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U.S. Department of Education

 

Redetermination of Comparabiity for Israel

 
Prepared September 2016
 
Background
 
At its September 1999 meeting, the National Committee on Foreign Medical Education and Accreditation (NCFMEA) determined that the accreditation standards used by the Council for Higher Education (CHE) to evaluate medical schools in Israel were comparable to those used to evaluate programs leading to the M.D. degree in the United States. A CHE decision in February 1999 authorized the establishment of a permanent committee, the Committee for Re-Evaluation of Medical Schools (hereafter, Committee), as the CHE entity responsible for the evaluation of medical schools in Israel.

At its September 2001, September 2002 and March 2004 meetings, the NCFMEA accepted the periodic reports submitted by the CHE on its accreditation activities in Israel. During its 2008 meeting the NCFMEA continued to find the CHE standards comparable to those used in the United States. In addition, the NCFMEA accepted the periodic report submitted by CHE during its April 2013 meeting.

Israel was originally scheduled to be reviewed at the Fall 2014 NCFMEA meeting, but had asked to be rescheduled due to personnel changes that had delayed compilation of the agency’s application narrative and documentation. Israel submitted its application in February 2015 and Department staff requested additional information regarding numerous areas, which were due by July 5, 2015. (The NCFMEA did not meet in Spring 2015.)

Israel never responded to the Department’s questions. Therefore, on July 28, 2015 Department staff wrote to Dr. Varda Ben-Shaul and Daniella Sandler informing them that as a result of its failure to respond by the deadline Israel could not be placed on the Fall 2015 NCFMEA agenda, and would be rescheduled for the Spring 2016 NCFMEA meeting. On July 29 Daniella Sandler responded that Israel would send the material needed for the spring 2016 meeting. Since the materials were never received, Department staff again wrote to Israel on January 4, 2016 and asked that Israel’s intentions be conveyed to the Department of Education expeditiously. As done previously, the email again noted that failure to submit the necessary information “could adversely affect Israel’s continued positive listing by the NCFMEA in 2016.” After some email exchanges and an additional request from the country for a delay, the country’s current application for a redetermination of comparability was received by the Department on July 14, 2016.

Based on the information provided, it appears that the country has an evaluation system that remains substantially comparable to that used to accredit medical schools in the United States. While the CHE has provided substantial information regarding the country’s quality assurance system standards for medical education in Israel, there are some areas where further information may be helpful. Those issues are noted in the Summary of Findings and the Staff Analysis sections.

(For an overview of related issues found by the international team that evaluated the Israeli medical schools for the CHE, the reader is encouraged to peruse Exhibit 22, which is the General Report on Israeli Medical Schools produced in August 2014 by the Committee for the Evaluation of Medical Study Programs.)
 
Summary of Findings
 
Additional information is requested for the following questions. These issues are summarized below and discussed in detail under the Staff Analysis section.

-- It is unclear how many medical schools in Israel that admit American students use MCAT scores in admitting those students. [Admissions, Recruiting, and Publications, Question 1]

-- The actual effect of the transitional provision to reduce the number of non-Israeli citizens admitted to medical schools is unclear. [Admissions, Recruiting, and Publications, Question 4]

-- It is unclear if the introductory Hebrew lessons offered to English-speakers at selected medical schools are sufficient for interpreting the Hebrew medical charts used in clinical training. [Admissions, Recruiting, and Publications, Question 5]

-- It is still unclear how the CHE expects each medical school to use the data resulting from national examinations for those not practicing medicine in Israel. In addition, it is still unclear how the CHE itself evaluates the relevant performance data that is reviewed. Furthermore, it is still unclear if the CHE would consider establishing any benchmarks to compare student achievement results from the accredited medical schools. [Student Achievement, Question 4]

-- It is still unclear how the evaluators verify the actual conditions at the local training sites where the students are being educated and trained. [Onsite Review, Question 1]

-- It is unclear if any Israeli medical schools utilize any international clerkships in countries other than India. [Onsite Review, Question 2]

-- It is unclear how the CHE fulfills the NCFMEA expectation that a comparable accreditor will conduct timely on-site evaluations of all core clinical clerkship sites as part of its standard accreditation process. [Onsite Review, Question 3]

-- It is unclear how Israel’s use of clinical sites in India will change now that India is no longer on the list of foreign countries found comparable by the NCFMEA. [Onsite Review, Question 5]

-- The NCFMEA may wish to inquire what concrete steps will be taken in the near future to meet the recognized need for more detailed student performance data. [Accrediting/Approval Decisions, Question 3]

-- It is still unclear if the CHE has any plans to incorporate the performance of graduates on licensing examinations into its medical school accreditation decision-making process anytime in the near future. [Accrediting/Approval Decisions, Question 4]

 
Staff Analysis
 
PART 1: Entity Responsible for the Accreditation/Approval of Medical Schools
 
Approval of Medical Schools, Question 1
 
Country Narrative
The Council for Higher Education has the authority and responsibility to certify or license the medical schools in Israel. The Council for Higher Education was established as a corporation under the Higher Education Law 1958 ("the Law") as the national body in charge of higher education.
As can be seen in Appendix 1 (CHE Law) and appendix 2 (CHE general information) The Council for Higher Education's decision to approve the opening and maintaining of an institution of higher education is the first stage in the process of accreditation of such an institution (section 9). At this stage the institution is not yet authorized to award academic degrees to graduates. The Council's decision to grant a permit to an institution of higher education requires governmental approval. The opening of any new study program requires the Council's authorization. An institution operating at this stage must notify its students that until it has received accreditation and authorization, it cannot award academic degrees.
The accreditation stage –Once the Council for Higher Education makes the decision to grant an institution of higher education, which has already received a permit, with accreditation in accordance with Section 9 of the Law, the institution becomes an accredited institution for higher education and it benefits from the academic and administrative freedom granted under Section 15 of the Law. The Council's decision to grant accreditation to such an institution requires governmental approval. An institution which has received accreditation is authorized to grant academic degrees in accordance with the specific authorization received.
In addition and in accordance with the decision of the Council for Higher Education, institutions of higher education must be non-profit organizations, therefore the medical schools in Israel are all non-profit schools.
 
Analyst Remarks to Narrative
Israel’s Council for Higher Education (CHE) is the body designated by law to evaluate all higher education institutions in the country and to provide those institutions with accreditation. The CHE carries out its work using the “Standards for Evaluation of Medical Schools and Medical Education.”

The CHE uses the services of an Evaluation Committee, comprised predominantly of international medical experts, to evaluate each medical school while on site and to prepare the site visit report of their findings. Only non-profit medical schools can be accredited.
 
Approval of Medical Schools, Question 2
 
Country Narrative
The entity in charge of monitoring and evaluating medical schools in Israel is the Quality Assessment and Assurance Division (QAD) which was established in 2004 and is a division of the Israeli Council for Higher Education (Appendix 3 QAU general information). The process of quality assessment and assurance is based on self-evaluation within and by the institutions, see appendix 4 (QA guidelines) for a detailed view of the self evaluation guidelines that are the base for the evaluation process.
The CHE decided that at the initial stage, quality assessment and assurance in the higher education system in Israel would be carried out at the study program level, as was done with the Medical schools.
The QAD only evaluates "recognized degrees" that are already accredited by the CHE Law section 22, and are authorized to visit and inspect institutions by section 25G
CHE Law (appendix 1):
" The institution in Israel shall present the Council, at any time the Council may so demand, details with regard to its structure and its activities and any other information the Council may demand from it; the Council or a person acting on its behalf shall be entitled to visit the institution in Israel in order to inspect and check that the conditions of the license are being compiled with".
 
Analyst Remarks to Narrative
The CHE is the body designated by law to approve and monitor all medical schools. Site visits are conducted every six years and the most recent series of site visits to medical schools under the auspices of the CHE included accreditation renewal visits to Ben-Gurion University on February 24-26, 2014; The Technion on March 2-4, 2014; Tel Aviv University on May 19-21, 2014; and Hebrew University-Hadassah on May 25-27, 2014. A site visit to a relatively new medical school in the process of seeking full CHE accreditation was conducted at Bar-Ilan University on June 1-2, 2014.
 
Approval of Medical Schools, Question 3
 
Country Narrative
In Israel, the governmental entity with the authority to close a medical school or to take away its right to operate is the CHE. according to CHE Law (appendix 1) section 18: "The Council may withdraw its accreditation of an accredited institution on the basis of rules prescribed by it for this purpose; but those rules shall not limit the freedom of opinion and conscience".
In addition, the decision to withdraw accreditation needs the approval of the government as seen in section 19 of the CHE Law (appendix 1): "A decision of the Council under section 18 shall require the approval of the Government; but the Government shall not approve such a decision until the institution, the accreditation of which has been withdrawn, has been given a reasonable opportunity to plead its case and produce its evidence before the Minister of Education and Culture or a person appointed by him in that behalf; the Government may also return the matter to the Council for reconsideration, and upon its deciding to do so, the provisions of section 11 shall apply mutatis mutandis".
 
Analyst Remarks to Narrative
In Israel the government entity with the ability to close a medical school is usually limited to the CHE. However, the country has a system of checks and balances that allows for a school to appeal the CHE’s decision to the Israeli government. The government may confirm the original CHE decision or send it back to the CHE for reconsideration. In any case, the government has the final say.

Regarding a school’s appeal to the Israeli government, it is unclear if a medical school has ever appealed an adverse CHE decision to the government, and the CHE decision was overturned or not confirmed.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response

Although no medical schools have appealed an adverse decision of CHE, it should be noted that the Israeli Government did accept the decision of CHE not to allow opening of private medical schools in Israel
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if a medical school has ever appealed an adverse CHE decision to the government, and that the CHE decision was overturned or not confirmed.

In response, the country indicated that no medical schools have appealed an adverse CHE decision. Alternatively, the country noted that the Israeli Government accepted the CHE decision to not allow private medical schools in Israel.
 
Staff Conclusion: Comprehensive response provided
 
Accreditation of Medical Schools
 
Country Narrative
The QAD is the entity responsible for onducting in-depth evaluations of each medical school in order to assess the medical school with respect to a defined set of standards of educational quality. As can be aseen in the QAU overview (appendix 3) Study programs at all levels in a given academic field will undergo a quality assessment process once every six years or so and willl follow the QA guidlines for self evaluation (appendix 4).
A single external committee is appointed by the CHE in order to examine all study programs of a certain field at all institutions and all recognized programs (section 22 CHE Law, appendix 1). The evaluation process is conducted by an external committee appointed by the CHE (see section 3.2.2 QAU overview, appendix 3): "The committee is composed of senior academic figures in the evaluated field from leading institutions in Israel and abroad, and the majority of its members are non-Israelis. A senior non-Israeli academic figure is appointed as chairperson. The committee examines the self-evaluation reports and performs on-site visits to the institutions. In the framework of its visit, the committee meets with various stakeholders, among them the institution's management, senior and junior faculty, students etc. and tours the institution. In the event that a member of the committee is also a faculty member at an evaluated institution , he/she will not take part in the discussions and evaluation of that institution".
 
Analyst Remarks to Narrative
CHE is the official entity responsible for conducting in-depth evaluations of each higher education institution, including medical schools. CHE uses general guidelines that cover the basics that would need to be present in every institution of higher education. Responsibility for the successful functioning of the evaluation process is overseen by the CHE’s Quality Assessment and Assurance Division (QAD).

In addition, due to the special nature of medical education, CHE has adopted a special set of standards and procedures for the evaluation of medical schools (cf. Exhibit 5). Furthermore, CHE obtains experts in medical education from outside of Israel to conduct those specialized evaluations of medical schools.
 
Accreditation of Medical Schools, Question 2
 
Country Narrative
According to the "Standards for Evaluation of Medical Schools and Medical Education" (appendix 5, section 5.2) to which the Medical Schools adhere too, "The program's faculty is responsible for the design, implementation, and evaluation of the curriculum. There must be integrated institutional responsibility for the design and management of a coherent and coordinated curriculum. The chief academic officer must have sufficient available resources and authority provided by the institution to fulfill this responsibility. The curriculum of the program leading to the M.D. degree must be designed to provide a general professional education, recognizing that this alone is insufficient to prepare a graduate for independent, unsupervised practice. Medical schools must evaluate educational program effectiveness by documenting the achievement of their students and graduates in verifiable and internally consistent ways that show the extent to which institutional and program purposes are met.
The committee responsible for curriculum should give careful attention to the impact on students of the amount of work required. The committee should monitor the content provided in each discipline in order that objectives for education of a physician are achieved without attempting to present the complete, detailed, systematic body of knowledge in that discipline. The objectives, content, and methods of pedagogy utilized for each segment of the curriculum, as well as for the entire curriculum, should be subjected to periodic evaluation. Redundancies and deficiencies in the curriculum identified by the evaluations should be corrected.
Medical schools should use a variety of measures to evaluate program quality, such as data on student performance, academic progress and program completion rates, acceptance into residency programs, postgraduate performance, and emerging measures that may prove to be valid. The results of such evaluations should be used to determine how well schools are fulfilling their objectives and to assess the need for program improvement. Schools also should evaluate the performance of their students and graduates in the framework of national norms of accomplishment. Review and necessary revision of the curriculum is an ongoing faculty responsibility".
As specified in section a and b, the QAD is the Israeli entity that is responsible for evaluating accredited programs such as the medical schools in Israel (appendix 3+4) reporting to the CHE according to the CHE Law (appendix 1). The relationship between the medical school's quality assurance internal process and the QAD's process is regulated by evaluations of the medical schools once in about 6-7 years by external evaluation committees. The QAD can verify "to what extent the contents, structure and scope reflect the goals of the study program, the distribution of studies throughout the academic year, the organization and content of the courses, the process of renewing and updating the content, adaptation to the established purposes and goals, the involvement of non-academic bodies in the study program's activities and, etc". (Appendix3, section 3.1.2).

 
Analyst Remarks to Narrative
As presented in the supporting documentation provided by the country in response to this section, there is a clearly defined system in Israel for the establishment, accreditation, monitoring and closure, if necessary, of medical schools. CHE is the only entity authorized to accredit medical schools in Israel.

 
Part 2: Accreditation/Approval Standards
 
Mission and Objectives, Question 1
 
Country Narrative
In each one of the Israeli Medical schools mission statement there is a declaration of public service and the schools are checked if the schools activities stand behind these declarations.
For example: Tel Aviv University mission statement: Our mission is to train outstanding physicians,
imbued with moral and professional values; and gifted with clinical skills and knowledge. We aim to provide them with the competencies that will allow them to excel in the hospital and the community work, during residency and throughout their entire career, as clinicians, researchers and teachers. (see appendix 7)

Ben Gurion University (Appendix 6) : "In keeping with the "Beer-Sheva" Spirit, the Faculty of Health Sciences at Ben-Gurion
University of the Negev views the approach to mental, social, cultural and inter-cultural
aspects of life as an inseparable part of study, research, health promotion and treatment of the physical and mental health of the individual. The faculty supports the advancement of health services in the community. In addition to the faculty's local and national mandate, the establishment of the Medical School for International Health (MSIH) was aimed to turn
BGU's focus internationally, a natural continuation and extension of its primary care, community focused and service oriented mandate. The MSIH was launched in 1998 specifically to advance global health medicine education. This school addresses the need for medical education that focuses on the interface between international health and community and preventive medicine. It follows the standard of the North American model for a 4 year medical program."
 
Analyst Remarks to Narrative
The Israeli “Standards for Evaluation of Medical Schools and Medical Education” (hereafter, Standards) closely reflect the language in this section of the NCFMEA guidelines. In addition, the Israeli narrative notes that in each medical school’s mission statement there is a declaration of public service. This statement ensures that each medical school will consciously strive to give its graduates the background necessary to serve the general public interest.
 
Mission and Objectives, Question 2
 
Country Narrative
According to the "Standards for Evaluation of Medical Schools and Medical Education" A medical school must define its objectives and make them known to faculty and students (appendix 5, section 1) to which the Medical Schools adhere too. "The program's faculty is responsible for the design, implementation, and evaluation of the curriculum" (appendix 5, section 5.2) in addition "the faculty must participate in a process that defines the objectives of clinical education and establishes quantified criteria for the types of patients (real or simulated), the level of student responsibility, and the appropriate clinical settings necessary to accomplish these purposes. A system for monitoring the achievement of clinical educational goals must be developed, based on these criteria, and students must be evaluated in this framework. If the level or diversity of student interactions with patients does not meet the school-based criteria, specific mechanisms must be in place to adjust the criteria or to alter the educational program. Either may be done only within appropriate, documented means that ensure continued educational quality." (appendix 5, section 5.3).
one of the questions the medical schools have to answer during the self evaluation process to describe the mission statement of the department/study programs, its aims and goals. What is the Strategic Plan of the department and its study programs? What actions will be taken in the near future? (appendix 4, section 1B, p.5;). when the schools submit their self evaluation reports (appendix 6,7,8) they answer these questions and have to show the committee that they answer to their own mission and goal and that they follow their curriculum and program objectives as stated in the Medical standards (appendix 5).
 
Analyst Remarks to Narrative
The Standards ensure that the faculty is highly involved and responsible for all aspects of the curriculum in a continuous manner. There is a clear sense throughout the standards that the prerogatives of the faculty regarding matters of curriculum are paramount. In addition, the medical school faculty is responsible for a curriculum that provides a solid basis for evaluating student achievement.
 
Mission and Objectives, Question 3
 
Country Narrative
According to the "Standards for Evaluation of Medical Schools and Medical Education" The faculty of a medical school must be appropriately qualified to teach and be involved in decisions involving admissions and curriculum (appendix 5, section 3, p. 1). That been said "the medical faculty is responsible for devising a curriculum that enables students to learn the fundamental principles of medicine, to acquire skills of critical judgment based on evidence and experience, and to develop an ability to use principles and skills wisely in solving problems of health and disease".(appendix 5, section 5.3, p. 4--5)
in order to ensure that the objectives of the educational program will be formally adopted by the faculty, as a whole, and through its recognized governance process
"the manner in which the medical school is organized, including the responsibilities and privileges of administrative officers, faculty, students, and committees must be promulgated in medical school or university bylaws. A committee structure is the usual mechanism for involving faculty and others in decisions concerning admissions, promotions, curriculum, library and research, etc. The names, membership, and functions of such committees are not prescribed by these standards, but rather are subject to local determination and needs (appendix 5, section 3, p. 2).
 
Analyst Remarks to Narrative
The Standards clearly require faculty involvement in the development of the objectives of the education program at each medical school. In addition, the Standards expect that the objectives of the educational program will be adopted by the faculty through its recognized governance process (cf. Exhibit 5, Sections 3 and 5.3).
 
Mission and Objectives, Question 4
 
Country Narrative
According to section 5.4 of the "Standards for Evaluation of Medical Schools and Medical Education" (appendix 5) the chairman of each discipline should set the standards of achievement by students in the study of that discipline. Furthermore "the medical school faculty must establish principles and methods for the evaluation of student achievement, and make decisions regarding promotion and graduation. The evaluation of student achievement must employ a variety of measures of knowledge, competence and performance, systematically and sequentially applied throughout medical school. Each provisionally accredited program must utilize methods for determining the quality of its program and the level of achievement of its students compared to national norms.The chairman of each discipline should set the standards of achievement by students in the study of that discipline. Narrative descriptions of student performance and of non-cognitive achievements should be recorded to supplement grade reports in all required clinical clerkships and in all courses where student-faculty interaction permits this form of assessment. The faculty committee should review the frequency of examinations and their scheduling, particularly when the students are enrolled in several subjects simultaneously. The Council for Higher education urges schools to develop a system of evaluation that fosters self-initiated learning by students, and disapproves of the use of frequent tests which condition students to memorize details for short-term retention only. Examinations (written and others) should measure cognitive learning, mastery of basic clinical skills, and the ability to use data in realistic problem solving. Institutions must develop a system of assessment which assures that students have acquired and can demonstrate on direct observation the core clinical skills and behaviors needed in subsequent medical training. Communication skills are integral to the education and effective function of physicians. There must be specific instruction and evaluation of these skills as they relate to physician responsibilities, including communication with patients, families, colleagues and other health professionals. There must be comparable educational experiences and equivalent methods of evaluation across all alternative instructional sites within a given discipline".
 
Analyst Remarks to Narrative
As expressed in the Standards (Exhibit 5, Section 5.4), it is expected that the “chairman of each discipline should set the standards of achievement by students in the study of that discipline. Narrative descriptions of student performance and of non-cognitive achievements should be recorded to supplement grade reports in all required clinical clerkships and in all courses where student-faculty interaction permits this form of assessment.”

In addition, “Institutions must develop a system of assessment which assures that students have acquired and can demonstrate on direct observation the core clinical skills and behaviors needed in subsequent medical training.”
 
Mission and Objectives, Question 5
 
Country Narrative
Section 1 of the "Standards for Evaluation of Medical Schools and Medical Education" (appendix 5), states that "The main objective of a program of medical education leading to the M.D. degree in Israel is to prepare its graduates to enter and complete graduate medical education, to qualify for licensure, to provide competent medical care, and to have the educational background necessary for continued learning. A medical school may establish additional objectives for its educational program, consistent with its program resources. A medical school must define its objectives and make them known to faculty and students".
In addition, they make sure that "The educational program of a medical school must be of sufficient length to meet the main objectives and its particular mission and objectives, and to provide students with knowledge and skills necessary to become qualified physicians. The curriculum must provide a broad-base education in the science basic to medicine, a variety of clinical subjects, and various ethical, behavioral and socioeconomic subjects pertinent to medicine. The requirements for successful completion of the program of medical education must include a particular focus on clerkships and other form of clinical training. Students must have hands-on experience"(appendix 5, section 5, p.3).
 
Analyst Remarks to Narrative
The Standards closely mirror the language of the NCFMEA requirements regarding the preparation of graduates to enter and complete graduate medical education, to qualify for licensure, to provide competent medical care, and to have the educational background necessary for continued learning. As well, the Standards are designed to ensure that all of these aspects are carefully evaluated when each medical school is visited during its initial evaluation and subsequent re-evaluations.
 
Governance, Question 1
 
Country Narrative
The CHE is the body responsible for requiring medical schools to be legally authorized or licensed to provide a program of medical education based on section 9 of the CHE Law (appendix 1) "The Council may accredit a particular institution as an institution of higher education on the basis of rules prescribed by it for the accreditation of institutions of higher education" and as "no educational institution shall use a designation which might be taken to refer to a permit or accreditation or license under this Law unless it has received such a permit or such accreditation, as the case may be"(appendix 1, section 21Hb, p.6)), therefore an accredited institution for higher education may award academic degrees to the graduates of a study program only after receiving specific authorization to do so. The Council's authorization is necessary in order for an institution of higher education to award academic degrees in any new study programs (appendix 1, section 22, p.6).
 
Analyst Remarks to Narrative
CHE is the oversight body for all higher education institutions, and as such, it is responsible for the oversight of all medical schools. All medical schools are required to be legally authorized in order to provide medical education, and CHE grants that authorization.

CHE’s authority and the requirements for a school to be legally authorized are established in Israeli regulations and specifically executed through the Standards, which provide the requirements regarding medical education.
 
Governance, Question 2
 
Country Narrative
The administrators of medical schools are held accountable for the operation and success of the school and its programs to an authority external and independent of the medical school, that authority is the Council for higher Education.
Section 3 of the "Standards for Evaluation of Medical Schools and Medical Education" (appendix 5) states that "The manner in which the medical school is organized, including the responsibilities and privileges of administrative officers, faculty, students, and committees must be promulgated in medical school or university bylaws." in addition to that, they must make sure they evaluate educational program effectiveness by documenting the achievement of their students and graduates in verifiable and internally consistent ways that show the extent to which institutional and program purposes are met." (appendix 5, section 5.2, p.3-4).
The QAD is the branch of the CHE that assess the quality and evaluates the recognized and accredited programs such as the medical schools. Study programs at all levels in a given academic field will undergo a quality assessment process once every six years. A single external committee is appointed by the CHE in order to examine all study programs of a certain field at all institutions. (Appendix 3). During the visit the committee meets with the administrators of the institution and the program and deliberates with them regarding different aspects of the program (appendix 4- QA guidelines; appendix 9- BGU site visit schedule).
 
Analyst Remarks to Narrative
As previously noted, all medical schools are required to be legally authorized in order to provide medical education, and CHE grants that authorization. Each medical school must be accountable to the Governing Board of their university and each university must be accountable to the CHE.

CHE is also in charge of authorizing accredited institutions to establish academic units in all fields, including medicine, and to grant academic degrees. As a further safeguard, the Israeli Standards require that a medical school in Israel must be part of a non-profit university. When a university wants to open a new medical school, gain authorization to provide medical education and grant an accredited academic degree in medicine, it must do it all through the CHE.
 
Administrative Personnel and Authority, Question 1
 
Country Narrative
Medical schools in Israel are to be administered according to the Standards for Evaluation of Medical Schools and Medical Education.
section 3 of the standards state that: "The administration of a medical school must be effective and appropriate in light of the main objectives and its particular mission and objectives.
The chief academic official of a medical school must be qualified by education and experience to provide leadership in medical education. The faculty of a medical school must be appropriately qualified to teach and be involved in decisions involving admissions and curriculum. Administrative officers and members of a medical school faculty are appointed by, or on the authority of, the governing board of the medical school or its parent university. The chief official of the medical school, who usually holds the title "dean," must have ready access to the university president or other university official charged with final responsibility for the school, and to other university officials as are necessary to fulfill the responsibilities of the dean's office.
The dean must be qualified by education and experience to provide leadership in medical education, in scholarly activity and research, and in care of patients. The dean should have the assistance of such associate or assistant deans and staff as are necessary for administration of admissions, student affairs, academic affairs, graduate education, continuing education, hospital relationships, research, business and planning, and fund raising.
The manner in which the medical school is organized, including the responsibilities and privileges of administrative officers, faculty, students, and committees must be promulgated in medical school or university bylaws. A committee structure is the usual mechanism for involving faculty and others in decisions concerning admissions, promotions, curriculum, library and research, etc. The names, membership, and functions of such committees are not prescribed by these standards, but rather are subject to local determination and needs.
In determining the appropriate organization, emphasis should be placed on the importance of the collegiality of the medical school faculty responsible for undergraduate medical education and for the continuum of medical education. Ambulatory consideration should be given to the commitments of faculty members who have multiple academic responsibilities in several educational programs of a complex university, so as to assure each educational program adequate faculty resources. A decision must be made concerning the provision of a single faculty or of combined faculties to serve the needs of each of several health-related or other academic programs of the university, and concerning the advisability of joint faculty appointments. The school must ensure that appointments such as “clinical professors”, must be made according to approved academic criteria." (appendix 5, section 3, p. 1-2)
 
Analyst Remarks to Narrative
The Standards expect the dean to have the assistance of such associate or assistant deans and staff as is necessary for administration of admissions, student affairs, academic affairs, graduate education, continuing education, hospital relationships, research, business and planning and fund raising.

In addition, the Standards expect that the commitments of faculty members who have multiple academic responsibilities in several educational programs of a complex university are balanced so that each educational program has adequate faculty resources, and that appointments such as clinical professors are made according to approved academic criteria.
 
Administrative Personnel and Authority, Question 2
 
Country Narrative
As stated before, the Medical schools in Israel are to be administered according to the Standards for Evaluation of Medical Schools and Medical Education.
section 3 of the standards state that: "The chief academic official of a medical school must be qualified by education and experience to provide leadership in medical education.
The faculty of a medical school must be appropriately qualified to teach and be involved in decisions involving admissions and curriculum.
Administrative officers and members of a medical school faculty are appointed by, or on the authority of, the governing board of the medical school or its parent university.
The chief official of the medical school, who usually holds the title "dean," must have ready access to the university president or other university official charged with final responsibility for the school, and to other university officials as are necessary to fulfill the responsibilities of the dean's office.
The dean must be qualified by education and experience to provide leadership in medical education, in scholarly activity and research, and in care of patients. The dean should have the assistance of such associate or assistant deans and staff as are necessary for administration of admissions, student affairs, academic affairs, graduate education, continuing education, hospital relationships, research, business and planning, and fund raising." (appendix 5, section 3, p. 1-2).
 
Analyst Remarks to Narrative
The Israeli Standards provide overall support for this section of the NCFMEA guidelines, and contain similar language describing the role of the dean (chief academic officer), his authority, and his access to the appropriate university officials.
 
Administrative Personnel and Authority, Question 3
 
Country Narrative
The program's faculty is responsible for the design, implementation, and evaluation of the curriculum. There must be integrated institutional responsibility for the design and management of a coherent and coordinated curriculum. The chief academic officer must have sufficient available resources and authority provided by the institution to fulfill this responsibility as stated in the Standards for Evaluation of Medical Schools and Medical Education (appendix 5, section 5.2).
In addition "The medical school must have adequate resources to provide clinical instruction to its medical students. Resources must include ambulatory care facilities and hospitals
where the full spectrum of medical care is provided and can be demonstrated. Each major clinical department must have a residency program accredited by the Israel
Medical Association Scientific Council. The number of hospital beds required for education cannot be specified by formula, but the aggregation of clinical resources must be sufficient to permit students in each of the major clerkships to work up and follow several new patients each week. Since undergraduate medical education usually requires the conduct of simultaneous and mutually supportive programs of graduate medical education, clinical facilities must be adequate for both parts of the continuum of medical education. A hospital that provides a base for the education of both medical students and residents must have adequate library resources, not only for the clinical staff, but also for the faculty and the students. Ready access to areas for individual study, for conferences, and for lectures is necessary." (appendix 5, section 7.4).

 
Analyst Remarks to Narrative
The Standards help ensure that the chief academic officer has sufficient access to the necessary resources and authorities. Although department heads and senior clinical faculty members are not addressed specifically, it is clear that the intentions of the Standards are to ensure that the faculty, including all the clinical faculty, has sufficient resources and authority to effectively instruct students.

 
Chief Academic Official, Question 1
 
Country Narrative
the person who holds the position of chief academic official of a medical school in Israel is the Dean. the Standards for Evaluation of Medical Schools and Medical Education set the criteria for the position: The chief official of the medical school, who usually holds the title "dean," must have ready access to the university president or other university official charged with final responsibility for the school, and to other university officials as are necessary to fulfill the responsibilities of the dean's office.
The dean must be qualified by education and experience to provide leadership in medical education, in scholarly activity and research, and in care of patients. The dean should have the assistance of such associate or assistant deans and staff as are necessary for administration of admissions, student affairs, academic affairs, graduate education, continuing education, hospital relationships, research, business and planning, and fund raising. (appendix 5, section 3, p.1-2).



 
Analyst Remarks to Narrative
The Standards require that the dean must be qualified by education and experience to provide leadership in medical education, in scholarly activity and research and in care of patients. Although the qualifications of the chief academic official or dean are not specified, it is expected that each school will have its own procedures to ensure that only a highly-qualified individual would be selected.
 
Chief Academic Official, Question 2
 
Country Narrative

As stated in the Standards for Evaluation of Medical Schools and Medical Education "Administrative officers and members of a medical school faculty are appointed by, or on the authority of, the governing board of the medical school or its parent university. The chief official of the medical school, who usually holds the title "dean," must have ready access to the university president or other university official charged with final responsibility for the school, and to other university officials as are necessary to fulfill the responsibilities of the dean's office." (appendix 5, section 3, p.1-2).



 
Analyst Remarks to Narrative
As noted under the previous section, the dean must be qualified by education and experience to provide leadership in medical education, in scholarly activity and research, and in care of patients. Although the qualifications of the chief academic official or dean are not specified in more detail in the Standards, each school has its own procedures to ensure that only a highly-qualified individual would be selected.
 
Faculty
 
Country Narrative

The Standards for Evaluation of Medical Schools and Medical Education make sure that "The manner in which the medical school is organized, including the responsibilities and privileges of administrative officers, faculty, students, and committees must be promulgated in medical school or university bylaws. A committee structure is the usual mechanism for involving faculty and others in decisions concerning admissions, promotions, curriculum, library and research, etc. The names, membership, and functions of such committees are not prescribed by these standards, but rather are subject to local determination and needs.In determining the appropriate organization, emphasis should be placed on the importance of the collegiality of the medical school faculty responsible for undergraduate medical education and for the continuum of medical education. Ambulatory consideration should be given to the commitments of faculty members who have multiple academic responsibilities in several educational programs of a complex university, so as to assure each educational program adequate faculty resources. A decision must be made concerning the provision of a single faculty or of combined faculties to serve the needs of each of several health-related or other academic programs of the university, and concerning the advisability of joint faculty appointments. The school must ensure that appointments such as “clinical professors”, must be made according to approved academic criteria.(appendix 5, section 3, p.1-2).

Members of the faculty must have the capability and continued commitment to be effective teachers. Effective teaching requires knowledge of the discipline and an understanding of pedagogy, including construction of a curriculum consistent with learning objectives, subject to internal and external formal evaluation. The administration and the faculty should have knowledge of methods for measurement of student performance in accordance with stated educational objectives and national norms. and "There must be clear policies for the appointment, renewal of appointment, promotion, granting of tenure and dismissal of members of the faculty. The appointment process must involve the faculty, the appropriate departmental heads, and the dean. Each appointee should receive a clear definition of the terms of appointment, responsibilities, line of communication, privileges and benefits, and policy on practice earnings. Faculty members should receive regularly scheduled feedback on their academic performance and their progress towards promotion. Opportunities for professional development should be provided to enhance faculty members skills and leadership abilities in teaching and research." in addition "The dean and a committee of the faculty should determine medical school policies. This committee typically consists of the heads of major departments, but may be organized in any manner that brings reasonable and appropriate faculty influence into the governance and policymaking processes of the school. The full faculty should meet often enough to provide an opportunity for all to discuss, establish, and otherwise become acquainted with medical school policies and practices." (appendix 5, 7.2, p.10-11).
 
Analyst Remarks to Narrative
The Standards require that the institution maintain clear policies for the appointment, renewal of appointment, promotion, granting of tenure and dismissal of members of the faculty, and that the appointment process must involve the faculty, among others.

Furthermore, the Standards expect the dean and a committee of the faculty should determine medical school policies. The full faculty is expected to meet often enough to provide an opportunity for all to discuss, establish and be familiar with the medical school’s policies and practices.

Finally, it is noted that a committee structure is the usual mechanism for involving faculty and others in decisions concerning admissions, promotions and the phases of the curriculum, including the library and research.
 
Remote Sites, Question 1
 
Country Narrative
According to The Standards for Evaluation of Medical Schools and Medical Education, "If components of the program are conducted at sites geographically separated from the main campus of the medical school, the chief academic officer of the medical school must be responsible for the conduct and maintenance of the quality of the educational experience offered at these sites and for identification of the faculty at all sites. The principal academic officer of each geographically separated site must be administratively responsible to the chief academic officer of the medical school conducting the accredited program. The faculty in each discipline, in all sites, must be functionally integrated by administrative mechanisms that ensure comparable quality in the educational experiences and consistency in student evaluation at the geographically separated segments of the program.
A large number of program sites or a significant distance between sites may require extra academic and administrative controls in order to maintain the quality of the entire program.
A medical school must specify its separated campuses and the faculty teachers in them." (Appendix 5, section 4, p. 2-3).
Ben Gurion University for example has a eight week clerkships at a remote site (appendix 10, MSIH report, p.18). The evaluation process of a remote site is done according to different guidelines than the regular QA guidelines (appendix 11, Guidelines for Evaluation of Clinical Sites for the Oversees Clerkship) but they asses the same main subjects.

 
Analyst Remarks to Narrative
As noted in the Standards, CHE expects institutions to ensure that quality is maintained at any geographically separated facilities, and that consistency is evaluated. In addition, the country provides special “Guidelines for Evaluation of Clinical Sites for the Oversees Clerkship” applicable to at least one medical school (Exhibit 10).

However, it is not clear if any part of the preclinical educational program (basic sciences portion of the program) can be taken outside of Israel.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
We confirm that no part of the preclinical educational program (basic sciences) at any Israeli medical school can be taken outside of Israel. (The “eight week clerkships” at Ben-Gurion University referred to in our application are clinical clerkships and take place in the final year of studies.)
 
Analyst Remarks to Response
The draft staff analysis noted that is was not clear if any part of the preclinical educational program (basic sciences portion of the program) can be taken outside of Israel.

In response, the country confirmed that no part of the preclinical educational program (basic sciences) at any Israeli medical school can be taken outside of Israel.
 
Staff Conclusion: Comprehensive response provided
 
Remote Sites, Question 2
 
Country Narrative
Ben Gurion University for has an eight week clerkships at a remote site: "The Global Health (GH) Clerkship is an eight week clinical experience that usually takes place in a developing country during the fourth year from mid-January to mid-March. The goal of the GH Clerkship is to learn how to promote health and provide good medical care, with limited resources, in a developing country". (appendix 10, MSIH report, p.18).
The evaluation process of a remote site is done according to Guidelines for Evaluation of Clinical Sites for the Oversees Clerkship (appendix 11).
 
Analyst Remarks to Narrative
The Standards require that the principal academic officer of each geographically separated site must be administratively responsible to the chief academic officer of the medical school conducting the accredited program. Furthermore, the faculty in each discipline in all sites must be functionally integrated by administrative mechanisms that ensure comparable quality in the educational experiences and consistency in student evaluation at the geographically separated segments of the program.

Among other issues, the Standards require that students assigned to a branch campus should receive the same privileges and access to student services as students on the main campus. (Since Israel is not particularly large, the distance between geographically separated sites is relatively limited.)
 
Program Length, Question 1
 
Country Narrative
The educational program of a medical school must be of sufficient length to meet the main objectives and its particular mission and objectives, and to provide students with knowledge and skills necessary to become qualified physicians. For students who hold a B.Sc a four-year study program in Medicine (with an additional internship year) for the "Medical Doctor" (M.D.) degree was established (Appendix 5, section 5.1, p.3).
According to their Technion TeAM evaluation report, the student in the TeAM program fulfills 36 months of study, as required from foreign (non-USA) medical school graduates in order to be licensed in the United States (Appendix 12, Technion american Program).
The Ben gurion University MSIH medical education program shall provide at least 130 weeks of instruction, and the curriculum of the medical school shall provide a general professional education and prepa re medical students for entry into graduate medical education in any discipline (Appendix 10, MSIH, p. 17-18).
 
Analyst Remarks to Narrative
The Standards expect a program leading to the M.D. degree to be of 6 years duration plus one year of rotating internship, or a four-year study program with an additional internship year designated for students that already hold at least a B.Sc. degree. In addition, the Technion has a specially-adapted program for Americans and Canadians (cf. Exhibit 11).
 
Curriculum, Question 1
 
Country Narrative
Section 5.3 of the Standards for Evaluation of Medical Schools and Medical Education discusses the content that should be incorporated in the medical schools:
"The curriculum cannot be all-encompassing. However, it must include the sciences basic to medicine, a variety of clinical disciplines, and ethical, behavioral, and socioeconomic subjects pertinent to medicine. There should be presentation of material on medical ethics and human values. The faculty should foster in students the ability to learn through self-directed, independent study throughout their professional lives.
The curriculum must include the contemporary content of those expanded disciplines that have been traditionally titled anatomy, biochemistry, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine. Instruction within these basic sciences should include laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data. Teachers and teaching assistants in the biomedical sciences must be familiar with the educational objectives of the course and be prepared for their roles in teaching and evaluation.
All schools must provide broad-based clinical education programs that equip students with the knowledge, skills, attitudes, and behaviors necessary for further training in the practice of medicine. Instruction and experience in patient care must be provided in both ambulatory and hospital settings. All schools must offer a core curriculum in primary care, utilizing the disciplines or multidisciplinary approaches involved in the delivery of such care." (Appendix 5, section 5.3, p.4)
Clinical education programs should include disciplines such as family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. Schools must ensure that their students possess the knowledge and clinical abilities to enter any field of graduate medical education. Clinical instruction should cover all organ systems, and must include the important aspects of acute, chronic, continuing, preventive, and rehabilitative care." (Appendix 5, section 5.3, p.5)
The curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. In addition, students should have the opportunity to participate in research and other scholarly activities of the faculty.
In view of the increasing pace of discovery of new knowledge and technology in medicine, The Council for Higher Education encourages experimentation that will increase the efficiency and effectiveness of medical education. Experiments should have carefully defined goals and plans for implementation, including methods of evaluating the results. Planning for educational innovation should consider the incremental resources that will be required, including demands on library facilities and operation, information management needs and computer hardware and software. (appendix 5, section 5.3, p.6)
 
Analyst Remarks to Narrative
The following summary of CHE curriculum-related requirements overlaps with the entire series of NCFMEA curriculum-related guidelines and questions. (It is apparent that the CHE made a concerted effort to incorporate both NCFMEA and LCME expectations into the Israeli Standards as they were being developed.)

The CHE Standards specify that the curriculum must enable students to:

-- learn the fundamental principles of medicine;
-- acquire skills of critical judgment based on evidence and experience;
-- develop an ability to use principles and skills wisely in solving problems of health and disease; and
-- acquire an understanding of the scientific concepts underlying medicine.

Consequently, in designing the curriculum, the faculty must introduce current advances in the basic and clinical sciences, including therapy and technology, changes in the understanding of disease, and the effect of social needs and demands on medical care.

Furthermore, the curriculum is expected to include:

-- the sciences basic to medicine;
-- a variety of clinical disciplines;
-- ethical, behavioral, and socioeconomic subjects pertinent to medicine;
-- material on medical ethics and human values;
-- the contemporary content of those expanded disciplines which have traditionally been entitled anatomy, biochemistry, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine; and
-- instruction within these basic sciences including laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data.

Overall, the Standards expect that all instruction will:

-- stress the need for students to be concerned with the total medical needs of their patients and the effect on their health of social and cultural circumstances;
-- specify how students are prepared for their role in addressing the medical consequences of common societal problems, for example, providing instruction in the diagnosis, prevention, appropriate reporting and treatment of violence and abuse;
-- encourage students to develop and employ scrupulous ethical principles in caring for patients, in relating to patients families, and to others involved in the care of the patients; and
-- enable students to possess the knowledge and clinical abilities to enter any field of graduate medical education.
 
Curriculum, Question 2
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education states that "In each of the major disciplines basic to medicine and in the clinical sciences, a critical mass of faculty members must be appointed who possess, in addition to a comprehensive knowledge of their major disciplines, expertise in one or more subdivisions or specialties within each of these disciplines. In the clinical sciences, the number and kind of specialists appointed should relate to the amount of patient care activities required to conduct meaningful clinical teaching at the undergraduate level, as well as for graduate and continuing medical education...the education of both medical students and graduate physicians requires an academic environment that provides close interaction between faculty members, so that those skilled in teaching and research in the basic sciences can maintain awareness of the relevance of their disciplines to clinical problems. Such an environment is equally important for clinicians, for from the sciences basic to medicine comes new knowledge which can be applied to clinical problems. A medical school should endeavor to provide a setting in which all faculty members work closely together in teaching, research, and health care delivery, to disseminate existing knowledge and to generate new knowledge of importance to the health and welfare of mankind." (appendix 5, section 7.2, p.10-11).

In addition, as we proclaimed before, "the curriculum cannot be all-encompassing. However, it must include the sciences basic to medicine, a variety of clinical disciplines, and ethical, behavioral, and socioeconomic subjects pertinent to medicine. There should be presentation of material on medical ethics and human values. The faculty should foster in students the ability to learn through self-directed, independent study throughout their professional lives. The curriculum must include the contemporary content of those expanded disciplines that have been traditionally titled anatomy, biochemistry, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine. Instruction within these basic sciences should include laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data. Teachers and teaching assistants in the biomedical sciences must be familiar with the educational objectives of the course and be prepared for their roles in teaching and evaluation. And, "the curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology"(Appendix 5, section 5.3).
 
Analyst Remarks to Narrative
The country narrative selections from the Standards (and Department staff summary found under the preceding section) briefly address the country’s approach to the basic sciences. In a concise statement, the Standards require that the basic sciences curriculum “must include the contemporary content of those expanded disciplines that have been traditionally titled anatomy, biochemistry, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine. Instruction within these basic sciences should include laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data.”
 
Curriculum, Question 3
 
Country Narrative
Medical schools are encouraged to make available sufficient opportunities for medical students to participate in research and other scholarly activities of the faculty as seen in section 5.3 of the Standards for Evaluation of Medical Schools and Medical Education: "The curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. In addition, students should have the opportunity to participate in research and other scholarly activities of the faculty.
Each required clinical clerkship must allow the student to undertake a thorough study of a series of selected patients having the major and common types of disease problems represented in the primary and related disciplines of the clerkship. The committee responsible for curriculum must require close faculty supervision of the learning experience of each student at the appropriate level of graded clinical responsibility. Supervision must be provided throughout required clerkships by members of the school s faculty. The required clerkships should be conducted in a teaching hospital or ambulatory care facility where residents in accredited programs of graduate medical education, under faculty guidance, may participate in teaching the students. Residents must be fully informed about the educational objectives of the clerkships and be prepared for their roles as teachers and evaluators of medical students. In an ambulatory care setting, if faculty supervision is present, resident participation may not be required. If required clerkships in a single discipline are conducted in several hospitals, every effort must be made to ensure that the students receive equivalent educational experiences." (Appendix 5, section 5.3)
 
Analyst Remarks to Narrative
The Standards expect that each medical school will foster research activities for students. The emphasis of the application narrative is on the opportunities provided during clinical clerkships for students to undertake a series of studies concentrating on selected patients.
 
Curriculum, Question 4
 
Country Narrative
In the latest evaluation that the medical schools went through -the international evaluation committee commented as follows: (appendix D)
"The Committee believes that development of physicians into highly competent professionals needs to be explicitly taught, modeled and assessed throughout the entire educational experience. Because many professionalism dilemmas are contextual, the teaching faculty should provide opportunities to discuss and learn from real life tensions in the practice of clinical medicine and research. While each institution can decide the specific content and delivery of the professionalism framework, it should include the following components, each of which should be integrated into all years of medical education:
• Honesty and integrity
• Respect for patients and families
• Interpersonal communication skills including respectful communication with all healthcare team members
• Altruism and social justice
• Self-reflection and commitment to lifelong learning

Also in the individual report that each school received there are recommendations for the schools to enhance their lifelong learning skills- in a couple of CHE meetings votes (January and February 2015)­ there was a demand from each school to develop and enhance the lifelong learning skills that students receive in the schools. The CHE will gladly provide in the next few months the plans from the schools on the ways they are going to approach this request and make the required changes asked of them.
But as of today there are attempts of the school to practice some lifelong learning- for instance from the BGU written handbook: (appendix 10)
The development of lifelong learning skills is a core focus of the School. All students are required to take courses in both Biostatistics and Epidemiology with a focus on the critical appraisal of the medical literature. Students are exposed to modern tools of medical informatics through an in-depth acquaintance with the medical library and sessions in how to best harness new technologies to help in patient care. These skills are then put into practice through the use of problem-based learning sessions and a required literature review of a major topic in Global Health. Students' ability to process information is assessed during the clinical rotations and through the extensive use of Objective Structured ClinicaI Exams
 
Analyst Remarks to Narrative
The application narrative indicates that the 2014 site visits to the Israeli medical schools were used as occasions to encourage an emphasis on lifelong learning with the students. In addition, the CHE voted in 2015 to ask each school to develop and enhance the lifelong learning skills that students receive during their training.

The CHE will be better able to address the outcome of this relatively recent emphasis on lifelong learning skills after the schools have had time to develop and implement their plans addressing those CHE expectations. (Department staff suggests that an appropriate time to do so would be within the country’s next periodic update report, if that is what the NCFMEA would find acceptable.)
 
Curriculum, Question 5
 
Country Narrative
In TAU SER: (Appendix 7 page 57-58)
The 6-Year Program includes the following subjects (divided by school year):
• First Year: A. Field experience: family clinics, nursing homes, lack of social support exposures (shelter for battered women, clinics for drug and abuse, A.A., N.A etc.). B. The physician and society: panel with
experts, including physicians, legal experts, philosophers and religious leaders and meetings on the topic of organ transplants with transplant recipients and donor families. C. Groups of approximately 12 students, overall years, facilitated by a senior physician, to accompany the activities. The group and facilitator convene every two weeks in the preclinical years, for two hours, to discuss issues of concern to the students.
• Second Year: A. Field experience: Rehabilitation centers. B. Therapeutic relationships project- accompanying a patient living with a chronic illness or disability. C. "Shadow" Project- accompanying a physician (the group facilitator) during his regular work, a number of times during the year. D. Teaching communication skills through simulations with simulated patients- two simulations.
•Third Year: A. Field experience: End of Life home visit. B. Learning from Families project- accompanying a family dealing with a chronic illness of one of its members- the family teaches the student. C. Teaching communication skills through simulations with simulated patients- two simulations for practice and one simulation as an exam.
• Fourth Year: A. Full day communications workshop with simulated within the framework of studying physical diagnosis in the Internal Medicine clerkship. B. Group process within the clinical years focused on professionalism in the hidden curriculum.
• Fifth Year: Group process within the clinical years focused on professionalism in the hidden curriculum.
•Sixth year: Breaking bad news workshop and group process of dealing with it.
The 4-Year Program includes the following subjects (divided by school year):
• First Year: A. Field experience: family clinics, lack of social support exposures (shelter for battered women, clinics for drug and abuse, A.A., N.A., etc.). B. The physician and society: panel with experts, including physicians, legal experts, philosophers and religious leaders and meetings on the topic of organ transplants with transplant recipients and donor families. C. Groups of approximately 12 students, overall years, facilitated by a senior physician, to accompany the activities. The group and facilitator convene every two weeks in the preclinical years, for two hours, to discuss issues of concern to the students D. Communication and inter-relation skills project including experiential simulations with simulated patients- 2 simulations.
• Second Year: A. Field experience: Rehabilitation centers; End of Life home visit. B. "Learning from patients" project- accompanying a patient or family living with a chronic illness or disability 6 meetings of minimum 2 hours each visit. C. "Shadow" Project - accompanying a physician (the group facilitator) during his regular work for a whole day. D. Communication and inter-relation skills project including experiential simulations with simulated patients- 2 simulations for practice and one simulation as an exam.
• Third Year: A. full day advanced communications skills workshop with simulated patients and skills trainers. B. Professionalism in medicine - small group meetings focusing on professional development and behavior as reflected in students written narratives.
• Fourth Year: A. Breaking bad news course. B. Professionalism in medicine- small group meetings focusing on professional development and behavior as reflected in students written narratives.

BGU:
From the BGU mission statement: (Appendix 6, page 27)
"...To open new frontiers through the pursuit of excellence in medical education, service and research. Within the context of the Beer-Sheva mission, excellence has the following specific dimensions:
Teaching Using progressive, quality teaching methods, including student participation, to educate humane and competent physicians who will be oriented towards the other, towards primary care and towards the community Service Collaborative development of effective preventive and curative health services for the population of the Negev with special emphasis on the provision of services to all with sensitivity to the needs of individuals and communities, and exploring appropriate innovative models of care.
Research
Encouraging excellent research projects in all fields of health sciences. Enhancing and supporting interdisciplinary research groups involving basic and clinical researchers in order to facilitate research conversion, translational science, implementation science, community service."
(Appendix 6, page 32):
BGU's assistance in establishing new community-oriented medical schools or reforming curricula in existing Western, and sometimes highly reputed schools, goes far beyond the institutions with which BGU has signed an agreement. Examples include the Catholic University of Ecuador in Quito, Ecuador (1996); University of Hawaii, Honolulu (2001-3) and the University of Hanoi, Vietnam (2003).
BGU can boast a history of providing assistance beyond medical schools. BGU participated
in providing emergency medical services to world disaster areas such as to refugees after the Cambodian holocaust (1981); to San-Salvador and Belize victims of a cholera epidemic (1991); to victims of the earthquake in Kosovo (2002) and to Congolese victims of a volcanic eruption in Goma (2003).
Furthermore, BGU scholars continue to advise governments and regional health authorities in
various developing countries including the fight against the spread of HIV in Ethiopia; treatment of famine in Ethiopia (2000); reforming rural health services in Somalia and primary care services in Kyrgyzstan and Tajikistan (2001) and Papua-New-Guinea (2003-4 ).
BGU has made several past efforts to promote regional cooperation but most of the projects were disrupted by the eruption of violence in the area from 2000. We are however, hoping to reinitiate cooperation with Jordan on a collaborative research project related to cerebral palsy. Page 30:
"In addition to our usual efforts in this domain, another strategy is the introduction of multiannual humanism studies in the curriculum: literature and poetry in the 1st year, psychology and ethics in the 2nd year and philosophy in the 3rd year.
Following a successful pilot in the international school (MSIH), teaching Ethics has become an integral part of clinical clerkships. Each discipline can decide how they would like to incorporate ethics into their rotation. Important in this regard is to view ethics not as an extraneous subject but as an integral part of the discipline. The importance of role-modeling cannot be overemphasized. Ethics rounds are carried out throughout all years. In these rounds ethical problems, related to the discipline which is taught at that time, are presented and discussed by the students" and: "Learning outcomes and achievements are not only successes in examination. In addition to their superb knowledge, our students also excel in qualities such as humanism, communication skills, empathy and ethics, and are heavily involved in programs that promote health
 
Analyst Remarks to Narrative
The country narrative describes how two of the accredited medical schools provide opportunities for students to be involved in activities that affect the health of the wider communities they serve.

However, it is unclear if the CHE Standards themselves encourage all the medical schools to provide their students to participate in “service learning,” as defined by the NCFMEA.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
Community service and involvement is an integral part of medical education in Israel - which is all conducted within a public health environment. The concept of “treating the patient instead of the illness” evolved from the community medicine approach introduced decades ago by Ben-Gurion University. Several articles about the Beersheva Experiment have been published and the concepts of community medicine have since been adopted widely (Appendix 1, Article in the Oxford journal of public health). A significant amount of the instruction in Israeli medical education is provided in a community setting. This is done in prenatal clinics, outpatient clinics, family medicine clinics and in Tel Aviv, at a refugee clinic. Such is the fundamental integration of community service, preparation, and reflection in the Israeli medical school curriculum that the CHE’s Standards for Evaluation of Medical Schools specifies that:

Section 5(3):

“The curriculum… must include ethical, behavioral, and socioeconomic subjects pertinent to medicine.”
“In designing the curriculum, the faculty must... and the effect of social needs and demands on medical care.”
“Instruction and experience in patient care must be provided in both ambulatory and hospital settings.”
“The faculty must… and the appropriate clinical settings necessary to accomplish these purposes.”
“If the level or diversity of student interactions with patients does not meet the school-based criteria, specific mechanisms must be in place to adjust the criteria or to alter the educational program.”
“Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled.”
“The required clerkships should be conducted in a teaching hospital or ambulatory care facility…”

At this time, CHE does not specifically require medical schools to provide opportunities for “service learning” because it is so integrated into the Israeli medical education system - which, as stated above, operates entirely in a public health environment.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the CHE Standards themselves encourage all the medical schools to provide their students opportunities to participate in “service learning,” as defined by the NCFMEA.

In response, the country indicated that the CHE Standards do not specifically require medical schools to provide opportunities for “service learning” because that focus is already integrated into the Israeli medical education system. In other words, the country explained that their medical education system as a whole operates entirely in a public health environment with the result that community service, preparation, and reflection are fundamentally integrated into the Israeli medical school curriculum.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 6
 
Country Narrative
Medical schools are encouraged to make available sufficient opportunities for medical students to participate in research and other scholarly activities of the faculty as seen in section 5.3 of the Standards for Evaluation of Medical Schools and Medical Education: "The curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. (Appendix 5, section 5.3).
In the Self-evaluation reports that the medical schools are required to prepare for the QAD they specify the content of what they teach, see attached SER of Ben Gurion University, Technion and Tel Aviv University (Appendix 6-8).
 
Analyst Remarks to Narrative
Regarding the basic sciences, the CHE Standards list the same subject titles as mentioned in the NCFMEA guidelines. However, there was no elaboration regarding the actual content covered in the treatment of those subject areas.

Therefore, it is unclear how the CHE consistently ensures that each medical school is providing its students with up-to-date content in its basic sciences curriculum.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
As stated in the submitted report, the CHE evaluates the medical schools and during the evaluation process the committee goes over the study program and the syllabi of each course. After the evaluation process is done, the CHE continues working on individual follow-ups regarding each program. They may ask to follow up on the basic sciences curriculum if they perceive it to be unsatisfactory. In addition the schools will go through another evaluation after 5-6 years and will undergo the same process again.

The list of basic science subjects and their curricula exists at each school and is available to Evaluation Committee members for perusal. Each school has an active Curriculum Committee that meets regularly to discuss the content of the curriculum and to update it according to need.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear how the CHE consistently ensures that each medical school is providing its students with up-to-date content in its basic sciences curriculum.

In response, the country indicated that during the evaluation process the CHE evaluation committee goes over the study program and the syllabi of each course. If questions arise, the CHE follows up as appropriate. This process is repeated during each of the subsequent re-evaluations that are regularly scheduled every 5-6 years.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 7
 
Country Narrative
At the same paragraph as mentioned above In the CHE standards (appendix 5 5.3 page 4) the following is included:
"Instruction within these basic sciences should include laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data. Teachers and teaching assistants in the biomedical sciences must be familiar with the educational objectives of the course and be prepared for their roles in teaching and evaluation".
 
Analyst Remarks to Narrative
The CHE Standards include an overall expectation that each medical school will include the appropriate laboratory or other practical exercises in the basic sciences curriculum (using language similar to the NCFMEA guidelines).

NOTE: There are a number of areas where the CHE Standards mirror the NCFMEA Guidelines, and where little further elaboration is offered in the country’s narrative and documentation. Rather than cite every instance individually, Department staff believes that any further questions regarding these subjects, if desired by the NCFMEA, can be raised in conjunction with questions on the overall curriculum, etc.
 
Clinical Experience, Question 1
 
Country Narrative

The Standards for Evaluation of Medical Schools and Medical Education state that "the curriculum must provide a broad-base education in the science basic to medicine, a variety of clinical subjects, and various ethical, behavioral and socioeconomic subjects pertinent to medicine. The requirements for successful completion of the program of medical education must include a particular focus on clerkships and other form of clinical training. Students must have hands-on experience." (Appendix 5, section 5). They also ask that "the chairman of each discipline should set the standards of achievement by students in the study of that discipline. Narrative descriptions of student performance and of non-cognitive achievements should be recorded to supplement grade reports in all required clinical clerkships and in all courses where student-faculty interaction permits this form of assessment... The chairman of each discipline should set the standards of achievement by students in the study of that discipline. Narrative descriptions of student performance and of non-cognitive achievements should be recorded to supplement grade reports in all required clinical clerkships and in all courses where student-faculty interaction permits this form of assessment. The faculty committee should review the frequency of examinations and their scheduling, particularly when the students are enrolled in several subjects simultaneously. The Council for Higher education urges schools to develop a system of evaluation that fosters self-initiated learning by students, and disapproves of the use of frequent tests which condition students to memorize details for short-term retention only. Examinations (written and others) should measure cognitive learning, mastery of basic clinical skills, and the ability to use data in realistic problem solving. Institutions must develop a system of assessment which assures that students have acquired and can demonstrate on direct observation the core clinical skills and behaviors needed in subsequent medical training. Communication skills are integral to the education and effective function of physicians. There must be specific instruction and evaluation of these skills as they relate to physician responsibilities, including communication with patients, families, colleagues and other health professionals."(Appendix 5, section 5.4).

the method we use to ensure that clinical instruction at medical schools cover all organ systems and include aspects of acute, chronic, continuing, preventive, and rehabilitative care is by using the QA guidlines as part of the QA evaluation process (Appendix 4) and ask the medical schools to details those points we want to clarify. For example in the Tel Aviv University's self Evaluation report it is stated that "the Clinical Curriculum Committee and Preclinical Curriculum Committee are the main mechanisms for coordinating and examining the contents that are, in fact, being taught. Each course is reviewed annually in the Preclinical Committee and once every 2 years or so (depending on changes that were made and importance of the course) in the Clinical Committee" ( Appendix 7, p. 36-42).

 
Analyst Remarks to Narrative
In summary, the clinical education programs are expected to:

-- provide students with the knowledge, skills, attitudes, and behaviors necessary for further training in the practice of medicine;
-- provide instruction and experience in patient care in both ambulatory and hospital settings;
-- include disciplines such as family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery; and
-- cover all organ systems, and include the important aspects of acute, chronic, continuing, preventive, and rehabilitative care.
 
Clinical Experience, Question 2
 
Country Narrative
Stated in the Standards for Evaluation of Medical Schools and Medical Education section 5.3:
"The curriculum cannot be all-encompassing. However, it must include the sciences basic to medicine, a variety of clinical disciplines, and ethical, behavioral, and socioeconomic subjects pertinent to medicine. There should be presentation of material on medical ethics and human values. The faculty should foster in students the ability to learn through self-directed, independent study throughout their professional lives.
The curriculum must include the contemporary content of those expanded disciplines that have been traditionally titled anatomy, biochemistry, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine. Instruction within these basic sciences should include laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data. Teachers and teaching assistants in the biomedical sciences must be familiar with the educational objectives of the course and be prepared for their roles in teaching and evaluation.
All schools must provide broad-based clinical education programs that equip students with the knowledge, skills, attitudes, and behaviors necessary for further training in the practice of medicine. Instruction and experience in patient care must be provided in both ambulatory and hospital settings. All schools must offer a core curriculum in primary care, utilizing the disciplines or multidisciplinary approaches involved in the delivery of such care.
Clinical education programs should include disciplines such as family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. Schools must ensure that their students possess the knowledge and clinical abilities to enter any field of graduate medical education. Clinical instruction should cover all organ systems, and must include the important aspects of acute, chronic, continuing, preventive, and rehabilitative care.
The faculty must participate in a process that defines the objectives of clinical education and establishes quantified criteria for the types of patients (real or simulated), the level of student responsibility, and the appropriate clinical settings necessary to accomplish these purposes. A system for monitoring the achievement of clinical educational goals must be developed, based on these criteria, and students must be evaluated in this framework. If the level or diversity of student interactions with patients does not meet the school-based criteria, specific mechanisms must be in place to adjust the criteria or to alter the educational program. Either may be done only within appropriate, documented means that ensure continued educational quality.
The curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. In addition, students should have the opportunity to participate in research and other scholarly activities of the faculty.
Each required clinical clerkship must allow the student to undertake a thorough study of a series of selected patients having the major and common types of disease problems represented in the primary and related disciplines of the clerkship. The committee responsible for curriculum must require close faculty supervision of the learning experience of each student at the appropriate level of graded clinical responsibility. Supervision must be provided throughout required clerkships by members of the school s faculty. The required clerkships should be conducted in a teaching hospital or ambulatory care facility where residents in accredited programs of graduate medical education, under faculty guidance, may participate in teaching the students. Residents must be fully informed about the educational objectives of the clerkships and be prepared for their roles as teachers and evaluators of medical students. In an ambulatory care setting, if faculty supervision is present, resident participation may not be required. If required clerkships in a single discipline are conducted in several hospitals, every effort must be made to ensure that the students receive equivalent educational experiences.
The faculty committee responsible for curriculum should develop, and the chief academic officer should enforce, the same rigorous standards for the content of each year of the program leading to the M.D. degree. The final year should complement and supplement the curriculum so that each student will acquire appropriate competence in general medical care regardless of subsequent career specialty. The curriculum should include elective courses designed to supplement the required courses and to provide opportunities for students to pursue individual academic interests. Faculty advisors must guide students in the choice of elective courses. If students are permitted to take electives at other institutions, there should be a system centralized in the dean s office to screen the students' proposed extramural programs prior to approval and to ensure the return of a performance appraisal by the host program. Another system, devised and implemented by the dean, should verify the credentials of students from other schools wishing to take courses or clerkships at the school, approve assignments, maintain a complete roster of visiting students, and provide evaluations to the parent schools.
All instruction should stress the need for students to be concerned with the total medical needs of their patients and the effect on their health of social and cultural circumstances.
The school must specify how students are prepared for their role in addressing the medical consequences of common societal problems, for example, providing instruction in the diagnosis, prevention, appropriate reporting and treatment of violence and abuse. Students must be encouraged to develop and employ scrupulous ethical principles in caring for patients, in relating to patients families, and to others involved in the care of the patients. Thes principles are essential if the physician is to gain and maintain the trust and respect of patients, colleagues, and the community." (Appendix 5, Section 5.3).
 
Analyst Remarks to Narrative
The country narrative describes some basic ways the Standards ensure that the medical school programs equip their students with the necessary skills and experiences. Primary among the CHE expectations is that the faculty will be heavily involved in a regular program of student assessment.
 
Clinical Experience, Question 3
 
Country Narrative
Stated in the Standards for Evaluation of Medical Schools and Medical Education section 5.3:
"The curriculum cannot be all-encompassing. However, it must include the sciences basic to medicine, a variety of clinical disciplines, and ethical, behavioral, and socioeconomic subjects pertinent to medicine. There should be presentation of material on medical ethics and human values. The faculty should foster in students the ability to learn through self-directed, independent study throughout their professional lives.
The curriculum must include the contemporary content of those expanded disciplines that have been traditionally titled anatomy, biochemistry, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine. Instruction within these basic sciences should include laboratory or other practical exercises which facilitate the ability to make accurate quantitative observations of biomedical phenomena and critical analyses of data. Teachers and teaching assistants in the biomedical sciences must be familiar with the educational objectives of the course and be prepared for their roles in teaching and evaluation.
All schools must provide broad-based clinical education programs that equip students with the knowledge, skills, attitudes, and behaviors necessary for further training in the practice of medicine. Instruction and experience in patient care must be provided in both ambulatory and hospital settings. All schools must offer a core curriculum in primary care, utilizing the disciplines or multidisciplinary approaches involved in the delivery of such care.
Clinical education programs should include disciplines such as family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. Schools must ensure that their students possess the knowledge and clinical abilities to enter any field of graduate medical education. Clinical instruction should cover all organ systems, and must include the important aspects of acute, chronic, continuing, preventive, and rehabilitative care.
The faculty must participate in a process that defines the objectives of clinical education and establishes quantified criteria for the types of patients (real or simulated), the level of student responsibility, and the appropriate clinical settings necessary to accomplish these purposes. A system for monitoring the achievement of clinical educational goals must be developed, based on these criteria, and students must be evaluated in this framework. If the level or diversity of student interactions with patients does not meet the school-based criteria, specific mechanisms must be in place to adjust the criteria or to alter the educational program. Either may be done only within appropriate, documented means that ensure continued educational quality.
The curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. In addition, students should have the opportunity to participate in research and other scholarly activities of the faculty.
Each required clinical clerkship must allow the student to undertake a thorough study of a series of selected patients having the major and common types of disease problems represented in the primary and related disciplines of the clerkship. The committee responsible for curriculum must require close faculty supervision of the learning experience of each student at the appropriate level of graded clinical responsibility. Supervision must be provided throughout required clerkships by members of the school s faculty. The required clerkships should be conducted in a teaching hospital or ambulatory care facility where residents in accredited programs of graduate medical education, under faculty guidance, may participate in teaching the students. Residents must be fully informed about the educational objectives of the clerkships and be prepared for their roles as teachers and evaluators of medical students. In an ambulatory care setting, if faculty supervision is present, resident participation may not be required. If required clerkships in a single discipline are conducted in several hospitals, every effort must be made to ensure that the students receive equivalent educational experiences.
The faculty committee responsible for curriculum should develop, and the chief academic officer should enforce, the same rigorous standards for the content of each year of the program leading to the M.D. degree. The final year should complement and supplement the curriculum so that each student will acquire appropriate competence in general medical care regardless of subsequent career specialty. The curriculum should include elective courses designed to supplement the required courses and to provide opportunities for students to pursue individual academic interests. Faculty advisors must guide students in the choice of elective courses. If students are permitted to take electives at other institutions, there should be a system centralized in the dean s office to screen the students' proposed extramural programs prior to approval and to ensure the return of a performance appraisal by the host program. Another system, devised and implemented by the dean, should verify the credentials of students from other schools wishing to take courses or clerkships at the school, approve assignments, maintain a complete roster of visiting students, and provide evaluations to the parent schools.
All instruction should stress the need for students to be concerned with the total medical needs of their patients and the effect on their health of social and cultural circumstances.
The school must specify how students are prepared for their role in addressing the medical consequences of common societal problems, for example, providing instruction in the diagnosis, prevention, appropriate reporting and treatment of violence and abuse. Students must be encouraged to develop and employ scrupulous ethical principles in caring for patients, in relating to patients families, and to others involved in the care of the patients. Thes principles are essential if the physician is to gain and maintain the trust and respect of patients, colleagues, and the community." (Appendix 5, Section 5.3).
 
Analyst Remarks to Narrative
In summary, the Standards expect that:

-- clinical clerkships be conducted in a teaching hospital or ambulatory care facility, where residents in accredited programs of graduate medical education (under faculty guidance) may participate in teaching the students;
-- residents be fully informed about the educational objectives of the clerkships and be prepared for their roles as teachers and evaluators of medical students;
-- if required clerkships in a single discipline are conducted in several hospitals, every effort must be made to ensure that the students receive equivalent educational experiences;
-- students undertake a thorough study of a series of selected patients having the major and common types of disease problems represented in the primary and related disciplines of the clerkship; and
-- the committee responsible for curriculum must require close faculty supervision of the learning experience of each student at the appropriate level of graded clinical responsibility.
 
Supporting Disciplines
 
Country Narrative
It is stated in Standards for Evaluation of Medical Schools and Medical Education that "the curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. In addition, students should have the opportunity to participate in research and other scholarly activities of the faculty" (Appendix 5, section 5.3)

 
Analyst Remarks to Narrative
When it comes to the supporting disciplines, the Standards specify that:

-- the curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology;
-- the students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled; and
-- the students should have the opportunity to participate in research and other scholarly activities of the faculty.
 
Ethics, Question 1
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education state that the study program "must include the sciences basic to medicine, a variety of clinical disciplines, and ethical, behavioral, and socioeconomic subjects pertinent to medicine. There should be presentation of material on medical ethics and human values" (Appendix 5, section 5.3).

For example look at the BGU Self-evaluation Report p.30: In addition to our usual efforts in this domain, another strategy is the introduction of multiannual humanism studies in the curriculum: literature and poetry in the 1st year, psychology and ethics in the 2nd year and philosophy in the 3rd year. Following a successful pilot in our international school (MSIH), beginning this academic year (2012/2013), teaching Ethics has become an integral part of clinical clerkships. Each discipline can decide how they would like to incorporate ethics into their rotation. Important in this regard is to view ethics not as an extraneous subject but as an integral part of the discipline. The importance of role-modeling cannot be overemphasized. Ethics rounds are carried out throughout all years. In these rounds ethical problems, related to the discipline which is taught at that time, are presented and discussed by the students (Appendix 6, p.30)
 
Analyst Remarks to Narrative
The Standards expect there to be a “presentation of material on medical ethics and human values.” In addition, “Students must be encouraged to develop and employ scrupulous ethical principles in caring for patients, in relating to patients families, and to others involved in the care of the patients.” In addition, the CHE noted how one school made improvements related to training in ethics.
 
Communication Skills, Question 1
 
Country Narrative
The criteria for assessing the extent and nature of the educational experience provided within the M.D. (or equivalent) program to provide instruction in communications skills is stated in the Standards for Evaluation of Medical Schools and Medical Education states: "Communication skills are integral to the education and effective function of physicians. There must be specific instruction and evaluation of these skills as they relate to physician responsibilities, including communication with patients, families, colleagues and other health professionals" (Appendix 5, Section 5.4, p.6).
Evaluating the mechanisms and medical education program has in place to monitor and evaluate the success of its instruction in communication skills is done through the QA guidelines for self-evaluation (Appendix 4) and through the answers the medical schools state in their self-evaluation reports.
For example in Tel Aviv university's self-evaluation report they write that their "mission is to train outstanding physicians, imbued with moral and professional values; and gifted with clinical skills and knowledge. We aim to provide them with the competencies that will allow them to excel in the hospital and the community work, during residency and throughout their entire career, as clinicians, researchers and teachers. We aim at four competency sets: Clinical competencies: Ethical and emphatic demeanor; clinical skills; deep knowledge; skills needed for teamwork; communication skills with patients and their families and with co-workers; and awareness to social needs. Cognitive competencies: The skill to formulate questions and ways to solve them; instruments for continuous, analytical self-learning; scientific curiosity and skills to begin their way in research. Core knowledge in basic and clinical science. Self-awareness and attentiveness to patients’ needs". (Appendix 7, p. 26-27).
Ben Gurion University's mechanism is IPE: "In March 2012, the Faculty curriculum council decided that IPE will be a part of the curriculum. The aims of this program are to expose students from medical professions to the various professions which surround them in the hospital and in the community and to improve team work and quality of care based on enhanced understanding and communication. During the program, the student will be taught the basic terms of IPE through an introductory lecture, and then gradually through the years he or she will be exposed to more professions and more complex cases which require a multi-professional approach. The shared activities with different medical professions will provide students with a better understanding of each role, improved communication and team work" (Appendix 6, p.30).
And the Technion have another way of imbedding communication skills to their students:" The clinical rotations in the different hospitals also serve one of the missions of the Faculty: to educate a physician with communication skills with patients. The hospitals in Northern Israel serve patients from different ethnic groups having different social and cultural customs. Being exposed to such diversity, helps our students relate to their future patients. Moreover, these hospitals are heterogeneous in working staff, working conditions, available medical equipment and resources. Our students are exposed, throughout their studies, to different working conditions, and we believe that this better prepares them for their future professional life" (Appendix 8, p.14).
 
Analyst Remarks to Narrative
The country’s expectations regarding communication skills parallel some of the language in the NCFMEA guidelines. Other than the general language in the CHE Standards, it is primarily up to the individual schools to ensure that their medical education program has in place appropriate mechanisms to monitor and evaluate the effectiveness of the training in communication skills. (Department staff believes that any further questions regarding this subject, if desired, can be raised in conjunction with questions on the overall curriculum.)
 
Design, Implementation, and Evaluation, Question 1
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education set the expectation of the role of faculty in curriculum evaluation. It is written in section 5.2 of the standards that "The program's faculty is responsible for the design, implementation, and evaluation of the curriculum. There must be integrated institutional responsibility for the design and management of a coherent and coordinated curriculum. The chief academic officer must have sufficient available resources and authority provided by the institution to fulfill this responsibility. The curriculum of the program leading to the M.D. degree must be designed to provide a general professional education, recognizing that this alone is insufficient to prepare a graduate for independent, unsupervised practice. Medical schools must evaluate educational program effectiveness by documenting the achievement of their students and graduates in verifiable and internally consistent ways that show the extent to which institutional and program purposes are met" (Appendix 5, section 5.2 p.3).
 
Analyst Remarks to Narrative
The CHE’s Standards expect the faculty to be responsible for the design, implementation, and evaluation of the curriculum. Furthermore, it is expected that the objectives, content, and methods of pedagogy utilized for each segment of the curriculum, as well as for the entire curriculum, be subjected to periodic evaluation by the responsible committee.

Regarding the clinical portions of the medical education, the Standards expect the faculty to participate in the process that defines the objectives of clinical education and establishes quantified criteria for the types of patients, the level of student responsibility, and the appropriate clinical settings necessary to accomplish these purposes. It is also expected that a system for monitoring the achievement of clinical educational goals will be developed and the students evaluated.
 
Design, Implementation, and Evaluation, Question 2
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education set criteria for evaluation of the effectiveness of its curriculum in section 5.2 as articulated in this paragraph: "Medical schools should use a variety of measures to evaluate program quality, such as data on student performance, academic progress and program completion rates, acceptance into residency programs, postgraduate performance, and emerging measures that may prove to be valid. The results of such evaluations should be used to determine how well schools are fulfilling their objectives and to assess the need for program improvement. Schools also should evaluate the performance of their students and graduates in the framework of national norms of accomplishment. Review and necessary revision of the curriculum is an ongoing faculty responsibility" (Appendix 5, section 5.2, p.3).

In addition, the curriculum of the medical schools is evaluated during the QA evaluation process as can be seen in the QA guidelines (appendix 4) and the self-evaluation reports of the medical schools (Appendix 6-8).
 
Analyst Remarks to Narrative
The CHE Standards expect regular evaluations of program effectiveness and that the results of these evaluations will be used to determine how well schools are fulfilling their objectives and to assess the need for program improvement. Furthermore, medical schools are reminded to evaluate the performance of their students and graduates in the framework of national norms of accomplishment. The Standards also remind faculty members that the review and necessary revision of the curriculum is their ongoing responsibility.

In addition, the Standards require that the medical school faculty establish principles and methods for the evaluation of student achievement, and make decisions regarding promotion and graduation. Student achievement evaluations are expected to employ a variety of measures of knowledge, competence and performance, and to be systematically and sequentially applied throughout each medical school.
 
Design, Implementation, and Evaluation, Question 3
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education states that "the program's faculty is responsible for the design, implementation, and evaluation of the curriculum. There must be integrated institutional responsibility for the design and management of a coherent and coordinated curriculum. The chief academic officer must have sufficient available resources and authority provided by the institution to fulfill this responsibility. The curriculum of the program leading to the M.D. degree must be designed to provide a general professional education, recognizing that this alone is insufficient to prepare a graduate for independent, unsupervised practice. Medical schools must evaluate educational program effectiveness by documenting the achievement of their students and graduates in verifiable and internally consistent ways that show the extent to which institutional and program purposes are met" (Appendix 5, Section 5.2, p.3).
 
Analyst Remarks to Narrative
The CHE Standards expect medical schools to use a variety of measures to evaluate program quality, such as data on student performance, academic progress and program completion rates, acceptance into residency programs, postgraduate performance, and emerging measures that may prove to be valid. And as previously noted, the CHE Standards expect regular evaluations of program effectiveness and that the results of these evaluations will be used to determine how well schools are fulfilling their objectives and to assess the need for program improvement. The periodic evaluation by CHE of how each medical school is evaluating the effectiveness of its curriculum is conducted every six years.
 
Admissions, Recruiting, and Publications, Question 1
 
Country Narrative
We will specify the process in three of the medical schools that have international programs: Ben Gurion University: (see appendix 10)
All applicants must have completed a four-year undergraduate degree from an accredited institution. Students from countries where the Medical College Admissions Test ( MCAT} is offered must submit MCAT scores obtained within the preceding four years. Applicants with graduate degrees and residents of countries where the MCAT is not offered may submit equivalent alternatives a s approved by the
school. Selection is based on the applicant's overall potential for successful completion of the program as indicated by undergraduate Grade Point Average (GPA), MCAT scores, extra-curricular experience, recommendations, and interview assessments.
Individuals with degrees from universities where the language of instruction is not English must submit results of the Test of English as a Foreign Language (TOEFL) taken within one year of the application date. Applicants who wish to transfer from other medical schools are reviewed individually and may be required to take additional course work before being admitted to the School. MSIH only accepts appropriate transfer students no later than into the 2nd year.
The Technion: (appendix 12)
To qualify for admission an applicant must:
1. Possess a baccalaureate degree (U.S. or Canadian college graduates) at the time of entrance into the program
2. Have successfully completed the following courses (from a U.S. or Canadian college/University):
• General Chemistry - one-year course with laboratory
• Organic Chemistry - one-year course with laboratory
• General Physics - one-year course with laboratory
• General Biology - one-year course with laboratory
• English Composition or Literature - one year
• (Statistics and Calculus are also strongly recommended)
3. Have taken the Medical College Admissions Test (MCAT)

Tel Aviv University: (appendix 7)
To apply, you must be a citizen or permanent resident of the U.S. or Canada. To be eligible for admission, students must:
1. Receive a Baccalaureate degree by August of the year they seek to enter Sackler School of Medicine.
2. Have completed at least one full year of coursework at a U.S. or Canadian college or university.
3. Have taken the Medical College Admissions Test (MCAT) of the American College Testing Service, Iowa City, Iowa. (The official results must be received by the NYC office no later than 4 p.m. (EST) on May 15, 2015 deadline. There will be no exceptions.
4. Meet the minimal requirements set by the New York State Education Department for the New York State Program for a premedical curriculum. This includes one year or six credits (two semesters) in English, Inorganic Chemistry, Organic Chemistry, Physics, and Biology. Note: These courses cannot be taken online.
 
Analyst Remarks to Narrative
The CHE Standards require each medical school to admit only those students who possess the intelligence, integrity, and personal characteristics that are generally perceived as necessary to become effective physicians. In addition, the Standards note that the selection of students for the study of medicine is the responsibility of the medical school faculty through a duly constituted committee and that there must not be any political or financial influence on the selection of students. As a safeguard, all factors utilized in the selection process must be made public.

The country’s narrative notes that MCAT scores are used as part of the admitting criteria for students at three medical schools in Israel. In addition, the country provided documentation regarding those three schools.

However, it is unclear if the CHE itself has any requirements regarding the use of MCAT scores in admissions, and whether those scores are evaluated consistently by CHE site visitors.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
Admittance to medical schools in Israel is extremely difficult and highly competitive, with only the very best candidates admitted. Medical Schools set admission criteria for Israeli student MD candidates based upon Israeli matriculation scores, psychometric tests, personal interviews, and other standards. For Israeli candidates these scores are consistently evaluated during CHE site visits.

Each of the three medical schools with international programs has a requirement for MCAT scores. MCAT scores are subject to evaluation during CHE site visits. For example, in the evaluation report conducted by CHE in June 2014 at Ben-Gurion University, the following appears on page 24 (Appendix 3):

b. MSIH
Students for this program have to complete a North American four year college degree course including pre-med science. Those meeting academic criteria described as high grades and a MCAT of 30 or above are interviewed by two faculty members at Columbia University in the USA. Though in past years, students could be admitted with low MCAT scores, internal concerns had led to a higher threshold for admission MCAT scores; and this reportedly has resulted in better results in the subsequent ULSME (sic) examinations.
 
Analyst Remarks to Response
The draft staff analysis noted that was unclear if the CHE itself has any requirements regarding the use of MCAT scores in admissions, and whether those scores are evaluated consistently by CHE site visitors.

In response, the country indicated that the CHE did not have any requirements regarding the use of MCAT scores in admissions. However, the response did note that the three schools with international programs decide on their school’s particular use of MCAT scores. The response noted the use of MCAT scores by one of those schools, but not the others. Therefore, it is unclear how many medical schools in Israel that admit American students use MCAT scores in admitting those students.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Admissions, Recruiting, and Publications, Question 2
 
Country Narrative
Section 6.1 of the Standards for Evaluation of Medical Schools and Medical Education deals with the admission to medical schools in Israel and state that "the faculty of each school should develop criteria and procedures for the selection of students, which should be published and available to potential applicants. To further the accomplishment of its purposes, each medical school should have policies and practices addressing the gender, racial, cultural, and economic diversity of its students. Medical schools must strive to select students who possess the intelligence, integrity, and personal and emotional characteristics that are perceived necessary for them to become effective physicians...the selection of students for the study of medicine is the responsibility of the medical school faculty through a duly constituted committee. Persons or groups external to the medical school may assist in the evaluation of applicants, but the final responsibility must not be delegated outside the medical faculty. There must not be any political or financial influence on the selection of students. All factors utilized in the selection process must be made public" (Appendix 5, Section 6.1, p.8).
 
Analyst Remarks to Narrative
The CHE Standards require that each school’s informational materials must describe the admissions process, including an enumeration of the criteria used in the selection of students by the faculty. Each school’s faculty is responsible for the selection criteria.
 
Admissions, Recruiting, and Publications, Question 3
 
Country Narrative
According to the CHE standards (appendix 5 section 6)
Medical school must admit only those students who possess the intelligence, integrity, and personal characteristics that are generally perceived as necessary to become effective physicians.
Medical school must carefully monitor the progress of students through the educational program and graduate only those students who successfully complete the program.
The faculty of each school should develop criteria and procedures for the selection of students, which should be published and available to potential applicants. To further the accomplishment of its purposes, each medical school should have policies and practices addressing the gender, racial, cultural, and economic diversity of its students. Medical schools must strive to select students who possess the intelligence, integrity, and personal and emotional characteristics that are perceived necessary for them to become effective physicians.
While physical disability should not preclude a student from consideration for admission, each school should develop and publish technical standards for the admission of handicapped applicants, in accordance with legal requirements.
The selection of students for the study of medicine is the responsibility of the medical school faculty through a duly constituted committee. Persons or groups external to the medical school may assist in the evaluation of applicants, but the final responsibility must not be delegated outside the medical faculty.
There must not be any political or financial influence on the selection of students. All factors utilized in the selection process must be made public.
A medical school's publications, advertising, and student recruitment should present a balanced and accurate representation of the mission and objectives of the educational program. The catalog or equivalent informational materials must describe all courses offered by the school, a complete description of the requirements for the M.D. degree and all associated degrees, the most recent academic calendar for each of the curricular options available, a description of the admissions process, and the enumeration of criteria used in the selection of students.
There must be no discrimination on the basis of sex, age, race, creed or national origin. Compliance with both written and implied public policy must be assured. The student body should be drawn from a wide spectrum of economic backgrounds. Advanced standing may be granted to students for work done prior to admission.
Each medical school or its parent university should define the standards of conduct in the teacher-learner
relationship. Schools should develop and widely promulgate written procedures that allow medical students to report violations of these standards--such as incidents of harassment or abuse--without fear of retaliation. The procedures also should specify mechanisms for the prompt handling of such complaints, and for the educational methods aimed at preventing student mistreatment.
 
Analyst Remarks to Narrative
As previously noted, the CHE Standards specify that the selection of students for the study of medicine is the responsibility of the medical school faculty through a duly constituted committee. In addition, the Standards note that there must not be any political or financial influence on the selection of students, and as a safeguard, all factors utilized in the selection process must be made public.
 
Admissions, Recruiting, and Publications, Question 4
 
Country Narrative
On October 12 2012 the Planning and Budgeting committee (PBC) of the CHE had voted and approved that every medical school is allowed to enroll up to 130 students per class per school. this number was recommended by a committee called "the An doran committee" that was established in order to address some of the deficiencies in the discipline that were brought up by the QA committee in 2007 and the follow up committee in 2010.
the Recommendation was as follows:
The clinical teaching medical fields are a limited national resource therefore allocations are required on the basis of the national priority order. In light of the Ministry of Health's figures that show a shortage in required medical students in order to ensure the supply needs of medical personnel in the country, the committee recommends to prioritize the use of clinical teaching resource as follows:
A. Israeli students (Israeli citizens) who are studying for a medical degree in an Israeli university (six-year program or four-year, including students who were accepted to the program based on pre-clinical studies from a foreign institution), at least in the budgeted quota/allotment that is covered by the PBC undergraduate and graduate degrees in medicine. Universities are responsible to meet the objectives prescribed from time to time by the PBC CHE in coordination with the Ministry of Health and the Ministry of Finance, with regard to the needs of the State regarding the number of Israeli medical students required.
B. Israeli students who studied medicine at universities abroad, and were accepted to an Israeli
university to carry out academic credits as part of their clinical training towards a University degree abroad.
C. Foreign students (non-Israeli citizens) who study in an Israel University medical program.
D. foreign students enrolled at universities abroad, and received Israeli university academic credits for clinical training as part of the Israeli university, towards a university degree from abroad.
Transitional provision:
• In light of the current situation in Israel in which there are operating medical programs for foreign students, in which about 130 students study during the academic year 2012, and that for legal reasons, academic and more are not immediately reducible, the Committee recommends that the PBC shall outline a gradual reduction of the number of students attending them, in favor of an increase in the number of Israeli Students who receive clinical training in Israel (groups a and b above).
• Accordingly, the number of Israeli Students in the group that appears in subsection B above, will be
determined by the number of clinical fields available to the university, deducting the students as provided in subsection A above, and deducting students attending the four Israeli universities medical curriculum for foreign students approved by the CHE (in which about 130 students study during the academic year 2012.
5. The universities are responsible to meet the country's planning goals and needs that will be
determined by the PBC and CHE for the graduates of medical programs, limited by the scope of clinical training in the hospitals.

 
Analyst Remarks to Narrative
In order to ensure the sufficiency of clinical experiences, every medical school is allowed to enroll up to 130 students per class per school. However, the country is currently experiencing a shortage of medical personnel who plan to stay in Israel after graduation. This has resulted in a desire to limit the number of foreign applicants.

It appears that there was no problem in the past in having a sufficiently large applicant pool, since there was no restriction on the number of non-Israeli citizens who could apply to study medicine.

However, it is unclear if the move to limit applications from non-Israeli citizens will result in a much less selective applicant pool.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
The transitional provision to reduce the number of non-Israeli citizens does not affect the pool of applicants. All programs continue their recruitment as usual and the same number and quality of applicants is being received. However, should the number of places for non-Israeli students be reduced, (which it has not at the time of writing), priority will be given to the most suitable and highest-performing candidates. The size and quality of the pool remains unaffected.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the move to limit applications from non-Israeli citizens will result in a much less selective applicant pool.

In response, the country indicated that the provision to reduce the number of non-Israeli citizens has not affected the pool of applicants so far. It appears that the number of places for non-Israeli students has not yet been reduced despite the apparent desire to do so. Therefore, the actual effect of the transitional provision to reduce the number of non-Israeli citizens admitted to medical schools is unclear.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Admissions, Recruiting, and Publications, Question 5
 
Country Narrative
Section 6.1 of the Standards for Evaluation of Medical Schools and Medical Education also states that "A medical school's publications, advertising, and student recruitment should present a balanced and accurate representation of the mission and objectives of the educational program. The catalog or equivalent informational materials must describe all courses offered by the school, a complete description of the requirements for the M.D. degree and all associated degrees, the most recent academic calendar for each of the curricular options available, a description of the admissions process, and the enumeration of criteria used in the selection of students" (Appendix 5, Section 6.1, p.8).
 
Analyst Remarks to Narrative
The CHE Standards expect each school to present a balanced and accurate representation of the mission and objectives of its educational program. Specifically, the catalog or equivalent informational materials, must describe all courses offered by the school, and a complete description of the requirements for the M.D. degree and all associated degrees. In particular, the Standards require that the informational materials must describe the admissions process, and an enumeration of the criteria used in the selection of students by the faculty.

As well, the Standards expect the medical school to publicize to all faculty members and students its standards and procedures for the evaluation, advancement, and graduation of its students and for disciplinary action. It is expected that the process be fair and relatively formal when taking any action that adversely affects the status of a student, including timely notice of the impending action, disclosure of the evidence on which the action would be based, and an opportunity for the student to respond.

The General Report of the Committee for the Evaluation of Medical Study Programs (Exhibit 22, Appendix D, pp. 16-17), and the Ben-Gurion University QA Report (Exhibit 23, Appendix A, pp. 9 #iv & 19) indicate that there may be a serious problem for speakers of English in Israeli medical schools. It appears that some students cannot read Hebrew medical records, and there is a concern that this deficiency may impair their educational experience in certain clinical clerkships. As well, there is a concern that this problem may lead to deficiencies in their proficiency as practitioners when they return to North America.

Therefore, it is unclear if there is any specific requirement that a medical school must publish the primary language of instruction, and any alternative language of instruction. As well, it is unclear if American students are aware that they need to be able to read Hebrew in order to interpret many patient records.

The NCFMEA may wish to inquire further regarding these matters.
 
Country Response
Conform to the requirements of Section 6 of the Standard for Evaluation of Medical Schools and Medical Education, each of the three international medical schools must publish the primary language of instruction. None of the schools offers an alternative language of instruction for their international programs.

To prepare their students for clinical studies and allow them to read and understand patient records, all of the programs offer Hebrew language instruction as part of the curriculum. At the same time, with mobile phones now being ubiquitous, in practice, students experiencing communications difficulties often revert to Google Translate to assist - a tool that is increasingly accepted in the global health arena.

Ben Gurion University's program specifically states: http://in.bgu.ac.il/en/fohs/MSIH/Pages/History.aspx
MSIH follows a four-year U.S. style curriculum that is taught in English by the medical school faculty.
The student handbook states (throughout) the use of Hebrew and the language of instruction (Appendix 4):
While acclimating to your new surroundings, you will receive intensive
introductions to the Hebrew language
Tel Aviv program specifically states (appendix 5): http://sacklermedicine.us/requirements/
All courses are taught in English. However, some competency in Hebrew is required for clinical studies. The school provides Hebrew language courses during the first and second years to prepare students for their clinical study experience.
The Technion program specifically states:
http://int.technion.ac.il/academic-programs/graduate/m-sc-ph-d-programs/
… to study an American-style medical school curriculum in English at one of Israel’s top medical faculties
The Technion sets a “positioning” exam for new students to ascertain their Hebrew competency. Students requiring lessons participate in a summer language course, and will receive Hebrew lessons throughout their first two years of study.


With reference to the NCFMEA analyst remarks about Ben-Gurion university’s “problem for speakers of English in Israeli medical schools...” we would emphasize that this particular medical school, the Medical School for International Health, is located in an area of Israel with large Bedouin, Ethiopian and Russian populations. In this region, English is less well known. The school was deliberately positioned at this location and is specifically geared to equip its students to work in Global Health in an international setting. In such an arena, often physicians must communicate with patients who do not speak their language or understand their culture. Indeed, this problem arises often in North American hospitals. MSIH specifically trains its students to deal with just such scenarios, offering possible solutions to the language/cultural barrier. Graduates of MSIH working in American hospitals report that they are often called upon as the “experts in cross-cultural communication” to deal with situations where regular staff cannot communicate with patients. Faculty at MSIH report that during the first two years, students may experience language difficulties, but as their expertise improves, language barriers become much less significant.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if there is any specific requirement that a medical school must publish the primary language of instruction, and any alternative language of instruction. As well, it is unclear if American students are aware that they need to be able to read Hebrew in order to interpret many patient records.

These questions were raised because the General Report of the Committee for the Evaluation of Medical Study Programs (Exhibit 22, Appendix D, pp. 16-17), and the Ben-Gurion University QA Report (Exhibit 23, Appendix A, pp. 9 #iv & 19) indicated that there may be a serious problem for speakers of English in Israeli medical schools.

The CHE evaluators were concerned because some students could not read the Hebrew medical records, thereby impairing their educational experience in certain clinical clerkships. Furthermore, the evaluators voiced their concern that this problem could lead to deficiencies in the graduates’ proficiency when they returned to North America as practitioners.

In response, the country indicated that the three schools with significant numbers of English-speakers offer introductory Hebrew lessons to their students. However, it is unclear if the introductory Hebrew lessons offered to English-speakers at selected medical schools are sufficient for interpreting the Hebrew medical charts used in clinical training.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Admissions, Recruiting, and Publications, Question 6
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education state that students have access to their records, as can be seen in section 5.4: "A student's records must be available for review by the student, and the student must have the right and be given the opportunity to challenge the accuracy of the record. Student records must be confidential and should be made available only to members of the faculty and administration with a need to know, unless released by the student, or as otherwise governed by laws concerning confidentiality" (Appendix 5, section 5.4, p.7).
 
Analyst Remarks to Narrative
The CHE Standards expect that each student's records be available for review by that student, and that the student be given the right and the opportunity to challenge the accuracy of the record. Furthermore, student records must be confidential and available only to members of the faculty and administration with a need to know, unless released by the student, or as otherwise governed by laws concerning confidentiality.
 
Student Achievement, Question 1
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education state that "The medical school faculty must establish principles and methods for the evaluation of student achievement, and make decisions regarding promotion and graduation. The evaluation of student achievement must employ a variety of measures of knowledge, competence and performance, systematically and sequentially applied throughout medical school. Each provisionally accredited program must utilize methods for determining the quality of its program and the level of achievement of its students compared to national norms" (Appendix 5, section 5.4, p.7).
 
Analyst Remarks to Narrative
As previously noted, the CHE Standards expect that the medical school faculty will establish the principles and methods for the evaluation of student achievement employing a variety of measures of knowledge, competence and performance, systematically and sequentially applied throughout medical school.

Under the CHE Standards, the chairman of each discipline is expected to set the standards of achievement by students in the study of that discipline. In addition, descriptions of student performance and achievements are to be recorded to supplement grade reports in all required clinical clerkships and in all courses where student-faculty interaction permits this form of assessment.
 
Student Achievement, Question 2
 
Country Narrative
According to the Standards for Evaluation of Medical Schools and Medical Education "medical school must publicize to all faculty members and students its standards and procedures for the evaluation, advancement, and graduation of its students and for disciplinary action. There should be a fair and relatively formal process for the faculty or administration to follow when taking any action that adversely affects the status of a student. The process should include timely notice of the impending action, disclosure of the evidence on which the action would be based, and an opportunity for the student to respond. A student's records must be available for review by the student, and the student must have the right and be given the opportunity to challenge the accuracy of the record. Student records must be confidential and should be made available only to members of the faculty and administration with a need to know, unless released by the student, or as otherwise governed by laws concerning confidentiality" (Appendix 5, section 5.4, p.7).
 
Analyst Remarks to Narrative
Institutions are expected to develop a system of assessment that assures that students have acquired and can demonstrate on direct observation the core clinical skills and behaviors needed in subsequent medical training. Since communication skills are integral to the education and effective function of physicians, it is expected that there be specific instruction and evaluation of these skills as they relate to communication with patients, families, colleagues and other health professionals.
 
Student Achievement, Question 3
 
Country Narrative
According to the CHE standards (appendix 5 section 6)
Medical school must carefully monitor the progress of students through the educational program and graduate only those students who successfully complete the program.
 
Analyst Remarks to Narrative
The CHE standards expect the chief academic officer and the directors of all courses and clerkships to design and implement a system of evaluation of the work of each student during progression through each course or clerkship. Furthermore, each student is expected to be evaluated early enough during a unit of study to allow time for remediation.
 
Student Achievement, Question 4
 
Country Narrative
As part of the CHE's quality assessment mechanism, which assures the continued quality and compliance with standards in higher education, programs are requested to submit self-study reports prepared according to the CHE's Guidelines for Self Evaluation (Appendix 4). Every year before the publication of the guidelines to the programs undergoing evaluation, the QAD reviews the guidelines and makes the appropriate alterations based on feedback and developments in the field of quality assessment. These reports are used for the basis of the evaluation and cover the main topics which the committees review: organizational structure, study program, students, faculty, teaching and learning outcomes, research, and quality assessment mechanisms (to assure that the schools and universities are conducting continuous QA practice and monitoring the quality of their programs). As well as an emphasis on the role of intended learning outcomes to evaluate the extent to which the programs have
defined the qualities which they intend their graduates to possess. In addition, programs are requested to submit teaching evaluation scores to assure quality teaching and the existence of proper mechanisms for teaching evaluation.
According to the CHE standards (appendix 5 section 5)
The Council for Higher education urges schools to develop a system of evaluation that fosters self­ initiated learning by students, and disapproves of the use of frequent tests which condition students to memorize details for short-term retention only. Examinations (written and others) should measure cognitive learning, mastery of basic clinical skills, and the ability to use data in realistic problem solving. Institutions must develop a system of assessment which assures that students have acquired and can demonstrate on direct observation the core clinical skills and behaviors needed in subsequent medical training.

5.2- curriculum: Medical schools should use a variety of measures to evaluate program quality, such as data on student performance, academic progress and program completion rates, acceptance into residency programs, postgraduate performance, and emerging measures that may prove to be valid. The results of such evaluations should be used to determine how well schools are fulfilling their objectives
and to assess the need for program improvement. Schools also should evaluate the performance of their
students and graduates in the framework of national norms of accomplishment. Review and necessary revision of the curriculum is an ongoing faculty responsibility.

Other then the Mentioned above, beyond the Quality Assurance investigation there is no acceptable numbers of graduates from the school passing a licensing examination, to determine whether to grant accreditation or approval to that school on a national level.
 
Analyst Remarks to Narrative
The CHE Standards take more of a general approach to encourage each school to have a student outcomes assessment program to help promote overall improvements to each school. Regarding the specific question concerning country-established benchmarks, the narrative indicates that Israel does not use them.

As a result, it is unclear how the CHE expects each medical school to use the data resulting from the suggested student assessment activities, other than promoting overall improvements to each school. In addition, it is unclear how the CHE itself evaluates the use of this data by each medical school. Furthermore, it is unclear if the CHE would consider establishing any benchmarks to compare student achievement results from the accredited medical schools.

The NCFMEA may wish to enquire further regarding these matters.

 
Country Response
Israeli Citizens
All Israeli medical students, must take the following final national exams:
At the end of 5th year - Psychiatry and Gynecology.
At the end of 6th year - Internal Medicine, Pediatrics and Surgery.
All students must pass all of these exams to be allowed to practice medicine in Israel.
The exams are prepared by teams of examiners from all of the medical schools in Israel and all students take exactly the same exams at exactly the same time. The results of these exams are collected by a single national examination unit - which analyzes student performance each year. These data are available to schools and are used to gauge student performance both within the school, and against other examined students. In this way, both the National Examination Unit and the schools can evaluate their performance both internally and externally.
The data from the national exams is available for perusal at any time by CHE and is reviewed regularly by periodical Evaluation Committee members.
CHE could establish benchmarks but the existing system is generally self-regulating and allows schools and the CHE to gauge their annual performance.

International Students are referred to in our final response below.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear how the CHE expected each medical school to use the data resulting from the suggested student assessment activities, other than promoting overall improvements to each school. In addition, it was unclear how the CHE itself evaluated the use of this data by each medical school. Furthermore, it was unclear if the CHE would consider establishing any benchmarks to compare student achievement results from the accredited medical schools.

In response, the country indicated that all Israeli medical students must pass certain national exams before being allowed to practice medicine in Israel. The country also noted that the results of the exams is available to the schools and to the CHE, and that the CHE evaluators routinely review that data. As well, the country sees no need to establish benchmarks because the current system is viewed as “self-regulating.”

As a result, it is still unclear how the CHE expects each medical school to use the data resulting from national examinations for those not practicing medicine in Israel. In addition, it is still unclear how the CHE itself evaluates the relevant performance data that is reviewed. Furthermore, it is still unclear if the CHE would consider establishing any benchmarks to compare student achievement results from the accredited medical schools.

The NCFMEA may wish to inquire further regarding these matters.
 
Staff Conclusion: Additional Information requested
 
Student Achievement, Question 5
 
Country Narrative
As can be seen in the self-evaluation reports of the medical schools, they have a formal process to collect and use information from students on the quality of courses and clerkships.
The Technion use Qualitative indices utilized to evaluate the program, "The main tool for evaluating the quality of teaching is the evaluation questionnaires that are filled by the students in the last session of each course, serving as a feedback mechanism to the course lecturers and instructors. Student evaluations of quality of the courses are used as a feedback tool to assess whether the goals of the course were achieved" (Appendix 8, p. 33).
Tel Aviv University uses these tools to assess the teaching quality as well. According to them, "The main tool for evaluating teaching at Tel Aviv University is the Internet-based teaching survey that students fill out to evaluate teachers and courses. We also enable teachers to use mid-semester survey questionnaires as a means of formative evaluation. The teachers who use these questionnaires receive a summary of their students’ feedback within a few days so that they have sufficient time to act upon their students’ comments and suggestions throughout the rest of the semester" (Appendix 7, p. 45).
At Ben Gurion University they also use questioners to evaluate both teaching and clinical teaching: There is a continuous and structured system for evaluating teaching. This includes
debriefings, lecture evaluations and personal evaluation of teachers. Debriefings take place at the end of all courses and clinical rotations (see 3.1.10). At the end of every course, the student is required to fill out evaluation forms which are summarized by the class representatives and presented to the forum which includes the course coordinator, the main teachers of the course, and the directorate of the medical school. For the lecture courses, individual evaluation of the teachers is carried out. Summaries of the evaluations are prepared by the Center for Teacher Evaluation of BGU. In the clinical courses, an individual evaluation form is completed related to the clinical instructors on the wards. Each student is requested to evaluate his/her teachers. The teachers pass out the evaluation forms to the students before the students receive their grades for that clerkship. The student grades are prepared before the evaluations are submitted. The evaluating questionnaire contains structured questions addressing the teacher's motivation, quality of frontal and bedside teaching, the ability of the teacher to serve as a role model, and a global assessment. The computer unit and the medical school administration prepare a summary of the student evaluations. The results for each clinical instructor are given to that individual and to his/her direct supervisor" (Appendix 6, p. 43).
 
Analyst Remarks to Narrative
The application narrative summarized how three of the Israeli medical schools fulfill the general expectation that they have a formal process to collect and use information from students on the quality of courses and clerkships.

(How the CHE itself evaluates the adequacy of the method chosen by each medical school to assess the quality of their courses and clerkships can be asked in relation to the previous section, if so desired by the NCFMEA.)
 
Student Services, Question 1
 
Country Narrative
Requirements for provisions of student services by medical schools are found in the Standards for Evaluation of Medical Schools and Medical Education.
Academic Counseling and Career Guidance is detailed in section 5.5: "The chief academic officer and the directors of all courses and clerkships must design and implement a system of evaluation of the work of each student during progression through each course or clerkship. Each student should be evaluated early enough during a unit of study to allow time for remediation. Course directors and faculty assigned to advise students should consider this duty a primary responsibility. All course directors or departmental heads, or their designates, should serve as expert consultants to the chief academic officer for facilitation of performance of both students and faculty. The Council will evaluate the programs designs to assist students in selecting a future medical career and in developing a strategy for application to residency programs. Any such system should not disrupt a student's curriculum in general medical education by external pressures to make premature application to residency programs"(Appendix 5, section 5.5).

A school must report its policies with regard to counseling about financial aid. To the extent possible, a school should provide financial aid to students Appendix 5, section 6.4).

A school should provide students with amenities that increase efficiency, such as study space, lounge areas and food service, if not available in the immediate vicinity of the school. The medical school should have an appropriate security system for its personnel and all properties(Appendix 5, section 6.5).

A school must report its system of personal counseling for students. The faculty and administrators should determine whether personal counsel is to be provided by an officer of administration, by assignment of faculty members or others for this purpose, or both...There must be a system for preventive and therapeutic health services to students, to make health insurance available to all students and their dependents, and to make disability insurance available to students. Schools must develop policies dealing with students' exposure to infectious and environmental hazards. The policies must include: (1) education of students about methods of prevention; (2) the procedures for care and treatment after exposure, including definition of financial responsibility; (3) and the effects of infectious and/or environmental disease or disability on student education activities. Confidential counseling by mental health professionals must be available to students(Appendix 5, section 6.6).
 
Analyst Remarks to Narrative
The CHE requires that each medical school have a system for preventive and therapeutic health services that is available to all students. The Standards expect each medical school to develop policies dealing with students' exposure to infectious and environmental hazards that specifically include: (1) education of students about methods of prevention; (2) the procedures for care and treatment after exposure, including definition of financial responsibility; and (3) the effects of infectious and/or environmental disease or disability on student education activities.

In addition, the school is to make health insurance available to all students and their dependents, and to make disability insurance available to students. Furthermore, confidential counseling by mental health professionals must be available to students.
 
Student Services, Question 2
 
Country Narrative
As stated earlier, the Standards for Evaluation of Medical Schools and Medical Education requires the medical schools to give students access to their records. " A school must report its system of personal counseling for students. The faculty and administrators should determine whether personal counsel is to be provided by an officer of administration, by assignment of faculty members or others for this purpose, or both. There must be a system for preventive and therapeutic health services to students, to make health insurance available to all students and their dependents, and to make disability insurance available to students. Schools must develop policies dealing with students' exposure to infectious and environmental hazards. The policies must include: (1) education of students about methods of prevention; (2) the procedures for care and treatment after exposure, including definition of financial responsibility; (3) and the effects of infectious and/or environmental disease or disability on student education activities. Confidential counseling by mental health professionals must be available to students" (Appendix 5, Section 6.6).
 
Analyst Remarks to Narrative
The CHE Standards parallel the language of the NCFMEA guidelines and expect that each student's records be available for review by that student, and that the student be given the right and the opportunity to challenge the accuracy of the record.

Furthermore, student records must be confidential and available only to members of the faculty and administration with a need to know, unless released by the student, or as otherwise governed by laws concerning confidentiality.
 
Student Complaints, Question 1
 
Country Narrative
In section 6.1 of the Standards for Evaluation of Medical Schools and Medical Education, they write: "Each medical school or its parent university should define the standards of conduct in the teacher-learner relationship. Schools should develop and widely promulgate written procedures that allow medical students to report violations of these standards--such as incidents of harassment or abuse--without fear of retaliation. The procedures also should specify mechanisms for the prompt handling of such complaints, and for the educational methods aimed at preventing student mistreatment." (Appendix 5, section 6.1, p. 8).
QA evaluation guidelines, question 3.3.8 asks the medical schools what are the mechanisms that deal with student complaints? Please provide a list of students' complaints over the last two years and the way they were resolved (appendix 4).
The medical schools answers are reported in their self-evaluation reports.
For example The Technion's response is :
"A student who has a personal complaint can appeal to the counselor of that year. If the whole class has complaints they are referred, through the class committee, to the counselor who decides whether the complaint should be referred to the course coordinator, Deputy Dean for Teaching or the Dean. In addition, in the Technion there is a Dean of Students to whom one can appeal with any complaint. In the Faculty there is a teacher-student committee whose task is to deal with problems and complaints of students as it sees fit.
Graduate Studies Program also has a complaint system explained in the SER.
Student ombudsman
If all the above-mentioned avenues for resolution have been exhausted and a satisfactory solution has still not been found for a problem that has arisen, it is possible to submit the complaint, with all the necessary relevant documentation to the “student ombudsman” as is explained below. [Comment: A complaint that has not previously been considered by the Dean of Undergraduate / Graduate Studies or the Dean of Students as mentioned above will be returned to the student without being dealt with].
The student ombudsman is an independent, neutral authority dealing with student appeals that have not been solved in the conventional channels. The ombudsman serves as an objective adjudicator between student and the academic and administrative authorities of the institution. He hears the sides and has access to any written relevant information. Any student can appeal to the ombudsman on any issue where he/she feels that an injustice has been perpetrated upon him/her with the exception of matters that have been discussed in the disciplinary committee and the Senate court or relate to scholarships and admission to dormitories. A student is entitled to appeal to the ombudsman or to consult regarding submission of a complaint. The ombudsman does not deal with anonymous appeals but the student is entitled to request that discretion be exercised regarding his/her name." (Appendix 8, p. 34-35, 51).
Ben Gurion's Response is:
Student complaints are usually submitted to the year committees and to the course coordinator. Individual counseling services are available through the services that were detailed in the section on Academic counseling. A counseling service and student clinic are located on the main university campus run by a senior family physician, appointed by the academic staff of the medical school. The clinic works on a regular schedule and the service is available to any student on the basis of self-referral. Generally, there are three types of complaints:
Related to exams (the majority); Related to curriculum; Personal matters
Examples:
Complaints related to exams: After the Limbs Anatomy exam, this year, students complained that the teacher did not remain until the end of the exam (contrary to the standing orders of the University) to answer questions, that the exam was difficult but fair – (by design) and that the exam included numerous questions with a high level of discrimination. A number of the students scored very well on it but a relatively high number of students failed the exam. Because the physical conditions did not allow the teacher to remain until the end, the Medical School Directorate, with the full agreement of the teacher, decided that every student who requested to take the second date of the anatomy exam could do so and only the higher score would count. Students who failed both exams would be allowed to take a third exam.
Complaints related to curriculum: This year, the Deans Forum decided to shorten the 6th academic year by three months. The only way to cut without significantly affecting the educational program was by canceling elective rotations, which caused great dissatisfaction among the students. The Curriculum Council reviewed the 6th year academic program and suggested shortening some of the clinical rotations and so to salvage four weeks of elective rotations. Nevertheless, the students were not completely satisfied Complaints/problems concerning personal issues A pregnant student who could not take an anatomy course due to Formalin hazards, complained that she would not be able to finish her studies in due time. After checking with The National Poison Control Center for guidelines, she was offered individual training in the dissection room financed by the faculty so she could continue her studies in the 4th year.
MSIH deals with these kinds of complaints in exactly the same fashion. (Appendix 6, p. 67-68).

Tel Aviv University's answer is similar:
Students’ complaints are dealt with by the Students-Faculty Committee. The committee is composed of students from each year and from members of preclinical and clinical faculty. The committee has two methods of activity: 1. Meeting at the University – 4 times during the academic year. 2. Direct contact with the chairman of the committee.
All students can personally approach the secretaries of the committee, or directly the chairman of the committee, by phone or by mail. With this method of activity, problems are being solved, in most cases, on-line, and, if needed, at the committee's meetings. For example, there was a case where a group of 6 students failed a clerkship in psychiatry, since they missed too many days during a one-week clerkship. The students complained, claiming that not all of them missed that many days. After discussion with the director of the department and the students, the chairman of the committee decided that only the 3 students who missed too many days failed and should repeat the clerkship.
B. Types of complaints
Complaints were broken down to the following types:
- Twenty percent related to tuition and fees;
- Twenty percent (about half undergraduate and half graduate) related to admission;
- Sixty percent related to other matters:
Grades, exams/papers and exams/assignments dates; Cancellation/registration to courses; Termination of studies; Reserve service; Eligibility for graduation; Exemption from courses; Faculty/administrative staff behavior; Transition between departments; Pregnancy/giving birth; Dormitories; Benefits for students with learning difficulties (Appendix 7, p, 69-71).
 
Analyst Remarks to Narrative
The CHE Standards expect each medical school, or its parent university, to define the standards of conduct in the teacher-learner relationship, and to develop and widely promulgate written procedures that allow medical students to report violations of these standards without fear of retaliation. The application narrative detailed how some of the medical schools implemented the CHE’s expectations regarding the handling of student complaints.
 
Student Complaints, Question 2
 
Country Narrative
As stated in the previous question, the student's complaints are dealt with in the different institutions and are usually regarding grades, curriculum or personal matters (Appendix 6-8).
The CHE, as the regulatory body of the Medical Schools receives a few complaints during the year from students from all different fields. The complaints we received from medical school students are usually similar to complaints from other students.
For example, the CHE received a question regarding entrance to Medical School in ben Gurion University, the candidate was wondering why they use a limitation on applying to Medical school (appendix 13).
Another complaint that was received was regarding the entrance exam to the 4-year medical program. The complaint was that applicants who take the GRE-Biochemistry test who have learning disabilities take the exam about two days after the rest of the students, thus giving them an advantage on other students.
 
Analyst Remarks to Narrative
Although the CHE Standards expect the written procedures to specify mechanisms for the prompt handling of complaints, it does not specifically require that those procedures include CHE contact information so that students can submit complaints not resolved at the institutional level.

Department staff did verify, however, that the CHE’s English web site (http://che.org.il/en/?page_id=6511) does provide a useful list of contact information, together with an option where any inquiry, including a complaint, could be submitted.
 
Finances, Question 1
 
Country Narrative
Besides being funded privately (tuition and donations) our medical schools are mainly financed by the financial branch of the Council for Higher Education (CHE), the Planning and Budgeting Committee (PBC). An independent intermediary body between the Government and the institutions of higher education, in all matters relating to funds allocations for higher education. (see appendix 24 -the Israeli Higher Education Budgeting model).
 
Analyst Remarks to Narrative
The country narrative noted that Israeli medical schools are mainly financed by the Planning and Budgeting Committee, which is the financial branch of the CHE. Their budgeting model allocates funds to the overall institution (based on its schools or departments), rather than to each one of its schools or departments separately. Documentation was also provided that contains a description of the budgeting formula (Exhibit 20).

The CHE Standards themselves do not directly address medical school finances, since their overall focus is to ensure that the various aspects of a successful medical school are in place and functioning properly, such as adequate faculty and facilities.
 
Facilities, Question 1
 
Country Narrative
Requirements related to the types and quality of facilities a medical school must have can be seen in Section 7 of the Standards for Evaluation of Medical Schools and Medical Education that state that "Medical school must have physical facilities that are qualitatively adequate for the size and scope of the educational program, as well as of the student body. The faculty must provide effective teaching and be of sufficient size to provide the scope of the educational program offered. Medical school must have a library sufficient in size, breadth and depth to support the educational program". Moreover, section 7.1 states that "A medical school must have, or be assured use of, buildings and equipment that are quantitatively and qualitatively adequate to provide an environment conducive to high productivity of faculty and students. Geographic separation between facilities may be dysfunctional. The facilities must include faculty offices and research laboratories, student classrooms and laboratories, amenities for students, offices for administrative and support staff, and a library. Access to an auditorium sufficiently large to accommodate the student body is desirable. The school should be equipped to conduct biomedical research and must provide facilities for humane care of animals when animals are used in teaching and research" (Appendix 5, section 7+7.1, p.9-10).
 
Analyst Remarks to Narrative
Regarding facilities, CHE Standards generally expect each medical school will have, or be assured use of, buildings and equipment that are adequate to provide an environment conducive to high productivity of faculty and students. Laboratories and other facilities are reviewed by the visiting teams as part of their evaluations.
 
Facilities, Question 2
 
Country Narrative
Section 7.1 of the Standards for Evaluation of Medical Schools and Medical Education explain that medical schools need to provide facilities for the humane care of animals when animals are used in teaching and research in such a way that "A medical school must have, or be assured use of, buildings and equipment that are quantitatively and qualitatively adequate to provide an environment conducive to high productivity of faculty and students. Geographic separation between facilities may be dysfunctional. The facilities must include faculty offices and research laboratories, student classrooms and laboratories, amenities for students, offices for administrative and support staff, and a library. Access to an auditorium sufficiently large to accommodate the student body is desirable. The school should be equipped to conduct biomedical research and must provide facilities for humane care of animals when animals are used in teaching and research" (Appendix 5, section 7.1, p.10).
 
Analyst Remarks to Narrative
As noted previously, the CHE Standards generally reflect the expectations of the NCFMEA Guidelines. The Standards expect that medical school facilities will have adequate faculty offices and research laboratories, student classrooms and laboratories, amenities for students, offices for administrative and support staff, and a library.

As well, the Standards expect the medical school to be equipped to conduct biomedical research, and that it provides facilities for humane care of animals when animals are used in teaching and research. Typically, the medical school’s facilities are reviewed by the CHE’s visiting team as part of its on-site evaluation.
 
Faculty, Question 1
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education The Standards for Evaluation of Medical Schools and Medical Education detailes requirements related to Medical School's faculty in section 7.2.
Regarding the qualifications for appointment to the faculty it states that "members of the faculty must have the capability and continued commitment to be effective teachers. Effective teaching requires knowledge of the discipline and an understanding of pedagogy, including construction of a curriculum consistent with learning objectives, subject to internal and external formal evaluation. The administration and the faculty should have knowledge of methods for measurement of student performance in accordance with stated educational objectives and national norms. Persons appointed to a faculty position must have demonstrated achievements within their disciplines commensurate with their faculty rank. The recruitment and development of a medical school's faculty should take into account its mission, the diversity of its student body, and the populations that it serves. It is expected that faculty members will have a commitment to continuing scholarly productivity, thereby contributing to the educational environment of the medical school" (Appendix 5, Section 7.2, p.10).

Requirements regarding the relationship between the instructional staff at remote sites and clinical locations and the medical school are also detailed in section 7.2 of the standards:
In each of the major disciplines basic to medicine and in the clinical sciences, a critical mass of faculty members must be appointed who possess, in addition to a comprehensive knowledge of their major disciplines, expertise in one or more subdivisions or specialties within each of these disciplines. In the clinical sciences, the number and kind of specialists appointed should relate to the amount of patient care activities required to conduct meaningful clinical teaching at the undergraduate level, as well as for graduate and continuing medical education.
Physicians practicing in the community can make a significant contribution to the educational program of the medical school, subject to individual expertise, commitment to medical education, and availability. Practicing physicians appointed to the faculty, either on a part-time basis or as volunteers, should be effective teachers, serve as role models for students, and provide insight into contemporary methods of providing patient care. The quality of an educational program is enhanced by the participation of volunteer faculty in faculty governance, especially in defining educational goals and objectives.
There must be clear policies for the appointment, renewal of appointment, promotion, granting of tenure and dismissal of members of the faculty. The appointment process must involve the faculty, the appropriate departmental heads, and the dean. Each appointee should receive a clear definition of the terms of appointment, responsibilities, line of communication, privileges and benefits, and policy on practice earnings. Faculty members should receive regularly scheduled feedback on their academic performance and their progress towards promotion. Opportunities for professional development should be provided to enhance faculty members skills and leadership abilities in teaching and research.
The education of both medical students and graduate physicians requires an academic environment that provides close interaction between faculty members, so that those skilled in teaching and research in the basic sciences can maintain awareness of the relevance of their disciplines to clinical problems. Such an environment is equally important for clinicians, for from the sciences basic to medicine comes new knowledge which can be applied to clinical problems. A medical school should endeavor to provide a setting in which all faculty members work closely together in teaching, research, and health care delivery, to disseminate existing knowledge and to generate new knowledge of importance to the health and welfare of mankind.
Graduate medical education and graduate education in the biomedical and behavioral sciences are important parts of the academic environment of a medical school. There should be regular institutional review of the graduate programs in which medical school faculty participate, addressing the quality of education, the research and scholarship of the faculty, and the progress and achievement of the trainees.
The dean and a committee of the faculty should determine medical school policies. This committee typically consists of the heads of major departments, but may be organized in any manner that brings reasonable and appropriate faculty influence into the governance and policymaking processes of the school. The full faculty should meet often enough to provide an opportunity for all to discuss, establish, and otherwise become acquainted with medical school policies and practices (Appendix 5, Section 7.2, p.10).

the requirments regarding the clinical site instructors can be seen in section 4:
If components of the program are conducted at sites geographically separated from the main campus of the medical school, the chief academic officer of the medical school must be responsible for the conduct and maintenance of the quality of the educational experience offered at these sites and for identification of the faculty at all sites. The principal academic officer of each geographically separated site must be administratively responsible to the chief academic officer of the medical school conducting the accredited program. The faculty in each discipline, in all sites, must be functionally integrated by administrative mechanisms that ensure comparable quality in the educational experiences and consistency in student evaluation at the geographically separated segments of the program.
A large number of program sites or a significant distance between sites may require extra academic and administrative controls in order to maintain the quality of the entire program.
A medical school must specify its separated campuses and the faculty teachers in them (Appendix 5, Section 4, p.2-3).
 
Analyst Remarks to Narrative
The CHE Standards expect that members of the faculty will have the capability and continued commitment to be effective teachers. In addition, the Standards expect the administration and the faculty to have knowledge of methods for measurement of student performance in accordance with stated educational objectives and national norms, and that faculty members will have a commitment to continuing scholarly productivity, thereby contributing to the educational environment of the medical school.

The Standards also expect that in each of the major disciplines basic to medicine and in the clinical sciences, a critical mass of faculty members will be appointed who possess, in addition to a comprehensive knowledge of their major disciplines, expertise in one or more subdivisions or specialties within each of these disciplines.

Regarding the clinical sciences, the number and kind of specialists appointed are expected to relate to the amount of patient care activities required to conduct meaningful clinical teaching at the undergraduate level, as well as for graduate and continuing medical education.

The Standards also note that physicians practicing in the community can make a significant contribution to the educational program of the medical school and that if appointed to the faculty, either on a part-time basis or as volunteers, they are expected to be effective teachers, to serve as role models for students, and to provide insight into contemporary methods of providing patient care.
 
Faculty, Question 2
 
Country Narrative
The Standards for Evaluation of Medical Schools and Medical Education section 7.2 specifies that "A medical school should have policies which deal with circumstances in which the private interests of its faculty or staff may conflict with their official responsibilities" (Appendix 5, section 7.2, p.11)

 
Analyst Remarks to Narrative
Again paralleling the NCFMEA Guidelines, the CHE Standards expect that a medical school will have policies that deal with circumstances in which the private interests of its faculty or the staff may conflict with their official responsibilities.

Other than that stated expectation, it is unclear if the various CHE visiting teams consistently evaluate the effectiveness of each medical school’s conflict of interest policies.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
Each of the medical schools in Israel is an academic unit inside a university and they are governed by the university’s General Code of Ethics. The Code of Ethics deals with, inter alia, conflict of interest. This Code is examined by CHE during regular evaluations of the medical schools, (and other Faculties that are subject to CHE periodic evaluations).

An example Code of Ethics from Ben-Gurion University (appendix 6). Section 5 (page 17) states:

“A faculty member who encounters a situation of conflict of interest in his administrative activities will declare this conflict of interest (due discovery), and ask to be released from the process that causes such conflict. A conflict of interest may arise because of a family relationship (of the kind which is not forbidden according to the University’s code of employment of relatives), links to any party outside the University, commercial activity, and so on. In all cases of conflict of interest, the faculty member must maintain his loyalty to the University and his commitment to its affairs and its values.”

Where there may be a breach of ethics at a university, the matter is taken before an Ethics Committee. In some cases, decisions of the Ethics Committee of the universities are available on the university’s web site for public scrutiny. An example is Tel Aviv Univerity: https://acad-sec.tau.ac.il/discipline. Being public, such decisions are also available for examination and evaluation by CHE visiting teams. In addition, the nature of Ethics Committee decisions are such that they draw enormous attention at the institution involved, and Evaluation Committee members will often hear of these decisions while conducting their evaluation.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the various CHE visiting teams consistently evaluate the effectiveness of each medical school’s conflict of interest policies.

In response, the country indicated that each medical school faculty is covered by the overall university’s code of ethics, and that code regularly covers conflicts of interest. As a result, the CHE visiting teams review each school’s code of ethics on a regular basis.
 
Staff Conclusion: Comprehensive response provided
 
Library
 
Country Narrative
The Quality of the medical school's library is depicted in the Standards for Evaluation of Medical Schools and Medical Education section 7.3: "The medical school must have a well-maintained and catalogued library, sufficient in size and breadth to support the educational programs offered by the institution. The library should receive the leading biomedical and clinical periodicals, the current numbers of which should be readily accessible. The library and any other learning resources should be equipped to allow students to learn new methods of retrieving and managing information, as well as to use self-instructional materials. A professional library staff should supervise the library and provide instruction in its use.
If the library serving the medical school is part of a medical center or university library system, the professional library staff must be responsive to the needs of the medical school, its teaching hospitals, the faculty, resident staff, and students who may require extended access to the journal and reference book collections. The librarian should be familiar with the methods for maintaining relationships between the library and national library systems and resources, and with the current technology available to provide services in non-print materials. If the faculty and students served by the library are dispersed, the utilization of departmental and branch libraries should be facilitated by the librarian and by the administration and faculty of the school.
The library should also be a community resource in support of continuing medical education" (Appendix 5, section 7.3, p.11-12).
 
Analyst Remarks to Narrative
The CHE Standards expect that the medical school will have a well-maintained and catalogued library, sufficient in size and breadth to support the educational programs offered by the institution. Specifically, the library is expected to receive the leading biomedical and clinical periodicals and that the current numbers of which should be readily accessible. Furthermore, the library and any other learning resources are to be equipped to allow students to learn new methods of retrieving and managing information, as well as to use self-instructional materials. In addition, a professional library staff is expected to supervise the library and to provide instruction in its use.

The Standards also note that if the library serving the medical school is part of a medical center or university library system, then the professional library staff is expected to be responsive to the needs of the medical school, its teaching hospitals, the faculty, resident staff, and students who may require extended access to the journal and reference book collections.
 
Clinical Teaching Facilities, Question 1
 
Country Narrative
The medical school should have affiliation agreements with each teaching hospital or clinical facility it uses that define the responsibilities of each party. As can be seen in the Standards for Evaluation of Medical Schools and Medical Education "The medical school must have adequate resources to provide clinical instruction to its medical students. Resources must include ambulatory care facilities and hospitals where the full spectrum of medical care is provided and can be demonstrated. Each major clinical department must have a residency program accredited by the Israel Medical Association Scientific Council. The number of hospital beds required for education cannot be specified by formula, but the aggregation of clinical resources must be sufficient to permit students in each of the major clerkships to work up and follow several new patients each week.
Since undergraduate medical education usually requires the conduct of simultaneous and mutually supportive programs of graduate medical education, clinical facilities must be adequate for both parts of the continuum of medical education. A hospital that provides a base for the education of both medical students and residents must have adequate library resources, not only for the clinical staff, but also for the faculty and the students. Ready access to areas for individual study, for conferences, and for lectures is necessary.
The nature of the relationship of the medical school to affiliated hospitals and other clinical resources is extremely important. There should be written affiliation agreements that define the responsibilities of each party. The degree of the school's authority should reflect the extent that the affiliated clinical facility participates in the educational programs of the school. Most critical are the clinical facilities where required clinical clerkships are conducted. In affiliated institutions, the school's department heads and senior clinical faculty members must have authority consistent with their responsibility for the instruction of students.
Recognizing the special relationship between the medical school and its affiliated teaching hospitals, it is imperative that the academic programs remain under the control of the faculty in all medical school-hospital relationships"(Appendix 5, section 7.4, p.12).
In addition, please check Appendix 15 to see an example of an affiliation agreement between Ben-Gurion University and Soroka Hospital.
 
Analyst Remarks to Narrative
The CHE Standards expect that the medical school will have adequate resources to provide clinical instruction to its medical students, including ambulatory care facilities and hospitals where the full spectrum of medical care is provided and can be demonstrated. Furthermore, the Standards list some of the specific requirements that it expects, and reminds medical schools that each major clinical department is expected to have a residency program that meets national standards.

Finally, the Standards expect that the medical school and its affiliated hospitals and other clinical resources have written affiliation agreements that define the responsibilities of each party, while emphasizing that the academic programs remain under the control of the faculty in all medical school-hospital relationships.
 
Part 3: Accreditation/Approval Processes and Procedures
Onsite Review, Question 1
 
Country Narrative
The entity responsible for accrediting medical schools (and other academic programs) is the Council for Higher Education (CHE). In the CHE, accreditation of medical schools is divided: the division to accredit a new medical school, upon its penning is the Academic Division, whereas the division to approve an existing, already operating medical school (re-evaluating an accredited school) is the Quality Assessment Division (QAD).

In both processes an on-site visit by a committee approving the school is required.

An evaluation committees of the QAD is composed of leading academics in the field of medicine, from respectable higher education institutions outside Israel (with one Israeli representative). The evaluation of the schools by the committee is based on two components:
1. Reading the self-evaluation report prepared by the institution. The report is comprehensive and includes: a description of the school's organizational structure; mission statement and strategic plan;
information regarding the study program, faculty, student body, teaching and learning outcomes, research and infrastructures. Please see examples of such reports- appendices 6-8.
2. An on-site visit at the institution- the evaluation committee is obligated to conduct an on-site visit at each one of the schools evaluated. The visit is of two days, during which the committee members meets with the heads of the institution, the dean of medical school, senior and junior faculty members, students at all stages of their studies, alumni, and also visiting the infrastructure of the school (including classrooms, labs, clinics, and other sites the students are trained at during their clinical studies such as hospital departments).
The visit is based on the guidelines provided to the committee (appendix 16). Before each visit the committee meets and writes questions for the visit (gathered by the coordinator). Please see an example of question for a visit attached as appendix 17.
During the on-site visit the committee members takes notes, that will serve as the basis for the evaluation report.
There in no separate report for the on-site visit itself.

The evaluation committee members visit the main campus, and also any other branch campuses (if there are any). They also visit the clinics and departments where students are being clinically trained. A schedule for such a visit, in one of the recently evaluated medical schools is attached as appendix 18
and the evaluation report of the committee based on that visit is attaches as appendix A .
 
Analyst Remarks to Narrative
The CHE implements parallel processes for initial accreditation, which is carried out upon the establishment of a new medical school, and re-evaluation of accreditation, which is carried out periodically in existing medical schools. External committees appointed by the CHE carry out both processes.

The accreditation processes require a site visit. The visit is conducted by a committee of the CHE that inspects all relevant aspects of the medical education program (such as curriculum, admissions, facilities, etc.); interviews leading figures (such as the Rector, the Dean, etc.); meets with faculty members and students; and suggests improvements. The visitors conduct the site-visit in all the school’s separate campuses, as appropriate.

The evaluation is an interactive process culminating in a final and comprehensive report that is submitted to the CHE. The CHE, in turn, decides whether to grant the university authorization to provide medical education and to grant academic degrees in the field of medicine (for a new program), or re-affirms the current authorizations.

The documentation provided by the country did include sample evaluation reports and the summary document that pulls all the findings together in order to note trends and recurring issues found among the schools. The documentation confirms that the visiting committees use their time as the required by the CHE, that is, to tour all the facilities, to meet with all the appropriate persons, and to review those materials that assist in the evaluation of the educational program.

It is clear from the documentation that the CHE team visits the medical school’s primary local clinical site. Perhaps all students receive their clinical training at that primary location and that there are no other local affiliated clinical sites being used. Until that question is answered, it is unclear if the CHE site evaluation team visits just the primary local clinical site, or all of the local affiliated hospitals and/or clinics where clinical training is provided, as appropriate.

The NCFMEA may wish to enquire further regarding this matter.

(Note: International clinical sites are covered under the following guideline section.)
 
Country Response
It is important to understand the structure and nature of the Israeli health and medical education systems - which are very closely integrated and engage the same personnel. Physicians at one hospital may be medical school faculty members at a university in another city. For example, physicians working at Barzilai Hospital in Ashkelon, are faculty members at Ben-Gurion University, some 40 miles distant. Thus, when a CHE evaluation team visits a “primary location” (Ben-Gurion) that location would bring in its faculty members from the “local affiliated clinical site” (Barzilai) for the day. The same would apply to the other medical schools in the country. This means that a site visit to a “primary location” will also give evaluation teams the opportunity to engage with faculty members from “the local affiliated clinical site.”

In addition, the evaluation teams include physicians from Israel’s medical profession. Israel is a very small country and such physicians are usually well acquainted with the medical facilities and personnel throughout the country. Naturally, such committee members do not take part in site visits where a conflict of interest may arise, but they are a source of valuable information to other committee members if questions subsequently arise about an affiliated site they have not visited.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the CHE site evaluation team visits just the primary local clinical site, or all of the local affiliated hospitals and/or clinics where clinical training is provided, as appropriate.

In response, the country indicated that the evaluators do not visit all of the local training sites. Instead, they typically have members of the faculty at those sites come to the main campus for discussions during the review. As a result, it is still unclear how the evaluators verify the actual conditions at the local training sites where the students are being educated and trained.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Onsite Review, Question 2
 
Country Narrative


The medical schools are responsible for ensuring the quality of clinical teaching sites, and conduct on­ site visits at the sites affiliated with the school. For example please see BGU's guidelines for evaluation of clinical sites (appendix 11).
 
Analyst Remarks to Narrative
The country provided an outline of the types of questions the teams review when visiting an international clinical site.

However, it is unclear where each approved international clinical site is currently located, and when each one was last evaluated by a CHE-approved on-site team.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
Please note that IN NONE of the international clinical sites utilized by Ben-Gurion University do clerkships EXCEED eight weeks. Nor are any international clinical sites used for core clinical education. That said, the university insists that all of the clinical sites to which students are sent are thoroughly evaluated for academic standards and suitability. Thus, CHE made site visits together with Ben-Gurion University faculty as follows:

India - Christian Medical College and Hospital, Vellore - site visit with CHE in 2010.
India - St. John's Medical College, Bangalore - site visit by CHE in 2010.
India - Mahatma Gandhi Institute of Medical Sciences, Sewagram - site visit by CHE in 2010.

In addition to the CHE team, there are regular visits to the sites by Ben-Gurion University faculty. At the time of writing, the academic coordinator of MSIH’s international clerkships, herself as senior cardiologist, is taking a three-month sabbatical in Bangalor and will spend time at St. John’s Medical College where she will work with local staff.

Further, upon completion of their clerkships, all MSIH students participate in mandatory debriefings to evaluate their on-site learning experience. Where deficiencies are identified, MSIH faculty communicate with site directors to discuss and remedy issues. There is ongoing, regular, and consistent evaluation by Ben-Gurion University.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear where each approved international clinical site is currently located, and when each one was last evaluated by a CHE-approved on-site team.

In response, the country indicated that none of the international clinical sites are used for core clinical clerkships and that none of the clerkships at these sites exceed eight weeks in length. The response also noted that the last time the CHE evaluated the international sites was in 2010, and the only international sites listed were all in India.

(As noted under another guideline, the CHE is aware that India is no longer on the NCFMEA list of comparable countries. This factor is not viewed as an issue by the CHE because the clerkships in India do not exceed eight weeks.)

However, it is unclear if any Israeli medical schools utilize any international clerkships in countries other than India.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Onsite Review, Question 3
 
Country Narrative
The responsibility for regularly evaluating the clinical clerkship sites, affiliated with the programs, is of the medical schools themselves, as stated before. Nevertheless, the international evaluation committee who evaluated and approved the schools in the past years has visited the core clinical sites, and were provided with all the necessary information, regarding any sites they have not visited. (See appendices 18-20 for site visit schedules by the international committee)
 
Analyst Remarks to Narrative
As noted under the two previous sections, there are some questions regarding the on-site evaluation of core clinical clerkship sites, both local and international. Under this section, the country reported that the individual medical schools themselves are responsible for visiting their own clinical sites. In addition, it is clear that the CHE team at least visits the primary clinical site during its on-site review to each medical school that is conducted every six years.

However, it is unclear if the CHE is considering the adoption of an official written policy sufficient to ensure that the individual medical schools will conduct their site visits to local core clinical clerkships with some consistency. In addition, it is unclear if the CHE is considering the adoption of an official written policy that would require all international core clinical clerkships to be site-visited on a regular schedule.

The NCFMEA may wish to enquire further regarding these matters.
 
Country Response
Again, an understanding of the Israeli health and medical education system is required. Each of the hospitals in which core clinical clerkships are conducted is associated with a university. (For example, at Ben-Gurion University, the associated hospital is “Soroka University Medical Center.”) Physicians working in these hospitals are faculty members in the medical schools. As such, all clinical teaching hospitals are staffed permanently by university faculty and are under their constant supervision and assessment. Faculty members will have an office in the university, then “cross the street” to their office in the hospital.

In such circumstances, it is not necessary for CHE to “ensure that individual medical schools will conduct their site visits … with some consistency” as all times, the medical schools are situated alongside and inside the hospitals and are staffed by the same personnel. That said, CHE recommends that medical education committees of the schools visit relevant hospitals regularly.

As for the foreign schools, as stated above, all core clinical clerkships are conducted only in Israel and the students share the same facilities, faculty and education resources as Israeli students.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the CHE is considering the adoption of an official written policy sufficient to ensure that the individual medical schools will conduct their site visits to local core clinical clerkships with some consistency. In addition, it was unclear if the CHE is considering the adoption of an official written policy that would require all international core clinical clerkships to be site-visited on a regular schedule.

In response, the country noted that in Israel many of the faculty at the core clinical sites are the same faculty that teach in the medical schools. Therefore, the country considers this situation as an adequate alternative to having the CHE conduct on-site evaluations of all core clinical clerkships, as expected by the NCFMEA guidelines. The country also believes that the situation in Israel precludes even the need for the medical school to conduct regular on-site evaluations of the clinical sites. Regarding international sites, the country declared that all core clinical clerkships are conducted only in Israel.

Since Israel considers regular site visits to core clinical clerkships sites unnecessary, it is unclear how the CHE fulfills the NCFMEA expectation that a comparable accreditor will conduct timely on-site evaluations of all core clinical clerkship sites as part of its standard accreditation process.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Onsite Review, Question 4
 
Country Narrative
The clinical clerkships in Israel are located in the public hospitals and other medical services, each of them is bound to the medical schools by individual affiliation agreement, which details the mutual responsibility of the parties (the school and the hospital) for the clinical training of the students. Among others it relates to the curriculum, the clinical instructors, supervision and evaluation of the students etc.) These agreements were reviewed by the international evaluation committee, which evaluated the medical schools recently. Please see an example of such an agreement attached as appendix 15.

 
Analyst Remarks to Narrative
The country provided a minimal affiliation agreement from 2012 between Ben-Gurion University (BGU) and Soroka Medical Center. However, the notes made by the CHE evaluation team in preparation for their upcoming site visit noted that “We are given a list of affiliated hospitals without any description of what each does in relation to BGU – type of affiliation, number of students of various types each year, etc.”

Therefore, it is unclear if the CHE Standards require that its own periodic site visiting team will consistently receive at least minimally detailed affiliation agreements that meet the CHE’s published expectations.

The NCFMEA may wish to enquire further regarding these matters.
 
Country Response
Like many other countries, in Israel, each medical school has affiliated hospitals. Tel Aviv has affiliations with some 15 hospitals/medical centers. Ben-Gurion University is affiliated with three hospitals from Beersheba, Ashkelon, and Eilat. The Technion is affiliated with Rambam Hospital in Haifa, and others. The Hebrew University is affiliated with two Hadassah Hospitals in Jerusalem, and more. Each of the medical schools has formal affiliation agreements (in Hebrew) with the medical centers - which may run to scores of pages. Taken together, all the agreements between all the hospitals and all the medical schools amount to many hundreds, if not thousands of pages. The sole reason to translate such documents in their entirety into English would be to make them accessible to the non-Hebrew speaking members of the CHE Evaluation Teams. CHE was informed that it was impractical to translate all affiliation agreements so abbreviated versions were presented to the committees for perusal. However, CHE itself operates in Hebrew and full affiliation agreements are available to Hebrew-speaking Evaluation Committee members upon request.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the CHE Standards require that its own periodic site visiting team will consistently receive at least minimally detailed affiliation agreements that meet the CHE’s published expectations.

The question was raised because one of the CHE evaluation teams noted that “We are given a list of affiliated hospitals without any description of what each does in relation to BGU-type of affiliation, number of students of various types each year, etc.”

In response, the country indicated that the affiliation agreements are very lengthy documents written in Hebrew. Since it is impractical to translate all those agreements for all members of the CHE evaluation team, the non-Hebrew speaking members must rely on those who are fluent in Hebrew, which can be viewed as an acceptable solution in this particular situation.
 
Staff Conclusion: Comprehensive response provided
 
Onsite Review, Question 5
 
Country Narrative
The only institute relevant to this question is BGU (as the others don't offer foreign clinical training programs) Due to the requirement of the American Department of Education in Washington, the Medical School for International Health (MSIH) at Ben Gurion University was required to evaluate sites to be used for an eight week clerkship in international health for senior medical students in the developing world.
This program contains three elements: a two week elective on a clinical service at the teaching hospital, a three week rotation in a primary care setting and two weeks dedicated to data collection for a project to be submitted to the school as part of the requirements for graduation.

Countries approved by NCFMEA were selected for the eight week clerkship and teams composed of a faculty member from MSIH and a representative from the CHE visited each of the sites to determine quality equivalency. The CHE appointed three officials, all professors of Medicine in Israeli medical schools, to review three clinical sites in India. The teams reviewed the three sites using the QAD guidelines (Appendix 4) in line with its quality assessment standards.

Following examination of the CHE appointed officials' reports, the CHE determined the clinical teaching in India at the Mahatma Gandhi Institute of Medical Sciences, Christian Medical College, and St. John's
National Academy of Health Sciences to be consistent with its quality assessment standards and as such approved the three sites for the purposes of clinical education.

Ben Gurion University received final approval from the United States Department of Education on February 24, 2011 to utilize the three clinical sites in India for short-term medical site training.

 
Analyst Remarks to Narrative
The country narrative noted that the only school that uses foreign clinical sites is BGU, and that those sites had been visited by a representative of BGU and a representative of the CHE. Other than an outline of the areas that the visitors were to evaluate, there was no documentation of dates, or findings, or when the next visits are scheduled to take place.

More important, however, is the fact that India is no longer on the list of countries found by the NCFMEA to have standards for the evaluation of medical schools comparable to those used by the United States. Therefore, it is unclear if the CHE still approves the use of clinical training sites in India.

The NCFMEA may wish to inquire further regarding this matter.
 
Country Response
CHE does approve the use of clinical training sites in India, as long as they conform to the standards of QAD guidelines. As explained in our original answer, three official of CHE visited the Indian sites along with qualified Ben-Gurion University faculty and reviewed the sites using QAD guidelines. As the sites were deemed consistent with the CHE’s quality assessment standards, CHE issued its approval of their use for clinical training. On the matter of India no longer being on the list of NCFMEA-approved countries, as stated above, MSIH students do not attend Indian clerkship sites for periods exceeding eight weeks.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the CHE still approves the use of clinical training sites in India.

In response, the country indicated that the CHE continues to approve the use of clinical sites in India. Even though India is no longer on the NCFMEA’s list of comparable countries, the CHE does not view this as an issue since the clerkships do not exceed eight weeks.

However, as the country noted, Ben Gurion University received final approval from the United States Department of Education on February 24, 2011 to utilize the three clinical sites in India for short-term medical training. Furthermore, that approval hinged on the fact that India was on the NCFMEA list of comparable countries at that time. Since that is no longer the case, it is unclear how Israel’s use of clinical sites in India will change now that India is no longer on the list of foreign countries found comparable by the NCFMEA.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Qualifications of Evaluators, Decision-makers, Policy-makers
 
Country Narrative
As stated above, the accreditation and approval of medical schools are conducted by international evaluation committees. The committee members participate in all the aspects of the evaluation, including the on-site visits and are the ones to submit the evaluation report, the basis for the CHE's decision regarding accreditation of medical schools and programs.

Namely, the majority of a committees' members will be non-Israeli (except for in cases of initial accreditation, when there would be a majority of Israelis). The chairperson of the committee will be non­ Israeli as well.
When recruiting QA committee members, recommendations and comments made by the institutions and
departments undergoing evaluation will be considered. Experts in the field of medicine, either Israeli or non-Israeli, will be consulted as well.
The committees' chairperson should be a senior academic holding the rank of "full professor" or a
comparable rank abroad. The chairperson should have distinguished reputations in his/her field. Committee members should be senior academics and have distinguished reputations in their fields. When selecting the committees' chairs and members, preference will be given to those with administrative experience (e.g. department chairs, deans, etc.) and with experience in quality assessment activities. The committees' compositions should cover major areas in the discipline, as recommended by experts in the field from Israel and abroad.

The last medicine evaluation committee (2014) members are (appendix 21):

Prof. Stephen Schoenbaum- The Josiah Macy Jr. Foundation, New York, USA: Committee Chair Prof. Raymond H Curry- Northwestern University Feinberg School of Medicine, Illinois, USA
Prof. Shimon Glick- Professor emeritus in medicine, Faculty of Health Sciences, Ben Gurian University of the Negev, Israel
Prof. Peter Creme- School of Medicine, Keele University, United Kingdom
Prof. Elliot Gershon- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Illinois USA
Prof. David Katz- Professor Emeritus of Immunopathology, Faculty of Medical Sciences, College of
London, United Kingdom
Prof. Ora Paltiel- Clarfield, Attending Physician, Department of Hematology- Hadassah & School of Medicine, Hebrew University
Prof. Jo Shapiro- Harvard Medical School, Harvard University, Massachusetts, USA

The material supplied to the committee by the QAD, in preparation for their work include: background on the CHE and its authority; background on the field of medicine in Israel; guidelines for the evaluation process and the committee's mandate and template for writing the evaluation report. all the training material are supplied by the coordinator of the committee who also companies the committee throughout the entire process.(Please see the training material attached as appendices 1,22,2,5,15,16,23,24,25,26).

The standards for medical schools (that guides the committee's work) were established by the previous evaluation committee in 2007 and were not changed since. (Please see appendix 5).
 
Analyst Remarks to Narrative
The individuals responsible for all decisions regarding the accreditation of institutions of higher education and of study programs (including medical schools) are members of the CHE, which is made up, according to law, predominantly of senior academic figures.

The on-site evaluators hold senior positions in the medical field, as indicated by the list provided in the country’s narrative. As well, an examination of the reports composed by these individuals demonstrates that they are well-prepared for their tasks, and very thorough in their evaluations of medical schools.
 
Re-evaluation and Monitoring, Question 1
 
Country Narrative
As can be seen in the QAU overview (Appendix 3)The Quality Assessment Division (QAD) at the Council for Higher Education (the accreditor for medical schools) conducts a quality assessment (re-evaluation) of the accredited medical schools once every 6 years.

 
Analyst Remarks to Narrative
The re-evaluation of medical schools in Israel takes place once every six years. An external re-evaluation committee, appointed by the CHE, is responsible for this process. As previously noted, the committee evaluation includes the attainment of each medical school’s goals, the performance of its administration, the educational program, and the achievement of its students, etc.
 
Re-evaluation and Monitoring, Question 2
 
Country Narrative
As described in the previous paragraph, the entity at the Council for Higher Education (CHE) responsible for the quality assurance of accredited medical school is the QAD.

The QAD conducts a quality assessment process at the schools every 6 years, as part of the process the schools are required to perform a self-evaluation process and to submit a self-evaluation report. The report should provide detailed information regarding (among others): the school's organizational structure; mission statement and the strategic plan to support that statement; study program; faculty members; student body; research and infrastructure. Please see the guidelines for writing the report attached (appendix 4). The reports submitted by the schools serve as a basis for the evaluation process.

After receiving the reports, the QAD compose an international quality assessment committee, of distinguished academics in the field from various leading institutions. The committee reads the reports submitted by the schools and conducts an onsite visit at each school. Based on the reports and the visits, the international committee submit her own evaluation report, which include observations
regarding the quality of the programs (also in comparison to the standards stated by the CHE for medical schools- appendix 5) and recommendations for improvement, where needed.

The committee's reports are brought to the CHE for discussion and acceptance (in January and February of 2015 the CHE and the QA sub committee discussed the QA reports thoroughly and had voted upon many changes that will be demanded to be implemented by the schools in the following yeara and up to the next evaluation cycle). The QAD stands in contact with the evaluated schools for follow-up on the implementation of the recommendations accepted by the CHE.

Student complaints are referred to at the self-evaluation report and address by the international committee in her evaluation. The evaluated schools are required to detail the support systems available for students under the chapter "student support services" and especially the mechanism for dealing with student complaints, please see paragraph E in the chapter:
"What are the mechanisms that deal with student complaints? Please provide a list of students' complaints over the last two years and the way they were resolved."
In the committee's report, the committee often address the student complaints mechanism and evaluate its effectiveness and sensitivity to students' problems and criticism. Further more, during the onsite visit the committee meets with students at all stages of their studies for hearing more about their view of the school. As part of these sessions students are encouraged to share any problems they encountered while studying in the school.
 
Analyst Remarks to Narrative
The handling of student complaints by each school is examined on-site during the evaluation process. In addition, students are free to present the CHE’s visiting committee with any input during the on-site process, including any complaints they may have. Records of student complaints received by the CHE’s committee are then used when drawing up its recommendations and conclusions for the final report used by the CHE in its decision-making process. And as previously noted, students could file complaints directly with the CHE using its website, if so desired.

The monitoring of medical schools between six-year site visits can be accomplished through progress reports. The CHE is able to request a progress report to address steps taken to correct specific areas of concern in the committee's report, or to describe the results of program changes that are underway.
 
Substantive Change
 
Country Narrative
An accredited medical school (or any other academic program in the matter) who wishes to make a substantial change to its study program, organizational structure or any other aspect should submit its request to the CHE.

In the first stage the school should submit the request for a change to the institution management. only after approved by the institution heads will the request be submitted to the CHE.
The second stage is an examination of the request by the relevant sub-committee at the CHE. The sub­ committee will discuss the objectives of the change and any material submitted by the school to support its request (during the examination the school might be asked to supply the committee with additional materials). The committee then submit its recommendation to the council.
The council discuss the request and the sub-committee's recommendation, and its final decision is then sent to the school.

Another procedure for monitoring substantial changes is the quality assessment process. In the self­ evaluation report submitted by the institution, it is asked directly to provide information regarding changes made to the program in the last 5 years (see paragraph I under "study program" in the guidelines­ appendix 4). Furthermore, other data given by the school in the report might indicate changes in the program (for example, the students number table provide information about any changes in the student body size, presenting data of admission and dropout rates in the last 3 years).

Any substantial change indicated in the self-evaluation report, is discussed by the evaluation committee and later on by the CHE.
 
Analyst Remarks to Narrative
If a medical school wants to make a substantive change it is expected to notify the CHE and to receive approval for the change. In addition, each institution is expected to notify the CHE of any changes to its study program when it submits its self-study prior to renewal of accreditation every six years.
 
Conflicts of Interest, Inconsistent Application of Standards, Question 1
 
Country Narrative
When composing an accreditation or evaluation committee, in order to avoid a conflict of interest, all committee members are asked to sign a Declaration of Conflict of Interest (COl) and Confidentiality before being appointed as committee members. (Please see appendix 25).

A COl would be in case that a person is holding any of the following positions or similar positions in an institution for higher education in Israel:
* Member of the Governors Board
* Member of any Executive Committees
* President, Vice President, CEO, Rector
* Dean or Vice Dean of a Faculty/School/College o Dean of Students
* Member in an organization that holds authority equal to an organization or company for the benefit of
the public
* Management positions reported directly to the CEO, such as Head of Budget Dep.

and also in the following cases:
* The person is fully I partly employed in an institution undergoing evaluation and I or affiliated with it in any way
* The person or any of his immediate family holds any of the positions as mentioned in section 1.
* The person or any of his immediate family is fully/partly employed in the institution in any of the positions as mentioned above with a direct affiliation to the field undergoing evaluation.

(In Regards to that section, "Immediate family" refers to a partner, brothers, sisters, parents or step relations of this kind).

In all the cases mentioned above, one can not be a member of an accreditation/evaluation committee, due to a conflict of interest.

Also, in order to avoid situations that may bring into question the credibility and integrity of the evaluation process, we prevent situations are not qualified as COl but as Appearance of COl- such as a committee member whose family is studying in the evaluated institution for example. In that case the member with the Appearance of COl will not participate in the evaluation of the specific institution.
 
Analyst Remarks to Narrative
The country narrative contains the basic language found in CHE’s conflict of interest policy. The CHE requires all those considered for an appointment to an evaluation committee to sign the document. The CHE language is similar to that used in the accreditation process in the United States. As well, the country noted that it is even careful to avoid the appearance of a conflict of interest when assigning members to an evaluation committee.
 
Conflicts of Interest, Inconsistent Application of Standards, Question 2
 
Country Narrative
Due to it being a very small country, only 5 medicine schools operate in Israel. All the medical schools were accredited and are periodically being evaluated by the same governmental authority- the Council for Higher Education (CHE). A situation when all schools are accredited by the same authority, that is also the authority to state the standards for accreditation, ensures that the same standards are applied to all the schools.
When evaluating the medical schools (once every 6 years) one evaluation committee is composed. That committee evaluates all the schools and is provided with the standards for evaluation by the coordinator of the committee (a CHE employee). The coordinator companies the committee in its process of evaluation, including onsite visits and report writing, and makes sure the same standards are applied to all schools.
As the fifth school is still under an accreditation process the accreditor committee follows the standards strictly in building every aspect of the school and supervises that the development of all aspects of the school will be done according to the standards mentioned through out this report (appendix 5)
In addition please note that the schedules to all site visits are conducted by the same committee (Appendix 21) and that they have all signed confidentiality agreements (Appendix 25).
 
Analyst Remarks to Narrative
The establishment by the CHE of external evaluation committees predominantly composed of non-Israelis helps reduce the probability of a conflict of interest. In addition, the members of the CHE itself are not permitted to take part in procedures regarding institutions where they may have a conflict of interest. Furthermore, all evaluations and site visits are conducted according to common evaluation instruments, i.e. the standards and procedures, thereby maintaining consistency in evaluation.
 
Accrediting/Approval Decisions, Question 1
 
Country Narrative
As mentioned in the previous question, all medical schools in Israel are accredited and periodically evaluated by the same governmental authority- the Council for Higher Education (CHE).
A situation when all schools are accredited by the same authority, that is also the authority to state the standards for accreditation, ensures that these standards are applied to all the schools.

When evaluating and approving the medical schools the QAD compose an evaluation committee. That committee evaluates all the schools and is provided with the standards for evaluation by the coordinator of the committee (a CHE employee). The coordinator companies the committee in its process of evaluation, including onsite visits and report writing, and makes sure the committee's evaluation and recommendation are based on the CHE's standards for medical schools.
 
Analyst Remarks to Narrative
The CHE receives the external evaluation committee’s re-evaluation reports that are based on the Standards for Evaluation of Medical Schools and Medical Education. As the sole entity responsible for accreditation and evaluation of higher education in Israel, the CHE is authorized to make any decision regarding the accreditation of these schools based on those reports. In addition, the overall report of the site visits demonstrates the consistency of the evaluations based on the CHE Standards.
 
Accrediting/Approval Decisions, Question 2
 
Country Narrative
In the self-evaluation reports the evaluated medical schools are preparing for the committee, data on alumni is required (see the section on "Alumni" in chapter 3, appendix 4).

The schools are asked about their contact with their alumni, whether their alumni are employed and do they continue to residency.
Not all schools hold that information, the committee base its evaluation on the data collected and presented by the schools.
 
Analyst Remarks to Narrative
Information regarding the performance of medical school graduates is obtained from the schools themselves as part of their self-studies. However, as the application narrative indicates, not all medical schools maintain contact with their graduates. As well, it appears that there is no actual requirement from the CHE that the medical schools follow-up on the success of their graduates, or the lack thereof.

Department staff believes that the NCFMEA, if it so chooses, can combine any questions that it may have with regard to this particular issue under the following guideline section concerning the collection, and use, by Israel of medical school performance data.
 
Accrediting/Approval Decisions, Question 3
 
Country Narrative
The CHE does not have a structured mechanism for collecting data regarding the medical schools' graduates.
The CHE encourage the medical school to keep contact with their alumni and to collect data regarding
their progress after graduation (via the data required in the self-evaluation reports), however it does not rely on graduates performance for accreditation.
 
Analyst Remarks to Narrative
As noted in the application narrative, the CHE does not have a structured mechanism for collecting data regarding each medical school’s graduates. As a result, the CHE cannot use data such as performance in post-graduate residency programs and licensure exams, etc. in its decision to accredit a medical school.

Therefore, it is unclear if the CHE has any plans to establish a structured mechanism for collecting data regarding each medical school’s graduates, including the types of performance data suggested by the NCFMEA guidelines.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
In respect of Israeli graduates, alumni associations, although existing in Israel, are not as highly-developed as they are in the US and there remains room for improvement. Being a relatively new country, it is only in the last few decades that alumni have become significant contributors to society, and the universities have been more engaged in building their programs and facilities than tracking their graduates. This issue has been raised by individual Evaluation Committees and the CHE is very much aware of the need for more detailed data collection. It may be that CHE must make a policy decision in this regard and this is being considered. Meanwhile, through regular site evaluations, CHE continues to encourage the universities to collect such data.

International Graduates
For logistical reasons, it is very hard to follow the progress and performance of graduates in the United States. All of the foreign medical schools in Israel track their graduates’ Match placements, and these data are exhibited to CHE and Evaluation Committees. Generally the schools do not have well-developed alumni organizations in the US and are dependent upon the goodwill of graduates to keep them up to date with their progress.

The schools are conscious of the need to develop their foreign alumni organizations and are constantly examining options to improve. Budgetary limitations prevent deployment of professional staff to deal with this in the US.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the CHE has any plans to establish a structured mechanism for collecting data regarding each medical school’s graduates, including the types of performance data suggested by the NCFMEA guidelines.

In response, the country indicated that this is being considered. In addition, the country noted the difficulty it has in tracking medical school graduates in the United States.

Since Israel indicated that it is aware of the need for more detailed data collection, the NCFMEA may wish to inquire what concrete steps will be taken in the near future to meet the recognized need for more detailed student performance data.
 
Staff Conclusion: Additional Information requested
 
Accrediting/Approval Decisions, Question 4
 
Country Narrative
The Standards for Evaluation of Medical Schools address student performance, and requires the schools to create valid measures to evaluate student performance and thus evaluating the program quality. Among others, the schools are required to evaluate the performance of their graduates in post-graduate studies and in the framework of national norms of accomplishment (for example licensing exams). The evaluation committee also refers to student outcome and tracking of students and graduate performance by the schools. Please see the paragraph on measuring students performance in the standards
(appendix 5, p.4).
 
Analyst Remarks to Narrative
The CHE expects the schools to create valid measures for evaluating student performance so the schools can measure their own success and make improvements to their own programs. However, as noted under the previous guideline sections, there is no consistency as to what data schools need keep, how they keep it, and whether or not the CHE considers that data useful in the country’s accreditation decision-making process.

As a result, it is unclear what value the CHE places on student achievement data for medical schools, or if the CHE plans to incorporate the performance of graduates on licensing examinations into its medical school accreditation decision-making process.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
To date, there is no official policy by the CHE to track student achievement data for medical schools. The CHE and PBC collect data regarding school finances but there is no oficial CHE database with student data. It has come up in a number of different evaluation committees over the past few years but the CHE is still deliberating the subject.

For foreign students, all of the medical schools in Israel are required to keep detailed records of their students’ performance in Step 1, Step 2 (Clinical Knowledge) and Step 2 (Clinical Skills) of the USMLE. These data are provided every year in detailed reports to the US Department of Education as a condition to continued eligibility for US Federal loans. The data are presented also to the CHE Evaluation Committees during site visits.

Where one or more of the first-time pass rates falls below a defined threshold, eligibility for federal loans for students of that school are suspended for the following year. Subsequent failures to reach the threshold threatens the overall eligibility for the school. Should this happen to any of the schools, it is doubtful that the school would continue to operate; federal loans are crucial for applicant students. This possibility ensures that each school dedicates all necessary resources to ensure that such thresholds are always passed.

In the circumstances, CHE relies on the schools to ensure that they remain above the threshold. Should they fall below for more than one year, we do not believe it would require an accreditation decision from CHE to determine the continuation of the school.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear what value the CHE places on student achievement data for medical schools, or if the CHE plans to incorporate the performance of graduates on licensing examinations into its medical school accreditation decision-making process.

In response, the country indicated that the CHE has considered this matter over the last few years, but to date, nothing has come of those discussions. The CHE believes that it is each medical school’s responsibility to ensure that its students are successful, otherwise their American students will no longer be eligible for student loans due to the loan eligibility requirements of the U.S. Department of Education.

Nonetheless, it is still unclear if the CHE has any plans to incorporate the performance of graduates on licensing examinations into its medical school accreditation decision-making process anytime in the near future.

The NCFMEA may wish to enquire further regarding this matter.
 
Staff Conclusion: Additional Information requested