Many Israelis are attending medical schools abroad of very low quality, with little clinical experience with patients, threatening the quality of Israeli health care when they return, a senior Health Ministry official says.
“If we don’t take meaningful steps, then even if only 25% to 30% pass their licensing exams and slip through the system, this could influence the quality of Israeli medicine,” says Prof. Shaul Yatziv, director of the Health Ministry’s department for licensing medical professionals.
For several years rumors have abounded about the low quality of some medical schools in eastern Europe and elsewhere, where thousands of Israelis who didn’t qualify for Israeli medical school are studying. In 2016, the Health Ministry even recommended that Israelis not study medical professions at Armenian universities and said it doesn’t recognize medical studies in Armenia for licensing in Israel.
Last month, a low point was reached when the police arrested 40 doctors, residents, and pharmacists who presented medical and pharmacy diplomas from Armenian universities but who actually only studied there for a short time. Some of the people detained had already passed Israeli licensing exams and were working at both public and private medical institutions.
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Yatziv, who began his term about a year ago and is the gatekeeper for Israel’s medical professions, has shed light on the affair in an interview with TheMarker.
“In the last year or two, reports have reached us, first anonymously, that there are credibility issues regarding studies in Armenia. There are several medical schools there, and there have been rumors about forgeries,” Yatziv says.
His predecessors already received reports on the matter, and at a certain stage his office asked the police to investigate. Then came the arrests.
“You have to understand, it’s not that there’s a sound medical school there and students forged diplomas. It seems that there was full cooperation between medical schools and students. For example, there were instances when students attended the medical schools for a very short period.”
Despite this, some of them managed to pass the licensing exams in Israel.
How did this happen?
“The licensing exam mainly tests knowledge; it isn’t a clinical exam. It’s possible to learn things theoretically without any clinical experience with patients. It’s also possible to pass the exam by cheating with all sorts of methods for copying, though there’s no solid proof yet that the people who were caught actually copied.”
Yatziv tells how he went to Armenia as part of the investigation.
“There were four schools, and we investigated the curricula, syllabi and the amount of clinical interface; that is, interaction with patients .... We were negatively impressed by the level of studies, by the fact that students hardly saw patients. In Israel, students at medical schools spend three years in clinical departments.
“In Armenia, we saw students who had studied for a year or two at medical schools in Jordan or Italy, which are of a high level, and then, for financial reasons but also because of the relatively high demands or failed courses, went to study in Armenia, where schools let them skip several semesters ahead.
“They come to Armenia to receive a diploma, because it’s a place where it’s easy to work the system. Diplomas don’t represent satisfactory knowledge and clinical experience, but the graduates of these institutions return to Israel and want to be doctors here.”
And sometimes they succeed.
“Some of them succeed, which is truly troubling, so we decided to address all levels at which they can obtain a license. First, the issue of medical schools. There’s a medical school in Kishinev in Moldova where there are about 1,300 Israeli medical students and about 200 dentists.
“There’s very little clinical interface because it’s simply impossible to provide satisfactory clinical experience for 2,000-plus students, Israelis and foreigners, in one hospital. For the sake of comparison, in Israel a comparable number of students are trained in 20 different hospitals.”
The story becomes more frightening by the moment.
“So we’re putting out a severe warning about Moldova as well, under which we’re not committing to recognize these studies. We want to address the problem at its root, from medical school, so that someone who studies at a good place has a chance to pass the exams and become a good doctor.”
Many people who studied at problematic places are now doctors in Israel. You haven’t received feedback about this from the field?
“Of course we have. Directors of departments contact me all the time. They receive interns, come to me and say that ‘these people don’t know anything, they haven’t seen a patient in their lives, they have no idea about medicine.’
“By the way, the chance that people like this will be accepted to residencies at top medical centers is less than zero. But there are struggling fields that accept some of them because they have no alternative. The moment they reach the thousands, they completely infiltrate.”
The Israeli licensing process for doctors who graduated from institutions abroad is like a chain with many links. One of the most important is the preparation course for the licensing exam. Students who pass the preparation exam receive a bonus that helps them pass the licensing exam; sometimes that bonus is all the difference.
Yatziv says these courses, about which the state comptroller has produced a report, are also riddled with problems. “These courses were launched to help a small number of doctors who arrived in the country as new immigrants,” he says.
This bonus can actually determine who’ll be a doctor in Israel.
“Right. People would go to this course not to learn and improve their knowledge, but to receive a bonus that would help them pass the licensing exams. The Health Ministry wasn’t responsible for these courses. They were run by independent bodies, each of which conducted exams at different levels of difficulty and taught according to a different syllabus.”
Is something expected to change?
“Yes. We’ve decided to place all the preparatory courses under the direct auspices of the deans of Israel’s medical schools. They’ll put together a uniform exam for everyone, with the same syllabus. It will be written not by directors of courses, but by the deans .... The course before the next exam will already taught based on this structure.”
Another link is the licensing exam itself, the final bar before receiving a license to practice medicine in Israel. “The licensing exam will also go through a fundamental change,” Yatziv says. The change will focus on the reliability of the exams.
“Some 1,400 people took the last exam and received the same questions in the same order. The exam will change; there will be a personal computer for each person,” he says.
“The order of the questions will be different for each one, and in the examination hall there will be electronic screening so that no one will be able to receive information from the outside. It will be almost impossible to copy.”
Testing clinical experience
Another change, no less dramatic, is the addition of a clinical-practical section to the exam. “We’ve concluded that we have to add a section like this due to our visits to eastern Europe, where we saw that students have no clinical experience,” Yatziv says.
“This is a message to students and to medical schools, so they’ll know that if they don’t teach clinical medicine, the students will have no chance to pass the test. We’re also going to publish the results of the exams from all the foreign medical schools.”
What about the doctors who have already managed to enter the system?
“We haven’t checked everyone who studied in Armenia, but there may be a need to do this. This is a very complicated issue and I don’t know how far back we’ll be able to go in the investigation. We’ll have to think about it with the ministry’s legal adviser.
Let’s say a doctor who graduated from an institution in Armenia is treating someone. Does the patient need to worry?
“If a doctor works at a department in a hospital, for example, he’s subject to review and has the possibility to consult and learn through working. The big danger is in places where doctors work almost alone ... where oversight is minimal.”
How worried are you?
“Very. I don’t sleep at night because of this. I also ask myself how the level of Israeli medicine will look in 10 years. Will we still be considered a country where the quality of medical care is high? I’m worried that it will be hard to say this if we don’t take meaningful steps to prevent the entrance of undeserving doctors into the system. This is a national mission.”