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.