Israeli Physicians Protest Plan to Let Nurse Practitioners Do Doctor's Tasks

More than 400 physicians within the Maccabi healthcare organization re against bringing nurse practitioners into community clinics

The entrance to a branch of Maccabi, one of Israel's four health maintenance organizations.
Eyal Toueg

More than 400 physicians in the Maccabi health maintenance organization signed a petition last weekend against plans to bring nurse practitioners into the country’s community clinics.

The Health Ministry has for years been advancing plans to integrate highly trained nurses into clinical settings and grant them expanded authority. The petition was a reaction to a recent circular from the ministry defining the authorities of nurse practitioners, in preparation for their service in community health clinics.

In the petition, the Maccabi doctors warned of the “dangerous measure” in which “a large part of the authorities of primary-care physicians – family doctors, pediatricians and gynecologists – [would be transferred to] to nurse practitioners, who after very brief training will be able to diagnose in an amateurish manner acute and chronic illness, to write prescriptions for a range of conditions, to refer [patients] for tests and specialists, to draw up treatment plans for patients, to write medical directives and more.”

The petition went on to warn of “the great danger! both to the health of the insured and the professional image of Maccabi” that will result from the implementation of the Health Ministry’s recommendations, which “is likely to cause widespread chaos in the existing system and to bring to an unprecedented nadir to the quality of primary medicine. We staunchly and uncompromisingly oppose any measure by Maccabi that is based on the latest Health Ministry circulars. We will not lend a hand to the implementation of the recommendations, and we intend to take any step necessary to foil any move based on them.” The doctors argue that any expansion of nurses’ authority must be carried out in a responsible manner and coordinated with physicians in the community.

In a recent discussion held by the Israel Medical Association on the topic, physicians in Israel’s other HMOs supported the views of their colleagues in Maccabi.

“We were against this move from the very beginning,” says the chairman of the Israel Medical Association, Dr. Leonid Eidelman. “We think it will distance patients from doctors and will not yield a benefit. We support teamwork, in which the physician does the medical work and the nurse the nursing work.... Instead of seeing a doctor, the patient will see a nurse. Nurses aren’t trained for medical work, and it will harm the patients,” Eidelman says. “Even in the United States, where the idea of nurse practitioners began, today there’s an understanding that it doesn’t contribute to patients and there, too, there is opposition from the American Medical Association,” Eidelman says.

Plans for training and giving professional recognition to nurse practitioners have been under discussion for years. In 2015 the Health Ministry and the Civil Service Commission recognized the profession as a medical profession. The United States has had nurse practitioners since the 1960s, and the idea has been adopted in a number of European countries.

The aging of Israel’s population and the rise in the number of people living with chronic illness have been cited to justify the expansion of the authorities of some nurses. Health Ministry officials came to the conclusion, partly on account of the recommendations of a committee headed by Prof. Shlomo Mor-Yosef, that properly trained nurse practitioners could assume some of the burden of care now provided by physicians while better serving patients.

Registered nurses with at least a master’s degree in nursing are eligible to enroll in a nurse practitioner program, which includes academic studies and clinical training.

According to the recent Health Ministry circular, nurse practitioners are qualified to examine patients and assess their condition; refer patients for diagnostic tests and monitoring; initiate and end treatment with medication; identify and treat complications; identify emergency situations and render first aid; refer patients to specialists, and more.

To name a few examples, nurse practitioners are authorized to diagnose respiratory infections and to prescribe antibiotics and steroids; to treat diseases of the digestive system; various skin conditions and wounds; and to treat muscle and skeletal pain. In the area of emergency medicine, nurse practitioners can perform resuscitation and treat pulmonary edema, cardiac arrhythmia, convulsions and poisoning. (In all these situations a physician must be present, if one is available.) Nurse practitioners can also give one-time treatments for anxiety and talk therapy for sleep disorders. In addition, they can make decisions in the treatment of patients with diabetes, high blood pressure, cardiac insufficiency and other chronic conditions, in coordination with the patients’ physicians.

“I don’t think the doctors should be opposed. I also don’t think that one sector can prevent the professionalization of a different sector,” Israel Nurses Association Chairwoman Ilana Cohen said in response. “A committee was formed and made a decision, that must be respected. Even today, nurses bear more than a little medical responsibility for patients.”