There is an overall shortage of medical manpower in Israel, expressed in the low ratio of practicing physicians relative to the population. The shortage, though, is not equally pervasive in all medical fields. Some specialties suffer from the lack of human resources more than others, and this causes, among other things, overload, burnout, frustration, and stress among the doctors, which can in turn can impair the staff’s ability to provide proper medical care. These specialties are considered medical fields in crisis, and without an underlying and all-encompassing solution, their future is heavily at risk.
The nature of certain medical fields makes them especially demanding and creates a higher burnout rate. Often the remuneration from these jobs is also comparatively lower, at least in light of the responsibilities these medical providers shoulder. The result is that many doctors avoid these specialties, and practitioners at all levels – department heads, specialists, and interns – even leave their positions. As such, these fields are characterized by a shortage of manpower and an infrastructure that is inadequate for the existing needs, resulting in a crisis that may impair the quality of medical care.
Is there a way to systematically quantify or measure crisis, so as to identify those medical fields most severely at risk? A few years ago, researchers at the Brookdale Institute attempted to answer this question by developing criteria to measure the extent of crisis in a clinical field. The researchers identified five criteria that are likely to indicate the existence of a crisis:1
- A shortage of "good" residents (those whom the department heads consider most suited to the specific medical field).
- Difficulty filling vacant positions.
- Not enough physicians for the quantity of clinical work and, consequently, an increasingly heavy workload.
- A sense of insufficient remuneration and limited opportunities to supplement income within the hospital.
- Impaired quality of working life – overload, lack of job satisfaction, and a sense of burnout.
The definitions of these criteria involve theoretical and methodological drawbacks that should not be taken lightly2 but this research does constitute an important step in identifying methods of coping with a specialty’s crisis. According to these criteria, the following fields find themselves in acute crisis: anesthesia, neonatology, and intensive care (general, respiratory, and pediatrics). These specialties are currently in grave condition. The Society of Anesthesiologists warns, for example, that within a decade, there may be a deficit of about 300 anesthesiologists. This would create a national crisis, impairing surgery in Israel. Similarly, the future of neonatology is in danger due to a severe shortage of residents – a mere total of two interns began their residency in 2010. Apart from these fields, the Israeli Medical Association identifies additional fields whose situations will become acute if they do not experience drastic improvement: hematology, pediatric oncology, family medicine, surgery, internal medicine, physiatry, pediatric psychiatry, pathology, emergency medicine, geriatrics. In addition to these two categories, we have distinguished a number of fields whose crises stem from lack of positions: nephrology, oncology, imaging (Roentgen), medical administration, hematological oncology.
In 2009, the State Comptroller examined the issue and determined that “… it is the obligation of the Ministry of Health, as a ministry and regulator, to determine a policy for everything related to human resources in the medical and nursing professions, to put effort into training doctors and nurses, and to deal thoroughly and systematically – while determining suitable incentive – with the issue of the clinical specialties in crisis, and the problem of manpower in the periphery.” 3
The Comptroller’s report indicated which specialties are in crisis and detailed their severe condition.4These fields (excepting geriatrics) were recognized in the last arbitration agreement as clinical specialties in acute crisis, whose existence is found to be in actual danger:
- Anesthesia – The field of anesthesia is in grave crisis. In 2007, Israel had 704 anesthesiologists – specialists and interns – and anesthesiology departments in Israel had a physician shortage of 30% compared to the required standard. Since 1998, more than 10% of Israel’s anesthesiology specialists have emigrated. According to documents of the Society of Anesthesiologists, surgeries are postponed, and waiting time for surgery is prolonged, due to the insufficiency of physicians. This is true not only of scheduled surgeries, but also emergency and semi emergency operations.
- Pediatric intensive care – Pediatric ICU’s are in a state of crisis because of the deficit in specialists and the reserve of competent personnel. There are 25 pediatric intensive care specialists, while about 45 are required according to standard. From 2001-2007, 15 pediatric ICU physicians left the country or stopped practicing actively, and in 2008, only three doctors completed their residency in Israel. Five doctors are likely to retire in the near future. Work in this field demands long hours and doctors on call are exceptionally active. The documents of the Israel Association for Pediatric Intensive Care show that this situation causes physician burnout, to the extent that interns do not continue on into the field, and the crisis intensifies.
- Neonatology – In the Comptroller’s 2003 inspection, NICUs (newborn intensive care units) were found to have insufficient doctors and nursing staff. In 2008 an additional inspection showed that the shortage of neonatal specialists is still large: there were 96 neonatologists, and only 80% of the clinical positions, as determined in collective agreements signed with the doctors in previous years, were filled. In 2002-2007, 34 neonatologists retired or otherwise left the hospital – five of those emigrated from Israel. During the same period, only 29 neonatologists received their certificate of specialization. In the 2003 inspection, the shortage of staff in Israeli NICUs was said to increase the danger of infection, and could explain the high incidence – 30% – of infection among babies whose birth weight was less than 1,500 grams. Studies published in England and the US provide evidence that the ratio of clinical staff to infants is linked to the incidence of infection and mortality in neonates. In a 2008 Israeli study, the infection rate in newborns whose birth weight was less than 1,500 grams was found to be 50% higher than the infection rate in similar newborns in the Western world.
- Geriatrics – The number of elderly residents is increasingly growing, heightening the need for geriatric doctors. In a 2005 inspection made by the State Comptroller regarding the treatment of the dependent elderly, it emerged that the Health Ministry was not sufficiently prepared to train specialized physicians and certified nurses in the field of geriatrics. In December 2005, the healthcare system required 500 geriatrics specialists, according to the Health Ministry’s estimate. Even then, the State Comptroller told the Ministry that it needs to intensify its attempts to encourage physicians to specialize, and nurses to acquire certification in this field. In 2008 there was still a great manpower crisis in the field of geriatrics, resulting from a shortage of specialized physicians and interns in this field. According to Brookdale’s research, in 2005 only 14 physicians chose to specialize in geriatrics, compared to 23 in 2000. According to the Health Ministry data, there was a decline in the number of geriatrics specialization certificates issued during those years: 12 in 2005 and 13 in 2007. Nonetheless, according to the Ministry’s data, 73 interns completed their residency.
- The State Comptroller also notes several additional medical fields that are at risk of crisis5 The Israeli Medical Association maintains that these fields are already in crisis, and if appropriate solutions to their problems are not found, they may deteriorate into acute crisis:
- Pathology – During 2000–2007 the number of biopsies performed in the hospitals increased by an average of 30%. At the same time, the number of pathologists working in the pathology wards in 2008 was 149 – a number much lower than the number of pathologists required by the standard (at 178 physicians) in order to juggle the workload. In 2008, a single intern completed his residency in pathology. Based on documents of the Israel Pathological Association it appears that the manpower crisis prolongs the waiting period for test results, and may lead to delays in surgery that requires the presence of a pathologist.
- General surgery – According to the documents of the Israel Surgical Association, the number of Israel medical school graduates that began their residency in surgery is dwindling – 18 in 1999 vs. 7 in 2006. 80% of the residency positions are occupied by graduates from abroad. According to the Health Ministry data, the percentage of foreign graduates constituting new medical license recipients, is just 50%–60%. According to the evaluations of experts in the field, the standard of these foreign students’ studies is lower than that of Israel’s graduates. The number of candidates for vacancies in the surgery ward declines, and in some hospitals, residency positions are not filled. Thus, for instance, in August 2008 there were no residents whatsoever at the Hillel Yaffe Hospital in Hadera. Based on the Association’s documents, it also appears that the shortage of interns is manifest in that senior physicians perform complex surgery with the help of medical students as opposed to interns, and in that the waiting periods for surgery are prolonged as a result of overload. It should be noted that the Health Ministry also agrees that a crisis is developing in the field of surgery, and that there is a shortage of residents.
- Internal Medicine – Young physicians are not specializing in internal medicine. According to research done by the Brookdale Institute, 601 of 646 internal medicine graduates between 2000–2005 went into subspecialties such as cardiology, geriatrics, general intensive care, and emergency medicine, i.e. only 45 specialists remained in internal medicine. According to the documents of the Israel Society of Internal Medicine, the shortage in human resources leads to a tremendous overload in the internal department, discharging patients before the completion of their treatment, and a lowering of the quality of their treatment. It should be noted that the Health Ministry also agrees that the internal wards are in crisis, and that the care rendered in these wards requires improvement.
- Pediatrics – According to the Health Ministry’s data, in 2006 the hospitals and the community had 1,786 pediatricians under age 65. 24% of them were 55–64 years old. The documents of the Israel Pediatrics Association show that the number of residency candidates beginning their residency in pediatrics is dwindling: 84 in 2001, and 61 in 2006. Documents of the Health Ministry show that the number of physicians completing their residency in pediatrics is smaller than that of the physicians retiring, a fact that will ultimately lead to a shortage of pediatricians in the hospitals and within the community.
- Radiology – In a 2002 State Comptroller inspection of manpower planning in the field of imaging, it was found that the significant rise in the number of imaging tests dictates that a significant number of physician and technician positions be added, and that in order to determine the scope of the required additions, the human resources inventory should be examined to determine how many radiology physicians, residents, and technicians the system currently requires and will require in the future. A 2008 inspection showed that the issue of positions was not yet attended to, and that the field is at risk of crisis. According to the Israel Radiological Association data, there is a shortage of 200 radiology specialists, and there is a decline in the number of residents – 14 in 2008 vs. 30 in 2000. According to the Association’s documents and the report of a Health Ministry committee that examined the human resources requirements in the various fields of imaging in view of the field’s development, there is a shortage of physicians and X-ray technicians. This reduces the availability of these tests, prolongs the waiting period for testing, and increases the waiting period for test results.
Thus, Israel has a shortage of physicians in particular medical fields. The crises in these fields are more pronounced than in others, and may eventually impair the medical staff’s ability to provide proper medical care. Several recently-developed criteria help identify the crisis, manifest in the lack of “good” residents; difficulty in filling vacancies; the shortage of physicians that puts strain on the system; a sense of low remuneration and a lowering of the quality of working life.
There are several specializations in particularly great crisis – which can be defined as acute crisis – endangering the future of these fields. These include anaesthetization, intensive care (general, pediatrics, respiratory, cardiologic) and neonatology. Many other clinical fields may deteriorate into a state of acute crisis should the State fail to accord their problems immediate, extensive and comprehensive attention, in accordance with the solutions offered by the Israeli Medical Association.
1 The Myers-JDC-Brookdale Institute, Medical Specialties in Crisis – an exploratory study. N. Nirel, R. Matzliach, S. Birkenfeld, J. Benbassat, 2008.
2 N. Nirel, S. Birkenfeld, and J. Benbassat, “Criteria for a Medical Specialty in Crisis – Case Study of General Surgery and Internal Medicine," Healthcare 147 (f), June 2008, page 554.
3 State Comptroller, Yearly Report 59b, Ministry of Health, 2009