Ray Bitton, 31, has known that she wanted to be a doctor since she was a young girl. But she also knew that her chances of realizing that dream were slim.
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In Israel, as in most countries, admission into medical school is highly competitive. Just getting to the interview stage requires near-perfect scores on the bagrut matriculation exams and at least 750 points (out of a maximum of 800 points) on the psychometric test (the Israeli equivalent to the SAT).
Bitton knew it was a long shot, but she did her best. She took the most advanced courses possible in her Jerusalem high school, but it did not even offer the college-prep levels of English and math that she would need to pass the advanced bagrut exams in those subjects. “When I begged the English teacher to let me study advanced English, she said that because I was the only one who was capable of passing those exams or who wanted to, she would requisition the prep materials, that I would pay for,” Bitton says. She studied independently and she was indeed the only student in her school to take the advanced English exam. She was unable to obtain a similar arrangement for advanced math.
After high school, she paid out of pocket for advanced courses and tests she needed in biology, literature and Oral Torah. Each course cost her hundreds of shekels and in some subjects she needed private tutoring, at a cost of 80 shekels ($20) an hour. Yet even so her matriculation scores fell short of medical school requirements.
She enrolled at Ben-Gurion University of the Negev, in a college prep, or mekhina program, costing 13,000 shekels, after which she was able to take the advanced bagrut exams in physics and in math. Then she was drafted into the army.
After completing her compulsory military service, Bitton tackled her next challenge, the psychometric exam. She put all of her separation allowance toward prep courses, but still came up short. She took four prep courses and ended up taking the exam five times in all, yet even her highest score, 651, was too low for med school. “I had a lot of difficulty making up for the gaps from high school in math and English,” she says.
A year’s tuition just for test prep courses
Most prospective medical students in Israel apply to multiple schools to increase their odds of getting in somewhere. Application fees alone to apply at all four Israeli med schools — at the Hebrew University of Jerusalem, Tel Aviv University, Ben-Gurion University of the Negev and the Technion Israel Institute of Technology come to 2,000 shekels.
Many aspiring physicians need to improve their matriculation results and/or their psychometric test scores and, as Bitton did, they often spend serious money on test preparation courses and tutoring. In addition to the bagrut and psychometric tests, some Israeli med schools require applicants to undergo a personal assessment (there are two types, Mor and Mirkam) costing 1,620 shekels. As one might expect, there are prep courses for these as well, costing thousands of shekel. One company, for example, offers a three-day program for 2,490 shekels.
Because med school admissions are so competitive, many applicants are willing to spend a great deal in the hope of increasing their odds, even while knowing that they may be rejected in the end.
You have to be rich to be a doctor
The story of “Yair” (not his real name) is very different from that of Bitton. Born to an affluent Tel Aviv family, Yair was in a math and physics track in high school and he performed well on his matriculation exams. After completing his military service he took a psychometric prep course that cost 8,000 shekels, living on his parents’ dime while he studied. He scored a high 750 on the test, and applied to three med schools. He studied independently for the assessment, but spent 1,000 shekels for a prep course in order to retake his matriculation test in chemistry. Yet for all that, despite his good grades he was not accepted to med school and went on to a different field.
Yair’s family spent between 13,000 shekels and 14,000 shekels trying to get him into med school, around the cost of university tuition for one year, says his mother: “I don’t know how a child from a family without money can do it. It’s true that medical school is subsidized by the state, but getting there costs a fortune. We paid it happily but I kept thinking about people who can’t afford it. What do they do?”
In fact, tuition for medical school in Israel costs between 10,000 shekels and 13,800 shekels ($2,500 to $3,300) a year, a bargain by U.S. standards.
The Mirkam assessment consists of eight short personal interviews in a row, mean to evaluate the candidate’s ethics, empathy and interpersonal skills. The Mor assessment includes a written test, personal interviews and a group simulation exercise. In the past, the Hebrew University required applicants to take the Mirkam assessment, while Tel Aviv University and the Technion used Mor. That meant anyone applying to Hebrew University and either or both of the other two schools had to do both assessments. Now such applicants need take only one of the assessments.
Are doctors really rich and elitist?
One address for the not-well-to-do is the ISEF Foundation, which grants scholarships to the needy for higher education, in order to narrow social gaps. It is presently financing medical school for 27 students, who are at various stages of study. ISEF isn’t just for medical school, but the barriers to students from poor backgrounds are higher there — the long years of study, for instance.
The sense that medical school is only for those who can afford it has affected the medical profession in Israel and the “standard” image of doctors, agrees ISEF deputy director Galit Caspi Cohen.
The foundation feels it important that doctors be people who grew up in the community and who know the community: Israel’s social diversity should be reflected in its physicians, too.
Former Health Ministry Director General Prof. Roni Gamzu, who received aid from ISEF himself as a medical student, agrees that Israel needs doctors who come from all socioeconomic groups. “Universities should provide equal opportunities, without economic barriers,” he says. Gamzu has also spoken out against nepotism in medicine, for instance when the children of senior physicians get preferential treatment in internship placements. Now he says the expensive test-prep system is an obstacle to equality and is unacceptable.
Bitton puts it less delicately. “Studying medicine is a status symbol. The default for people who come from good homes and have money and high marks is to study medicine, even if that isn’t their dream,” she says. . “That’s one reason the profession is so elitist and you find doctors who have no empathy for patients, or who have forgotten why they’re really there. Ultimately society pays for it, because the community of doctors tends to be homogenous, not diversified. It should be in all our interests to change this, to bring new people into the profession, because there’s no reason on earth for medicine to be the province of the rich.”
‘It’s a free country’
After taking the psychometric test five times without scoring well enough to even apply to medical school, Bitton gave up on that route and enrolled in an undergraduate program in emergency medicine. If she could ace her courses, she reasoned, she would have a leg up on getting into med school. She graduated with honors, but her psychometric score was still nine points under the minimum requirement for medical school.
At this point most people would have given up. Not Bitton, who decided to study medicine in Hungary instead, at an annual cost of $14,500. She was awarded a special $10,000 scholarship from ISEF and scraped together the rest of the money. “The whole family helped out, my sisters and my parents,” Bitton says. “When I left, I didn’t have enough money to finish school. I just decided to start and see what would happen.”
She was admitted as a second-year student. In her fourth year, Bar-Ilan University opened a medical school (in Safed), with an accelerated, three-year program for students with a relevant undergraduate degrees. Bitton was accepted, and is now in her sixth and final year at Bar-Ilan. When she finishes it she will finally be a doctor.
“I’m not bitter, but I feel strongly about bringing about change,” she says to sum up the tortuous journey she took in order to fulfill her childhood dream of becoming a doctor. “Medical studies in Israel are for the rich. I see my fellow students – most come from wealthy homes and could afford this trek.”
Israeli medical schools are well aware of the problem and have been considering ways to ease the financial burden for applicants, but it’s a tall order, they say.
“The number of candidates just keeps growing from year to year,” says the Dean of Hebrew University’s Faculty of Medicine, Prof. David Lichtstein. “If last year we had 1,429 candidates vying for 110 seats, this year there were 1,695. Competition is fierce and we in the medical school have to make choices. My goal is that the competition be fair and equal. We don’t choose based on economic status, but on academic achievements — the matriculation, the psychometric and the interviews.”
Lichtstein admits that candidates have to spend thousands of shekels. “I can’t change that, or stop any candidate from trying to improve his position, whether through a prep course or by improving his matriculation grades,” he says. “It’s a free country. But the moment a student has been accepted to the study program and is in economic difficulty, we bend over backward to help him. We have various scholarships for that purpose. If I look at the students studying now, there are a lot from different backgrounds, not just the richest 10 percent.”
“The population of first-year medical students is varied, includes among others students from the Haredi community, the Ethiopian community, minorities and students from all over the country, from the wealthy areas and the periphery too,” the Hebrew University of Jerusalem said in a statement.
Ben-Gurion University’s medical school does its own screening of applicants and does not charge for the process, but admission is highly competitive and courses costing hundreds of shekels are available to help candidates prepare for the interviews. Dov Chernichovsky, a professor of health economics and policy at the university, says Ben-Gurion University is “less elitist” than other Israel universities. “The interview is the place where corrective discrimination can be exercised,” he explains. “That’s the place to give higher priority to Ethiopian, Arab and Bedouin candidates, for instance, and indeed our student body is highly diverse.”
The Association of University Heads in Israel said, in a statement, that it was aware of the economic difficulty faced by candidates who apply to multiple universities and was working on a two-component solution in two ways. “First, two years ago the association decided that candidates would pay for and take just one assessment, that would be recognized by all the universities. Second, the universities are developing a universal application procedure for medical school,” under which event candidates who apply to multiple med schools would pay only one application fee. The association said that this measure could save applicants hundreds of shekels.