We have thus far dealt with the physician shortage, but this is just one aspect of the workforce crisis, which is also sharply expressed in the shortage of positions in the public healthcare system. Increasing the number of doctors alone will not resolve the existing shortage, if the new doctors have no way of being absorbed by the system.

There is no doubt that the shortage of staffing standards in the public healthcare system is a difficult problem on both a national and professional level. Doctors' staffing standardization is a matter of the utmost consequence. For many years, the IMA has been involved in this issue, trying to promote it against the indifference of the state, and this matter constitutes an integral part of the collective agreements. Doctors' staffing norms, which were set according to staffing standardization keys in the 1970's, are outdated, and fail to account for the following parameters:
 

• Technological changes in the medical world
• The growth and aging of the population
• The scope of medical activity
• The development of the medical professions and sub-professions.¹
• Changes in the manpower quota enabling more women to enter the field – a trend implying a higher incidence of maternity leave, nursing hours, part-time work etc. It goes without saying that all this creates a need for higher staffing standardization.
   

The inadequate staffing norms have severe ramifications that include the following:
 

• Prolongation of the waiting time for receiving medical treatment
• Increase in doctors’ workload
• Insufficient manning of hospital wards
• Unreasonable overload of shifts, imposed mainly on the residents
• Acceleration of burnout among doctors
• Compromising the quality of medical care
   

Over the years, a number of committees have warned of the shortage of positions, with one of the major problems in this area being the fact that the number of regulated positions in hospitals is determined solely by the number of beds – an outdated, unfounded and unrealistic method, extremely incongruous with the current circumstances.

We therefore suggest that additional parameters be included in the establishment of regulated positions, such as the types of activity and patients. Staffing standardization must address the nature and essence of the work in each medical field.

It should be emphasized that the shortage of regulated positions is not limited to hospitals. With the current staffing regulations, the time allotted to each patient in the context of community medicine is too short, and the health funds (kupot cholim) are consequently attempting to shift some of the doctors’ activities to the realm of nursing, another field which suffers from under-staffing. This problem is exacerbating with time, since medical tests become more complex with the advancement of medical technology and the increase of scientific knowledge. For this reason, more time should be allocated to each patient. This problem results from budgetary constraints, which are determined according to the government's priorities.²

The Amorai Committee, whose recommendations were published in December 2002, concluded that the human resources system is outdated and does not correspond to the developments in healthcare services. The State Comptroller too, in his 2003 and 2008 reports, maintained that the staffing standards for human resources are not compatible with the needs of the healthcare system. Similarly, all of the committees who examined the staffing standardization problem in the context of the IMA's initiative to tackle the challenges of the public healthcare system in 2009, reached the sweeping conclusion that the failure to update the staffing standardization agreements for dozens of years, had a severely damaging effect on the public healthcare system and the doctors’ working conditions.³

Among other things, the Amorai Committee recommended that a professional body that specializes in workforce standardization and process engineering investigate the staffing standardization system in public hospitals, and that the body’s recommendations be gradually implemented in all hospitals, but the Ministry of Finance refused. In response, in 2006, the IMA hired the services of the Ergo engineering company, in order to develop a model staffing- standard for physicians, which would be adapted to the discipline inspected and take into account other relevant parameters apart from the number of beds, including justified and seasonal absences, activity outside the wards and clinics, surgery etc. Today, staffing standards in general surgery is determined according to the number beds, but it was found that doctors spend an average of 25% of their time in operating rooms, a fact not taken into account in the staffing standardization.  

The pilot was conducted in five different wards in hospitals throughout Israel, in various medical specialties (internal medicine, pediatrics, general surgery, gynecology, obstetrics, and orthopedics) in cooperation with ward directors and the scienctific associations. Their unequivocal conclusion was that all the wards require much higher staffing standards than those that currently exist. The additional staffing standards required range from 25% to 100%.

The investigation also revealed that the time doctors spend on personal activities is about half the time designated for these same activities in other professions, based on research. This means that doctors work more and rest less than commonly accepted, although their field of employment requires optimal alertness and concentration at all times. Staffing standards were also discussed in arbitration proceedings between the IMA and the Ministry of Finance, but the employers objected to this discussion, claiming that the subject was not part of the arbitration mandate.⁴

IMA is currently conducting another staffing regulations project, using the model that was validated in the previous project to examine various disciplines: general surgery, radiology, cardiology, nuclear medicine, neonatology, physiatry and rehabilitation, internal medicine, anesthetics, pathology, pediatrics, oncology, gastroenterology, nephrology, neurology, occupational medicine, rheumatology and neurosurgery.

The unfortunate state of medical human resources in the healthcare system was once again exposed. Preliminary findings indicate that for internal medicine wards in which 38 beds have an occupancy rate of over 80%, 16.4 positions are required as opposed to the 11 that currently exist.⁵ In the general surgery ward, it was found that for 31 beds with an occupancy rate of over 80%, 17 positions are required as opposed to the 11 that currently exist.⁶

 These findings clearly indicate that these fields currently suffer from inadequate staffing standards. Moreover, it was once again found that the staffing standards are outdated and do not reflect the reality. For example, in the field of neurology, it was found that current staffing standards are determined by patient visits to the clinic, whereas in practice, much of the work involves providing consultation services in hospital wards and the emergency room.

The shortage of staffing standards intensifies the doctors’ feelings of hopelessness about the medical profession, which results in their accelerated withdrawal from the profession and emigration, and contributes to the diminishing status of the field of medicine. This implies that the under-staffing is closely linked to the shortage of physicians, which results from shortsighted government policy. The system tries to find "creative" solutions for under-staffing instead of tackling the root of the problem. The result is temporary, undesirable arrangements such as joining wards and having one doctor on duty or call in two wards simultaneously. These arrangements compromise the quality of care provided as well as the patients’ safety. The individual doctor is forced to shoulder the repercussions of the system’s shortcomings, and handle daily professional, emotional and physical strain, in the form of pressure, excessive workload, burnout, exhaustion and even patient violence – virtually on his own. These phenomena are accompanied by an ongoing sense of dissatisfaction and lack of fulfillment, which ultimately drive the individual doctor away from the system. The individual doctor’s decision to leave the profession increases the strain on his/her colleagues, causing further deterioration of their working conditions, and exacerbating the situation of the medical institution and the healthcare system at large, in an ongoing process. 

Thus fades the appeal of medicine as a profession and as a mission, and with it, the public’s trust in the public healthcare system.

¹ The current tendency in the medical world is sub-specialization (e.g., orthopedists specializing in surgery of the spine, as opposed to those who specialize in the palm). More sub- specialties require more standards.

² IMA – Preparing for the medicine of the future – IMA's initiative to tackle the challenges of the healthcare system 2009, p. 21-23.

³ Ibid.

⁴ Ibid.

⁵ IMA, Presentation: Standardization 17 March 2011.

⁶ It should be emphasized that the project is still carried out, and the data is not final.