We Israelis are quite a healthy bunch. Our pre-pandemic average lifespan was 82.6 years, well above the OECD (80.7) and the US (78.9). Avoidable mortality (premature deaths) in Israel is about half the OECD average. Life expectancy fell a bit, by 3.5 months, owing to COVID.
Israel enjoys a National Health Insurance system. Every Israeli belongs to one of four HMOs: Clalit, Maccabi, Meuhedet and Leumit. Clalit is the biggest, with about half of the population belonging to it. The four HMOs are required by law to offer a minimum package of health services and treatments, known as the “Health Basket.” (In contrast, 27.5 million Americans, or one in eight, have no health insurance at all. In the US, health insurance is largely supplied through employers. Lose your job, lose your health insurance.)
All this is done with Israeli healthcare spending of only 7.5% of gross domestic product, which is only 40% of the US figure (18%).
Moreover, the four HMOs did an outstanding job in quickly and efficiently organizing to vaccinate adults against COVID-19. Some 15 million doses were administered, vaccinating 87% of the adult population. Millions of third-dose booster shots have been given.
So far, so good. Yet, a deeper look shows that Israel’s healthcare system is ailing and has been for years.
There is a growing shortage of doctors. Israel has only 3.1 doctors per thousand, well below the OECD average. And they are concentrated in Tel Aviv – 5.3 per thousand, compared with less than half that in the South. It will get worse, as Russian doctors who emigrated to Israel in the 1990’s grow older and retire. Half of Israeli doctors are over age 55, the eldest of the OECD nations.
Moreover, nurses too are increasingly scarce – around five per thousand people, half that of the US. And try to find a hospital bed; 3.6 beds per thousand, down 20% from the year 2000 and less than half that in Germany (but slightly more than the US, which also desperately lacks beds).
All these shortages occur against a backdrop of the pandemic that has severely stressed healthcare facilities and those who work in them, all over the world. Even before COVID-19, a study by Dov Chernichovsky and Roy Kfir, Taub Center for Social Policy Studies, concluded that “there are systemic failures in planning, budgeting and regulation by the government” in the healthcare system, growing worse as Israel’s population ages. Today one person in every nine is over 65; by 2050, it will be one in every six.
To gain an expert’s perspective on these and related issues, I interviewed Dr. Jesse Lachter, a longtime family friend, a (retired) Technion professor and head gastroenterologist, Haifa region, for the Meuhedet HMO.
Israel has a severe and growing shortage of physicians – this has been obvious for years – but little is being done. How can Israel ensure that we have sufficient doctors in future, when the wave of Russian immigrant doctors retires?
In 2019, there were 4,700 medical students in Israeli universities, up by one-third from a decade earlier. But this is far from adequate. Today fully 60% of Israel’s new doctors were trained abroad.
There is no dearth of excellent applicants for medical school. Thousands of people who could become excellent physicians are denied entry to the Israeli med schools; some go abroad, others pour their high-level abilities into other pursuits.
The ZOOM era was advanced by COVID-19; online recording of lectures made the first three years of medical school available online – other than labs, which are a small fraction of the time students’ time during those three years.
So, the number of students could easily be doubled if classes were expanded.
The clinical years are more difficult for getting medical training, and the current emphasis on in-hospital training is widely seen as becoming antiquated. Much more community-based learning should be instituted, as health in Israel and worldwide is moving more and more into the communities. The hospitals are needed less and less.
Allowing and encouraging community-based physicians to be teachers is the obvious solution to getting good learning experiences for medical students.
Another answer to the physician shortage is to quickly develop and expand the efforts in Israel to have nurse practitioners, who are very capably delivering healthcare in many places in the world but training them has been resisted in Israel.
The Residents’ Rebellion: In Israel, a vast number of social and economic problems are ignored, unless and until social protest explodes. Take for instance the Great Residents’ Rebellion. Many hundreds of residents demonstrated in early October and many of them submitted “I quit” letters, in protest of 26-hour shifts.
First, some background. A medical residency for freshly minted MDs takes place in a hospital and gives in-depth training. First-year residents are called interns; they become “residents” from year 2 onward as they concentrate more on their specialties and serve for three years. Later, many doctors advance to subspecialties; their training is then called a fellowship.
In Israel medical residents work very long hours – 26-hour shifts, often without rest or breaks. They provide much of the professional healthcare in hospitals, at low pay. There are currently 7,000 medical residents and 2,000 interns.
Dr. Lachter, as a former chief resident of internal medicine, what is your position on residents’ 26-hour shifts?
The dilemma regarding hours for medical residents has been around forever. The reason for calling them residents is that these trainees literally resided in hospitals and were present 24/7, or nearly that much, in previous times.
“The 1987 Libby Zion case in New York involved an exhausted trainee missing a vital diagnosis, leading to a needless death. [18-year-old Libby died in a New York hospital; her father, a prominent journalist, attributed her death to sleep-deprived resident physicians working 36-hour shifts].
At that time, a NY resident in internal medicine trained for just three years – during which their hours were brutal, sometime exceeding 100 (of the 168) hours of in-hospital work weekly.
At that time, in Israel, residency in internal medicine was a year longer, but the schedule less brutal, usually about 72 hours of work in the hospitals per week. I had published a letter in the New England Journal of Medicine, as a chief resident in medicine at Rambam Hospital during that time period. My claim was that treating residents more humanely could be seen as wise investment: Shorter hours that would allow the trainees not to have their humanity lost during training, thus continuing to be humane physicians. We all want the physician who treats us to be humane, empathic, patient. Extending the time of residency while lessening the hours per week amounts to the same sum of training hours, experienced more reasonably.
[Since that time, the tables were turned. The US and other advanced countries shortened work shifts for residents, while Israel increased them.]
I personally and hopefully understandably can attest that a 30-hours long shift with no sleep is painful and lacking in mercy, and can affect one’s personality when such shifts occur twice weekly for three to four years during the formation of one’s career professional identity. The US has various agencies that have shortened the hours of trainees during residency. The European guidelines are similar and even for fewer hours – usually up to 55 hours/week. Israel has not shortened the rough hours for residents while the US and Europe have done so. The need is clear.
Before the agreement on shorter residents’ shifts was reached on October 20, I asked Dr. Lachter:
The Health Ministry has submitted a ‘reform’ plan, which purports to reduce the 26 hour shifts, but rather slowly, and in stages. Residents are the backbone of hospital care. Can the 26-hour shift be sharply reduced, without breaking the bank?
The 26 hour shift can be shortened to 16 hours, which is also more than anyone who is saving lives and caring for our health should have to work without rest. Splitting the time of shifts has been done elsewhere, and it can be done in Israel. Residents’ shifts are calculated by the hours worked, and thus there would be less income for those who work less, but still a living wage by Israeli standards. The overall costs are not really the underlying issue.”
The problem of inhumanly-long sleepless shifts for residents has festered for decades. But nothing was done. Exasperated, and led by Dr. Ray Biton and the younger residents, in early October the residents demonstrated; 2,500 of them threated to quit. The Health Ministry responded with an inadequate reform plan, which the residents rejected.
Finally, on October 20, Health Minister Nitzan Horowitz announced an agreement. In April shorter 18-hour residents’ shifts will begin in the periphery (where doctor shortages are most acute). Next November, the reform will be expanded to two hospitals in central Israel, and on March 31, 2023, 18-hour shifts will be implemented in internal medicine and emergency medicine country-wide.
A further expansion will occur in November 2023.
Why the delay? Why not now, at once? Because it will take time for hospital administrators to reorganize and find ways to remedy the shortfall of resident hours. And they are already complaining.
The burning questions remain: Why have medical residents been subjected to inhumane 26-hour shifts for so long? How many errors occurred, owing to sleep deprivation? Why did it take militant young residents to effect change? And why does it take strikes and street demonstrations to achieve long-overdue reforms?
A day in the life...
Dr. Colleen Mary Farrell, New York City physician: “I had been awake for nearly 24 hours working in the ICU. Earlier that night, one of my patients died unexpectedly. Breaking the news to his family was still a fresh wound. Later, amidst the exhaustion and frenetic pace of my work, I made an error by ordering a patient a medication she wasn’t meant to receive. I was terrified I had harmed her. I hadn’t had a moment to rest my head on the desk, let alone sleep. By hour 22, I still had five admission notes to write – critical patient information was stored in my head and needed to be entered into the Electronic Medical Record. I fantasized about curling up under a blanket on the floor. I wondered if my patients would feel safe if they knew how exhausted and depleted their doctor was. I wondered what they would say to hospital administrators and medical education leaders who insist these work hours are not only safe, but good for me and my colleagues. My friends and family outside of medicine are routinely horri
fied that resident physicians are required to work 24-hour shifts, often every third or fourth day, while providing life-saving medical care. They ask me why this is still common practice.” (Source: Op-Med website)
Dr. Lachter has the last word:
“Israel needs to take the long view; we need an effective healthcare system, and few are fooled into believing that ours is sufficiently well-staffed or well-equipped to meet the uncertainties of the next two decades. The needs for healthcare will go up, our staff numbers are going down, and the level of care reflects this. We all need or will need health care and taking care of each other is mandated – veahavta l’re-echa kamocha! (You shall love your neighbor as yourself.)”
The writer heads the Zvi Griliches Research Data Center at S. Neaman Institute, Technion and blogs at www.timnovate.wordpress.com.