Health Care Under the Knife

Releasing patients from the hospital before their treatment is complete, a rise in the number of infections among premature babies, delivering babies without an anesthesiologist present, postponing operations, and a drop in the level of treatment - these are some of the worrisome implications of the drastic and ongoing shortage of doctors and nurses in Israel's hospitals.

The findings were reported in the annual State Comptroller's Report for 2009, released yesterday, which examined the shortage and how the Health Ministry is dealing with it. State Comptroller Micha Lindenstrauss predicted that the situation will only become worse over the next few years.

Since 2000, there has been a gradual decrease in the number of doctors under 65 years old, and by the year 2020 there is expected to be a 26 percent decline in the total number of doctors nationwide.

The shortage is expected to worsen over the next few years particularly in the specializations of anesthesia, pediatric intensive care, neonatal special care and geriatrics. The report noted that the ministry stated at the end of 2008 that there was a serious manpower shortage since there were too few specialists and too few interns going into these fields.

But the report added that "there is concern that problems will develop" in the fields of pathology, general surgery, internal medicine, pediatrics and radiology as well.

The report noted that the ministry does not have figures showing the actual number of people currently engaged in these fields nor does it have data about the scope of the shortage and its seriousness. Meanwhile the degree of safety in anesthesia and its use during operations is being affected as is the ability of doctors to respond quickly to medical emergencies. The likelihood of doctors making mistakes is increasing.

The comptroller stated that, according to data from 2007, there were 704 specialist-anesthesiologists and intern anesthesiologists in the country - about 30 percent below national standards. According to the Israel Association of Anesthesiologists, the shortage of specialists leads to operations being delayed and to a long waiting list for both elective and urgent surgeries.

There is also a huge and ongoing shortage of doctors treating newborn babies. The comptroller noted that it had stated back in 2003 that the shortage of personnel in the neonatal intensive care units could lead to life-threatening infections. This could explain the high incidence of infection - some 30 percent - among babies in Israel whose birth weight was less than 1.5 kilograms.

Lindenstrauss noted that research published in the United States and Britain showed that the ratio of nurses and doctors to the number of premature babies was connected with the incidence of infections and death in neonatal intensive care units. The report said that a survey carried out in Israel in 2008 had shown that the rate of infection among neonates with a birth weight below 1.5 kilograms was 50 percent higher than the rate among similar cases in the Western world.

In addition, there is an acute shortage of specialists in geriatrics and in pediatric intensive care, the report said. In pathology, the shortage means that patients have a long wait before getting results of pathological examinations (used to locate cancerous growths) and this could lead to a delay in performing operations that require a pathologist present.

There is already a manpower shortage in general surgery, internal medicine, pediatrics and radiology, the report stated.

The Health Ministry and the Council for Higher Education are aware of the shortage of doctors, the report noted, and have been cooperating with the Finance Ministry and have taken considerable steps to expand training programs to fill future needs.

But despite the recommendations of a number of committees, the number of students who complete medical studies in Israel has not grown significantly.

The comptroller also warned that, despite the ongoing shortage and the warnings, the Health Ministry does not keep an updated and comprehensive database on registered health personnel in Israel. Unlike most Western nations, in Israel there is no obligation for doctors to register themselves at fixed intervals and to update relevant particulars. Hence there is no possibility of keeping track of doctors' positions and changes that have taken place in his situation once he receives his medical license.

The comptroller noted that it normally takes 11 years for a doctor to qualify (seven years of basic studies and another four of specialization) and that it was therefore important that the ministry take steps to train doctors according to present and future needs of the health system immediately.

"The Health Ministry, as regulator and ministry, must decide on policy with regard to planning medical and nursing human resources and must take steps to train doctors and nurses and deal with the subject of professional fields where there is a shortage, thoroughly and systematically - and also by offering suitable incentives," the report stated.

The Health Ministry sent its response to the Prime Minister's Office, stating that it had already undertaken a long list of steps aimed at decreasing the shortage of doctors, including a decision to open a fifth medical school, in Safed, and to carry out a census (together with the Central Bureau of Statistics) to gather and study updated data about those medical practitioners in Israel.

Mind the gaps

The periphery of the country is characterized not merely by geographic distance from the center but also by a population that has a lower socio-economic status and by ethnic and cultural groups that differ from the population in the center, Lindenstrauss stated.

According to the national health insurance law, the report says, health services must be based on principles of justice, equality and mutual assistance so that all citizens of the country receive equal health services. However a number of studies have shown that there are gaps between the center and the north and south in the availability of health services and their accessibility.

According to the Central Bureau of Statistics, the comptroller says, there is a significantly higher infant mortality rate in the north and south of the country than in Tel Aviv and the center. He says that 23 percent of infant deaths occurred in the south of the country.

Surveys have revealed that there are more specialists and nurses per capita in the center than in the north and south, and the number of hospital beds is also higher in the center of the country.

In most Western countries, the comptroller says, when health services are planned, special attention is given to the needs of the population in outlying areas so as to close gaps as much as possible. But studies done in Israel show that there is "no steady policy to close gaps in infrastructure - beds, equipment and human resources - between the center and the periphery and there is a lack of suitable funding of resources for encouraging the development of health services in the periphery, which creates and perpetuates the gaps in infrastructure, including human resources in medical professions."

The comptroller noted that it is difficult to persuade high-level interns to work in the periphery since they prefer hospitals in the center where there is more of a chance to develop professionally.

In 2007, the ministry, together with the Israel Medical Association and the Council for Higher Education, began to examine ways to attract personnel to outlying areas, the comptroller said.

However, this has become a more urgent need, in view of the gaps and the continued shortage of doctors and nurses in the periphery that affect availability of medical services and the health of the population, and they must act immediately, together with the treasury, to set up a system of remuneration that will attract personnel to these places.

Until the report was completed (in November 2008) this had not been done, the comptroller said, and the means of attracting doctors to the periphery was also not discussed in mediation over the doctors' wages. Lindenstrauss called on the ministry to establish a policy with regard to medical and nursing personnel and all other health professionals, and to take steps to train doctors and nurses in the periphery.

The ministry said in its response that it was working on this and making efforts, together with the finance ministry and the Civil Service commissioner, to offer attractive possibilities for interns to specialize in the periphery. One such example was the 2007 decision to increase the number of job slots for interns in the periphery, including at Yoseftal Medical Center in Eilat.