Discussion and recommendations
Unlike many other western countries,
2 Israel does not have mandatory periodic re- registration for physicians, a mechanism which could serve to update and enhance knowledge of the employment status and patterns of the active workforce by collecting information about a physician’s activities at the time of renewal. Physician projection data has until now been largely based upon the number of registered medical licenses, information that does not take into account employment status, changes in residence, variations in retention rates and retirement patterns.
In years prior to this study, various professional bodies addressed the significance of the lack of accurate, updated data on the number and characteristics of employed physicians [
9‐
13] and included among their recommendations taking steps to establish periodic re-registration for professionals in the health fields. Aside from improving the knowledge of active employment in the medical workforce, establishing physician re-registration in Israel would also likely add to the sense of commitment on the part of the physician to his or her clinical field of practice - all the more so if it also entailed continuing medical education requirements - and as such is recommended by the current authors.
The methodology upon which the current work was based [
3,
7] took an important step forward towards obtaining accurate information on the gap between the physician registry and the actual, active physician workforce, as a starting point for workforce projection and planning. The study sheds light on inactive or only partially active license holders in Israel, on retirement patterns, and on age and gender differences within these parameters.
Studies have shown that female participation in the Israeli medical workforce has increased over time [
5,
12‐
15], alongside a parallel increase in other OECD countries [
16]. The female participation rate in Israel is higher than in the United States, where in 2012 about one-third of actively licensed physicians were women as compared to 41% in Israel [
16]. The percentage of females in most specialties in Israel has also increased except in the field of anesthesiology, with the highest rates of females in family medicine followed by oncology, pediatrics and psychiatry [
15]. By comparison, in the United States, the highest percentages of females specialists reported in a 2015 study were in obstetrics/gynecology, pediatrics, family medicine and psychiatry [
17].
While the current study could not provide a precise number of work-hours per physician to convert to full-time equivalent (FTE) positions (one of the study’s limitations), the age-categorized data did demonstrate a lower work-hour contribution by female physicians. Data from other studies indicate that female physicians also practice at lower activity levels during childbearing age, have a higher tendency to work part time and see fewer patients per day. They also take more parental leave, are more likely to leave the practice of medicine during childbearing years and are more likely to retire early [
1,
14,
15,
18,
19]. A study from Canada concluded that if current gender practice patterns of doctors persist "an overall decrease in doctor productivity is to be anticipated" [
19].
Greater female workforce participation in Israel would mean fewer FTE positions to be contributed to the workforce [
15], creating a situation described by the Horev "by which the supply of FTE physicians is rising at a slower rate as compared to the supply in terms of the number of active physicians" [
13]. The trend of an increasing percentage of female new licenses seems however to have leveled off since 2006 where it was and remains at 41% [
17]. Moreover, there is evidence that, in recent years the proportion of women among the younger physician population has been getting lower [
3,
15].
The contribution of women to the physician workforce however is not solely a function of hours and years worked, but also of the kind of care and time given to patients, and the quality and nature of the professional relationship [
15]. With the so-called ‘feminization’ of medicine, it has been hypothesized that there may be a shift towards a more bio-psychosocial approach to patient care changing both patient-doctor relationships and the nature of health care delivery [
19]. Differences between the genders were also found pointing to higher productivity among female physicians particularly in primary care [
15]. A recent study published in JAMA Internal Medicine found that older hospital patients treated by female internists had slightly lower death rates and readmission rates to the hospital, as compared to those treated by male physicians [
20]. Although further research on differences such as these would need to be done in Israel, recognition of gender differences in workforce participation is important for policy-makers to consider in planning the development of the future healthcare workforce.
Since lifestyle issues regarding the balance between home and career are important in women’s deciding on amount of time to work in a week, choice of specialties etc., it is worthwhile to further study the use and effectiveness of incentives such as family-friendly working hours and training programs, childcare options and financial incentives when planning to attract female physicians to specific programs, specialties or geographic areas in Israel.
In Israel, as in other countries, age plays a role in how many hours doctors work, as well as how any more years they will continue to contribute to the workforce. Overall, fewer younger physicians than older ones worked less than full-time, with the percentage of physicians who worked shorter hours rising with age. A similar trend in European countries was seen wherein weekly work-hours rise for physicians between ages 35–39 and 45–49 but fall from 50 to 54 onwards as physicians approach retirement age [
1]. Attempts to directly compare age characteristics between countries, however, is hampered when age and/or work-hour categories are not identical, as is often the case. An American Medical Association survey data from 2014 [
18] did provide partially comparable data to our study, indicating that almost a quarter of US doctors worked 61 h or more, as compared to 15% of Israeli doctors.
The percentage of younger physicians in the labor pool in Israel has decreased over the years while doctors approaching retirement both comprised a growing segment of the labor force, and worked fewer hours [
11]. In the United States as well, the age composition of the actively licensed physician population continues to display a definite shift from younger to older, reflecting the gradual but significant shift seen in the general population [
21]. Studies from the U.S. have also shown that older physicians see fewer patients per day and work fewer weeks per year [
1,
16], thus contributing even further to the diminishment of total physician care services. The Israel Medical Association (IMA) site reports that the average age of Israeli physicians is rising; in 1990, doctors under 45 constituted 48% of the physician population in Israel, in 2000 the percentage was 37%, and in 2008 only 27.7% [
22] Our 2008-based data found that 10% of working physicians were aged 65 and over [
3] and increased to almost 13% in 2012. In the US in 2010, a comprehensive analysis [
21] found 22% of physicians to be 60 years or older, which increased to 26% in 2012 [
23], identical to the 26% found in our current (2012) study.
The Horev committee reported on the aging of the medical specialist population based on data from the publication of the Health Information Department of the MoH [
6]. In 1990 the rate of specialists under age 45 from among all specialists was 40% whereas in 2008 the rate was 26% and in 2012 it was 22.3%. The current study also illustrated that in some specialty fields young physicians were not replacing retirees at a compensatory rate. Furthermore, with Israel’s population growth, just replacing retiring physicians would not necessarily be adequate. This strengthens the argument that policy planners both encourage specialists, especially in fields of distress, to continue working past retirement age as well as incentivize the entry of young specialists into these fields [
6,
13]. Even though older physicians predominantly work part-time, it is still likely to be beneficial to the healthcare system to have more physicians, especially those with much experience, working more years and retiring later.
The group responsible for the largest gap between the numbers of licensed and practicing physicians in Israel was that of physicians residing abroad. The findings indicated that at any point in time, approximately 10% of registered physicians of all ages were unavailable to the Israeli labor pool for this reason. The data also showed that the majority of those who were abroad were not young, recent licensees pursuing time-limited, post-graduate training. From among the 3275 physicians who were living abroad in 2012, 82% of them had been there for at least 5 years, a further indication that they may not have been there only temporarily.
The study could not provide information on whether the physicians residing abroad were actually employed, and if so, in what capacity, nor could it determine their reasons for moving abroad. However, the phenomenon of leaving the country, even if only for a period, in effect removed a portion of physicians from the employment pool in Israel. Seven percent of licensed younger physicians (aged 30–44) were abroad-- many perhaps pursuing advanced training with a plan to return to Israel upon completion. Other doctors will presumably take their places abroad as the former return. So, while it may be of benefit to the quality of the workforce to have its physicians pursue fellowships or sabbaticals abroad, for the purpose of workforce projection and planning, this absence needs to be taken into account.
We further recommend obtaining more information on Israeli physicians residing abroad to determine whether and in what capacity they are employed as well as any potential for their re-entry into the Israeli medical workforce and under what conditions. In addition, since our study shows the percentage abroad at a point in time, we recommend following this statistic over time.
Immigration out of a country may well be an indication of discontent, and could increase. Indeed, there is evidence of Israeli physicians’ lack of satisfaction, overload, burnout and consequent withdrawal from the profession [
14,
15]. As one of its limitations, the current study could not directly shed light on the number of physicians who have abandoned the practice of medicine in favor of other areas of employment. A survey conducted by the Technion and published in 2003 [
24] found that in retrospect, 12% of medical graduates would not have chosen to study medicine, an additional 23% were not sure whether they would have, and 4.2% of the physicians surveyed left medicine in favor of biotechnology or pharmaceutical industries and start-up companies. A later study published in 2011 [
25] found that among young Israeli physicians licensed between the years 2000 and 2006, the drop-out rate from medicine among Israeli trained doctors was 5.6%, with another 10% having interviewed for jobs to examine their options for changing professions. It was also found that 13% of the physicians reported that they often contemplated the prospect of leaving the field, and only 65% of the sampled population of physicians never or very infrequently contemplated leaving. OECD international data [
13] reported that about 5% - and the US Health Resources and Services Administration [
26] reported about 6% - of licensed working age physicians were not active clinicians as their main occupation. In comparison, 1998 surveys from the United Kingdom found that as many as 17.6% to 21% of participants left medicine 7 to 11 years after graduation [
27].
Reasons for abandoning the medical profession and doctors’ emigration are similar worldwide and include burnout, poor conditions in the country of origin including work conditions, attraction to other professions and the erosion of medical autonomy. For the most part, reasons for emigration and the abandonment of the field of medicine do not stem from doctors’ negative sentiments towards the profession itself, but from the conditions inherent in its practice [
22]. The Van Dyke and Associates’ study [
25] on Israel found a low level of satisfaction with the physical conditions of the work environment, the level of income and the lack of balance between work and personal life among medical practitioners. This is especially important as the field of medicine may be struggling to maintain its status in competition for the best undergraduate candidates among other lucrative professions such as high-tech and engineering.
We recommend that healthcare systems’ thinking about how to cope with existing or impending shortages in the supply of physicians, include both efforts for reduction on the demand side, as well as changes on the supply side. Doctors need to be supported to best leverage their time so that their days are not organized around tasks related to documentation and clerical and administrative activities which should be handled more appropriately by others in the system. Added clerical support can also reduce “no-shows” through concentrated appointment confirmations, especially in practices with limited or no clerical help, again, freeing up physician time to see more patients.
In a report of American experts independently addressing the question of how to meet the challenge of impending physician shortage, the most common thread running through their responses was that, to the greatest extent possible, other healthcare professionals should be working with physicians on multi-professional teams, with each member working "to the top of their license", and each member taking on tasks that match their professional competencies [
28]. A team-based model of care is aspired to and exists to some extent in the Israeli healthcare system today. However, it may be achieved more thoroughly if and when inter-professional education is advanced, wherein clinicians who are initially trained in this approach become integrated into the system, as is recommended by these authors.
The team approach also incorporates the adoption of newer models of clinical care professionals which have been shown to be comparable to, or better than, physician-provided care on several process and outcome measures [
29,
30]. In Israel in 2013, recommendations were accepted in the MoH regarding the expansion of clinical capacities of existing health professionals (nurses, paramedics etc.) in specific treatment areas so as to serve as physician assistants subordinate to and under the supervision of physicians [
31]. At the end of 2013 the role of the nurse practitioner was created [
32], authorizing the expansion of independent nursing responsibilities and treatments relevant to specific specialty areas such as palliative care, geriatrics, diabetes, neonatology, internal medicine, surgery and primary care.
Increasing the employment of such physician extenders in Israel, through both expanded training programs and broader acceptance and mobilization of these other professionals, could improve both access and quality of clinical care for patients. At the same time, it could free up physicians to do what only they are trained to do, and thus contribute to alleviating a potential physician shortage. Another specific recommendation that follows from the findings of the current research would be developing additional non-physician personnel such as clinical microbiology professionals and/or nurse anesthetists.
In addition, policymakers should consider promoting the use in Israel of specific technological advances, such as telemedicine for monitoring conditions remotely. This could result in reductions in use of services including fewer unnecessary physician visits and hospitalizations, thus easing up the demands on physicians’ time and enhancing efficiency [
33].
The methodology of this study can serve as an important tool for policy planners to periodically provide up-to-date information on active healthcare workers and on those who are unavailable, either fully or partially, to the healthcare system, in the service of planning for a potential shortage [
34]. To this end, it has been applied to similar studies on other health professions. Several such reports were published by the Ministry of Health in 2016 [
35,
36] and others are in progress.