A 45-year-old woman was diagnosed with metastatic cancer and was in urgent need of radiation therapy. After receiving expedited radiation treatment, she began a longer-term course of treatment that was to include surgery, chemotherapy and drug therapy matched to her individual needs. But just after the radiation, her case became mired in bureaucracy.
“Nobody was overseeing my treatment, and after they had already giving me an appointment with an oncologist, they postponed it and told me he was ill and that I should wait until he was back at work. I had to go see a private doctor who charges 2,000 shekels ($560) per visit, and he said it was urgent that I begin treatment. After a bureaucratic battle with the hospital, they put another doctor in charge of my case, and then finally they scheduled me for treatment, in another three months’ time.”
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The woman, who asked not to be identified, said that “in the condition I was in, if I had waited three months to begin therapy, I wouldn’t have survived.” In the end, she did what many Israelis are unfortunately forced to do to manage in the public health system. She used connections.
“That’s the only thing that helped,” she says, adding: “The way the system looks today, I urge anyone with life-threatening illnesses to make use of connections. Ask any doctor you may now, make it unpleasant for them, because otherwise, you face a death sentence.”
The woman’s case is not an isolated incident in the sequence of treatment. Quite to the contrary, it is rather representative of the deficiencies in oncology treatment in the public health system.
The wider picture of the situation was recently spelled out by Prof. Ido Wolf, the director of oncology at Tel Aviv’s Ichilov Hospital and an adviser to the Israel Cancer Association. The testimony that he delivered earlier this month to a committee investigating Finance Ministry policy and the alleged collapse of the state medical system was stark and worrying. The panel was established by a number of groups representing patients, doctors and civil society organizations.
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‘That’s the allocation’
“A cancer patient with an active illness sees their oncologist just once every other month for 15 minutes. That’s all there is available. That’s the allocation,” Wolf testified.
When retired Judge Michal Levit, who heads the panel, asked him whether that was sufficient, Wolf replied: “It’s enough for only the most minimal treatment. In 15 minutes time, all I can manage to do is see whether the person is all right, that no disaster has taken place since I last saw them. I look at their PET-CT scan [a cancer diagnosis tool] and check whether they’ve responded to therapy or not and then put the necessary information into the computer about the future course of therapy. I have no time to talk to them about their problems. We have no time for that.”
Cancer is the No. 1 killer in Israel. Over the years, the country’s population has grown, medical advances have been made, cancer patients are living much longer – and are being cured – and their needs are growing as well. In 2002 there were 21,000 new cancer patients a year, in 2016 the number has jumped to 27,000.
“The population of cancer survivors has also soared,” Wolf said. The problem is not necessarily financial. “It’s very easy to approve an expensive drug that extends life by about two months, and to think we’ve done a lot,” he declared. Israel’s basket of medical services and drugs available to all through the public medicine system is a “world leader.” The problem, he says, is mainly structural, and has to do with sequence of care involving diagnosis, treatment and support services.
Wolf describes an oncology treatment system that is in real crisis – with some patients falling between the cracks and who are not receiving optimal treatment. Medical care involving some types of treatment is on the verge of collapse.
The torturous path of an Israeli cancer patient can begin at the stage of the diagnosis. “At Ichilov, we analyzed the path undergone by the typical Israeli cancer patient in 2018, and we discovered that it can take four to six months from the moment the patient detects symptoms until a final diagnosis is made, and that depends on whether or not there’s surgery, the type of cancer, etc.,” Wolf said.
The committee asked him why it would take so long to make a diagnosis. “For many reasons,” he replied. “First of all, each test is consecutive rather than taken at the same time. Take the classic patient as an example. He has stomach pain and the doctor sends him for blood tests. The tests show he has liver problems. The doctor calls him back. A week goes by. Then the patient returns and is referred for a CT scan. In the scan, they see that something is abnormal and send the person for a colonoscopy and a liver biopsy. Another two or three weeks pass until there’s a diagnosis by a hepatologist and then the person has to go back to their doctor to refer him to an appropriate physician.”
That’s how it works. Every link in the chain involves waiting your turn and waiting a week or two and that’s how you get to two months before any diagnosis is made. Some of these problems are due to a lack of resources. There’s a shortage of pathologists and radiologists. Some have to do with one medical test leading to another and some of it is caused by the bureaucracy of waiting for a referral.”
Wolf gave what he called a typical example of how delays are caused by unnecessary bureaucracy: “A woman has a mammogram that doesn’t come out right and she’s sent for a biopsy. The person who recommends the biopsy is the doctor who took the mammogram, but because of bureaucracy, he cannot give her a referral. So the woman goes back to her family physician, who refers her to the clinic where she had the mammogram. It can take a few weeks until a cancer patient begins treatment. That’s a very long time. Sometimes it’s quicker, but there are more than a few people who wait as long as eight months between their first consultation and the start of treatment – which can be a matter of life or death for the patient.”
The main bottleneck in the diagnostic process is pathology testing, Wolf says, due to a shortage of professionals. “The time it takes for pathology results is two to three weeks. That’s when you have top staffing. When you apply a lot of pressure you can get an answer in three days instead of three weeks.”
Wolf leaves no room for doubt: “The weaker the population group, the longer the process takes. The wait depends on variables such as whether you’re in the center of the country or in an outlying area, whether at a private or public facility. There are places that do quick diagnoses, such as Sheba [Tel Hashomer], Ichilov, Assuta. These are stronger places in the center that know how to arrange it. When you know how to work it out, you can complete your screening in two to three weeks instead of taking many long months.”
After the tiresome screening phase, comes the treatment phase, which can be no less problematic. With advances in medicine, cancer patients are now living longer. Many are cured, but their treatment is more complicated and lasts longer. It’s a phenomenal achievement of course but it changes the needs of a system that isn’t always prepared for it.
“If, for example, someone with metastatic colon cancer used to die in five months, today we’re happy to see they can live for three years or more,” says Wolf. “And during this period, they are actively treated by an oncologist. The oncology center and not their family doctor becomes their regular medical home,” he notes. “At least five oncologists are involved in the typical treatment, in addition to nurses, and there are a lot of needs, many of which aren’t met.”
The field of oncology is suffering from a severe shortage of doctors and national planning is faulty or nonexistent, Wolf says. There are 175 senior oncologists handling 25,000 new cancer patients a year [in addition to] 100 medical residents. Israel is the only place in the world where there are residents in oncology, “but a resident is still not an oncologist,” Wolf says.
How do these numbers translate into reality in the field?
“Recommendations call for 1,700 patients per year per oncologist, but in fact oncologists in Israel see an average of 2,400 to 2,800 patients. The gap is growing and the complexity of the visits is increasing. Today a doctor must address complicated genetic examinations and attend to a million other things that didn’t exist in the past, but the time for doctors’ visits hasn’t been increased and the standard hasn’t been revised,” Wolf states.
Doesn’t this reality send patients from the public health system to private medical care?
“Perhaps but only partially because private medicine can’t address all the needs. There are no private oncology clinics, but you can get a private oncology opinion. A small private system cannot address complications and pain. And what about psychologists, the social worker and the sexual counselor? These are real challenges and it only happens in the public system.”
Referring to a complex procedure involved in planning individual therapies, Wolf said: “If a doctor is supposed to do about 250 simulations, they all do 450 a year.”
The shortage of radiation physicists is no less severe. They play a key role in planning radiation therapy. “With regard to physicists, we face a real national crisis. There aren’t enough physicists to handle all the cancer patients. The Health Ministry has proposed plans to solve the problem, but they haven’t been carried out.”
The problem extends well beyond staff shortages, says Wolf. “In our system at Ichilov, there are 4,000 patients a year. There are a few hundred every day, and we have only three social workers on duty. It’s clear how important a figure the social worker is in the treatment process. As for psychologists, there’s the same problem. Many patient support systems are lacking.”
The ‘softer’ systems get less attention
In a system facing such problems, the ‘softer’ aspects of patient care, such as palliative care, which focuses on patients’ quality of life and how to ease their suffering, get less attention.
Palliative care extends the lives of cancer patients more than a lot of drugs, as long as it is offered from the outset, says Wolf.
“Not long ago, they created a great app in which the patient describes how they feel once a week and their symptoms, such as pain, diarrhea, or nausea, and they get a response that pops up. If they’re experiencing something out of the ordinary, the patient gets a quick and professional reply. Researchers have shown that this app extends the lives of cancer patients by half a year.”
“If this app were a drug, it would cost $100,000 per patient, but it isn’t a drug. It requires nurses who answer the telephone to make it happen,” he said.
Another issue that’s rarely discussed is the treatment of those who recover. Such patients can come down with various symptoms, beginning with having a much higher risk of heart disease at an early age, dropping out of the labor force and psychosocial affects,” he says.
“Despite this, I hardly know an expert on recovery from cancer in Israel and there’s no follow-up plan for those who recover,” he adds. “This has tremendous significance, both from the standpoint of quality of life and the economic [standpoint]. Anyone who recovers from breast cancer who returns to work and hasn’t remained on the outside, depressed and in pain, is a tremendous asset to society. We don’t have a system that can rehabilitate those who recover. It doesn’t exist. You need a system that can return people ... to resume functioning.”
Wolf says oncologists and medical staff suffer severe burnout. There’s also a shortage of oncologists,which he attributes to a mistaken concept about the profession.
“Cancer medicine suffers from a problematic image,” as if it were still about treating people who can’t be cured, says Wolf. Medical schools also provide minimal exposure to the field, he claims, which also erodes demand for the profession. The solution, he says, has to be multidimensional. It should include central planning and also must include the addition of doctors and incentives for students to go into physics, and a program to prevent burnout.