Filling the holes in our health system

Physician’s assistants, members of a long-respected profession in the US, are still persona non grata in Israel, despite looming doctor shortage.

By JUDY SIEGEL-ITZKOVICH
Physicians Assistant 311 (photo credit: nmnwse.org)
Physicians Assistant 311
(photo credit: nmnwse.org)
In the mid-1960s, when doctors and educators in the US realized that it was suffering from a lack of primary-care physicians, and an uneven distribution of those they had, they decided to take action. Forty-five years ago, Dr. Eugene Stead of Duke University Medical Center in North Carolina established the first class of physician’s assistants (PAs), basing the curriculum partly on his knowledge of the fast-track training of doctors during World War II. The class consisted of Navy veterans who had considerable medical training during the war in Vietnam but who couldn’t put that knowledge and experience to use in a civilian job.
Today, the PA profession – based on Stead’s model – has grown and thrived, and some 80,000 PAs who graduated from places as diverse as Harvard, Stanford, Duke University and Touro College are currently working for impressive salaries in hospitals and clinics under the supervision of MDs.
According to the American Academy of Physician Assistants (AAPA), more than 43 percent of PAs work in group practices or solo physician offices, and over a third in hospitals. The rest are employed in rural clinics, community health centers, freestanding surgical facilities, nursing homes, school- or college-based facilities, industrial settings and correctional systems.
But Israel – which is already suffering from a growing shortage of doctors as the wave of physicians from the former Soviet Union begin to retire – refuses to recognize certified PAs as medical professionals.
“The profession ‘physician assistant’ that exists in the US is known to us. This profession is not recognized in Israel, and as a result, we do not issue licenses to work in it. Unlike the US, we see no need to train or recognize professionals who would work as physician’s assistants in Israel,” wrote Dr. Amir Shanon, head of the Health Ministry’s division of medical professionals, three years ago.
Nothing has changed since then, despite the fact that Israel licenses only four new physicians per 100,000 residents each year, compared to an average of nine in other OECD countries. While shortages used to be found only in the country’s periphery, they have reached the center. Of nearly 60 medical specialties, 50 have too few doctors. In addition to the retirement of immigrant physicians, the shortage is being spurred by veteran Israeli doctors leaving public institutions for private ones, and the increasing number of female graduates, who tend not to want to work full time.
A new (fifth) medical school will open in Safed next year, but it takes 12 years or more to produce a doctor, thus the need is now. There are already some US-trained PAs who came on aliya even though they can’t get work in their profession, and a relatively large number of Jewish PAs who could be encouraged to make aliya.
“David,” a California-born, New York-trained PA with over 10 years of experience in emergency medicine, came on aliya with his Israeli wife and young son in the hope that he would somehow be able to work in the medical profession. He hasn’t.
“Many Israeli doctors who have experience studying and working in US hospitals are familiar with the PA profession, and tell me that they’d love to hire PAs, but the ministry and the Israel Medical Association (IMA) won’t allow it. I can’t even work as a consultant. I have gone to meet heads of emergency departments in Jerusalem hospitals; they know what PAs are and told me they’d hire me ‘in a minute’ if PAs were recognized here.”
DAVID SAID the only way he could get a medical job in Israel would be to take a full paramedics course and then be hired by Magen David Adom, even though he already has long experience in emergency care.
Having to start all over again would be degrading and a waste of time, he said. Asked why he didn’t go to medical school in the US to become a doctor, he replied: “At my age of 49, I’m not interested in starting from scratch and spending $250,000 for studies to earn $50,000 here. I can earn $120,000 in the US, but I want to raise my family in a Jewish state.” Although he loves emergency medicine and says he is “very good at it, until the government recognizes the PA profession, I may as well work here in hi-tech or biomedical companies because as a PA – one of the fastest-growing professions in the US – all doors are closed to me.”
In a recent interview with The Jerusalem Post, David (who preferred not to give his full name) said he earned $120,000 a year in his West Coast hospital.
Such a salary is somewhat higher than the mean annual income of $93,000 for full-time American PAs, but professionals like him are in high demand. The health maintenance organizations (HMOs) are enthusiastic about them. “It’s true that PAs in the US earn more than twice what the average Israeli physician earns, but it is half the salary of a US physician, so employers can get two PAs for the price of one doctor.”
David worked in hi-tech marketing and then earned bachelor’s degrees in business and biology from California State University, but couldn’t afford to go to medical school and thus chose a career as a PA. He graduated after three years of PA studies at Touro College, was board certified in 1995 by the National Commission on Certification of Physician Assistants (NCCPA) and then specialized in emergency medicine. As soon as he returned from New York to the West Coast, he found a good job. His license is also approved by the American Medical Association, which has a very positive view of PAs; its doctors don’t feel threatened by the profession but welcome it because it makes their jobs easier. He noted that PAs work not only in the US but also in European countries like Great Britain, Holland and Belgium.
PAs practice medicine under the supervision of physicians and surgeons, and are formally trained to provide diagnostic, therapeutic and preventive health care services, as delegated by a physician. They take medical histories, examine and treat patients; treat minor injuries by suturing, splinting and casting; record progress notes; instruct and counsel patients; order or carry out therapy; order and interpret lab tests and Xrays; and make diagnoses. In all 50 US states, PAs may issue prescriptions. Almost every medical subspecialty has a corresponding PA subspecialty.
Their duties are determined by the supervising physician and state law. “Physicians face malpractice suits and high insurance fees. As a PA in California, said David, “I had an easier life. As we work under physicians, they take the full brunt. But I have often worked for doctors who hadn’t a clue about what they were doing. When PAs are together with MDs, there are more eyes to see the same patient. There’s a builtin safety net, reducing negligence and malpractice.”
PAS WEAR white coats and stethoscope. David estimates that the difference between an MD’s and a PA’s studies is just 42 weeks. American PAs do not do what they were not trained to do. “Working one-onone with a physician, you’re watched and put on probation. The doctor sees how you treat patients, to whom you introduce yourself as a physician’s assistant. The vast majority of Americans are familiar and comfortable with the profession. Patients specifically asked for me. We learn on the same hospital floor as medical residents and study the same basic material, but don’t have to go through the same rigorous course as medical students. Our abilities and knowledge advance a great deal by osmosis, from being there with the patients,” said David, whose sister works as a well-paid PA in the US.
According to a nationwide survey conducted by the NCCPA, 94.2% of the doctor and medical institution employers of PAs said they have helped increase the number of patients seen; 92.5% agreed that PAs have enabled them to shorten the time patients must wait for appointments; and 91.2% said PAs enable them to allow patients more time during their office visits. In addition, 99% of employers agreed that they provide high-quality health care, are compassionate clinicians and valuable members of the health care delivery system.
Dr. Robert Bergman, a Miami-born internal medicine and geriatrics specialist for Kupat Holim Meuhedet and medical director of the Ahuzat Beit Hakerem home for retirees in Jerusalem, is enthusiastic about the possibility of recognizing both PAs and nursing practitioners (NPs) as medical professionals here. Bergman, who was an assistant professor at the University of Miami and medical director of the large Miami Jewish Home for the Aged, told The Post that PAs and NPs are part of the growing US trend of non-MDs providing excellent medical services at lower cost.
“They are licensed to practice with a specific doctor, and the end results are determined by teamwork.
They expand tremendously doctors’ ability to do things. It is a more efficient system, and very good medicine. All doctors know they have to do things that others can do very well. PAs and NPs greatly expand our ability to do doctoring.”
Asked why the ministry and IMA have so far done nothing to advance these auxiliary professions, Bergman suggested “ignorance and fear.” While many Israeli physicians go to the US for fellowships, “I don’t know how many of them see PAs, as they are busy doing research. And maybe they fear that PAs and NPs want to take over. But that is nonsense. They should take the word of doctors like me who are jumping and screaming about the need to start a pilot program, and recruit very good people who want to work in the medical profession but can’t make the commitment to become MDs, including women who want to devote time to their families. A group can be trained, licensed, supervised and certified, and experienced PAs who come on aliya can be approved. It’s painful for me to see how doctor shortages are eating into the quality of Israeli medicine when I see the answer – these professionals.”
HEALTH MINISTRY associate director-general Dr. Boaz Lev, when asked to comment on PAs, said: “We are looking into it. We are examining every possibility to relieve the doctors’ shortage. There is a committee headed by our deputy director-general for economics, Dr. Tuvia Horev. But there are no recommendations yet; it is complicated, and there are legal aspects.”
IMA chairman Dr. Leonid Eidelman, himself an anesthesiologist and former immigrant from the Soviet Union, said PAs were discussed by his organization last year, but no recommendation was made. “I am examining it further and have a positive attitude toward PAs, whom I got to know in the US.
For it to succeed, there must be suitable training in medical schools. It must be for the good of patients.”
If and when the profession’s status is changed, the law will be changed and new immigrant PAs would be able to work with doctors. If there is an initiative from the ministry, we will discuss it with a positive attitude.
I believe it can be done.”
TEREM, the private network of urgent-care clinics based in Jerusalem, stated that “Israel’s shortage of critical medical staff must be addressed as soon as possible. Unfortunately, it will take some time until sufficient numbers of doctors and nurses are trained.”
The essence of these auxiliary professions, said TEREM deputy director Dr. Nahum Kovalski, is that “their practitioners can provide high-quality medical care that would free physicians from many sometimes-mundane tasks. These professionals could provide the time to patients. At the same time, the simple reality is that these professionals are generally paid less than physicians and thus can help reduce costs in Israel.”
There are many high-ranking programs that have been running for many years. Top emergency rooms around the world make heavy use of these professionals. ER specialists here in Israel (who trained in the US and continue to work there), agree that PAs and NPs are essential components of their American practices. There are many such professionals who would happily move to Israel if they could. In TEREM, we definitely could use such professionals to further speed care and provide high quality across the board.”