Haifa Doctors Confess: Patients Are Pushed to Get Unneeded Surgery, and the Damage Is Devastating

Doctors within the ear-nose-and throat department at Rambam hospital speak up about a lucrative procedure they say is being done unnecessarily and in a slipshod manner, and about department heads whom they say insist indiscriminately on operating

Send in e-mailSend in e-mail
Go to comments
Rambam Medical Center.
Hilo Glazer
Hilo Glazer
Hilo Glazer
Hilo Glazer

The confession

It all began with three doctors. One was agonized by an unnecessary operation he witnessed that had damaged the patient’s eye. The second was fed up with his superiors’ incessant efforts to increase the number of operations being performed. A third physician was disgusted at the way patients who suffered damage during surgery were shrugged off.

After much soul-searching they decided to speak out about what has been going on in recent years in the Department of Ear, Nose and Throat, Head and Neck Surgery in Haifa’s Rambam Health Care Campus. This didn’t happen right away, however. One agreed to speak with Haaretz only through mediators and acquaintances. The dialogue with him went on for two-and-a-half months, as he gradually opened up. Another agreed to meet in his home, after being assured that his identity would not be revealed. The third plucked up the courage to confess to a senior physician, and in the end decided to speak out as well.

Weekend banner.

The story begins in 2012, when Prof. Ziv Gil was recruited to head the Department of Otolaryngology – Head and Neck Surgery, as it’s officially known, at Rambam, after having excelled in the comparable department at Ichilov Hospital in Tel Aviv. Gil immediately proved his worth, in more than one sense. He took over a department with a moderate volume of activity and soon transformed it into a vibrant, profitable unit. The road to that status, as an Haaretz investigative report shows, was unrelenting.

It happened through nasal surgery known as FESS (functional endoscopic sinus surgery), which is recommended for individuals with persistent sinus infections and helps to improve drainage in the nasal cavities. This is a particularly profitable operation – short and expensive: 41,000 shekels (nearly $12,000) for a procedure that typically takes 90 minutes. But not at Rambam.

Gil and his colleagues crammed more and more of these operations into their schedules and performed them assembly line-style, at 20 minutes per procedure. They cajoled patients to undergo FESS even when their tests did not indicate the need for it, adopted an aggressive surgical method, dismissed the professional literature on the topic – and, in some cases, left patients with damage. Departmental staff who raised an outcry were silenced. Patients who needed further treatment due to complications were sent to other departments, so as not to compromise the success rate of Ziv’s team.

The heart of the matter is the lightning surgical method that was used. “Gil had a mantra – ‘within 20 minutes’ – that he repeated over and over,” one doctor says. “He would ask why the operations were taking us so long and boast about his rapid pace. He would really get on our case.”

The three physicians relate that they were instructed to refer every case of sinusitis to surgery, contrary to standard clinical practice. Usually, an operation is recommended for a patient only when medicinal treatment has failed, and only if a CT reveals certain findings.

“You detect blockages via CT,” one explains. “A CT finding is a condition for surgery. Gil told us, ‘I don’t want to hear about blockages – if they have sinusitis, bring them in for FESS.’”

Sometimes, adds a colleague, “a resident would call me and say he didn’t see anything in the CT. But from the moment surgery was decided on, it was irreversible. In medicine that operates according to the accepted principles, surgery is canceled left and right. Things change, people get better. One day you complain about a stuffy nose, but the imaging doesn’t identify a problem. Here it was forbidden to say anything like that to the patients. There was no option of shifting into reverse.”

One resident in the department describes the tensions that arose with the director of its sinuses and orbital disorders unit, Dr. Demitri Ostrovsky: “When I started to receive people ahead of the operation I would examine the CT and discover that it was fine. In other words, surgery was not indicated. That bothered me, especially in cases of patients who were hesitant [about undergoing surgery]. If I said something, Dr. Ostrovsky would fume. He would berate me in front of patients and say that my role was not to think or examine, but to copy the formula and get a signature.”

Two of the doctors say that residents who talked too much could be punished, and recall a case in which a young resident laid out for a patient the risks involved in the FESS procedure.

Prof. Ziv Gil.
Prof. Ziv Gil.Credit: Hagai Frid

“He mentioned the possibility of bleeding, leakage of brain fluid, damage to the eye socket,” explains one. “It may sound scary, but it’s necessary – after all, one of the basic principles of medicine is informed consent. In any case, after hearing the explanation the patient said he didn’t want the operation. There was an uproar in the department, and the resident was informed that he would not be tasked with preparing pre-surgery for an indefinite time.”

According to the physicians, Gil’s instruction was unequivocal: “If you see that a patient is unsure and starts to make trouble, take his consent form and bring him to me.”

One thing that angered members of the department was the way that they dealt with situations in which operations had led to complications.

“In the case of complications, the resident would call the attending surgeon, and then Gil would shout, ‘You’re not re-admitting him to my department – sell him to whomever you can.’ Eye damage? Take them to ophthalmology. Headache? Neurosurgery. Do everything to send him in other directions. That burned up the staff in the department; people were disgusted by it.”

Another physician confirms this account. “Readmissions were forbidden, because that’s one of the indicators measured by the Ministry of Health. Ziv’s directive was zero admissions of those patients.”

Their testimony show that the three are remorseful. They talked about patients who were left with permanent damage, of years in which every hint of criticism was suppressed. Their accounts were the impetus for this investigation.

The investigation

In the past few months, Haaretz spoke to dozens of sources in Israel’s health system. The numerous testimonies and documents that were amassed indicate that staff in Rambam’s otorhinolaryngology department, notably Ziv and Ostrovsky, sometimes performed unjustified operations. When Gil took over, the department performed about 100 FESS operations a year. In 2018 that number was almost 1,000 – two times as many as at Ichilov and seven times as many as at Soroka Medical Center in Be’er Sheva, and one-quarter of the total performed nationally in that year.

The first hints that something was amiss appeared in 2016. First to take notice was the Clalit health maintenance organization. “Suddenly it seemed that everyone who lived north of Tel Aviv needed a sinus operation,” says a source in the HMO’s management. “The numbers were insane, the money simply vanished. We’re talking tens of millions [of shekels].”

Clalit appealed to Rambam about its apparent overbilling, and some of the complaints were accepted. Still, the numbers continued to soar. “We decided to do an in-depth check,” another senior HMO source relates. “We went over operations, medical histories, we examined the discharge letters. Some of the patients hadn’t needed surgery at all.”

'You detect blockages via CT. A CT finding is a condition for surgery. Gil told us, ‘I don’t want to hear about blockages – if they have sinusitis, bring them in for FESS.’'

How abnormal was the deviation from the norm?

“It was exceptional.”

But the numbers kept rising. Two years ago, Clalit conducted an in-depth examination of a limited number of cases. Thirty-five files of patients who had undergone FESS were sent for examination by three different specialists affiliated with the HMO, who went through them separately. The conclusion was that only in 40 percent of the cases was the nature of the operation consistent with the diagnosis. In a third of the cases a simple (and less expensive) operation would have sufficed, and a little under one-third of the operations were deemed to have been altogether unjustified.

Clalit was not the only HMO that noticed something wasn’t right: The Maccabi HMO also discovered unexplained operations and decided to designate its internal control mechanism to oversee what was happening in the department at Rambam. For its part, the Israel Defense Forces’ Medical Corps took more drastic action: After connecting the dots, they decided to stop sending soldiers to the Rambam department.

“There was a feeling that they were overdoing it,” says an IDF source. “We were puzzled. After all, these were young, healthy people. Their ailment did not justify intervention on that scale.” Recently, the cooperation between the army and the department was renewed.

Other hospitals, too, began to take notice of what was going on. Haaretz spoke with a substantial number of ear-nose-and-throat doctors throughout Israel: One after another told about the multitude of patients who had undergone aggressive surgery in Rambam.

“A patient who had undergone a huge FESS operation came to see me, and when I looked at his presurgical CT, I discovered that at most he’d needed nasal spray,” one specialist recalls. Another met a patient whose life was in danger. “He had required a simple procedure, but they did a complex FESS on him and he ended up in intensive care with meningitis." A third physician describes the aftermath of an operation at Rambam as “a nose into which a grenade was thrown. It’s completely empty, nothing is left, a useless cavity.”

The impression of yet a fourth doctor was that “all the patients undergo the same operation in Rambam, no matter what the individual pathology is. Performing radical surgery on a patient who doesn’t need it is terrible, because you have both harmed his natural body structure and also exposed him to further complications,” she notes.

Dr. Demitri Ostrovsky.
Dr. Demitri Ostrovsky.Credit: Rambam Medical Center's Youtube channel

What led to the uptick in the number of FESS operations at Rambam? One member of the department attributes it to an intense preoccupation with improving the statistics: “There was an obsessive pursuit of numbers. They didn’t like canceling operations and wanted to exploit the hospital’s resources. I believe it came from a good place, from a desire to streamline the system and shorten the waiting period. But it became totally disproportionate. At one stage the means already justified the end. And the end was as many patients as possible, as few breaks [between operations] as possible, as much income as possible. Only numbers, numbers, numbers.”

The numbers

Prof. Gil insists that all operations in his department have always been performed on the basis of pure medical necessity. He believes that the complaints against him are being fueled by a few doctors, principally those with private practices, whose income has been affected by Rambam’s success. As proof, the department he heads in recent year registered an increase in types of surgery that are considered to be unprofitable for hospitals.

That’s an argument that is not to be taken lightly, if only the FESS procedures were a natural part of the usual operating schedule – taking place sometimes in the morning, sometimes in the afternoon, as needed. But our investigation turned up a different picture: No fewer than 92 percent of the FESS operations were performed in the afternoon, within the framework of SHARAN (additional medical service). In these operations, which are performed after 3 P.M., payment is made to the hospital’s corporation – which splits it with the surgeons. The standard rate of payment to senior surgeons in these cases is about 3,000 shekels (currently $867) per operation. Neither the patient nor the HMO has to lay out an additional sum, however.

With his star ascendant, Gil, in interviews with the press, adopted the profile of a warrior in the service of public medicine. (Rambam is a public hospital.) He would lash out at colleagues maneuvering between the public system and private operations, declaring that “the loyalty of a physician who earns 300,000 shekels a month is not to the hospital but to the money.”

He portrayed colleagues in his department as the complete opposite of those greedy doctors, saying they were inspired by the “model of the Second Aliyah pioneers” – referring to the Second Wave of Jewish immigration to Palestine, 1904-1914. He also drew a direct connection to his childhood in Kibbutz Metzer of the left-wing Hashomer Hatzair movement.

Does Gil himself earn substantially less than the physicians who make 300,000 shekels a month? According to reports, his base salary is 100,000 shekels a month. And what about the SHARAN operations? The Haaretz investigation found that he receives 130,000 shekels a month as “remuneration according to activity.” During the past four years of surgery fever he thus raked in 6.2 million shekels (more than $1.7 million), making him the top earner at Rambam.

'The patient had required a simple procedure, but they did a complex FESS on him and he ended up in intensive care with meningitis.'

Nor was the professor the only member of the department who enjoyed high earnings: Ostrovsky received close to a million shekels for SHARAN operations; he became the fourth-highest earner at Rambam.

One of the explanations offered by Gil and Ostrovsky for the surge in FESS surgery, and for their high incomes, is a vigorous approach in general. That approach is reflected in the increase in all operations performed in the department, not only FESS. Gil is proud of the fact that under his direction the operating rooms have achieved maximum utilization and thus the patients’ waiting time was shortened. A patient requiring a sinus operation will thus prefer Rambam, where surgery will usually be conducted less than a week after the referral is made, as compared with a month’s wait at any other hospital.

In addition to shortening the waiting list for operations, the Rambam physicians would also refer patients to themselves. Until three years ago, Gil ran a private clinic that channeled patients to the hospital; Ostrovsky also referred patients to Rambam, in his capacity as a community doctor for the Meuhedet HMO. Recently the HMO summoned him for a clarification meeting, in which he was asked to desist from this practice.

Yet another pipeline was a Galilee clinic headed by a resident from the department. Four colleagues relate that the doctor was absent from the department for lengthy periods, during which he worked in his clinic – which refers patients to Rambam.

Confirmation of his absences is seen in correspondence that was made available to Haaretz, in which a fellow resident warns that his colleague rewrote old operative reports, so that his name appears on them as a participant even when he wasn’t present. At one point she asks Ostrovsky outright: “Did you authorize him to use your code in order to open case files and replace names in the operative reports?” To which the senior physician replies, “I allowed him to add his name to four FESS operations. If it’s FESS, it’s all right, he needs it for the syllabus [for certification in the specialty].” When the resident repeated the complaint in correspondence with Prof. Gil, the reply was, “Clarify it with Ostrovsky.”

According to the sources in the department, the sometimes-absent resident channeled patients to Rambam at an exceptional rate. “Anyone who sneezed in his clinic received a referral to a FESS operation,” one doctor relates. Rambam itself maintains that in 2016-17 the clinic in question referred 30 patients altogether. However, a request by Haaretz for all relevant data over the years went unanswered. According to the resident in question, it is claimed that he “fulfilled all the requirements of his specialty, and that, with regard to referrals to Rambam, there was no deviation from legitimate behavior.”

The resident who confronted Ostrovsky with the fabrications eventually left the hospital and moved to Ichilov – where, in an unusual arrangement, Rambam is funding her residency. She, for her part, is saying nothing.

Exposure of the purportedly fabricated records led to a visit by the Israel Medical Association’s residency certification committee. They tried to coax the resident who moved to Ichilov to talk, but she chose not to cooperate. Another resident, who shared her thoughts with confidants about what was going on in the department was also unwilling to cooperate. A representative of the hospital on the committee, Prof. Amir Karban, noted during its deliberations that he was disappointed with the way Gil’s department was being managed and with the atmosphere of fear that prevailed in it. The prospect of receiving objective information from the residents seemed to be nil, he said.

In this intimidating climate, staff found it difficult to balance the maximalist approach of the department’s senior personnel and the price paid by the patients. A case in point is Pavel.

Pavel

“Four years ago I started having all kinds of unexplained health problems,” says Pavel Timofiev, 35, from Haifa, who works with computers. “Leaps in my pulse rate in the middle of the night, high blood pressure, dizziness, vision disorders, pains in the temples.”

He embarked on a series of tests and consulted with an otorhinolaryngologist who said he didn’t think the problems were related to his field of expertise. Seeking a second opinion, he was referred to Dr. Ostrovsky’s clinic in Haifa. Ostrovsky was the first physician who recognized Timofiev’s distress, diagnosed it and suggested a solution: FESS surgery.

Pavel Timofiev
Credit: Rami Shllush

“I told him I had never had sinusitis and did not suffer from shortness of breath, and asked if there was another option,” Timofiev relates. “He said there wasn’t, that I had already had too many antibiotics. I understood from him that it [the procedure] involved going in a little and cleaning out pus, something simple, like a filling a cavity. He gave me a referral to Rambam and said he would do the operation himself. After two months without sleep, you reach the limit of your ability, you’re exhausted. I agreed.”

Before the operation, Timofiev went ahead with a previously scheduled MRI. It determined explicitly that his sinuses revealed “no noteworthy pathology,” but it did raise a different explanation for his aches and pains: “It turned out that I had three bulges in discs in the neck region, and that’s what was causing most of my troubles. I went to a chiropractor and an osteopath, and within a short time most of the problems were resolved.”

At the pre-surgery meeting, Timofiev told Ostrovsky about the new findings and the improvement in his condition. “I came in with the new MRI and asked him to check if there was any change [regarding the operation]. He said that nothing had changed or could change.”

On the day of the operation he was given an overview by one of the residents. “He explained what was going to be done to me: clean out the sinuses, expand openings, cut a bit of the nasal conchae. That was the first time I had heard the word ‘cut.’ In the meantime the anesthesiologist was already putting me to sleep, and I was like, ‘Hang on, I just came for a cleaning.’ He stammered something about how they were doing it so I would breathe better. The next thing I remember is waking up after the operation.”

Afterward, Timofiev constantly threw up blood. When his condition failed to improve after several months, he returned to Rambam and asked for a copy of his full operative report. “Ostrovsky suddenly claimed I had polyps, a diagnosis that doesn’t appear anywhere before that. I was shocked when I went over the material – I understood that they had done excisions on top of excisions. I became depressed. I don’t know how to explain it – it was as though I had been raped, I have no other word. I tried to get explanations from Ostrovsky. I repeated that I had not had breathing problems. I kept hearing different stories from him. To this day, I don’t understand why he did this to me.”

Time passed, but the symptoms that had appeared after the operation remained: a constant sore throat, difficulty with nasal breathing and a bad smell emanating from the nose. Timofiev consulted Bnei Zion Medical Center in Haifa. “The doctor who received me held his head in his hands, and called in another expert. From their faces and the way they were talking, I understood that this wasn’t something they saw every day. Finally, they told me, ‘Listen, you had a big operation, we have no way to help you.’”

Timofiev then consulted a private specialist, whose summary report stated that Timofiev had undergone a “complex FESS operation including almost complete removal of middle conchae and partial removal of lower conchae.” Both this physician and another expert agreed that there was no way to help him surgically.

'I was shocked when I went over the material – I understood that they had done excisions on top of excisions. I became depressed. I don’t know how to explain it – it was as though I had been raped.'

Pavel Timofiev

Timofiev is not the only patient who came out of Rambam’s ear-nose-and-throat department with irreversible damage. A series of patients told Haaretz about the serious harm done to them by the aggressive surgery they underwent. A good portion now have to cope with the resultant syndrome.

The syndrome

Empty nose syndrome is the term for a disability stemming from removal of the conchae, the small bony chambers of the nasal cavities. The lower conchae, for example, play a role in filtering the air inhaled by the nostrils. Overall, an overly open nose tends to be dysfunctional. When air enters unchecked, the nervous system is affected and the brain interprets it as respiratory difficulty. These are basic assumptions that are not in dispute. Until Rambam enters the picture.

Prof. Gil denies the very existence of the empty nose syndrome; he believes it’s an invented phenomenon. Overall, he believes that he does not have to cite great experts to justify his maximalist approach, because he himself is the great expert. Accordingly, he and his staff shunned professional conferences and advanced refresher courses, to the point where they lost contact with other colleagues in the field.

As one of the doctors who spoke to Haaretz put it, “Gil would say that we in the department are the ones who are writing the textbook.” A colleague said that he “encourages the residents not to read the book that is considered the bible of the field, claiming it’s out of date, even though that’s the book they are examined on [when they apply for certification in the specialty].”

Gil may deny the syndrome in question, but reality isn’t listening. For example, there is the case of a Galilee woman of 63 who underwent a lightning operation in Rambam.

“Ostrovsky looked at my CT and said all I needed was a nasal rinsing,” she recalls. “In the summation of the meeting he wrote clearly: left side only. But I was operated on by Gil. He came over to me about half an hour before the operation, for just a few seconds. I remember that it was 6:10 P.M. when I was taken to the operating room, and when I woke up it was 6:30.”

Two weeks later, she arrived for a follow-up with Ostrovsky. “Only then he told me that they had done both sides. He didn’t answer when I asked him why they also did the right one.”

A few months later, breathing disorders appeared, along with sleeping difficulties and a pesky cough. The woman returned repeatedly to Rambam and was told that all was in order. “I’ve been making the rounds of doctors for a year, going through hellish agony, finding it hard to eat and barely sleeping,” she says. In January she sought a private opinion. The diagnosis states that she “underwent a bilateral conchae removal, despite unilateral pathology.” The specialist attributed her suffering to empty nose syndrome.

Rambam Medical Center
Credit: Hagai Frid

“She [the doctor] looked at the documents and asked over and over, ‘It says left side, why did they go into both sides with you?’ She explained to me that my nose is now like an open faucet, everything is dripping into the throat, and that the damage was irreversible.”

The physician who oversees referrals to Rambam on behalf of the Clalit HMO says she encountered a series of cases that required a minor procedure but ended up with major surgery. “I remember one woman who was referred for a small operation, not even FESS. She came out with an empty nose and is really suffering now.”

What do you do in a case like that?

“I saw her a year after the surgery. At that point, there was nothing that could be done.”

To understand why so many patients treated at Rambam now suffer from empty nose syndrome, we have to go back to the norms that were in place at the hospital – above all, to operate fast. That was the only way the department’s surgeons were able to perform four and sometimes five operations in one SHARAN shift. Most otolaryngologists and head/neck surgeons maintain that a hastily performed FESS procedure tends to be aggressive, riding roughshod over healthy tissues in the nasal cavity and increasing the risk of complications.

But in Rambam the idea of haste making waste was ignored. According to two sources in the department, Gil told them that operations using the conservative approach, which is less invasive, “take too much time.” He thus ordered the surgeons to follow his method.

According to one staffer, “Ziv would say that a nose-and-sinus operation starts with removal of the middle concha. That’s a quote from him. Imagine that you have to clean a room that has a curtain hanging in the middle. You can go back and forth around the curtain, or simply remove it in one fell swoop, and then everything goes faster. At the beginning there were those who told him that this was not the way to do it, that people would suffer from the syndrome, but in the end everyone toed the line.”

'To apply oncological principles to people who have a runny nose or sinusitis? That’s like your coming to me with an ingrown toenail and my amputating the toe.'

Gil did not develop this method out of nowhere. Before coming to Rambam he was known as a daring and talented practitioner in the field of oncological surgery, which is often characterized by aggressive intervention.

“There’s no fooling around with cancer, when there’s a growth you go in deep and remove the whole thing,” a source in the department explains. “But to apply oncological principles to people who have a runny nose or sinusitis? That’s like your coming to me with an ingrown toenail and my amputating the toe. I solved the problem, no?”

Thus, by excisions and more excisions – the problem was “solved” in Rambam. Which is how Majdi’s life became a nightmare.

Majdi

Majdi, a 59-year-old driver for charter bus companies from Upper Galilee, needed a FESS operation to deal with chronic sinusitis and a bothersome runny nose. He was operated on by Gil two years ago. Hospital records show that the procedure took 32 minutes.

“The moment I left, I felt there had been a screw-up,” Majdi relates. “Something seemed to be suffocating me, and suddenly I started throwing up blood nonstop. The whole bed was blood. But they explained to me that this was natural.”

He was discharged but the bleeding didn’t stop. “The inflammation and the runny nose were the same as before, maybe even worse. Everything leaks uncontrollably. When I bend over it feels like everything is coming out of me. Since the operation I’ve lost my sense of smell. My sleep was also affected. And the most terrible thing is that there is a strong odor coming from my nose. My wife avoids me, she doesn’t sleep in the same room as I do anymore. I can’t go to family events, because everyone backs away. My 3-year-old grandson said, ‘Grandpa, you’re disgusting.’ I have become a lonely person.”

Majdi went back to Rambam a number of times, but kept getting the same answer: “We fixed it, we cleaned it, it’s impossible.” He consulted with Ben Zion Medical Center. Their verdict: “This patient had a FESS operation and the complete removal of the conchae. The tests indicate serious inflammation, with large open cavities.”

According to Majdi, the doctor who examined him at Bnei Zion called in several others during the examination. “I could see that the doctor couldn’t believe it. He called another doctor and another doctor – ‘Come and see what they did to him.’ At the end of the examination, he said that my nose was an empty cavity, with no filters, that the damage was irreversible and that he couldn’t help me.”

Majdi is currently collecting material to determine whether his case amounts to one of medical malpractice. His lawyer, Ehab Asaad, already has no doubts. “He was left with empty nose syndrome and had to undergo private, experimental surgery in Assuta [Medical Center] to resolve part of the damage. We will check with experts whether there was a deviation here from the reasonable criteria, but based on my experience, the malpractice here is clear-cut.”

Alu Diab, 37, from Haifa, is another victim of the in-and-out method. He was referred to Rambam for surgery in 2015, in the wake of sinusitis and chronic migraines.

Alu Diab.
Alu Diab.Credit: Rami Shllush

“I was supposed to go home on the day after the operation, but there was a lot of bleeding,” Diab recalls. “I was only discharged after three days. On the first night home my wife woke me up crying that the whole bed was covered in blood. I went to ER first thing in the morning with a rag on my face, dripping blood into a pail. I filled half a pail before they could stop the bleeding.”

The long-term consequences turned out to be extremely grave: “Since then I have had a stuffed nose all the time and I’ve lost the sense of smell. I can’t distinguish between different tastes, either, only between bitter and sweet.” Diab is a pastry chef by profession, so for him this situation is particularly galling. A month ago, with the coronavirus crisis at its height, he was fired.

“It happened in part because of the crisis,” he says, “but also because my ability to work properly was affected. And all because of the operation.”

For its part, the Clalit HMO detected early on that something was amiss in Gil’s department at Rambam, and in-depth examination of a sample of 35 cases confirmed it. Haaretz wanted to speak with those who administered the tests, but Clalit denied the requests, behaving behaved as though they had something to hide. It’s worth pausing over this. The Haifa and Western Galilee district medical director, Dr. Lilach Tzoler, rebuffed persistent requests. The previous district director (an administrative position), Eli Cohen, said it was a sensitive subject and declined to elaborate. The current director of the district, Ronen Nudleman, initially displayed willingness to answer questions, but quickly stopped responding to phone calls.

The district ombudswoman, Orit Gamliel, said she would address the issue. She agreed that transparency was essential in this case, in order to allow the HMO’s insured clients to make an educated choice. But the weeks passed and no response arrived. Similarly, Dr. Yitzhak Antebi, who is today supervisor of referrals for ear-nose-and-throat surgery for Clalit, did not respond to a request for information.

With no other option, Haaretz approached Clalit CEO Prof. Ehud Davidson. Maybe he would acknowledge the public importance of the issue and urge his senior personnel to speak openly about what had happened. But Davidson did not respond to phone calls.

Finally, the HMO issued a general response that does not refer to any of the questions it was asked. So evasive and irrelevant was the response that even Clalit’s spokeswoman, Michal Kizelstein, said she would understand if the response were not included in the article.

For its part, Rambam issued the following response:

“At the end of 2012, a revolution on a national scale took place in the realm of otorhinolaryngology – instead of a wait of weeks for the clinic and of months for surgery, the waiting period for the clinic was shortened to a few days and for surgery to a few weeks. The department offers a choice of surgeon, provides the cell-phone numbers of the directors to everyone who requests them, provides an accompanying nurse and more. In the wake of this activity, the department was also commended in the last report of the state comptroller. The otorhinolaryngology department is the only one that publishes information about its annual activities and surgical complications transparently on the hospital’s website.

“In addition, for many years the senior surgeons in the field of sinusitis, Demitri Ostrovsky and Ziv Gil, have not performed surgery outside Rambam – not in private hospitals and not abroad. All their energies are devoted to public medicine. The result is activity at the highest rate in the country regarding all types of surgery, including hundreds of complicated operations for head and neck cancer, which are referred to us from every part of the country. More than 25,000 patients a year visit the department. The major allegation in the article is that more sinus operations are performed at Rambam than at other hospitals – a fact related to the capacity of the clinic at Rambam. We are proud of the number of procedures, which reflects our hard work and the increased availability of public medicine. In general, one has to compare the number of operations to the number of patients who undergo consultations at the clinics of all of the hospitals.

“Regrettably, the allegations raised in the article are an attempt to malign an exceptional initiative, the only one of its kind, which was created at Rambam, with the aim of bolstering public medicine. It is easy to identify among the allegations individuals with vested interests whose scope of activity was infringed upon as a result of the public activity at Rambam. The allegations in the article include lies, half-truths, gossip and manipulations that are tantamount to libel.

“We reject outright an allegation in the article that draws a connection between the number of operations performed at Rambam and the lack of their necessity. This is a false allegation that is libelous. Every operation performed at Rambam meets a basic condition: HMO doctors approve the operation in advance, after examining the recommendations and the imaging. In addition, FESS operations are not performed in Rambam without imaging, and the consideration as to whether to perform a complex or simple operation is purely medical. Overall, there is much support in the literature for this surgical method, and the differences of opinion cited here are differences in practice that are accepted among physicians throughout the world.

“As to the cost of the procedure, public hospitals receive only part of the official fee determined by the Ministry of Health, because of structural discounts. Not only that, but the more operations performed by a hospital, the larger the discount.

“Rambam will not comment on questions involving privacy concerning its physicians’ salaries, but the figures cited are distorted and inflated. We shall note only one datum: A senior surgeon can perform a sinus operation on a private basis and receive many times more than he earns in a public hospital. Every thinking person will make their own calculation as to what the salary of the Rambam doctors who were excoriated in this article would be if they were to perform just one private operation a day in their spare time.”

Comments