Being a ‘hospitalist’ after the big physicians’ strike

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.”

This 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 academician.

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 were females.

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.

FIRSTLY, WOMEN 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 predecessors.

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 insurance.

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.

Public 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 funds.

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 strike.

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 system.

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 now.

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 hospitals.

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 physicians.

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.

Sadly, 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 Medical Center.