The Holyland. Pt 3.

 Monday 29th Jan.

Met with Dr. Ben-Basud, head of the clinical decision making group at BG . A very interesting man who moved here from Jerusalem to head up the decision making group. We talked about changes in medical education, (he is about my age) and the change from traditional histo - pathologic based diagnosis and treatment, to 'evidence based medicine', which attempts to encourage professionals and decision-makers to pay more attention to statistic -based evidence to inform their decision making and to eliminate traditional or outdated practices. unless to some of the recent Russian emigrants who had been accepted into the FMR program. The Residency here is a four year program, the last of which is, more or less a social service year in which the resident practices independently for the most part, with some general supervision. This usually occurs in the various outlying clinics in the Negev. These immigrant physicians are faced with the task of trying to learn Hebrew and English at the same time- no easy job. Incidentally, they are among the best dressed people I have seen in Israel, where most of the physician are in jeans or cords and shirts. Afterwards I was driven back to the hospital by one of these residents, who was driving one of the nicest cars I've seen in Israel.
Irene has a bad cold so we didn't go out once I came home. I tried plugging in the modem, and though I didn't manage to make the connections I wanted, it didn't fry the modem. So I'l have to experiment a bit. Meanwhile, I will continue to use computers around the hospital.

Tue 30th January.
This morning I went up the the shopping centre to have a haircut, while waiting for Irene to wake and see how the cold is and whether we would be able to make the trip to Jerusalem or not. Went into an Israeli salon where they didn't speak much English and I said I wanted it short. And boy, did I get it short, in a very military sort of style! At least I won't need another haircut for a long time! We still haven't become used to the manner in which Israelis invade your space, quite unlike Canada and the US. As I sat in the chair, one of the female stylists came over to talk to the young man who was cutting my hair. She leans over to talk to him, her bare midriff right in my face, totally oblivious to my presence.
We left for Jerusalem at about two p.m. and made our way across the countryside enjoying the rolling hills, the very green fields, this must be the greenest time of the year, the trees and the sights. Just coming out of Beer Sheva, the Bedouin Shanty towns, followed by nice new permanent Bedouin housing developments. Took some photos of both of these to illustrate the contrasts. Once onto the main Tel Aviv Jerusalem stretch, the traffic was horrendous, and we observed the Israeli phenomenon of turning a normal human into a lethal driving machine. As we get into Jerusalem and the traffic slows down before the ultimate gridlock, the other Israeli compulsion of honking the horn incessantly becomes evident. Israelis sound their horns insistently and incessantly, for reasons that are often not clear. Sometimes I think its just to let you know that they are there. They also pass on single lane highways in situations that most sane N.Americans wouldn't think of.
Jerusalem was far busier than when we were last here in 1989. As we were driving in we recognized the area where we were living then, and drove and walked around a little 'til we found 18 Mitudela where we had stayed, a big stone apartment block that was always cool - without air conditioning. It was so designed that the cool evening air blew gently through. We then drove downtown and after much hunting around managed to find a parking place. Ambled around King George street and Ben Yehuda St. and finally found a nice outside restaurant and had fish and chips. Thought it time to start heading back to Beer Sheva as I had no idea how to start back. Stopped at a gas station for some directions and they advised me to head the most direct way which was through Jericho. Now even we are not so poorly informed that we don't know that this is a dangerous place, and since the attendants at the gas station seemed a bit vague perhaps they were underestimating the dangers. Since we remembered that we came in on the Tel Aviv road we headed back out that way to look for the turn off to Beer Sheva, which we somehow seemed to miss. We soon found ourselves almost at Ben Gurion Airport, and I decided to turn into the airport for further direction. As we turned into the airport there was a sort of obstacle course, which quite obviously, was to stop any would- be car bomber from getting in to the airport. As I came through the path, three heavily armed soldiers, came out and. waved me down. I stopped the car immediately and jumped out. They had me pull the car out of the traffic lane, but quickly seemed to rule me out as a serious terrorist threat, despite my military haircut. They could speak hardly any English, and I just kept saying in my very few words of Hebrew "Where is Beer Sheva?" They told me in very simple Hebrew how to get back on the road, and sent us on our way. Later discussed our avoidance of the Jericho route with some of our local acquaintances. They assured me it was the right decision.

Wed 31 Jan 1996.
Went to Research meeting on Bedouin Health and their perceptions of their health care. Main coordinator of the research program is Maroud, a medical resident who speaks Hebrew, Arabic, Czech, English and Russian. He is carrying this project almost single-handedly, because acceptance of researchers of other ethnic origins would not be acceptable to the Bedouins. The research project calls for many meetings involving all the different communities and requires separate meetings for men and women, and Maroud attends almost all of the meetings. In addition he attends to his duties as a family medicine resident on his one year rotation of Internal Medicine. Many of the issues are similar to those of our Canadian Indians, to provide continuity and comprehensiveness of care in the rural areas. One of the differences is that the distances are so small in Israel, that even from the most remote areas it's at the most a couple of hours drive to a major centre. Anyway, after the meeting I had an interesting chat with Maroud, and he suggested I might like to go and visit some Bedouins and drink some coffee in the tent. I said I'd love to. He said he would arrange it.
Later I went to a meeting of the Family Medicine Dept, during which time all the peripheral teachers come in to have a department meeting and a continuing medical education presentation. When I came in to the meeting the Chairman asked me if I could follow the meeting in Hebrew. When I answered no, he said, "Dr Smith does not speak Hebrew, does anyone have any problem with changing the working language to English?"
Nobody had any trouble with that.



Thur 1 Feb.
Spent the morning in the Family Medicine Unit seeing patients with some of the staff physicians and residents. Some of the residents were experienced physicians who had emigrated to Israel and were working towards full licensure. Most, but not all had a working knowledge of English. Several were from South American countries including one from Cuba and several were from Russia. There were quite a few Americans and Canadians. Very few were fluent in Hebrew.
In afternoon went to old part of the city and sought out another well of Abraham. Seems to be several around here. This one was a tourist centre with information handouts and a women in the office who was delighted to have someone to talk to. This area had four wells and were not as old nor as impressive as the much narrower, deeper well at Tel Beer Sheva. This was in a part of the old city that we had not seen before, and had an interesting looking market and shops that would stand a little exploration.
In the evening we go with Mickey and Sid, the couple we rent the apartment from, to a social gathering a friend of theirs is hosting to present a lecture on the 'Alexander Method', a sort of alternative therapy ', aims to re-educate the mind and the body through a series of movements so the body uses muscles more efficiently'. The relationship between the head and spine is the key. The talk is given by an Israeli therapist, a fortyish, lean man who is the therapist of the aging hostess. He delivered the talk with some difficulty in English. It turns out to be another worthless, crack-pot theory but being the only physician there among the converted, I managed to keep my mouth shut and look thoughtful. Something I don't easily accomplish.

Sat. 3rd. Feb.
Got up at a respectable hour this morning and headed to Ein Gedi, a kibbutz on the Western sore of the Dead Sea. Ein Gedi was an ancient Oasis Settlement of great significance during the First Jewish Rebellion against Rome (66CE). The drive was incredible involving a drive through Arad and on to the Dead Sea, which goes through very picturesque sandstone mountains, up and down winding narrow roads, some overlooking dramatic precipices, the crazy Israeli drivers passing blindly on the dangerous curves. When the Dead Sea comes into view, 400 meters below, it does so as a glorious panorama of intense blue and white, overshadowed by the monumental Jordanian mountains. We drove on to Ein Geddi, where we stopped at the Spa, had some lunch, (an interesting salad bar, which included one of my favourites, egg-plant - known as hatzilim here.) walked on the beach, for a while and then went on to the En Geddi beach. Ein Geddi, has been an Oasis in the desert for thousands of years, across the Sea from which is the Moab mountains, where Moses was buried. Here is one of Israel's most important archaeological sites, which we did not go to see nor even know about. We will have to go there again.

February 5, 1996
Meeting in morning re Inf Hepatitis Study. Pesach is very good at getting drug Co. money for acceptable research studies.
Went over to library to do a lit search on stroke incidence in Israel. Librarian from California. In the afternoon met with Vice Dean Carmi Margolis. Talked to him re computerized medical record. Very interesting. Need to spend more time with him re CPGs. He's from NY. He told me the story of how he and others developed an electronic medical record for Kupat Cholim, complete with all the bells and whistles, and that it needed updating and K.C. pulled their funding and decided to go with another system - that the clinics involved are now back to writing records manually. He referred me to someone else for further information. We talked for about an hour about emr. My diagnosis is they were shooting too high, and should have extemporized and tried to hang on to what they had, but there may be factors that I don't know about. We never did get on to talking about CPGs, and will have to schedule some further meeting to discuss this and other issues. Carmi's explanation for Israeli behaviour-Israelis got their country by fighting relentlessly, winning the war, and estalishing the state-and feel every issue has to be won in the same way, by fighting a war there is no such thing as resolution by compromise.

February 5, 1996
Today went to Ashkelon to the K.C. Clinic to spend the day working with David Tobin, a physician from Ottawa who has been in this area for about ten years. The clinic is very busy and David sees from 40 to seventy patients per day. This is a bit hard to understand in view of Israels very high ratio of physicians to patients. There seems to be some very real competition between family physicians and various specialists, and perhaps between the various managed care groups, of which there are four or five. A great cultural cross section of patients, varying from Ethiopians (very difficult to diagnose because of cultural differences and somatization), to new Russians, many of whom don't speak Hebrew. Patients tend to be pushy and tend to push into the Drs office without invitatiion, so Dr. Tobin locks the door between the examining room and the waiting room once he shows his patients in. Although part of Israel is extremely high tech in some ways, this clinic which could be very easily computerized at little expense, has an archaic record system. David seemed glad to have someone to confer with and I think must feel a bit isolated practicing alone. I saw a few interesting patients, David interpreting for me. I think I could pick up 'medical hebrew' pretty quickly. David stated he feels aware of the booming Israeli economy. His analogy of Israeli life is of the person getting on the bus getting trampled by the other passengers running over him, but when they see the poor fellow cannot get off the bus they carry him on their backs to the hospital.
Tonight we were invited to Noga Porter's for dinner and met her son, ready to go into the army, and her husband Basil, a pediatrician. He is very interested in CPGs and I think we shuld meet in the business setting to discuss this and other issues.
Basil is a S.African who immigrated to Israel years ago.

February 6, 1996
Met with Dr.Haim Belmaker, a transplanted American psychiatrist who is the head of Psychiatry here. An interesting fellow, who recently co-authored a paper entitled:
Dopamine D4 Receptor (D4DR) Exon III Polymorphism Associated with the Human Personality Trait of Novelty Seeking.
This made Time Magazine in January.
Of more mundane interest is that Dr. Belmaker holds the Chair of Ortho- Molecular Psychiatry, endowed by the Vikars family, brother-in-law of Abraham Hoffer. Dr.B. has been active in O-M research, recently publishing a paper entitled, "Double-Blind, Controlled Trial of Inositol Treatment of Depression," which was reported in a newspaper that came to the notice of Hoffer, who was not at all pleased that the research was not directly concerned with the use of vitamins in the treatment of schitzophrenia. He wrote quite a nasty letter to Dr. B. saying how displeased he was with the direction of B.s research, and that they would have done better to give the money to a Canadian or American University. He hasn't replied to this letter yet, and he states that he will show it to me before responding. Apparently the whole endowment brings into Psychiatry $3000/yr. I'll be iterested in the follow up. We have arranged a meeting between Dr. Elana Belmaker and myself for later, as she is some sort of a public health physician.
Walked round old BeerSheva and had a light supper at a side-walk cafe.
Rena phoned at one am, just after I had dropped into a nice deep sleep. She sounds great.

February 8, 1996
Met with Jeff Borkan this morning to talk about a possible low back pain project and made a few notes.
Also found an office that has word perfect, where I hope I will be able to print up some of the stuff I have written.

February 9, 1996
Dimona to meet with Dr.Alan Bitun, a graduate of BGU practicing in a Kupat Cholim Clinic. He lives at Sde Boker, Ben Gurion's clinic, and invited us to visit him at the Kibbutz, which I hope to do. I had a short but interesting takl with him, which covered the fierce competition between Israeli Family Physicians and other primary care specialists. Interestingly he very definately distinguished between 'specialists in Family Med, and other primary care physicians. Irene came withme and we went on to Mamshit, a city built by the Nabotheans two thousand years ago. A really impressive site and sight, of which i took many pictures.
Dimona is interesting apart from its Nuclear reactor. Noga told me that a large black commuity had come there to settle from Chicago years ago