The year 2011 will be remembered as the year of the longest and most frustrating
physicians’ strike in the history of Israeli medicine. The slogan chosen for the
physicians’ struggle under the leadership of their union was “To Save Public
Medicine in Israel.” As lofty as the slogan’s pretensions, so was the height of
the physicians’ expectations. As high as their expectations was the depth of
their frustration with the final outcome.
Most Israeli physicians are
salaried. With the exception of a few relatively small private hospitals,
Israeli hospitals are mostly public institutions, and their physicians are
employees of the hospital. Israeli hospitals are owned by either the government,
or by one of the health funds or they are operated by public not-for-profit
organizations, such as the medical centers in Jerusalem.
In the Israeli
social democratic healthcare system, similar to the European countries and far
different from the capitalistic US system, governments send a clear and loud
message to their employed physicians: “We cannot afford to pay you a decent
salary. If you want more money, go out and earn it elsewhere.”
message is increasingly impacting the public hospital system and it was part of
the background for the 2011 strike.
Excluding hospitals in Jerusalem
where SHARAP (private practice service) is allowed within the public hospital
facilities, most senior physicians in the public hospitals currently hold down
more than one job. Surgeons and interventional physicians (such as
cardiologists, gastroenterologists, and radiologists) are involved in the
treatment of private patients in the few private hospitals that operate a few
hundred hospital beds.
Internists and pediatricians are employed by the
health funds’ community clinics, where they are reimbursed twice the hourly wage
(or more) that they receive in the hospital.
The fact that senior medical
figures are left no choice but to compete with their own hospitals for patients
is an anomaly that torpedoes the efforts of hospitals to retain top-quality
physicians. Time allocation preferences as well as financial temptations are
leading to a situation in which more and more talented physicians in the public
system reduce or altogether abandon their efforts to develop their research and
academic skills. As a result, when searching for department heads, it is
becoming more and more difficult to find a physician/scholar who is both a
trained and experienced clinical leader and a role model
There are three social and economic processes that accompany
and intensify this damaging effect on the efforts of public hospitals to hold
onto and further develop their human resources.
One is the percentage of
women physicians, which has been growing worldwide and in Israel as well. When I
studied medicine (some 30 years ago), only five percent to 10% of the students
Today, women comprise 60% of all the medical students and
graduates. This phenomenon has many implications on the practice of medicine,
both outside as well as within the hospital setting.
physicians are expected to favorably influence the highly troubled
physician-patient relationship. Secondly, unlike their male counterparts, female
physicians who want also to devote themselves to family life will find it harder
to devote a similarly significant part of their time for the development of
their careers as both clinicians and academic researchers. This means that we
may be faced with even more difficulties in finding suitable candidates to run
academically affiliated hospital departments.
The second process that
influences the current generation of our physicians is the fact that they belong
to the “Y” generation which, besides being more technically and digitally
inclined, they have a different approach to work.
Specifically, they are
much less likely to respond to the traditional command-and-control type of work
force, but they will speak their mind. This is a phenomenon that in and of
itself is revolutionary in the arena of a hospital’s tight discipline. Even more
importantly, however, while they do want to work, they do not want work to be
their entire life.
This, again, may influence “Y” generation physicians
to not dedicate themselves unreservedly to their profession as did their
The third process, unique to Israel, is the rapid diffusion
of supplementary health insurance that is promoted and sold to the public by
both the four public health funds and by private companies. Close to 80% of
Israeli residents are insured over and above their basic health
The main benefit sought by the privately insured patients is
the option to choose their physicians and surgeons. The cost per member is not
expensive, but the annual accumulation amounts to about NIS 6 billion, which
represents about 7% of the total national expenditure on healthcare. This
enormous sum is without significant benefit to public health, because the basic
health insurance – also supplied by the health funds – furnishes all the basic
medical needs of its members and all of the evidence-based clinical measures
that may be required.
This staggering amount of money is channeled each
year by government instruction solely to the private system.
hospitals are not allowed to benefit by selling services to the second-tier
health fund policy holders. Thus, as they say, “money talks” – and the
government’s message to our physicians in the public hospitals is that their
future, especially their financial future, lies in the private system which is
the only recipient of the second- and third-tier health insurance
Now, if you combine the lack of adequate salaries in the public
hospitals, the government’s earmarking of huge amounts of financial resources
solely for use by the private system, and the characteristics of the young
doctors who are now filling the positions of residents and young senior
attendants who cannot or are not willing to invest many hours every day to reach
an adequate salary, you can begin to understand the frustration that fueled the
These young people who look up to their teachers see them running
from one job to another to earn a decent income. They witness senior physicians
that not too long ago were young physicians like themselves who have become
frustrated and cynical, having lost their faith in the public health
And so they speak up – had it not been for us, the leaders of the
hospitals, who called upon them to stop their battle, they were ready to break
all ties with the system.
The agreement signed by the physicians’ union
tied the hands of the current system for an additional nine years. If that were
not enough, its leaders agreed to do something unprecedented in any sector of
the job market.
HOSPITALS IN the periphery have always found it difficult
to recruit elite professionals, with young physicians competing for residency
positions in the major hospitals in the center of the country. Many are
attracted to positions in central Israel not only because of the more
sophisticated capabilities of delivering care, but also because the region
offers better earning potential in the private market after they end their
residency program in the public institutions.
In an effort to support
peripheral hospitals, the physicians’ union agreed to an uneven distribution of
the total amount of salary increase, delegating a significantly higher increase
to the physicians in the periphery and a significantly lower salary upgrade for
physicians working in the center.
So, instead of the government’s
stepping in and taking the responsibility to give priority to the periphery by
subsidizing their salaries, the doctors’ own unions took the initiative and
voluntarily sold the physicians in the center down the river in favor of their
colleagues in the periphery. The bitterness among the young physicians that
followed this betrayal needs no further explanation. They are the ones who show
promise to become the leaders of our health care system 10 years from
The union leaders had one more highly regrettable “achievement” –
they agreed to the government’s demand to enforce electronic reporting of
physicians’ presence at work. This is an unprecedented step here and one that is
almost unheard of in most Western countries. This demand of the Finance Ministry
was a result of talk that many physicians leave their post early in order to go
to their private practices. While this is probably true for a small minority of
the physicians, the overwhelming majority work for many overtime hours without
asking for or receiving payment.
The introduction of electronic reporting
has revamped the relationship between physicians and the system. Doctors
previously saw their commitment to the hospital and their patients as an
unlimited one, unrestrained by time and space. They were willing to respond
immediately to any important call, and they also worked from home,at the expense
of time with their families.
These same physicians are deeply insulted to
the point of outrage by the doubts cast on their integrity and the lack of
confidence in them on the part of the system. They are enraged by what they
consider a blot on their professional integrity.
It is hard to predict
how the strike that brought about electronic reporting of doctors’ attendance
will shape the future of public medicine here. There is no doubt whatsoever that
it harms the alliance between the system and the physicians. The loss of these
young physicians to the private sector may seem to the Finance Ministry as being
a less costly and quick fix at this time, but it may well prove to be disastrous
in just a few years. What is certain is that, in the long run, it will lead to
fewer top quality physicians who are willing to work in public
The new generation of the brightest Israeli physicians will be
accessible only to patients who are able to afford private health insurance.
This current policy has already increased the costs to the public hospitals of
doctors’ wages. Treasury officials apparently forget that there is no “Great
Wall of China” between the public and private health care systems. The same
physicians work in both of them.
The higher reimbursement in the private
hospitals leaves no choice for the public hospitals but to push their hands more
deeply inside their already depleting pockets to retain some of their leading
There are feasible and reasonably priced solutions, but they
fall on deaf ears. Like the problems concerning illegal migrants, governments
tend to wait until they reach a crisis before dealing with them.
in this case, there will be no single earth-shattering crisis, but rather a
gradual and steady decline of one of the most outstanding achievements of
Israel’s social system.The writer is CEO of the Tel Aviv Sourasky
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