Healthy Israelis, sick healthcare: inside the paradox

Israel enjoys a national health insurance system. Each Israeli belongs to one of the four HMOs: Clalit, Maccabi, Meuhedet and Leumit. Clalit is the largest, with about half the population belonging to it. All 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, do not have any health insurance. In the US, health insurance is provided largely through employers. You lose your job, you lose your health insurance).

All of this is done with Israeli healthcare spending of just 7.5% of gross domestic product, which is just 40% of the US figure (18%).

Additionally, all four HMOs did an outstanding job organizing quickly and efficiently to vaccinate adults against COVID-19. About 15 million doses were administered, vaccinating 87% of the adult population. Millions of third dose booster injections have been given.

So far so good. However, a deeper look shows that Israel’s healthcare system is sick and has been for years.

Dr. Jesse (Yishai) Lachter (credit: Courtesy)

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 to less than half in the south. It will get worse, as Russian doctors who emigrated to Israel in the 1990s grow old and retire. Half of Israeli doctors are over 55 years old, the oldest of the OECD countries.

In addition, nurses are also increasingly rare: about five for every thousand people, half the number in the US And trying to find a hospital bed; 3.6 beds per thousand, 20% less than in 2000 and less than half that in Germany (but slightly more than in the United States, which also desperately lacks beds).

All this shortage occurs in a context of pandemic that has severely affected health centers and those who work in them around the world. Even before COVID-19, a study by Dov Chernichovsky and Roy Kfir of the Taub Center for Social Policy Studies concluded that “there are systemic failures in government planning, budgeting, and regulation” in the health system, which they get worse as Israel’s population ages. . Today one person out of every nine is over 65 years old; by 2050, it will be one in six.

To get an expert’s perspective on these and related topics, I interviewed Dr. Jesse Lachter, an old family friend, Technion professor (retired) and principal gastroenterologist, Haifa region, for Meuhedet HMO.

Israel has a severe and growing shortage of doctors, this has been obvious for years, but little is being done. How can Israel ensure that we have enough doctors in the future, when the wave of Russian immigrant doctors withdraws?

In 2019, there were 4,700 medical students in Israeli universities, a third more than a decade earlier. But this is far from adequate. Today, 60% of Israel’s new doctors were trained abroad.

There is no shortage of excellent applicants for medical school. Thousands of people who could become excellent doctors are denied entry to Israeli medical schools; some go abroad, others invest their high-level skills in other pursuits.

The ZOOM era was anticipated by COVID-19; Online recording of the lectures made the first three years of medical school available online, aside from the labs, which are a small fraction of the time students spend during those three years.

Therefore, the number of students could easily double if the classes were expanded.

The clinical years are more difficult to obtain medical training, and the current emphasis on hospital training is generally considered outdated. Much more community-based learning should be instituted, as health in Israel and around the world is increasingly moving into communities. Hospitals are needed less and less.

Allowing and encouraging community physicians to be teachers is the obvious solution to good learning experiences for medical students.

Another response to the physician shortage is to rapidly develop and expand efforts in Israel to have nurse practitioners, who provide medical care very competently in many parts of the world, but their training has been resisted in Israel.

The rebellion of the residents: In Israel, a lot of social and economic problems are ignored, unless and until social protest breaks out. Take, for example, the Great Residents’ Rebellion. Many hundreds of residents demonstrated in early October and many of them sent “Resignation” letters, protesting the 26-hour shifts.

First, some background. A medical residency for newly minted doctors is held in a hospital and provides in-depth training. First-year residents are called interns; they become “residents” from the second year onward as they focus more on their specialties and serve for three years. Later, many physicians advance to subspecialties; then their training is called a scholarship.

In Israel, resident doctors work long hours: 26-hour shifts, often without breaks or breaks. They provide much of the professional medical care in hospitals, at low pay. There are currently 7,000 resident physicians and 2,000 interns.

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 hours a day, 7 days a week, or nearly as long, in earlier times.

“The 1987 Libby Zion case in New York involved an exhausted apprentice who was missing a vital diagnosis, resulting in an unnecessary 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 the time, a New York resident trained in internal medicine for just three years, during which his hours were brutal, sometime exceeding 100 (out of 168) hospital work hours a week.

At the time, in Israel, the residency in internal medicine was another year, but the hours less brutal, usually around 72 hours of work in hospitals per week. He had published a letter in the New England Journal of Medicine, as chief medical resident at Rambam Hospital during that time period. My contention was that treating residents in a more humane way could be seen as a smart investment – shorter hours that would allow trainees not to lose their humanity during training, and thus continue to be humanitarian doctors. We all want the doctor who treats us to be human, empathetic, patient. Extending residence time while reducing weekly hours equates to the same sum of training hours, more reasonably experienced.

[Since that time, the tables were turned. The US and other advanced countries shortened work shifts for residents, while Israel increased them.]

Personally, and I understandably hope, I can attest that a 30-hour sleepless shift is painful and merciless, and can affect one’s personality when such changes occur twice a week for three to four years during the formation of the professional identity of the career. The United States has several agencies that have shortened the hours of trainees during residency. European guidelines are similar and for even fewer hours, generally up to 55 hours a week. Israel has not cut harsh hours for residents, while the United States and Europe have. The need is clear.

Before an agreement was reached on shorter resident shifts on October 20, I asked Dr. Lachter:

The Ministry of Health has presented a ‘reform’ plan, which aims to reduce shifts from 26 hours, but rather slowly and in stages. Residents are the backbone of hospital care. Can the 26-hour shift be drastically reduced without breaking the bank?

The 26-hour shift can be shortened to 16 hours, which is also more than those who are saving lives and taking care of our health should have to work non-stop. Shift time division has been done elsewhere and can be done in Israel. Resident shifts are calculated by hours worked, so there would be less income for those who work less, but still a living wage by Israeli standards. Overhead costs are not really the underlying problem. “

The problem of inhumanly long sleepless shifts for residents has been aggravating for decades. But nothing was done. Exasperated, and led by Dr. Ray Biton and the younger residents, residents demonstrated in early October; 2,500 of them threatened to quit smoking. The Health Ministry responded with an inadequate reform plan, which neighbors rejected.

Finally, on October 20, Health Minister Nitzan Horowitz announced an agreement. Shorter 18-hour resident shifts will begin in April in the periphery (where the shortage of doctors is most acute). Next November, the reform will be expanded to two hospitals in central Israel, and on March 31, 2023, 18-hour shifts in internal medicine and emergency medicine will be implemented throughout the country.

A further expansion will occur in November 2023.

Why the delay? Why not now, at once? Because hospital administrators will need time to reorganize and find ways to remedy the shortage of work hours for residents. And they are already complaining.

Burning questions remain: Why have medical residents been on inhumane 26-hour shifts for so long? How many errors occurred due to lack of sleep? Why were militant young residents needed to effect the change? And why are strikes and street demonstrations needed to achieve long-awaited reforms?

One day in the Life…

Dr. Colleen Mary Farrell, New York City Physician: “I had been up for almost 24 hours working in the ICU. Earlier that night, one of my patients died unexpectedly. Breaking the news to his family was still a recent injury. Later, amid the exhaustion and hectic pace of my work, I made a mistake by ordering a patient a medication that she was not meant to receive. He was terrified that he had hurt her. I hadn’t had a moment to rest my head on the desk, let alone sleep. At 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 snuggling under a blanket on the floor. I wondered if my patients would feel safe if they knew how exhausted and exhausted their doctor was. I wondered what they would say to hospital administrators and medical education leaders who insist that these work hours are not only safe, but also good for me and my colleagues. My friends and family outside of medicine are routinely horrible.
Fied that resident physicians must work 24-hour shifts, often every three to four days, while providing life-saving medical care. They ask me why it is still common practice. “(Source: Op-Med website)

Dr. Lachter has the last word:

“Israel needs to have a long-term vision; We need an effective healthcare system, and few are fooled into believing that ours is staffed or well-equipped to deal with the uncertainties of the next two decades. Health care needs will increase, our staff will decrease, and the level of care reflects this. We all need or will need health care and caring for one another is mandated: Seehavta l’re-echa kamocha! (You love your neighbor as yourself.)”

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