpatient clinic. The environment was exciting. Instead of the Anglo-Saxon and Afrikaans patients, I was now working with and treating native Israelis, who were mostly from the Mediterranean littoral and who had a different outlook on life. I had never met people from Morocco, Libya, Egypt, Syria, Iraq, and Iran. They were more gentle but more vociferous and loaded me with presents of food and fruit. The clinic rooms were interconnected so that I could go from consulting room to consulting room without emerging into the patients’ corridor. The residents would see the patients, take their history, and then, I would supervise systematic history-taking and the detailed physical examination. We would discuss the diagnosis and plan a management program. There was a subtle difference in approach, as the Israeli graduates hade less training in physical examination. The number of patients in the clinic grew exponentially, as each patient brought his father, uncle and cousin. They were unaccustomed to a very friendly doctor, who placed the patient rather than the disease at the center of activity.

Soon, I had acquired sufficient patients to start catheterization. There were also sufficient patients in Internal Medicine with severe cardiovascular disease, who needed investigation, and it became possible to increase the number of studies. This disturbed the gentle pace of the technicians, but we soon expanded the program from three patients a week to three or four patients a day. Fortunately, this did not create a budget crisis, as we reused all the equipment; the catheters were cleaned carefully and sterilized in Cidex (gluteraldehyde). We also used Kifa tubing, which was heat malleable and we could fashion different shaped catheters. Later, we allowed ourselves the luxury of using disposable catheters.

I introduced daily meetings in order to analyze and discuss the catheterization studies and the patients in the ICCU. This was a new kind of clinical routine and inter-physician relationship, but soon, it became part of our daily activity and was the forerunner of what is now called “The Heart Team”.

I met with the hospital administration to plan a master program. Prof. Kalman Mann, the hospital director, and Dr Jack Karpas, his deputy, were very helpful. Mann was a father figure, who disliked arguments and confrontations, while Karpas, a fellow South African, who had been a general practitioner in Parow, near Cape Town was determined that my passage should be smooth and that I should succeed. We spent hours discussing the potential improvements. Hadassah had an important US Financial Aid Plan, which consisted of a large annual grant to buy American equipment that was shipped free of charge in American ships that had available cargo space. After two months, the new equipment began to arrive. First, the electric typewriter - the first one at Hadassah - an IBM Selectric with a golf-ball head. Then, the indicator dye dilution recorder to measure cardiac output, intracardiac shunts and valve incompetence. Then, the photographic recorder (NEP) for the catheter lab to make high fidelity pressure and phonocardiographic recordings. Next came the Elema X-ray cut film changer, so we could record angiograms of the patients with congenital heart disease at high resolution using full size X-ray films. This was a great improvement as we had to take the patents up 4 floors to the X-ray department with the catheters in place to use their roll film changer. The metamorphosis had started. There was a series of step-wise intellectual and technological advances. Once, one starts running, the race continues. The technicians changed their habits, as we streamlined the procedures and updated the laboratory to the standards of 1974.

It was clear that we did not have enough space, and Prof. Mann decided that we would inherit the basement area occupied by the Haematology Department. They had been allocated space in the new oncology block, but we had to wait until this was completed and opened. This took a year to materialize, but this addition provided space for a new catheterization theatre and anteroom, conference room, rooms for echocardiography, a new office for myself, and a rehabilitation suite. At last, I had a window overlooking the Jerusalem Hills and a separate examining room. Unfortunately, the Kupat Cholim would not subsidize the rehabilitation program, but we converted the suite into a spacious computer room with a large PDP-15 computer and hired Danny Sapoznikov from biomedical engineering to handle the programming.

It took two weeks to knock down the existing walls, but another year to finish the building with many unnecessary halts, while the builders went elsewhere to complete other building operations in parallel. My patience was stretched to the limit as the days, weeks, and months rolled by, and I sat watching the incomplete building project. Ultimately, it was finished, and we moved into our new cardiology department, which was already far too small for our needs.

I breathed a sigh of relief. We were up and running at full speed.

The Yom Kippur War

The Yom Kippur War was an abrupt introduction to the fiery dynamism of sudden change, which was so typical of Israeli life. Since Israel had taken control of the Sinai Peninsula in 1967, the Egyptians had been preparing to regain control of the Suez Canal and restore their pride. They rebuilt their armies on the Southern side of the Suez Canal. They also placed Russian heat-seeking SAM3 missiles to prevent the Israeli planes from penetrating Egyptian air space beyond the Canal Zone. Israeli army intelligence underestimated the Egyptian rearmament and despite the mounting signs of Egyptian activity, delayed mobilization of the army. The sudden attack on Yom Kippur of the Egyptians in the South and the Syrians in the North took the senior political echelon by surprise, and both fronts were unprepared for the sudden violent onslaught, particularly on Yom Kippur when most of the nation was in the synagogues. Mobilization of the Israeli Army was slow, and the Egyptians crossed the canal and started to penetrate into Sinai, while the Syrians rolled tank divisions across the Golan Heights. Mobilization of the army reserves took 72 hours. The opposing armies progressed unchecked, and their forces moved forward. Finally, after 72 hours, the Israeli forces started to dominate the battle, but the cost in casualties was very heavy.

The Yom Kippur War interrupted the renovation of the department. The entire staff, except myself and Rogel, were taken off to the army, and I was drafted to help Prof. Zaltz, Head of Surgery, to run an extended emergency room. The entire entrance foyer of the hospital was filled with beds. No one expected the ferociousness of the battle on the Southern Front. The Egyptians overran the Bar-Lev Line along the Suez Canal and decimated the Israeli Forces. There were hundreds of casualties, and after 12 hours, Soroka Hospital in Beer Sheva, the main hospital in the South, was inundated and the overflow poured into Hadassah. We had a major crisis, and the surgeons and anesthetists were swept off their feet in the operating rooms. I was left dealing with the acute emergencies as they arrived, including diagnoses along with emergency fluid and blood replacement for the patients in shock. The pragmatic instruction, which I received in surgery at medical school and my experience in Gatooma stood me in good stead.

All the cardiologists except Rogel were drafted. The staff disappeared overnight, so I offered temporary appointments to Andre Hirschorn (Keren) and David Halon. Both were studying at Ulpan Etzion, and soon, they came to work in the hospital. They were bright and eager beavers, absorbed the cardiology, and mastered Hebrew. Andre had just arrived from Targu-Mures in Rumania and David from Birmingham in England.

As the Egyptian onslaught abated and the Israeli troops reversed the tide of war, the Emergency Room became quieter, and I was able to return to cardiology and investigate the patients who had been deferred. Danny Tzivoni had been injured in the forearm and needed a period of convalescence, but the new medical team waded into the fray.

The two professors of Internal Medicine - Profs. Eliakim and Stein, who were in control of the hospitalization beds were interested in learning a more modern clinical approach to cardiology, so I spent an afternoon each week rounding in Internal Medicine A and B with the chiefs and the residents. I introduced the English tradition of bedside clinical cardiology and physical examination, which had dominated London since Paul Wood had taken charge of the National Heart Hospital. I became known as the cardiologist who had introduced the fourth heart sound and percutaneous coronary angiography.  

Expansion and Consolidation

The Cardiology Department at Hadassah continued to develop, grow, and expand. The outpatient clinic grew from 20 to 80 patients a week. I had my own program in working with the residents: they would receive the patients, and I then saw and examined all the patients personally with them, and, in this way, taught them good clinical medicine.

The department was very active. I put in long 12-hour clinical days, interspersed with regular ward rounds and staff meetings. I also made rounds in both internal medicine departments and liaised closely with the surgeons in pre- and post-operative care, carefully reading all the current literature and introducing new technologies. The clinical research, reviewing the different patient groups, progressed, and we spent most of our free evenings at my home with the residents poring over the results of the research and analyzing the information. The excitement was contagious.

We expanded and changed the secretarial staff, so they were able to handle the large clinical and research load.

We built the new catheterization suite. The space was limited but consisted of a very large room with an anteroom for preparing the patients. Unfortunately, the patients, who were awaiting a procedure, were parked in the corridor, as were the patients who had finished the angiography. This was very uncomfortable for the staff and the patients, since the corridor was the main passageway between the medical school and the hospital with very heavy foot traffic.  

We were limited to equipment made in the United States, as it was funded by a United States Congressional Grant, and we elected to purchase a General Electric unit, which had a rotating table, although I would have preferred a Phillips trapezoidal gantry, which would have provided additional caudal and cranial views.

There was no storage space, and all our equipment was stored in cupboards in the public corridor.

The number of patients who needed catheterization grew exponentially, and within a month or two, we studied four patients a day, and this continued to increase. The floodgates had opened, and patients poured in from all parts of Israel as our reputation expanded.

The technicians were unaccustomed to this workload, but gradually Ya’akov and Michael, our new technicians, adapted to the hard work schedule. They had to be the porters, technicians, and nurses, and we always worked with insufficient staff.

Our days became longer. Ya’akov, Michael, Bianca, and Leah, the new technicians, were prepared to work hard, and we rarely closed the cath lab before 7:00PM.

Ya’akov Fisher came from Slovakia, where he weathered the Holocaust and survived with difficulty. In the work camps, he volunteered to do any work that was available and made himself indispensable. He came to Hadassah as the cleaner, helped prepare the animals in the experimental lab, learned how to clean the cath lab and use the equipment, became an expert in photography, and was the most loyal of the workers in the department.

Michael and Leah came from Georgia, and for them, after-hour work was part of the daily routine.

Bianca came from Rumania and had great empathy with the patients.

Later, Rebecca Shein joined.

The work in the cath lab was very difficult and complicated. The technicians had to move the patient onto the catheter table, help with the cleaning of the skin, help drape each patient in a sterile fashion, prepare the pressure measurement and angiographic equipment, monitor the patients, help with resuscitation, record all the pressures, develop the angiographic films, and then, take down the blood-covered drapes, which were cleaned and then sent to the laundry. The catheters were cleaned meticulously and then re-sterilized. The cleaning process took as long as the actual catheterization, and the next patient was waiting impatiently in the corridor for his/her turn.

It was difficult to recruit Israeli medical staff, who were unwilling to work such long and demanding hours.

When I came to Jerusalem in 1973, I had been promised the beds of the pulmonary in-patient service on the eighth floor of the hospital. Unfortunately, when the administration closed the pulmonology in-patient service, they re-allocated the beds, which had been promised to me, to the new staff, who were recruited to open the new Department of Internal Medicine at Mount Scopus Hospital. The renovation of the old hospital was two years behind schedule, and the newly recruited medical staff were very impatient, as the hospital had no beds available for patients. Ultimately, the Mt. Scopus Hadassah Hospital was completed, and the internal medicine physicians moved out of the Ein Kerem facility. The area was renovated, albeit slowly at Israeli pace, and we expanded the ICCU to six beds with a pace-making suite and another eight beds for cardiology. We always had a chronic bed shortage, but the nurses were good, and the turnover of the patients was very quick and efficient.

We received a new generation of 3-channel ECG machines and provided a much more effective service.

We acquired our first echocardiographic recorder, and Basil Lewis, who had arrived from South Africa, took over the service. At first, we had a simple M-Mode machine, and with a few energetic young students, we produced our first studies on mitral stenosis and started studies on the heart in Thallasaemia. We had a group of very bright students running in and out of the echo room. Richard Popp from Stanford brought a 2-D echo machine for demonstration. It was so impressive that Prof. Mann found the funds for it immediately, so it never returned home. This was the great revolution in cardiology and provided non-invasive real time imaging of all the structures of the heart excluding the coronary arteries.

The service flourished, but it took 35 years to persuade the administration to realize that a second shift would triple the income of the unit.

When we introduced coronary angioplasty in 1979, we continued with the same staff, having doubled the workload.

The administration calculated my physician-staff needs on the basis of the department of health’s staffing structure, which had been drawn up in 1973, before expansion into coronary angioplasty had even been introduced.