From crisis to catastrophe

A medical manpower shortage is already here.

By JUDY SIEGEL-ITZKOVICH
doctor 311 (photo credit: Avi Hayoun)
doctor 311
(photo credit: Avi Hayoun)
Treasury officials are apparently living back in the early 1990s, when Israel’s health system was enjoying the gift of thousands of trained immigrant physicians from the former Soviet Union, and the highest doctor/patient rate in the Western world.
But while the Finance Ministry remains tightfisted in subsidizing additional hospital manpower slots, beds and medical students, a growing number of these FSU immigrants are retiring, veteran Israeli doctors are leaving public institutions for private ones, biotechnology, pharmaceuticals and other fields, and the increasingly female graduates don’t want to work full time.
The result is a crisis in the health system that threatens to become a catastrophe in a few years, according to Health Ministry officials, the Israel Medical Association (IMA) medical center and health fund administrator and MKs.
An “emergency meeting” was recently held in a Knesset hall at the initiative of Kadima MK Rachel Adatto, a gynecologist, lawyer and medical administrator. She noted that there’s an urgent need to explain the problem to the public and MKs, and that strategy and tactics had to be prepared, as the Treasury will soon present plans for 2011-2012 health expenditures. The IMA was an enthusiastic partner – but as it proceeded, it was clear that the impetus was not the professional union’s mere desire for more members but the realization that the country already faces real trouble.
“Only one who is blind or wants to be blind can say there is no doctor or hospital-bed shortage,” declared IMA chairman Dr. Leonid Eidelman, himself a former immigrant from Russia. “Every day, patients pay the price,” he said. There has been a series of committees since 2002 to investigate the looming doctor shortage, but nothing has been done, even after the State Comptroller criticized the government for failing to take action. “Even in cardiology, where we thought there would never be a shortage because of the prestige, there are not enough.”
THE DEARTH of physicians in many hospital departments leaves fewer to bear the burden, meaning that those remaining get tired and fed up, leading to a vicious cycle of more leaving, said Eidelman. While shortages used to be in the periphery of the country, they have reached the center. Of nearly 60 medical specialties, 50 suffer from too few physicians. The four medical schools are allowed by the government (which subsidizes their studies) to admit only about 520 annually, including the new military medicine school in Jerusalem and Tel Aviv University’s fouryear program for bachelor’s degree graduates (this will near 600 when the school in Safed opens), “but we need 850 graduates annually,” and it takes 12 years or more to produce a doctor.
A particularly worrisome statistic is that developed countries have an average of nine new doctors per 100,000 residents, while in Israel it is only four.
About 1,000 Israelis who were not admitted to local medical schools due to strict limits (and not necessarily because they would not make excellent physicians) study medicine in Hungary. Now their license is pan-European, allowing them to work anywhere on the continent; no incentives, said Eidelman, are given to draw them home.
THE NEW Health Ministry director-general Dr. Ronni Gamzu – until recently director-general of Ichilov Hospital at Tel Aviv Sourasky Medical Center – was very familiar with the issues, and said he was in the process of meeting the heads of medical specialty associations. The ministry is under constant pressure to close premature-baby units and internal medicine departments temporarily when they can take no more patients, he said, but increasingly, hospital administrations ask for permission to permanently close departments with too few doctors and nurses.
Gamzu pledged to meet with each of the 120 MKs about these problems. “The Knesset should shake over the situation. Our health system is eroding.
Department heads fight over medical residents. There are not enough funded beds. If we don’t have enough infrastructure, the gap in the availability and quality of care between the center of the country and the periphery only widens. It’s a terrible situation.”
Dr. Chezy Levy, chief of the ministry’s medical branch and a former chief medical officer of the Israel Defense Forces, said there are devoted doctors and nurses and advanced hospitals, “but there is more demand for medical services. People are living longer and having chronic conditions that require more complicated care. Four days’ average hospitalization could look like increased efficiency, but it can also mean early discharge and put excessive pressure on the staff,” said Levy. “Already, there are only 5.5 nurses per 1,000 residents – the lowest in the West – and too few doctors. We don’t even know who is actually working in medicine and how many have emigrated or moved into medical administration or another profession entirely.”
Levy suggested that the long-contemplated idea of hiring “physician assistants” and “nurse practitioners”– strongly opposed by the IMA on the grounds that it would lower the level of medical care, even though these are successfully used in the US – be considered so that physicians will have more time free for what they only can do. “It has shortcomings, but it may become an urgent need.” The ministry official suggested presenting an interim plan to the Treasury as to where hospitals can be added without building new infrastructure and then adding doctors and nurses drawn there by incentives.
“I came to this meeting to honor Rachel [Adatto], but when I see these graphs and hear the statistics, I am shocked. I didn’t know the health system was in such trouble,” said Kadima MK Arye Bibi. “I will leave this session with a bad feeling. When I was in Taiwan and South Korea, I praised Israel’s health system to my hosts, but now I see we have passed the red line. I will be an active partner and help you!” Dr. Yitzhak Berlovich, formerly a senior Health Ministry official who is now director-general of Wolfson Medical Center in Holon, said the most serious decline is among physician up to the age of 45 who have decades of work ahead of them. With the ageing of the population, the increasing share of chronic diseases among the elderly that requires more patient care and the growing number of doctors who drop out of the profession or emigrate, Israel’s health system is in big trouble, said Berlovich.
The number of new medical licenses has dropped below that of young medical graduates who begin to learn a specialty. That means, Berlovich said, that hospital department heads can no longer choose the best among applicants but are lucky to have any who arrive. Many public-sector doctors move to betterpaying jobs in private hospitals and clinics. There are only 1.9 hospital beds per 1,000 residents, average bed occupancy is 95% and the average hospital stay is just four days – not because medical centers here are super efficient, said the Wolfson director, but because patients are often discharged too early. When he meets foreign medical administrators, they “pity us” and “can’t believe our statistics,” he said.
COMPARATIVE OECD figures (and now Israel has become a member) show Israel has one of the lowest hospital bed/capita rates. If more are not financed by the state, there will be more beds – but in the corridors, where infection rates grow and the level of care and privacy plummets. The number of official Israeli hospital beds per 1,000 residents has dropped to 1.9, while the average OECD figure is over three, and patients stay for an average of six days.
Berlovich continued that the rate of magnetic resonance instruments (MRIs) in the country is just 1.4 per million while in the OECD countries including Turkey, the figure is 8.7. MRI scans are not toys: they don’t expose patients to radiation – and are thus safer than computerized tomography (CT) scans – and can reduce unnecessary surgery. A shortage of MRIs also means that necessary scans are delayed. The number of MRIs is so much lower than in Western Europe that Adatto and fellow physician and MK Arye Eldad are preparing a private member’s bill to allow hospitals to purchase them with their own funds without having to beg the Health Ministry for a license. Berlovich concluded that Israel “is very proud of its medical system and its high average life expectancy, but our reserves have disappeared.”
Eldad, a maxillofacial surgeon, suggested that because the government fails to make urgent decisions, laws such as one setting hospital manpower requirements or cancelling the need for MRI purchase permits should be passed to force it to do so, even though such decisions do not ordinarily require legislation. Merely threatening to do so could scare the government, the MK said. “Treasury officials are “suffering from denial.” He suggested that advocates of increasing health budgets for training doctors, encouraging more to go into specialties with critical manpower shortages and getting emigrant doctors to return need to plan their course of action. He added that it was unusual that only opposition MKs came to the meeting. Coalition legislators have to be persuaded that there is a crisis, Eldad said. Kadima chairman Tzippy Livni popped in between commitments to say she puts her full backing behind Adatto’s demands, and that her party would support any moves she recommended.
TAU SACKLER Medical School dean Prof. Yossi Mekori commented that the four medical schools have already significantly increased the number of medical students, which is good. But “due to this increase, a significant workload has been imposed on more senior physicians in the hospitals, that has led them to to refuse to increase clinical teaching of students without adding manpower to their departments.
There is a real threat that there will be a shortage of residency positions for the increased number of graduates, as there hasn’t been any addition of beds or positions to the hospitals in many years.”
Doctors are forced to spend too much time on tasks that can been done by others and even computers, suggested Prof. Arye Lindner, head of the IMA’s scientific council, which supervises the education of specialists. “Instead of explaining basic things to patients about to undergo elective surgery, we can prepare them by using interactive computer programs,” said Lindner, “and if they have any remaining questions, the doctors can answer them.”
The public health system is heading for catastrophe, he added. “We hide these things, and for some, the shortages are convenient. But they upset the balance between public and private medicine, and eventually could cause both to collapse. If the public hospitals are strong, the private hospitals can benefit from the public system, but if the public system is weak, a lot of their burden will fall on the private ones, and they can’t handle it.”
With only six senior anesthesiologists for every 100,000 residents, compared to an average of 18 in other OECD countries, said Israel Anesthesiology Society chairman Prof. Azriel Perel, “we are becoming like Eastern Europe. Anesthesiologists are leaving Israel for greener pastures. Seventeen percent of deliveries are cesareans. There are today 620,000 operations annually that need anesthesia; in 2025, there will be many more.”
How will there be operations without anesthesiologists? Why doesn’t the state prepare for this? “I am so angry with your Treasury colleagues,” said Perel, looking directly at twenty-something Yair Zilberstein – the new budgets division official named the liaison in charge of health matters and the only Finance Ministry man in the audience.
“They play Monopoly with themselves and think only about the short term. There is no long-term planning, and when they do agree to increases, they are made only in small installments over time. I lack faith in the Treasury, which spreads disinformation. People will die [because of the problems], and you won’t be there when it happens. Maybe you will be different,” said Perel.
Zilberstein, whose predecessors have all gone on some five years after joining the Treasury to highly paid jobs in the banks and elsewhere, just sat in silence.