By BASIL PORTERHow good is Israeli medicine? A new operating theater at Jerusalem’s Hadassah Ein Kerem hospital(photo credit: MARC ISRAEL SELLEM/THE JERUSALEM POST)Over the cold winter in Israel, the media once again bombarded us with stories of 12-hour waits in emergency rooms, old ladies lying in corridors, and the need for patients’ families to become private nurses for their loved ones. “Not enough beds, not enough doctors, not enough nurses, not enough hospitals” are the familiar headlines. A secretary in my clinic arrived red-eyed to work having spent twelve hours in the emergency room of Tel Aviv’s main hospital with her ailing mother. Wiping away some tears, she said, “I know there are staffing problems, and I know there is enormous pressure, but why can’t they at least talk to you?”A head nurse of an internal medicine ward appeared recently in a prime time spot on one of the television channels. She looked exhausted and angry. “I don’t have a bed, except in the corridor, I don’t have nurses to do proper coverage of the patient’s needs, and the on-call doctor is stretched to his limits. On top of that I have the families constantly (and quite justifiably) crowding the nursing station and demanding information and better care.” A number of department heads reinforced her words, including one declaring matter-of-factly that people were endangering their lives if hospitalized in these circumstances.Israeli medicine, by international standards, qualifies as among the best in the world. Life expectancy in Israel is still among the highest, and though Arabs live shorter lives, they are still doing better than others in neighboring countries. Infant mortality, the number of infants dying before the age of one year, is also among the lowest in the Western world, for both Jews and Arabs. If more babies survive, and we live longer lives, is all the complaining just Jewish kvetching?One may be happy to walk around holding a sign saying “We live longer,” and argue that we have all the mainstream technologies, outstanding surgeons and cancer researchers to support the pride in our system. However, in real life, things look different. Spending twelve hours in an emergency room after being referred by the family doctor for a suspected pneumonia or fracture following a fall will not result in pride regarding the national picture. Any one sitting next to an elderly parent with an IV and oxygen tube lying in the corridor of a ward, with a noise level approaching Grand Central station at 5 p.m., will also not be singing the praises of the system. Despite all the progress in medical technology, the replacement of X-rays with CTs and MRIs and state of the art drugs for the nagging chronic diseases of the 21st century, medical care still usually boils down to the doctor-patient encounter. When patients have time to talk about their problems with a sympathetic nurse or doctor, they feel better. The list of vital signs on the chart at the foot of the bed, the lists of laboratory results stored in the computer and the MRI performed at 3 a.m. with few words of explanation by a human being, do not themselves guarantee the ailing person’s well-being.Maimonides, who became the physician for the royal leaders of Egypt had little to offer other than his sensitive ears, eyes and wisdom for a person’s ailments. Medicine was stagnated at the level of talking about the body’s humors, with blood-letting being the commonest technical intervention. But somehow, through careful listening, observation and talking, he was recognized as a great physician of the times. We have no evidence that his patients (even kings) lived longer, but it seems they were happier.Today’s medical encounter will usually involve little listening, little observation, and too frequently, little wisdom as well. The Kupat Holim physician will be locked into documenting the encounter in the computer (otherwise he won’t be paid), his remuneration will depend on the number of patients seen, with no recognition of the importance of time in the physician-patient encounter. The referral for laboratory tests, imaging or to a sub-specialist will offer the quickest route to getting the patient out and bringing the next one into the room. The patient with a more chronic problem, or a number of them, who is frequently elderly and alone, will face the additional problem of lacking a manager. The family doctor in the past accepted the role of helping manage the patient’s health issues, which would include arranging any additional consultations or investigations. Today, the patient or family members are forced to take up this role, at a time when negotiating the system has become far more complicated and overflowing with bureaucracy. Protektzia, knowing someone whose brother is a neurologist or orthopedic surgeon or dermatologist, is usually seen as the only solution.Within the hospital, other pressures operate, but the result is the same. Doctors and nurses must deal with large volumes of patients, worried family members and administrative hassles such as getting the patient to the imaging department and back, performing the minimal monitoring required for adequate care, and answering to the hospital’s demands to perform a host of actions deemed by various committees as essential in evaluating the quality of care given by the institution. Whether in the doctor’s office, the hospital emergency room or ward, the patient is met by tired, stressed medical personnel, with little patience for giving essential information, and even less for listening to the patient’s complaints.Some thirteen years ago, I survived being involved in a train accident, while sitting in the lead coach which ploughed into a coal truck stuck on the railway line. I regained consciousness an hour later and was diagnosed with a shattered vertebra in my neck, fractured ribs and severe bruising of my whole body. Thanks to the judicious placement of a neck brace by a medical team worker while lying unconscious outside of the train, and subsequent surgery involving replacement of the damaged vertebra, my life was saved. However, when reflecting back on the experience, my main memories, together with the relief of survival and return to almost normal function, centered on the poor communication with medical personnel. I was amazed at the lack of attention to my personal problems, the adherence to protocols seeming to be more important than giving a few moments to listen to my causes of distress.In order to improve things, we need to ask some basic questions. Do we really need more hospitals? More doctors and nurses? Is it a simple dichotomous issue of too little versus enough? There is a physician shortage today. The medical schools in Israel are unable to supply the perceived needs, and young Israelis are standing in line to pay hefty sums of money to train in medicine in Padua, Budapest, Moldavia and Armenia, while the new medical school in Safed and the planned school in Ariel will provide only a fraction of the needed additional physicians. While many of the physicians from the Soviet Union who arrived at the end of the last century are now leaving the system, pensioners in fields such as emergency medicine, newborn medicine and pediatrics are being recalled to supply extra hours to the system. In addition, politically, the Ministry of Health is the booby prize in any new government, and is notoriously powerless in obtaining resources for improvement of the system.
The reason people wait for 12 hours in the emergency room or lie in corridors isn’t always because they are so sick. Many of these patients do not need care in the hotel atmosphere of the modern hospital, 24/7, including food. Providing an interim station, such as the secondary care centers provided by some of the Kupot Holim and private agencies, can often fill the bill and be a win-win situation for all – patients, doctors and managers. Competent, experienced doctors and nurses can evaluate the patient, perform a minimal level of tests and imaging, and send the patient back to his home environment, with follow-up by a care team, without needing to occupy a bed all day and eat cold food. The management of the Kupot Holim must be convinced that paying for more time for consultations and encouraging better patient management may save expenditures on unnecessary tests, visits to emergency rooms and further consultations, and most importantly, expensive hospitalizations. We must find ways to revive the basics of medical consultation. Medical students and physicians in training must be exposed to role models who demonstrate the skills of good communication with patients, doctors who listen carefully and do not communicate with the patient through a computer screen, demonstrating the empathy and clinical skills necessary for any successful consultation.Unfortunately, the world of managed care in medicine has resulted in a split between doctors and managers. Managers see the doctors as a necessary evil, who cause waste and increasing costs in the system, while doctors view managers as super clerks responsible for saving money without considering the best health interests of the patients. This is a worldwide problem, causing even the gold standard National Health Service in the UK to lose much of its reputation as a world leader in health care provision. Both sides can contribute to change the situation. The medical profession must agree to take part of the responsibility for the control of spiraling costs in the health system, and the managers must be ready to engage in true partnerships with the medical profession, testing changes in the system that will preserve the high quality of health care, while continuing to control rising costs.Finally, we must find ways to improve communication throughout the health system. Every doctor, nurse, technician and clerk must learn to listen sympathetically to the patient, explain patiently what is happening (even if just to explain long waits!), and show true empathy regarding the patient’s suffering. In the 13 th century, Maimonides summed up in his classic prayer for the physician, the lesson for all doctors: “O God, let my mind be ever clear and enlightened. By the bedside of the patient let no alien thought deflect it. Let everything that experience and scholarship have taught it be present in it and hinder it not in its tranquil work. For great and noble are those scientific judgements that serve the purpose of preserving the health and lives of Thy creatures.”Basil Porter is a pediatrician specializing in child development, and has had extensive experience in community medicine in Israel, including senior administrative roles in one of the major HMOs.
