The nurse practitioner is in

Geriatric institutions in Israel are the most desperate to find more highly trained medical staffers.

DR. ADI SASSON 370 (photo credit: Judy Siegel-Itzkovich)
(photo credit: Judy Siegel-Itzkovich)
For centuries – from Florence Nightingale to ER – the medical professionals who treated patients have been nurses and physicians.
Yet in a world with a dearth of such trained individuals, new professions in the healthcare system have emerged to attempt to fill the void. While the expansion of health professions in the US and other Western countries has been rapid, recognizing and welcoming nurse practitioners (NPs), physicians’ assistants (PAs) and nurse anesthetists (NAs) has been a very slow process, especially in a country like Israel whose union-oriented conservative medical establishment is not enamored of change.
The NP is Israel’s first new medical profession to be recognized by the Health Ministry, which organized a first, year-long course that turned 19 veteran nurses from around the country into recognized NPs.
Four members of the class were from Herzog Hospital, the ever-expanding psycho-geriatric hospital in Jerusalem’s Givat Shaul quarter. The two top grade-earners were also from Herzog. Two were men, a Jewish and an Arab male nurse. Half of the course was spent at Tel Aviv University’s Sackler Medical Faculty in frontal teaching, with the second devoted to clinical work with patients at their own geriatric departments.
The advanced-practice nursing role first appeared as nurse anesthetics and nurse midwives in the US in the 1940s. In the next decade, psychiatric NPs were trained and recognized. Due to the shortage of MDs in the 1960s, NPs became primary care providers there as well. An MD named Henry Silver and a nurse named Loretta Ford established the first official training for NPs – significantly cheaper than doctors – in 1965 to save money as US health expenditures began to skyrocket.
NPs are advanced-practice registered nurses who have completed additional training beyond that of a registered nurse (RN).
Nudged between the professions of RNs and MDs, NPs treat both physical and mental conditions after taking a comprehensive medical history, conducting physical exams and ordering tests for interpretation. Each according to her (or his) specialty, NPs can diagnose acute and chronic conditions and provide appropriate treatment for their patients, and in some US states and countries can even prescribe medications. But they can’t do everything on their own, as they are supervised by physicians and regarded as members of the medical team in hospitals and outpatient and community clinics.
NPs can serve as a patient’s primary health care provider and see patients of all ages depending on their specialty. Similar to all medical professions, the NP is more holistic and provides individualized care that focuses not only on disease but also on the effects of illness on patients and their families. Prevention of disease, promotion of good health, and education of patients are also integral parts of their profession. Like RNs and, of course, doctors, NPs may conduct research within their specialty.
Although the ministry in Jerusalem has approved only the geriatric specialty for NPs so far, in the US they are taught and certified not only in geriatrics but also in family health, pediatrics and its subspecialties such as pediatric oncology, neonatology, gynecology, emergency medicine, occupational health and psychiatry.
“THE RECOGNITION of nurse practitioners is the best development here since sliced bread,” exclaimed Herzog’s director-general Dr. Yehezkel Caine. “I would grab any NP I could get. The lack of doctors – especially in the field of geriatrics – is so severe that I don’t know where we’ll be able to get physicians to treat the elderly. I don’t see any medical residents in geriatrics coming to us in the next six years.
“Geriatrics is a difficult specialty because patients are elderly, often difficult to communicate with and have a number of diseases simultaneously. But it’s very challenging and satisfying as well. Maybe some residents will arrive here by mistake,” he said sarcastically.
Caine, an expert in aviation and space medicine who administrates the hospital, told The Jerusalem Post in an interview that Israeli-born or trained physicians do not seem interested in specializing in geriatrics.
“While the US and the former Soviet Union are unlikely to be major sources of immigration in the next decade, it looks as if the UK and France will be a relatively good source, and we hope Jewish physicians will be among them. Islam and anti-Semitism will be the impetus for this aliya,” continued Caine. “Life in these countries is becoming increasingly untenable for the Jewish communities, so we hope at least some of them come on aliya and then we’ll get more doctors.”
Caine even met with officials of the Western aliya-facilitating organization Nefesh B’Nefesh to ask them to seek out doctors and nurses as immigrants from the US and the UK. But if they don’t come, NPs – and physician’s assistants who don’t have a MD degree but can perform tasks that doctors don’t have to do – are a partial solution.”
In geriatrics, a great chunk of the work is routine, said Caine, “and this can be handled properly by PAs and NPs. I don’t need a physician for half of what has to be done in Herzog, such as renewing existing prescriptions for medications. For a doctor to do this is a waste. They can easily hand over this job to NPs.”
The Israel Medical Association (IMA), said Herzog’s director-general, was for many years against recognizing NPs. But ministry director-general Prof. Ronni Gamzu, who previously ran Ichilov Hospital at Tel Aviv Sourasky Medical Center, “has been in his job for more than four years and developed more self-confidence for tackling the IMA on these controversial issues. The demand that the ministry recognize NPs came mostly from geriatric hospitals because they are so desperately short of medical manpower. Ministry nursing administration director Shosh Riba was also a strong advocate of NPs.”
“The 2011 wage accord between the IMA and the Treasury made it possible to give generous stipends and standing loans to physicians willing to move to and work in the periphery of the country, but few of those have been willing to specialize in geriatrics,” said Caine.
He bemoans the fact that even though family medicine specialists have many elderly patients in their primary-care practices, they are not required to study geriatrics.
“They study pediatrics and obstetrics/gynecology, so why not geriatrics if most of their patient load is older. There are basic distortions in the system that have to be dealt with. Congratulations to the ministry for taking the bull by the horns and agreeing to recognize and train NPs despite objections and internal politics.”
But Caine objects to the ministry’s policy decision to get most NP candidates from among Magen David Adom paramedics.
“These are technicians who do what they do on their ambulances very well. They attach defibrillators, perform intubation on those who can’t breathe, treat injuries and resuscitate – things they learn in a year-long course. They shouldn’t be turned into something they weren’t trained for,” Caine insisted. “Most of the new NPs in the course have been nurses at the patient’s bedside for a few decades.”
Caine and Herzog medical director Dr. Ady Sasson went through their lists of geriatric nurses with master’s degrees and looked for the best clinical professionals among them to be recommended for NP studies. “I took four of my absolutely top nurses for the course. Most other geriatric hospitals and departments sent nurses who were good administrators but not those involved in clinical work,” Caine said.
“Ours are coming back to Herzog and will be hands-on with the patients.”
But with four nurses turning into NPs, there will be the problem of getting nurses to replace them, as there is a shortage of these in geriatrics as well, he said. “I think some other geriatric institutions were opposed to training and recognizing NPs because they didn’t have nurses to replace the graduates,” Caine suggested.
SASSON, A NEPHROLOGY specialist who with Caine has also been at the forefront of Herzog’s demand for NP recognition and training, noted in the interview that his hospital’s four graduates were among the six NPs to receive the highest grades in the 19-person course. The four, who were also interviewed at the hospital by The Jerusalem Post, were Chana Kalifa. Shana Gottesman, Ronit Bechar and Dorit Golub.
“Dr. Sasson took NPs as a personal project. Herzog was the only hospital in the country to get encouragement right from the beginning – and it has proved itself,” said Bechar.
“We don’t replace physicians,” added Golub. “We supplement them and have a more comprehensive and personal approach. We can do many things under doctors’ supervision.”
“To be an NP, you have to have lots of experience,” said Gottesman. “Nurses who are too young and don’t have enough selfconfidence would not be suitable for NP work. They have to know how to work with the doctors.”
Gottesman worked at Hadassah University Medical Center in Jerusalem’s Ein Kerem for 35 years, mostly in the demanding internal medicine department, so it was natural for her to be offered a place in the NP course at Tel Aviv University. “We took off from our work at Herzog to take the course and were paid as if we worked. The Health Ministry set the curriculum. All the text was in English, as material isn’t available in Hebrew.”
Sasson was among the doctors who lectured for the course.
Golub noted that NPs are well known in the US, UK, Australia, Canada and some European countries, where the profession is in demand because of the wide dispersal of the population. In the US, the trigger is economic, said Golub, while in Israel it’s the shortage of doctors.
Taking the course required a change in thinking, said Kalifa. “Yes,” said Gottesman. “Now we NPs do our assessments of patients as if we were doctors.We look for the unusual. We listen to their lungs and, if there’s a problem, know how to deal with it.”
“We enjoy much more satisfaction as NPs than as nurses,” said Bechar.
Although one might have expected some Herzog physicians to fear that their professional boundaries had been encroached on by NPs, Sasson insisted that “not a single doctor refused to accept them. They cooperated, because they saw the NPs greatly assisted them. They are an integral part of the treatment team.”
Patients who see the newly minted NPs with their stethoscopes around their necks tend to call them “doctor,” said Golub. “Special NP name tags are being printed up for us.”
Sasson noted that the Finance Ministry, which often intervenes in medical issues, didn’t get involved in setting technical guidelines for the NP profession. “Officials check the economic pluses and minuses in state hospitals, but they let the Health Ministry set the guidelines,” he said.
“But we were trained not only because of the shortage of doctors,” added Gottesman.
“We bring with us something very positive. We have lots to contribute to geriatric medicine. We can be more creative. We can give medical care with more humanity. We identify diseases and take it a step further – to decide what to do. We have a rounder view. Our patients tell us now: ‘How nice that you look at us as human beings,’” Gottesman said.
“Identifying prescription medications that elderly patients no longer need – due to polypharmacy – is an important part of our work,” said Bechar. “Many admitted patients have gotten drugs for years from their family doctor or specialist, but there is no reason for them anymore.”
In a decade from now, concluded Caine, “our NPs will be heading geriatric clinics and be senior people in departments. I envision NPs eventually working in relatively large numbers in emergency medicine, family practice, anesthesia and other fields. They will be a lifesaver for only for patients but also for geriatric healthcare.”