Following several years of uncertainty, new Health Ministry regulations published this week clearly define the procedures that medical students will be able to perform in Israel’s hospitals. In light of the growing shortage of doctors here, and because the increase in the number of medical students will only be felt a few years from now, students will now be able to undertake a series of medical procedures, albeit under the close supervision of doctors.
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Veteran and senior doctors used to work in hospitals during their studies as assistants carrying out nursing tasks, but due to the opposition of the Nurses Association, this activity was stopped about a decade ago. In recent years, certain hospitals have begun to reemploy medical students as doctors’ assistants, but until now their authority was not clearly delineated.
The directive, which was sent out to hospital directors over the past few days and took effect immediately, was issued by Prof. Arnon Afek, the head of the Health Ministry health administration. From now on, the authority of medical students will be specified. The directive emphasized that medical students will not be able to replace doctors or carry out medical procedures in a manner opposed to the doctors’ orders. They will also be required to introduce themselves to patients as medical students.
At the same time, the directive enables them − starting from the first year of clinical studies, which is the fourth year of their six-year study course − to take patients’ medical histories and do a physical examination with their consent, including checking their pulse, blood pressure, lungs and stomach; write the treatment summary at the end of the period of hospitalization, so the doctor can sign a letter of release; take venal blood from patients, except in sensitive situations where blood is needed in order to determine blood type prior to a transfusion; and, during surgery, to hold a device called a retractor, which is designed to distance the organs adjacent to the site of surgery and enable the surgeon better access to the target area.
These procedures are presently carried out for the most part by interns and young residents and, according to Afek, “The new directive could make things easier for the residents and doctors during busy rotations.” The directive even permits learning activities during work hours, for example assisting doctors in a surgical procedure, under the direct supervision of a doctor in charge.
The directive applies only to Israeli citizens or permanent residents, and requires that the students’ activity be monitored by doctors, and not by interns (who work in the hospitals as part of their seventh year of studies). The Health Ministry has decided to apply it not only to students studying medicine in Israel, whose number is increasing by the year and is estimated to include about 750 first-year students this year, but also to the estimated 500 to 600 Israeli students who are studying abroad each year.
“Most Israelis studying medicine abroad will eventually work in hospitals in Israel,” Afek says, “and therefore it was important to include them in the directive.”
In accordance with the directive, department heads or doctors will be required to give the medical students feedback about their work once every six months, in order to advance their professional level. Medical students will only work on shifts when at least one certified doctor is present on the ward, and they will not be allowed to engage independently in activities requiring medical judgment. These include admitting or releasing patients, visits on the hospital wards, and medical instructions, such as an order to administer medicine.
The health-care system welcomes the new regulations, although their effect on relations between doctors and patients in the hospitals are as yet unknown.
Afek believes the new regulations “will not adversely affect medical treatment. On the contrary, the night shift is very busy, and even if the medical student doesn’t have the same level of skill as the doctor, the patient will be pleased that he [the student] has joined the staff. The student is far more attentive to the patient when gathering medical information, and is free to invest more time to gather such data from the patient, and will later be able to present it to the doctor, occasionally even to sound a warning in situations requiring special attention. His presence reinforces the treatment by medical staff, which is one of the advantages of public over private medicine. And when doctors cooperate in treating patients, that reduces the risk of irregularities.”
The Society for Patients Rights in Israel explained this week that they are open to the absorption of medical students as ordinary hospital employees, in light of the shortage of doctors. However, according to chairman Shmuel Ben Yaakov, “It’s important that this be an interim solution, until the fundamental solution of increasing the number of expert doctors and nurses. We welcome creative solutions that will ease the pressure in the health-care system at the moment, on condition that they won’t make a temporary situation permanent.”
Medical schools also welcome the move. Prof. Eran Leitersdorf, dean of the Hebrew University Faculty of Medicine, says: “Since medical students stopped working in nursing, they have gone to work as waiters and in other jobs unrelated to the profession, which did nothing to further their medical training and medicine in Israel. If we bring them back as doctors’ assistants, that’s a welcome move.”
Dr. Leonid Eidelman, chairman of the Israel Medical Association, concurs. “Many students complete their medical studies without have experienced medicine in the hospitals, and if they carry out procedures under the supervision of doctors, that will help both them and the doctors.” He cautions, though, over the importance “that the student does not become the one administering treatment, and remains in the role of assistant.”
Dr. Rachel Adatto, who headed the health lobby in the outgoing Knesset, also expressed her support. “There’s nothing better for the system than bringing in medical students with motivation and abilities to help the doctors in their work,” the former Kadima MK said. “We should recall that these are people with high grades on the psychometric and matriculation exams, intelligent people, and if a medical student can work in a hospital in support of a doctor, instead of waiting tables, that must be allowed.”
The initiative is also being welcomed by medical students, one reason being that the new directive will determine the scope of their authority. “As opposed to other students − science students, for example, who are eligible for stipends after receiving their bachelor’s degree − medical students receive a bachelor’s degree after three years of theoretical studies, but they don’t have such stipends,” says Uri Levy, chairman of the Medical Students Organization at Tel Aviv University. “During the years of clinical work they study full-time in the hospitals every day from 8:00 AM to 4:00 PM, and they have no opportunity to miss a day or half a day in order to earn money. That’s why the new track is welcome.”
The salary of medical students working in the hospitals is not expected to be high, and will probably be close to the minimum wage (presently NIS 23.12 per hour). The students will be paid by the hour, since students can be employed only after study hours and on weekends. Levy notes that although the salary is “lower than what medical students can earn − nowadays they try to get work as analysts, or as teachers preparing students for matriculation and psychometric exams − and certainly doesn’t enable medical students to support themselves on a monthly basis, work in the hospital improves their professional abilities and prepares them for hospital work.”