hadassah hospital arad.
(photo credit: Oz Schechter)
Where have all the doctors gone? Although this question is only partially relevant today - due to the nationwide shortage of certain specialists and of general practitioners in certain parts of the country - it will be almost universally true in years to come. Better-paying and more convenient jobs in computers and engineering, the brain drain, the increase in the percentage of women doctors (who tend to work part time) and other influences are working to destroy the truth of the axiom that Israel has more doctors per 1,000 residents than any country in the world.
If we think we have "too many" physicians, we are living in the 1990s, when thousands arrived from the former Soviet Union. That source has largely dried up.
The Israel Medical Association, whose membership constitutes most of the doctors in the country, is so worried that it recently devoted most of an issue of its journal, Zman Harefuah, to the theme "Is There a Doctor Around?" and warning that we are approaching the point of no return.
Although the Health Ministry has been rather quiet about the trend, ministry deputy director-general for economics Gabi Bin-Nun - who headed a committee to investigate future manpower needs - recently stated that unless the number of medical students is doubled immediately, the country will soon find itself with the lowest rate of physicians per 1,000 citizens. This will constitute a "manpower catastrophe," he said. "We have asked the Prime Minister's Office and the Council for Higher Education's planning and budgeting committee to immediately approve funds for increasing the number of medical and nursing students. Nothing was done over the years because the ratio was high, but now it is clearly dropping. The population is growing and ageing, and the need for medical and nursing care is expanding," Bin-Nun says. "It takes seven years to educate a physician, and even longer to train medical specialists."
ACCORDING TO Bin-Nun's report, the number of licensed physicians under 65 was 25,138 last year, or 3.53 per 1,000 residents. Since 1999, this rate has been dropping, and without intervention, it will reach 2.72 in 2020. The annual number of medical graduates, he said, must immediately be increased to 600.
Bin-Nun's statistics were backed by a 164-page report titled "Manpower in the Health Professions" issued by the ministry last month. According to the section on physicians, it was noted that the number of new medical licenses issued has continued to decline from the middle of the 1990s to only 575 in 2006. Half were granted to women, compared to only 39% in the Eighties. Only 14% of doctors in 1948 were women. There has been such a decline in doctors from Eastern Europe that the number of new Israeli medical school graduates - between 250 and 300 a year - has risen above that figure. In addition, 9.5% studied in Western Europe, 6% in America and 2% in Asia/Africa.
Many of the foreign graduates receiving an Israeli MD license are Israelis whose grades were not high enough to be accepted to one of Israel's four university-affiliated medical schools. Of the 32,371 Israelis holding medical licenses today, more than 7,000 are over 65. Last year, there was 283 Israelis per physician under retirement age, compared to 267 10 years ago. Only 30% of Israeli physicians are under 45, according to the ministry report. Four in 10 doctors are women today, compared to 37% in 1997, and half of those under 45 are women - indicating a definite trend for the future.
As for doctors who have completed a medical specialty, there are almost 15,000, with 12,000 under 65. A growing share of doctors are going into a specialty or sub-specialty - 1.7 under 65 per 1,000 Israelis in 2006 compared to 1.4 in 1995. And women now constitute 34% of the specialists, compared to only 27% in 1995. About half of all specialists are in internal medicine, pediatrics, family medicine, obstetrics/gynecology and psychiatry.
ALL THIS means there are fewer general practitioners to go around, with doctors seeking specialties and likely to earn more from offering private medical services. A quarter of the specialists are immigrants. Half of all family doctors and pediatricians are women today. There are relatively few female surgeons, but relatively more women in oncology and psychiatry.
Bin-Nun was the only member of the Halevy Committee - headed by Shaare Zedek Medical Center director-general Prof. Jonathan Halevy - to oppose the establishment of a new medical school to produce more doctors. The senior ministry official argued that the existing medical schools can easily expand.
But despite ministry opposition to the establishment of a fifth medical school, it was actually approved in principle a few weeks ago by the Council for Higher Education, which decided it would be set up in the Galilee to develop that region and alleviate the expected shortage of physicians. Such an idea has been promoted for years by Shimon Peres.
Education Minister Yuli Tamir, who is also the council's chairwoman, and other council members will soon set down the procedures for choosing a university that will establish the new medical school. The only universities that are "unattached" - meaning they have no affiliated medical faculty - are the Weizmann Institute in Rehovot, Bar-Ilan University in Ramat Gan and the University of Haifa. Weizmann has said it is not interested in having a medical school, leaving the field to Haifa and Ramat Gan. But it is understood that the university chosen would have to commit itself to raising the bulk of funds for building the infrastructure. The council said that a total of 600 new doctors could be produced per year with the opening of a facility in the Galilee, a moderate expansion of existing medical schools and the continuation of training programs for doctors from abroad.
However, the deans and former deans of the four existing medical schools at the Hebrew University, Tel Aviv University, Ben-Gurion University and the Technion oppose this move, arguing that there is none of the necessary infrastructure in the Galilee. The hospitals in the area, they declared, do not have enough doctors on a level high enough for clinical teaching, as the existing medical schools already suffer from a shortage of suitable hospital departments for teaching their students.
Halevy told The Jerusalem Post that the medical school whose establishment he advocates would receive the same NIS 50,000 annual state subsidy (from the Council of Higher Education's planning and budgeting committee) per student as the other medical faculties. He added that the cost of infrastructure for a new medical school is not huge, and less than many general hospitals are getting from donors for development today.
The Shaare Zedek director-general, a specialist in internal medicine and liver disease, urged that Ziv Hospital in Safed and Poriya Hospital in Tiberias become the focus of an upgrade in clinical infrastructure and manpower so they can educate the new medical school's students, who need to be exposed to a wide variety of complicated cases like those in big city hospitals. This will eventually boost the level of medicine in Galilee hospitals, he said. Afula's Emek Medical Center and the Western Galilee Hospital in Nahariya, added Halevy, function at a good level and have less need to upgrade. Safed particularly would be a good location for the medical school and dormitories, he suggested. He also recommended that top medical school faculty members aged 60 and some years beyond pension age be offered teaching positions in the new Galilee medical school. "If they were offered homes there, they would be happy to teach there."
ACCORDING TO Zman Harefuah, the Israel Defense Forces is worried about a shortage of doctors in its ranks. The number of high-school graduates who join the academic program that subsidizes their studies so they can pursue careers in the military has seriously declined. This puts more of a burden on physicians in IDF clinics, who sometimes have to examine 200 soldiers a day.
Dr. Yitzhak Berlovich, now director-general of Wolfson Medical Center in Holon and formerly a deputy director-general of the Health Ministry who headed the medical branch, says there is already a significant shortage of hospital specialists in anesthesiology, internal medicine, general surgery and pathology. The specialties with the largest shortages are those that do not offer private practices, as many want to earn extra in the late afternoons and evenings.
Even more bewildering is that around 3,000 senior lecturers and researchers who were trained in Israel are now working in the US, where they earn better salaries. Many of them went abroad for post-doctoral studies and chose to remain. "There are many Israeli doctors and medical researchers who want to return from the US, but Israeli institutions don't have anything to offer them," says Prof. Alex Keinan, a senior adviser to the Israel Academy of Sciences. "If in one of our institutions an attractive position becomes vacant," he told Zman Harefuah, "30 Israeli expatriates may apply, some of them outstanding, but only one will be hired."
The US requires 10,000 new physicians each year, but its medical schools don't produce nearly that many, so a quarter of all doctors in the US studied medicine outside its borders. With the ageing of the American population, the demand for physicians will increase.
But even some of the most talented young Israelis who remain here are tempted into hi-tech careers in computers and electronics, where one doesn't have to worry about malpractice suits, working through nights and weekends and rushing to hospital for urgent cases. According to the Israel Medical Association, applicants for studying hi-tech professions have risen 12% in the past few years, but applications to medical schools by only 2.3%.
The Health Ministry and the academic world had better look for cures for these problems rather than BandAid "solutions."