Not everyones happy about Israels newest med school

Is a private medical school a cure for the doctor shortage?  credit: Shutterstock
Is a private medical school a cure for the doctor shortage? credit: Shutterstock

As Israel faces a doctor shortage, Reichman University is establishing a new, NIS 90,000-a-year medical school, attracting scorn and skepticism.

When Reichman University initiated the establishment of Israel’s first private medical school, it was, as its website put it, "with the aim of helping to solve the existing shortage, and to immediately increase in the number of medical students in Israel." The new school, according to Reichman’s optimistic plan, will open as early as 2024, if the curriculum receives approval from the Council for Higher Education of Israel (CHE). It will initially train about 80 students a year in the first phase, and will peak at approximately 120 students a year. The school will be established in cooperation with Sheba Medical Center at Tel HaShomer, and health funds Clalit Health Services and its central region hospitals, and Maccabi Health Services.

While the program’s leaders are excited about its implementation, and tout its use of medical simulators, there are those who claim that it is a delusion, a project that will not really help increase the number of doctors but will be established using public resources at the expense of other solutions. There is no doubt that the school will charge its students significantly higher fees than those at Israel’s public universities, but the opponents of the move also cast doubt on the professional standard that the students will receive in return.

Racing to stay in place

But first, some background on the situation which the new school is entering. There are about 30,000 doctors in Israel, only 3.2 doctors per thousand people, compared with an OECD average of 3.4 T. Even this low number is will soon fall significantly, mainly because of the Yatziv reform in licensing foreign medical graduates (Prof. Shaul Yatziv is head of the Division of Licensing of Health Professions in the Ministry of Health) that disqualified many institutions, but not just that. Other reasons include population increase and, in the coming years, a massive retirement wave of doctors who came to Israel during the mass immigration from the former Soviet Union during the 1990s and filled a void which had already begun to form at that time and was never dealt with.

During the past decade, the number of medical school graduates in Israel has increased significantly, but still has not managed to keep up with population growth. A committee headed by Prof. Ronni Gamzu, CEO of Tel Aviv Sourasky Medical Center (Ichilov), published a report in early 2022 with recommendations for a rapid increase in the number of students so that the number of medical license recipients in Israel would increase to 2,000 a year by 2035 (compared with approximately 1,800 today), of which about 1,200 (60%) would be home-grown. Meaning, by the middle of the next decade, the ratio of doctors per capita would return to roughly the same level as today. However, if the plan is not implemented, is delayed, or not budgeted, or if doctors leaves the country or the profession en masse, it will be very difficult to close the gap. Currently, another Gamzu committee is working on expanding the recommendations, while the Ministry of Health is itself preparing a plan that should make these recommendations operational, although nothing has yet been officially decided or budgeted.

Today, only about 40% of new doctors entering Israel’s medical system have studied in Israel, the lowest rate of locally-trained qualified doctors among all OECD countries. In a special OECD report on medical education and training In Israel, published in May of this year, Israel received low marks for its number of medical school graduates, the lowest in the OECD relative to the population.

The reason is that there are not enough places in Israel’s medical schools to train enough doctors for the country’s entire medical system. But there is also a revolving door: universities in Israel -- Tel Aviv University, Ben-Gurion University of the Negev, and the Technion-Israel Institute of Technology -- train foreign students (in 2021, 113 out of a total of 1,020 new registrants for all of Israel). In addition, those who study in Israel do not always remain within the system, but move abroad for work, with 9% of Israeli-trained doctors employed abroad at any given time.

The gaps in the system are filled by Israeli students who studied abroad, usually in Western or Eastern Europe. Some, but not all, of these foreign education institutions are excellent. The Yatziv reform defined threshold conditions for medical schools abroad graduates of which could be integrated into the Israeli health system. According to Gamzu report estimates, the Yatziv reform will subtract about 400-500 doctors a year from the supply of new doctors available to the Israeli health system, mainly in the periphery.

The country woke up late to the need to train a critical mass of new doctors, but steps have nevertheless been taken in recent years. Up until 2009, four faculties of medicine operated in Israel, at the Hebrew University of Jerusalem, Tel Aviv University, the Technion, and Ben Gurion University, with only 250-350 graduates each year. By 2020, 850 students began studying at Israel’s various faculties of medicine, that is, triple the number of students within a decade. This was done by consolidating the existing faculties, opening a four-year medical study track at Tel Aviv University for those already holding a bachelor's degree, with another similar track at Ariel University, as well as establishing a new medical school, the Bar-Ilan University Azrieli Faculty of Medicine in Safed, where there is also supplemental training for foreign-trained graduates who do not meet the new criteria. A special degree is also planned for research physicians at the Weizmann Institute, which will open in the coming years.

Despite the claims about the limited capacity of the medical training system in Israel, the universities themselves are not the bottleneck. The main problem: the clinical fields (clinical rotations), meaning, the training that students undergo at hospitals. Today, all the medical teaching institutions in Israel rely on clinical fields. Naturally, competition for places will intensify as new institutions enter the picture.

NIS 90,000 yearly tuition, no cadavers

Prof. Uriel Reichman, founding president and chairperson of the board of directors of Reichman University, explains why he decided to enter the arena: "Up until 1995, the gates of higher education were closed, and under the control of seven large universities. Hundreds of thousands of people were denied social mobility. Anyone who wanted to study law, for example, and was not accepted to one of these very few places, had to go to study in England, and this damaged the social fabric of our country.

"Fortunately, the Freedom of Occupation law was passed in the meantime, and they told me - okay, open a university, but you won't get a cent from the state. My goal has always been to establish an institution that will be a university in every respect. The medical school is important to us because of this vision, and because we are an interdisciplinary institution. We want to make medicine part of the other faculties here. We’re also doing it as a mission, because of the lack of doctors, and even though this faculty will be loss-making in the first years. We were happy to receive a large donation from Udi Recanati [the school will be named after his late mother, Dina Recanati - G.W.], which helps us get started and later we will raise more."

The person designated as the dean of the new school is Prof. Arnon Afek, the associate director general and acting director of Sheba General Hospital. Afek has some innovative ideas for the new school. "We’re educating the doctors of the future and it is a big challenge to teach them differently. We want to give them skills and not just knowledge. This will be a discussion."

Afek plans to rely more broadly on medical simulators than other institutions do, to enable additional practice beyond the medical internships at hospitals, and reduce clinical fields demands. Also, unlike its competitors, the Reichman School of Medicine will not dissect cadavers. "Not because we can't do it, but because we don't need that today. Simulations are enough," says Afek.

"Every additional seat in a medical school is a blessing," says Dr. Orly Weinstein, deputy director and head of the Hospitals Division at Clalit Health Services. "I'm sure people raise an eyebrow at the fact that it's a private platform. But studying abroad at good institutions is more expensive than at Reichman. So, if there are going to be private schools, then better to keep the doctors here in Israel."

One of the major claims against the program is the very fact that it is private. The claim is that a public resource is being allocated to a private entity.

Afek: "I’d like to note that Reichman is not a for-profit institution. It is a non-profit. It is simply not funded by the CHE." Regarding the price, he says: "At a public university medical school, tuition is about NIS 12,000 per student. With us, the same student's studies will cost NIS 90,000 a year."

That’s a bit of difference.

"Yes, but it's not because we’re making a profit, but because at other universities, the state makes up the difference, while at ours, the student pays." Afek points out that one option being examined is for the CHE to fund tuition, but only for those students who, after receiving their degree, commit to working for a period of time in the periphery, or in a particular specialization that is in short supply. This seemingly solves two problems in one fell swoop. It enables students from financially weaker families to study, and more properly plans manpower allocation.

Institutions in Eastern Europe, not all of which will remain relevant after the Yatziv reform, can cost about NIS 15,000 a year, but there are also institutions in Europe where the cost of studying is about NIS 80,000 a year and they still attract Israeli students.

"What do they add? Nothing"

However, voices are heard from other schools claiming that there is no need for another university, certainly not a private one. A faculty member at one of the existing medical schools summed it up in the most emphatic way: "What does Reichman add? Nothing. Who’s going to teach there? Lecturers from other medical schools. Where will they do their training? At our clinical fields. The Gamzu program determines exactly how many doctors we need to train: 2,000 doctors a year. The existing medical schools can do it. Easily. I can add as many as the CHE will let me.

"Instead, they take something that is a college -- actually more like a high school -- and permit it to teach medicine. Medical studies are supposed to be academic. The lecturers are doctors and senior researchers. Reichman doesn’t even offer a bachelor's degree biology major yet. Who will they bring in? Either our doctors, or people who are not at research centers. This is dangerous and bad, and degrades the level of instruction.

"And then, where will they do their clinical training? This will also be at the expense of our clinical fields. If we had more clinical fields to work in, we would gladly increase the number of students we have. In practice, what’s happening is that they’re taking an institution that lacks experience and ability in the field, and it will basically sell our public system at a higher price, and use it less well.

"I have nothing against Reichman personally. But what’s the next step? Will every college be able to teach medicine? So, a lot of people can throw their caps in the sky and say they are doctors -- and the whole level of medical professionalism will decline. Just the way it happened with the legal profession. But the state will approve it in the end, if only as revenge on the Israel Medical Association for protesting and striking against the government’s legal system reforms."

"It's just not true," says Afek, who has a response to every critique. Regarding the lecturers, he says: "I don't intend to take professors from the other universities. That won't happen. I’ve chosen brilliant young doctors who are dying to teach, and I'm taking retired doctors to be their mentors. There are plenty of young doctors at Sheba, more than enough to fill the teaching hours for Tel Aviv".

One exception is Afek himself, who today is a professor at Tel Aviv University and who was formerly the head of the Sackler NY Medical Program at Tel Aviv University for medical students from abroad. When the new Reichman School of Medicine receives official approval, Afek is expected to leave his position at Tel Aviv University and join the Reichman faculty.

And what about the clinical fields?

"There is no shortage of clinical fields. There is every indication that the hospitals can and do want to teach more, and the OECD report that came out in May also agrees with us." Indeed, the report states that clinical fields in Israel are underutilized, and there are far fewer medical students per hospital bed than in other countries.

Reichman adds, "We’ve heard the criticisms and they’re disgraceful. If there aren’t enough clinical fields, and they are a 'national resource', how was it that, for years, the existing medical schools taught foreign students? Did they make a business out of it? This is hypocrisy."

Weinstein: "In the past, I also thought it was impossible to increase the number of medical students significantly because there were no clinical fields. But now that Clalit is also training doctors, we’ve seen there are unused resources in this area at the hospitals as well."

Training largely outside of hospitals

One of the proposed solutions is clinical fields in the community. Dr. Daniel Landsberger, chief physician at the Medical Division of Maccabi Health Services and responsible for the health fund’s relationship with the new medical school, explains: "Can you only learn about diabetes at a hospital, or can you also learn from the same endocrinologist who works at the hospital, but also treats patients in the community? After all, the medical world is actually trending away from hospitals and towards the community.

"No one intends for medical students in Israel to leave their studies straight away to specialize without going through a hospital internship at all, but that period can be divided into a year and a half in a hospital, and two and a half years in the community, for example. I have 400-500 doctors who are willing to be instructors. Even now, we have students doing some of their clinical fields in the community. This is happening not only here, but all over the world. In Canada, for example, all students are also required to train in the community."

And will these students aim to become community doctors?

"Not necessarily. When a student chooses their specialization, they usually follow a mentor. If they studied with an endocrinologist in the community, they will later join up with them at their hospital."

Landsberger also sees some challenges to this method. "The hospitals where Reichman's students are expected to undergo training are in the central region, but communities are all over the country. Perhaps it will be less convenient for them, but perhaps this way they will actually be exposed to the periphery."

In response, the official from the competing school muses: "Can you see Reichman students, the ones who drive to university in their SUVs and complain if their parking space isn’t wide enough, covering night shifts in the periphery? I don't think so."

There is also a diversity issue. Among students who go abroad to study, at the cheaper foreign institutions expected to be disqualified by the Yatziv reform, there is a higher proportion of students from Israel’s Arab population. We are eliminating this channel, and bringing Reichman students into the system instead.

Landsberger: "Things are not that dichotomous, of course. I know Arab families who have the resources, or make sacrifices, to send their children to very high-level institutions abroad, and they will also be able to send them to Reichman. At least that way they will stay in the country. And for those who cannot afford these studies, scholarships will be awarded. In any case, you must be realistic. Money plays a role today in every field."

Dr. Landsberger adds: "I’m not sure that the research universities are really prepared to expand their medical schools. These studies are considered loss-making. In Reichman, they will not be unprofitable, because the teaching methods are more efficient, with more emphasis on the virtual, and also, of course, because the price per student will be higher."

Do you understand the criticisms against you?

Afek: "All competition is disruptive. When they established the medical school at Ariel, it was a world war. Even when they opened in Soroka, the Hebrew University said, no way. And when the medical school of the Hebrew University was established, do you know what they said? Who needs it, there’s an excellent school of medicine in Beirut. Why set limits? I think we should open as many medical schools as possible. At Weizmann, and Haifa too. But it will take years."

Landsberger: "5% more medical students at Reichman University is not what will shake up the system."

Reichman: "We really are not taking anyone's place. There is room for another medical school or two besides us. We also want to help, lend a hand, especially during the current period which is so difficult, and although we oppose the regime coup, as an institution we also say, ‘Let's keep on building, let's keep on being optimistic.’ We continue to struggle for the future of our society. So that we shouldn’t lose heart."

Published by Globes, Israel business news - en.globes.co.il - on August 24, 2023.

© Copyright of Globes Publisher Itonut (1983) Ltd., 2023.

 
Is a private medical school a cure for the doctor shortage?  credit: Shutterstock
Is a private medical school a cure for the doctor shortage? credit: Shutterstock
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