22. Demarcating medical procedures for doctors and qualification to perform extraordinary procedures
There is a reason that nurses are granted special permission to perform only extraordinary procedures, in accordance with the law and regulations, since the scope of their education and training and their work load does not enable them to deal in clinical diagnosis and assessment and medical treatment itself.
It is therefore unclear why it is proposed to decide on the expansion of the nurses’ authority within the framework of a joint committee of the ministries of Health and Finance while for this purpose expressly the “Physicians Regulations (qualifications for performing extraordinary procedures) – 2001 were formulated. These regulations specified the extraordinary procedures which a certified nurse, a certified nurse assisting a doctor, a practical nurse and an assistant are permitted to perform based on the recommendations of professional advisory committees responsible for determining the procedures, conditions, continuing education, special permits, supervision and control procedures.
The regulations themselves state that extraordinary procedures will only be performed according to the regulations. The establishment of a joint committee of the ministries of Health and Finance to deliberate the transfer of medical authority to nurses or to any other professional, including pharmacists and para-medical personnel, will in effect be a committee that circumvents the law, does not include the professional entities that can discuss the parameters described above, and that acts contrary to the existing legal arrangement. It must be stressed that the involvement of the Ministry of Finance in any forum that deals in the complex issue that requires top-quality medical-professional knowledge is entirely incomprehensible.
23. The danger involved in nurses issuing medication prescriptions and determining medication dosages
Specifically pertaining to the issue of issuing medication prescriptions and/or determining medication dosages – these are activities that are not permitted to be performed by nurses – not by the regulations and not according to Ministry of Health circulars. Furthermore, many mistakes of nurses were publicized in the past concerning overdoses and types of medications administered as well as the ability to identify patients sensitive to certain medications.
24. Decentralizing authority
Decentralizing authority to doctors and nurses may endanger medical treatment, from the perspective of consolidating knowledge and obtaining the complete picture, and in terms of division of responsibility and the danger of “falling between the cracks”. Proper treatment will be achieved by consolidating medical information and granting medical treatment authority to the doctor, with the effective collaboration of the nursing team.
With respect to cost saving, doctors feel sufficiently secure in their knowledge and training that spans many years so as not to instruct the performance of superfluous procedures and examinations or to repeatedly refer patients to specialists.
26. Access to medical treatment by a doctor
Compared to other countries, the State of Israel supports access to medical treatment to every citizen, irrespective of socio-economic status, and this is also anchored in the National Health Insurance Law. Consequently, there is no justification to encourage the establishment of a multi-tier medical treatment system that is perhaps necessary in countries in which individuals without financial means or those living in remote areas do not have easy access to medical treatment.
Expanding the authority of para-professional caregivers through an exemption from the Physicians Ordinance by an inter-ministerial committee
27. Lack of institutionalization of para-medical professions
Proper legal institutionalization of “health professions” or professions dealing in complementary medicine is still lacking and to date all attempts to formulate a legal framework for this issue have failed. Medical professionals themselves disagree with each other and with the legislature in defining the professions and concerning required education and training, licensing conditions and transfer procedures. Under these conditions it seems absurd to discuss the transfer of medical authority to a group that is undefined, unsupervised and is not legally institutionalized, certainly not indirectly by means of the Arrangements Law that is unrelated to the essence of the treatment provided by para-professional caregivers, and certainly not by expanding the exemption in the Physicians Ordinance and eliminating the need to receive the approval of the Labor, Welfare and Health Committee or by means of a committee chaired by the Ministry of Finance. It goes without saying that authorizing professionals whose licensing has not been regulated yet to perform medical procedures may be disastrous on the one hand, and interfere with the regulatory process on the other hand.
28. The qualification of para-medical professionals
We are perplexed by the explanations to the draft law that include unequivocal statements concerning the qualification level of para-medical professionals as the basis for granting them medical authority. It is important to remember that newspapers are filled with articles and reports about the large number of charlatans in these fields (which in fact motivated the Ministry of Health and the legislature to attempt to define recognized professions and the supervision and enforcement required in order to protect the public), and about caregivers that caused damage of one kind or another to patients after treating them in a way that did not suit their medical condition. In any event, it is unreasonable to compare the qualification and training of those dealing in health professions or that call themselves para-medical professionals, with the training doctors are required to undergo based on the strict criteria of the Scientific Council.
29. The need to receive the assessment of an accredited doctor before treatment provided by a para-medical caregiver
In a document sent both to the legal counsel of the Ministry of Health and to the Chairperson of the Labor, Welfare and Health Committee, the IMA clarified its position concerning the real danger in permitting para-medical professionals to provide medical treatment and/or to begin treating patients without having received a referral from a doctor or without receiving a status summary of the patient’s medical condition that rules out the existence of organic diseases or of pathological situations that may be the source of the problem from which the patient is suffering.
Unfortunately, there are numerous examples of serious diseases that are manifested in functional disorders or of caregivers that are unable, as indicated above, to identify these diseases because they are not equipped with the medical knowledge, experience and training of doctors. Therefore, any treatment provided by a para-medical professional requires prior evaluation of the patient’s doctor as well as close cooperation with the latter, and the transfer of medical authority from doctors to para-medical professionals is entirely unacceptable.
30. The requirement to include medical specialists in advisory committees on medical
The draft law for the institutionalization of health professions also specified the establishment of advisory committees on various professions. The IMA maintains that at least with respect to the professions in which there is greater risk of affecting the patient’s health (and similarly with respect to the decision to authorize extraordinary procedures by nurses), several medical specialists should be members of the committees that will discuss the qualifications for practicing these professions. We also maintain that the professional framework to be agreed upon in the law should not be expanded without consulting with medical-professional entities. The Ministry of Finance proposal to amend and expand Section 59 of the Physicians Ordinance and to establish a joint committee of the Ministries of Finance and of Health to discuss and decide on the said health professions, certainly does not meet the obligation to ensure the participation of medical-professional entities and borders on lack of responsibility towards the public.
In summary, we would like to reemphasize that the Ministry of Finance proposals concerning expanded authority to nurses, pharmacists and para-medical professionals that are planned to be placed on the government’s agenda pertain to the professional-medical field, that has nothing whatsoever to do with budget considerations and the Arrangements Law, but certainly has ramifications for the health of patients and for the quality of medical care.
It is imperative to strictly ensure that the Arrangements Law will be limited to issues with direct budget ramifications and to prevent damage to fundamental values and legal principles in an indirect and destructive manner.