Medicine / Doctor, Where Did You Go to School?

Why should students who want to be doctors have to pursue their studies in far-flung countries?

Nowadays, the physician in your local hospital is likely to be a graduate of one of Israel's few university medical schools, or of a similar institution abroad. But in the future, this may change. In coming weeks there will be a meeting of the Budget and Planning Committee of the Council for Higher Education in Israel (CHE) to discuss a proposal by Prof. Dov Lichtenberg, dean of the faculty of Medicine at Tel Aviv University. Lichtenberg has suggested that the faculty open an additional framework for medical training, which will require payment of higher tuition fees.

In 2003, Israel issued 282 new medical licenses to physicians trained in the country. According to an October 2002 report by the Pazi Committee examining future medical needs, the number of physicians per 1,000 residents is likely to decrease in coming years because of a growing population and a drop in the number of physicians. The report's authors recommended increasing the number of physicians trained locally from 300 per year to 600 or even 700.

The problem is that CHE budgets cover no more than 350 new medical students each year. Students who do not get accepted into local programs travel overseas, mainly to Eastern Europe. In 2003, for example, 340 new Israeli doctors who studied in Eastern Europe were granted professional licenses. If Lichtenberg's proposal is adopted, the country will benefit from more doctors who are trained locally, and medical students will not be forced to roam to Eastern Europe to be educated.

About 1,000 students compete each year for 350 places in local medical faculties. There are 100 students at each of the two major medical schools, in Tel Aviv and Jerusalem. Ben-Gurion University of the Negev trains another 75, and a similar number study in the Technion - Israel Institute of Technology in Haifa.

"During one day of screening exams, we invited 95 potential students to be interviewed," Lichtenberg reports. "The interviewee with the lowest score had a suitability test grade of 706, which is the equivalent of a 720 grade on the psychometric exam. His matriculation exam average score was 10.9. In the best scenario, we will accept 30 of the 95 candidates. If I had to get into medical school these days, I would not succeed."

The limited number of students is directly related to the budget allocated to medical schools by CHE. A local medical student pays an annual tuition of about $2,500, which is similar to he fee paid by a law student, an art student and others. However, the cost of training a medical student is much higher than that of other students. After three years of para-clinical studies, the student is engaged in clinical training for another three years. According to Lichtenberg, the cost of medical education is now estimated to be about $14,000 per student. The difference between tuition fees and this cost comes, in effect, in the form of national subsidies paid by CHE. The decision to accept only 350 new medical students each year is based on CHE's limited budget.

What do the rest of the students who want to study medicine do? Many travel to Hungary. "At Semmelweis University in Hungary, for example, there were periods in which the number of Israeli students exceeded the number studying in Tel Aviv," Lichtenberg says. The estimated $10,000 annual tuition fee in Hungary is based on cost, and is not subsidized. When one includes the $10,000 that it costs to live in Hungary per year, an Israeli medical student, who cannot work during the period of his studies, must spend about $25,000 to study there.

"Let's say you have a rich father who can afford to support you in Hungary for six years at a cost of $25,000 per year. I can't stop you from doing that," Lichtenberg says. "But why can't I make you a similar offer - perhaps, even a better one, in Israel?"

As far as the need for doctors is concerned, the Pazi Committee notes that the rate of doctors relative to population is rising in many nations of the world. For example, in 1990 there were 2.4 doctors per 1,000 residents in Finland, and in 1998 the rate rose to 3 per 1,000. In Austria, there were 2.2 doctors per 1,000 residents in 1990, and 3 per 1,000 in 1998.

And what about Israel? According to the committee's statistics, Israel had 3.6 doctors per 1,000 residents in the year 2,000. However, if one takes into account the number of new physicians who are entering the system, the number who are leaving, and population growth, there will be an estimated 3 physicians per 1,000 residents in the year 2,014. This rate will drop to 2.7 physicians per 1,000 residents four years later. This raises a question as to where we might find new physicians.

The shortage is now filled by doctors who study abroad, but Lichtenberg believes that the situation may change if tuition fees in Hungary and other countries increase in response to their joining the European Union. In addition, he wonders, "Why do we need to import? Why not charge Israeli students who want to study medicine a real tuition fee, and train them here?"

Lichtenberg notes that directors of Israeli hospital units prefer physicians who are trained in the country, because they believe that the training is superior, and local training is more suited to the needs of the Israeli medical system.

Prof. Gabi Barabash, director of Ichilov Hospital and past director of the Israel Health Ministry, agrees, but emphasizes that he is not entirely certain that there is a significant difference between the level of training in local faculties and that in foreign medical schools. "It's more of a matter of image," he says. What about Lichtenberg's proposal? Barabash does not oppose the proposal, but is quick to add, "As long as some of the increased tuition goes to the hospitals - not only to the universities."

The higher education system must act now to make a difference later because medical training spans more than a decade. That is why Lichtenberg presented his proposal a year ago to open a new course of medical training based on an American model.

Tel Aviv University educates American students with a bachelor's degree in the context of its "New York Program." These students undergo an abbreviated four-year course of study, including a year-and-a-half of para-clinical training and two-and-a-half years of clinical training. According to Lichtenberg, they pay an annual tuition of $22,000 - in comparison with the $59,000 that they would pay at Columbia University. The program has trained more than 1,100 graduates in its 25 years of existence.

"CHE must budget medical education according to market demands. This indicates a need for hundreds more physicians. However, if the nation is unable to fund this, they should let us train physicians in an alternative course," says Lichtenberg. According to his proposal, Israeli students who have completed a bachelor's degree in dentistry, exact sciences, pharmacology, psychology, and similar subjects with a grade average of 85 or more, who pass the medical entry exam, and who complete certain basic courses, will be eligible to enter the new course of medical study. They will pay a real tuition of about $14,000 per year and complete their medical education within four years.

"This is not an unprecedented proposal," Lichtenberg notes. "There are 200 medical students at Irbid University in Jordan. One hundred of them pay 1,000 dinars per year and the other hundred pays 10,000 dinars per year. Why? Because the country decided that it would subsidize only 100. Any remaining students who wish to study medicine have to pay the full tuition out of their own pocket. That is how Jordan prevents students from traveling abroad to get an education."