In the first part of the investigation published last week, we showed that in recent years, fewer medical licenses have been granted to students who studied in Israel, at supervised universities that are considered good - and more licenses to students who studied abroad, at universities that, according to the Ministry of Health's own definitions, are considered inappropriate. Ministry of Health Personnel Report Health published in January of this year, indicates that the number of licenses for Israelis who graduated abroad is on the rise. This, despite a report by the State Comptroller that harshly criticized the high rate of doctors who studied abroad and received a license to practice medicine in Israel. This is a figure that indicates that that the State of Israel relies to a large extent on graduates of medical studies, which has no influence whatsoever on the plans for their training.
As mentioned, despite the auditor's scathing report published in 2018, it turns out that the alarming trend has continued and even strengthened; the increase in the number of licenses granted to foreign graduates all over the world last year reached 60% of all licenses, and almost 50% of license recipients returned to work in hospitals in Israel studied in Eastern Europe.
But the truly alarming statistic is the source of these licenses: it turns out that the main countries of study for the recipients of medical licenses last year were Romania (229 licenses), Moldova (161), Ukraine (111), Hungary (74), Italy (52), Jordan (45) , Germany (33), Russia (23), Egypt (17), Armenia (15), Syria (11), universities in the Palestinian Authority (PA) (69), and Slovakia (46). In total, with several other countries , these are 985 new licenses. The note attached to the new report states that the number of graduates who studied in Romania, Moldova and Ukraine has increased greatly in the last five years.
The University of Debrecen in Hungary, photo: GettyImages
Why should this comment be of concern?
Because it is no secret that Romania, Moldova, Ukraine and Armenia are countries where the level of medical education does not meet the standards of the OECD countries.
According to senior officials at the Ministry of Health, this is a "strategic problem of the first order", partly because the students studying there are hardly exposed to the clinical issue.
Although, on their long way to the wards and to the operating rooms in the hospitals in Israel, the specialists gain a lot of relevant experience, but in recent years there have been several cases that have proven that the gamble is too dangerous.
Who pays the price?
Indeed - in a report called "Inequality in Health and Dealing With It", published by the Ministry of Health in September of last year, it appears that the various hospitals throughout the country employ many doctors and specialists from countries that are not currently approved by the Ministry of Health. "Looking at family medicine, Significant differences in the rate of specialists and the place of study.
In the Tel Aviv district, about 70% of the doctors are experts in the field or a related field, while in the Ashkelon and Jerusalem districts, more than half of the doctors are not experts in the field," the report states.
"Also, the districts of Ashkelon and South stand out, with 60-70% of the doctors who studied at institutions that the Ministry of Health does not approve of studies in as part of the 'stable reform'. In pediatrics, the district of Ashkelon stands out negatively, where 45% of the doctors do not have a specialization and 63% of the doctors studied at institutions Not approved. Examining the composition of the specialists in the hospitals, one can get the impression that in hospitals in peripheral districts the rate of graduates from non-approved institutions is higher than the rate of these graduates in the hospitals in the center of the country."
The number of medical licenses for Israelis who studied abroad,
The person who was called to deal with the issue and the reform is even named after him is Prof. Shaul Tizif, director of the Health Professions Licensing Division at the Ministry of Health.
Already in 2018, he appeared before the Labor, Welfare and Health Committee of the Knesset and said the following: "A problem has arisen before us that could mean a decline in the level of medicine in the State of Israel in the coming years. Today there are thousands of Israeli medical students studying in medical schools abroad whose level is very low.
I want you to understand that we have a first-rate strategic problem regarding the future of the level of medicine in the State of Israel.
This is how I see things, because these medical schools teach at a very low level.
Mainly what worries me is that the rate of clinical exposure is minimal, to say the least.
I will give you an example.
For example, during my last visit to Moldova I saw that there are 1,300 Israeli medical students.
1,300 - note the number - in one medical school.
1,300 plus 200 dental students and more pharmacy students from Israel.
They are all Israelis who study in one medical school there.
He has a 300-bed hospital, and he teaches all these students."
In January 2019, Prof. Tezif published a professional outline regulating the recognition conditions for studies abroad, which was named "Tezif Reform". The main conditions are studies in one of the OECD countries or in medical schools affiliated with accredited hospitals (control and certification process). Ministry of Health It even stated that students who began their studies at unrecognized medical schools starting in 2019 - their studies will not be recognized by the Ministry of Health. Moldova and Ukraine are not part of the OECD. Apparently this is good news, but the hospitals still employ interns and doctors who have not undergone sufficient training. The graduates Every year until 2015 they will continue to reach the hospitals at least until 2025. And according to the report, the first to pay the price will be the weakened populations in the periphery.
The auditor's report, which dealt with regulating the clinical training of doctors between the health system and the academy, already in 2018 revealed a series of serious deficiencies that have not yet been corrected. relies to a large extent on graduates of medical studies which does not have any effect on the plans for their training," the report states. "In doing so, the state gives up its ability to train the reserve of the best doctors it needs, and does not allow them to study in Israel in an educational framework, which it has determined the nature of, Its content and academic staff.
"The findings of the report point to the lack of a guiding hand when it comes to the training of doctors, and especially the lack of activity and lack of hands of the Medical Council and the Ministry of Health as factors of regulation and enforcement are very noticeable," it said.
"Given the lack of leadership and the laxity reflected in the report, they should also consider harnessing the Minister of Health and the Minister of Education to initiate a national plan that will enable a real expansion of the infrastructure for training doctors in Israel.
"The audit revealed deficiencies, which go as far as the failure of the Ministry of Health and the MLA, which could prevent the achievement of the national goal.
A significant portion of the doctors who join the medical workforce in the health system are Israelis who studied abroad, in educational institutions whose level and quality are not strictly monitored by the academic institutions themselves and the Medical Council.
Many of the graduates abroad do not pass the licensing tests, and a significant part of those who do pass them were only able to pass thanks to a generous bonus given to them. The audit shows that the MLA's hand is out of hand, which ignored the recommendations of an international professional committee it established to optimize and improve the medical training system ".
The report also states that the licensing department in the ministry gives the licenses to practice medicine without checking whether the license applicant who did not study in Israel produced a certificate that proves he has a basic knowledge of Hebrew. As a result, doctors work in the hospitals who do not have a proper command of the Hebrew language.
Bonus at the expense of the patients
Every medical student, regardless of where he studied, must pass his licensing and certification test in Israel.
However, a procedure that has existed for decades states that students who studied abroad will receive ten additional bonus points in the preparation course for the licensing test. The auditor criticized the fact that a generous bonus is awarded to those who complete the courses, but the Ministry of Health and the examination board never checked how many examinees successfully passed the licensing test Only because of him. The auditor's examination revealed at the time that 57% of the examinees who studied in Armenia passed only because of the bonus, while the students who studied in Israel had no bonus at all. The report stated that in view of the large number of medical license recipients in Israel among graduates of institutions abroad, the Ministry of Health, Through the Licensing Division, rob its control systems as soon as possible, in order to bring about that the preparatory courses for licensing overseas graduates will be reliable and effective.
He also demanded that the Ministry of Health examine the bonus awarding mechanism.
But despite the criticism, in 2023 a generous bonus of ten points will still be awarded to students from abroad in the certification exams.
Here is another omission that has not been corrected: in January 2019, the Ministry of Health published a call for corrections that it wishes to make regarding students who study abroad, in countries that do not provide the proper training. In order to deal with the poor knowledge with which they come to the certification exams, it was decided to add a practical clinical component and oral questions to test their level of knowledge and bypass any possibility of copying in the exams. However, as of today, nothing has been done, and there is still no clinical component in the licensing exams. This is an amendment that, if carried out as decided, would help filter out candidates who do not meet the threshold requirements.
to expand the teaching of medicine
Prof. Arnon Afek, who served as the Director General of the Ministry of Health in 2014-2015 and currently serves as the Deputy Director of the Sheba Medical Center, is very concerned about the situation.
"From 2026, graduates of medical schools that are not included in the list of medical schools of the stable reform, will not be able to take the medical licensing exams in Israel. That is, the gap and shortage will only deepen, especially in the periphery. As the data show, the proportion of doctors who studied in countries where the level of medical education is low and insufficient But pass the licensing exams, higher in the periphery and in the small hospitals. The reform is justified and necessary to maintain the level of medicine in Israel. On the other hand, what is required is the expansion of medical education in Israel and an increase in the number of students studying in Israel.
Prof. Arnon Afek, photo: Gideon Markowitz
"According to the goals of the Ministry of Health, we need to reach 2,000 medical students per year who will study in Israel. This necessary step must be accompanied by a change in the method of teaching medicine. It must be made more innovative, advanced and suitable for 2023. Some claim that there are not enough clinical fields, i.e. Departments and clinics in the hospitals and in the community, where the students can be trained. This claim is not true. There are enough clinical fields in the hospitals and health insurance funds. The medical system should be given budgets and standards so that the training of all the medical students that the State of Israel needs is possible."
How do you do that?
"The steps must be combined. We must increase the existing schools and open new medical schools. Sheba Medical Center is working together with the Weizmann Institute and Reichman University to open new medical schools. The innovative teaching programs are being built these days. The Rabin Medical Center, Maccabi and the College are working together with us to open the new medical school in Reichman. But increasing the number of students will not answer the plight and the great shortage of doctors. Standards must also be assigned to doctors in the hospitals and in the community. It is important that there be more standards, so that the training of additional interns, specialist doctors, and the opening of new hospitals in Be'er Sheva will be possible And in Kiryat. Not to mention necessary reforms such as shortening the duration of duty, in the periphery first."
But the MLA says they don't know your plan at all.
"We will present the plan for approval by the Legislature.
The MLA must work together with us to open the new schools. We undertake to meet the best standards in the world for educating the doctors of the future. I know that the ministries of health, education and the government will help us realize these plans. It is in our hearts."
Why would a medical graduate voluntarily go to work in the periphery?
"We propose that graduates who choose to work in the periphery and in medical professions in need receive scholarships. It is the right of every doctor to choose to work for a pharmaceutical company, but why must the Israeli taxpayer fund his medical studies with hundreds of thousands of shekels? If we want our parents and children to receive the best treatment, we must not We have to be the ones who teach medicine to the students."
How do you deal with the interns who studied in less good places in Eastern Europe?
"Together with the Ministry of Health, we opened a class for students from places not recognized according to the stable reform and taught them at Sheba, while extending the teaching hours even in the afternoon. Their medical knowledge and understanding have greatly improved. The day we train the doctors, the question will no longer exist, the doctors will be excellent. The way to deal with the problem is The right thing is to train all the doctors we need in the State of Israel. Just like the Israeli Air Force trains all its pilots. I say with full responsibility, we can do this. The level of medicine in Israel is high. There is no reason to send the young Israelis abroad.
This is an unnecessary, harmful and valueless step for those who are the future of the country and contributed as combat officers, and even volunteered in MDA and civil associations for many years.
"Also, as you have published, many good doctors remain abroad.
We can teach everyone and ask - allow us.
Give us the means and standards to teach all 2,000 students that Israel needs.
This is the only way to avoid this unnecessary and worthless trip to study abroad."
Prof. Uriel Reichman, the founding president of Reichman University and chairman of the board, also calls for the state's involvement in this national project.
"There is a task of national significance before us. The State of Israel needs to at least double the number of medical students at a sufficient and good level. We have decided to hire them for the good of the cause and open at Reichman University a track for medical studies at the highest level. In the first phase we will be able to train 80 students a year."
Prof. Uriel Reichman, photo: Gideon Markowitz
How will you compete with universities in Eastern Europe?
"We know that there is a problem with places of study in Eastern Europe. That is why the State of Israel needs to take this into account and solve the problem of training doctors in Israel. Only through a total effort of all bodies will we be able to train the future doctors of the State of Israel in Israel. We are now about to change the The approach regarding the training of Israeli medical students, and to assist in the national effort so that we can all promote the solution of training doctors in Israel."
Ministry of Health: "Students who did not comply with the rules will make improvements"
"The ministry works to ensure that all doctors who come to work in the State of Israel are those who studied at schools whose level is good and satisfactory. In 2019, the 'Stable Reform' was implemented, which disqualified medical schools abroad that do not teach at a good and satisfactory level, so that from 2025 students who study at these schools They will not be able to get a license to practice medicine in Israel."
Why will the reform only apply from 2025 and not apply retroactively?
"According to the legal guidelines, it was not possible to disqualify medical schools where Israeli students studied before 2019. Therefore, the reform was only applied to students who began their studies after 2019. In addition, the study paths of students who began their studies before the beginning of the reform were carefully examined, and students who did not They complied with the required rules and were required to perform additional clinical completions, which lasted between one and three years. It should be noted that among the graduates abroad who studied in countries that are now not approved, there are also high-quality graduates who succeeded in the licensing exam, the screening level of which is very high, and were accepted to specialize in hospitals in Israel." .
And what about the clinical component that is missing in the specialization of university graduates in Eastern Europe?
"As part of the reform, the Ministry of Health is working to increase the number of medical graduates. As part of the reform, the duration of the preparatory course has been extended to six months and also includes clinical experience. The Ministry is promoting the subject of the clinical component in the certification tests. In the near future, draft regulations will be published for public comments."
The State Comptroller also strongly criticized the granting of the ten bonus points in the qualification tests for obtaining the license, but they are still given.
Why wasn't this mistake fixed as well?
"The Ministry of Health made a fundamental change in the preparation course following the auditor's report published in 2018, so that the ministry's supervision was increased in establishing rules relating to the course contents and the shield exam and defining criteria for receiving bonus points."
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