Israel is the Western world’s leader at outsourcing medical training: 60 percent of all the doctors who receive their medical licenses in Israel were trained abroad. This is a rather dubious title for a country that boasts its health care system.
It was convenient for Israel to have the expensive and complicated medical school studies outsourced. But whoever thought it would be possible to continue to rely on the import of doctors who studied overseas at the expense of their own families – was mistaken.
In 2018, the Health Ministry made an important change and significantly limited which foreign medical schools are accredited in Israel, so now only graduates of foreign medical schools at a high academic and clinical level will be allowed to work in the Israeli health system. While this was an important correction in medical training in Israel, the change may cause a doctor shortage in the health care system.
Why has Israel become an empire of importing doctors from overseas to begin with, and why did it give up control over the quality of the training of most of its doctors? What barriers hinder young Israelis from getting accepted to local medical schools, and force many of them to do their grueling training overseas at their personal expense?
The accepted answer is that there is a shortage of “clinical fields.” This means there is a shortage of spaces in the hospital wards, where medical students do their clinical rotations in the final years of medical school, and gain experience in clinical work. Medicine is a profession of practical studies, so most of the teaching is conducted around the patient’s bed, alongside senior physicians; the doctors in Israeli hospitals devote a significant part of their efforts and time to training the next generation. The “clinical years,” in which the students are exposed to the different departments, are considered the most important part of medical school.
But does Israel really have such a severe shortage of clinical training spots? The common assumption is that the hospitals do not have enough beds, too few senior doctors and that overall, the health system in Israel is simply too small for its own training needs. But when we examine the matter in depth, we discover that this assumption is wrong: Israel may have a relatively low number of hospital beds per capita, but in comparison to the number of medical students in clinical training, the number is 50 percent higher than the average in the OECD (see diagram). In comparison to other Western countries such as the Netherlands, Belgium, Britain and Sweden, Israel has enormous potential for training doctors. So what is really preventing teaching new doctors in Israel, at a high academic level and subsidized by the government?
The hospital clinical training is under exploited
The first bottleneck is dedicating too few weeks a year for clinical training. Clinical medical training in Israel is spread over fewer weeks of the year in Israel than in other countries. An examination conducted by the Health Ministry found that the number of weeks in which clinical teaching is conducted in the hospitals is between 18 and a half and 20 and a half on average, out of the 52 weeks in the year, compared to an average of 40 weeks a year in OECD countries.
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The second bottleneck is the size of the groups of students in each clinical training group: The average in Israel is between seven students in a group in internal medicine and 9.5 in gynecology and obstetrics. It is hard to determine what exactly is the optimal number which preserves the high level of teaching while taking into account the national interest in training more students. At present, there are major differences between the medical schools: Some insist on small groups of 5 or 6 students, while others can reach 15 in a group. Moreover, the argument over the ideal size of the training groups verges on the absurd, considering the fact that the result is pushing prospective medical students abroad, where the Israeli health care system has no control over the quality of instruction and training.
Another absurdity is the hundreds of foreign medical students who study in Israel: While Israel is scrambling to figure out how to open up more spots for medical students here and prospective students leave for schools overseas, hundreds of foreign students come to Israel to study medicine. True, they make the universities a lot of money – about $40,000 a year per student – but they also take up invaluable clinical training spots that could have gone to Israeli students who would have gone on to swell the ranks at Israeli hospitals. The government understands this absurdity quite well, but has been dragging its feet for years to avoid having to compensate the universities for closing down these lucrative international programs.
What is preventing the clinical training programs from having a much higher output – with more students in each training group and, most important, for many more weeks a year? There is a great number of reasons, which are related – as in many cases – to problematic incentives. Teaching medical students is a heavy burden placed on both residents and specialists, who do it alongside – and sometimes at the expense – of their work treating patients.
Nonetheless, the money the universities pay their affiliated teaching hospitals – thousands of shekels for every week of training – does not necessarily reach the same departments that are doing the training. Instead, the money is given to the hospital, which can then use it as it sees fit and according to its own priorities. In this situation, the department that conducts the training has no incentive to accept more rounds of students.
The world of clinical rotations is run as a free market and without price supervision, even though it is clear that it is a national resource. For example, competition exists between the universities and hospitals over these clinical training spots, which leads to price hikes that make it difficult for the universities to pay for the training. The larger, more powerful and more in-demand the hospital is – the more money it can demand from the universities for every week of training, forming a barrier to the opening of more training spots.
At the same time, the opposite relationship of power also exists between the hospitals and universities, in which the stronger universities apply pressure on the hospitals to lower their prices – to very low levels in some cases. The bottom line is that the free and unsupervised market for clinical training rotation spots makes it hard for the state to fully take advantage of this national resource.
A solution is possible
The solution is eminently feasible and has been known for years. First, it is obvious that the number of spots in clinical rotations must be increased, while at the same time extending the periods of training rotations to close the gap with the OECD average – which will allow a major increase in the number of medical students studying in Israel.
It is also possible to introduce new training rotations in other places, such as the HMOs, where most of the day-to-day medical work is done. To take fuller advantage of the so-called clinical fields, the Health Ministry is proposing to bolster tuition and training in hospitals by increasing the size of training groups in existing clinical fields, by turning more hospital departments into academic teaching departments, and by expanding clinical teaching hours in the afternoon.
The Health Ministry has already begun implementing some steps in this direction. For instance, through a dedicated teaching program for the periphery, to guarantee a flow of Israeli-trained doctors to areas outside the center of Israel – where most of the doctors were trained overseas.
Additionally, the Health Ministry is also looking to expand programs for paramedical professions, such as doctors’ assistants, who could ease the bureaucratic burden on doctors today, allowing doctors more time for teaching.
These solutions are clear and well-known, but they require money, vision and most of all a feeling of urgency on the part of the government. Training doctors takes years, and the solutions must be implemented without delay. Israel must stop being the leader in the West in importing foreign trained physicians and take responsibility for raising more if its own.