Making Aliyah: An oleh's story: Beating my head against the wall in Israel

I came to Israel for love of the land. There is no other place in the world to raise a Jewish family, and the social and educational klita experienced by myself, my wife and three daughters has been nothing short of remarkable. My professional klita, however, my "welcome to Israel," would have had the typical US board-certified physician swimming the Atlantic to get back to America.

I am a recent graduate of an excellent program in pediatrics, at a children's hospital ranked by US News and World Report as one of the top institutions in the US.

I am US board certified in pediatrics. We celebrated the one year anniversary of our aliya just days ago, and I have become one of Delta's favorite customers because I continue to hold a position in a pediatric emergency room in the US. I am paid more for a week's work in the US than I would receive monthly as a more highly trained physician here (see comments on salary made by an Israeli cardiologist in The Jerusalem Post, August 14, 2009).

In a short-sighted policy unmatched, to my knowledge, by any other first-world country, I am permitted to commute back to the US and work without paying anything in tax to the State of Israel, while at the same time I am effectively prohibited from doing comparable work in my field in Israel. Why? The Israel Medical Association (IMA) has required return to residency before allowing me to work and to advance in my field.

Israeli pediatricians complete four and a half years of residency, of which six months are studies in the basic sciences. Typically, an American pediatrician with a comparable four years of hospital experience is asked to complete a three month "observation period" in an Israeli hospital. The hours are light, and there is no overnight call. What constitutes hospital experience is poorly defined; the American pediatric residency is three years, and the practicing community pediatrician fulfills the fourth year required by the IMA by holding "admitting privileges" to a hospital, whether or not that physician ever sets foot in the hospital. The IMA does not accept my continued experience as an attending physician in a pediatric ER because the environment is private rather than academic and because I do not admit patients to my own facility.   

I am not the only physician to face this challenge. One recent physician oleh had completed six years in two different residency programs in the US, and was assigned a nine month term that he bargained down to six.  Another US board certified physician, who came some years before me and under a different IMA administration, was essentially required to repeat residency. He declined, and is currently practicing outside of his specialty in Israel.

What makes this all the more ridiculous is that while I sit on my sofa and write this article, Israel is importing physicians from third-world countries to work independently in Israeli hospitals. Among the many reasons why I made aliyah is that Israel suffers from a very real shortage of physicians. Israeli medical schools graduate only 400 new physicians annually (of which 150 are foreign students, the large proportion of which return to their home countries).  All in all, Israel licenses about 600 physicians annually.  (See "Medical Myopia," The Jerusalem Post, August 13, 2009).

The physician shortage is less pronounced in the hospital setting than in the community; Israel's number of general hospital beds per 1,000 residents is among the lowest in the Western world ("An Urgent Revolution," The Jerusalem Post November 17, 2007), and fewer beds require fewer physicians. Still, hospital salaries are much lower than those in the community setting, making recruiting for these positions more difficult.

At the end of 2007 there were 3.49 doctors for every 1,000 people under the age of 65, a significant decrease from seven years prior. Furthermore, as the immigrant physicians from the FSU retire, the number of physicians under the age of 45 continues to decline. Approximately 29 percent of Israeli physicians in Israel are under that age; compared with 37 percent in 2000 and 43 percent in the mid-1990s. Dr. Yoram Belcher, then head of the Israel Medical Association, called the situation "very grave."  ("The Medical Tourist," The Jerusalem Post, September 24, 2008). 

At the same time, unlicensed practitioners of "alternative" medicine practice freely in Israel and advertise claims of medical benefit from their services, without any oversight by the Health Ministry ("Seeking optimal well being," The Jerusalem Post, June 10 2006). Chelm in Tel Aviv. 

I came to Israel at eighteen and knew that I would one day return for good. I attended a Hesder yeshiva at which I was the only native English speaker and have made significant efforts to make my Hebrew fluent. Six weeks after receiving my Israeli medical license I was practicing with the Terem urgent care network and able to hold my own in Hebrew. Terem was founded and is run by immigrant physicians predominantly from North America and the UK, and introduced a level of efficiency with quality of care to the Israeli medical system. They appreciate qualifications from these countries of origin. 

In November of 2006, almost two years prior to making aliya, I arranged a pilot trip. I spent that month in four pediatric hospitals, and received an invitation (reiterated two months prior to aliya) to continue my postgraduate training part-time in a major academic facility after completing the three-month observation period. I received an emphatic denial in the name of an IMA representative to my question as to whether I would be required to complete a year of residency; I, as a US graduate, would be eligible for a three-month observation period. The IMA did not reiterate that position after I had arrived in Israel.  

After completing residency, I submitted all of the requested documents to the IMA, then sat and waited.  The first response came late that summer - that the IMA would not review my file until I had passed the US pediatric board exam (an exam that 97% of graduates from my program do pass). Through the Fall, I continued to ask for guidance so I could begin the process of finding a hospital to host me. I received no response. On February 1, almost five months after I arrived in Israel, I received a letter (dated October 29 but not sent to me) in which the IMA required that I find my own residency position (a position funded by the cash-strapped hospital rather than the Ministry of Absorption), and that I then complete an additional twelve months of residency on an inpatient ward, with residency hours and every-fourth-night call. I would have to repeat the training which I had already completed.

The choices I have made in my life preclude an additional twelve contiguous months of residency. My children, strained as it is by their immigrant status, need me at home more regularly to help with homework.  Secondly, we left at the beginning of the housing crisis in the US, and although we have drastically curtailed our spending to avoid defaulting on a commitment and a responsibility, I could not in any circumstance feed a family on a resident salary of 7,042 shekels per month. The IMA has not made an allowance for intermittent travel to the US in order the bridge this financial gap.  

I met with the head of the IMA to protest their terms. I have also met with professors at four major Israeli hospitals to arrange a year of residency on terms that would be acceptable to both myself and the IMA.  One department head told me that I was "lucky to be able to practice here at all." Others have reiterated in these meetings that they would be happy to have me as a junior resident, but would make no further allowances. A far cry from the calls I received from US university fellowship directors just months before aliya, asking me to reconsider aliya and to continue postgraduate training at their institution. 

I would love to contribute to Israeli academic medicine, as I would have been doing right now in the US.  If only Israel was open to US-trained physicians....