When Professor Shaul Yatziv started his job as director of medical professions licensing in the Health Ministry in 2017, he found that total chaos prevailed regarding physician training. His job is to be the gatekeeper of standards for the medical and other health professions in Israel. However, this role is particularly difficult because Israel, with one of the West’s most advanced health systems, deeply depends on doctors who have studied medicine abroad, who account for a whopping 60 percent of medical license recipients.
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Yatziv also discovered that despite this exceptional statistic, which gives Israel the dubious distinction of having the highest percentage of foreign-trained doctors, the state has not supervised, in any way, the medical schools training its next generation of doctors. While there are many excellent medical schools abroad, some are substandard and do very poor clinical training, if at all.
The fact that so many young people still dream of being doctors despite the difficulty of getting into an Israeli medical school, that anyone can study abroad anywhere and then be eligible to take the Israeli licensing exam and that the state benefits from having families fund the expensive training of hundreds of doctors annually have combined to create a dependency on the level of training Israeli medical students receive abroad.
Yatziv visited some universities abroad frequented by Israelis seeking medical training. What he found shocked him. In Moldova, for example, 2,000 medical students undergo clinical training in a single hospital with only 600 beds. A similar number of students in Israel get training in 20 hospitals, many of them far larger. In Armenia, he discovered that some schools skip semesters or even entire years of study, and that some medical schools weren’t even accredited in Armenia itself. In a meeting to which he was summoned in the Knesset, he said, “We have a first-rate strategic problem regarding the future of Israeli medicine.”
When he returned from his trip, he bucked considerable political pressure and initiated reforms that included toughening the criteria for recognizing medical studies abroad. Starting in 2019, one had to study in a medical school in an OECD country or in a school recognized by the World Federation for Medical Education, and had undergone clinical training in hospitals accredited by a recognized agency to sit for the Israeli licensing exam. As a result, medical schools in Moldova, Armenia, Georgia, Romania and elsewhere – where thousands of Israeli students study annually – were disqualified. Only those already in the midst of studies at those medical schools were allowed to complete their degrees and to sit for the exam.
While Yatziv’s reform was vital to preserving Israeli medical standards, it had another dramatic consequence: Within three years there will bea sudden, sharp drop in the number of new licensees, which will in turn lead to a sharp drop in the number of doctors per capita. The shortage will only worsen unless a solution is found. And if that weren’t enough, those likely to be hurt the most will be those who even today suffer from serious inequality in medical services – the residents of outlying areas – because the residents at their hospitals are most likely to have been trained abroad.
Over the past decade, the number of new doctors being licensed has grown, a move aimed at keeping up with Israel’s population growth and its increasing percentage of elderly people. However, the rate of growth among newly licensed doctors who had studied abroad (22 percent) was considerably higher than the growth among graduates from Israeli medical schools (7 percent), making foreign medical schools the primary source of newly minted doctors.
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But the story gets even more complicated. Among foreign medical school graduates, the fastest growing group came from the countries that were disqualified in 2019. While there was a 17 percent rise in the number of students at medical schools approved by the Health Ministry, the number of graduates at schools that have since been disqualified grew by 39 percent. Thus, about 350 out of the total of 1,720 medical licenses granted in Israel in 2019 were given to graduates of medical schools that the Health Ministry has disqualified.
The meaning is quite clear: Starting in 2025, the year when the graduates of the now disqualified medical schools will stop entering the Israeli health system – the number of new doctors every year is expected to plummet dramatically.
Good news – or bad – for the periphery
Here is more news that should worry decision-makers quite a lot: The steep drop in the number of new doctors is expected to especially disrupt hospitals in the periphery, where many more doctors who graduated from foreign medical schools work. For example, 94 percent of residents at Barzilai Medical Center in Ashdod are foreign graduates, as are 83 percent of the residents in Safed’s Ziv Medical Center and Poriya Hospital in Tiberias. At the Western Galilee Hospital in Nahariya, 78 percent of residents are graduates of foreign medical schools. The figure is 98 percent at Nazareth’s Scottish Hospital.
In addition, a huge number of the new doctors in the periphery graduated from these disqualified medical schools. In 2020, over half of the medical school graduates living and working in Israel’s northern and southern regions were trained at disqualified medical schools. Consequently, an enormous shortage of doctors is expected starting in 2026 in places where they are needed the most.
The reform’s importance must not be underestimated; the changes should be very good news for residents of the periphery over the long term. The present situation, in which most graduates of the medical schools the Health Ministry has disqualified ultimately wind up in the medical system in the periphery, is a failure and great injustice. The expected substantial shortage in doctors stemming from the changes should force the state to find solutions to the periphery’s distress – and eventually raise the level of the medical treatment provided to people there.
A coalition of health organizations in the Negev and Shatil-led Citizens Forum for the Promotion of Health in the Galilee commented: “The shortage of doctors is already felt quite well today in the periphery, and it will only get worse. Over the years, the Health Ministry has avoided adequately increasing the requisite staff and infrastructure, and in doing so has allowed us to reach this situation. The plans promoted by the Health Ministry present an opportunity to strengthen the medical staff in Israel in general, and in the Negev and Galilee in particular.
“In light of the urgency, the Health Ministry must add to its basic budget in the next state budget the program to increase clinical [medical training] in hospitals and the community, especially in Be’er Sheva and Safed, and the important ‘Ilanot’ plan for increasing medical leadership in the Negev and Galilee.”
The obvious question is what are the barriers preventing a major expansion of the number of students accepted to Israeli medical schools, so at the very least we can move up somewhat in the not very complimentary OECD rankings – and how these problems can be dealt with.