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Physician assistants in Israel

Berkowitz, Oren PhD, MSPH, PA-C; Jacobson, Eyal MD, PhD, MHA; Fire, Gil MD, MHA, MA; Afek, Arnon MD, MHA

Journal of the American Academy of PAs: December 2014 - Volume 27 - Issue 12 - p 7–8
doi: 10.1097/01.JAA.0000456577.54756.e8

Oren Berkowitz is director of research and an assistant professor in the PA program at Boston University School of Medicine in Boston, Mass. Eyal Jacobson is medical assistant to the director of health administration in the Israel Ministry of Health. Gil Fire is deputy director of the Tel Aviv Sourasky Medical Center in Tel Aviv, Israel. Arnon Afek is director general of the Israel Ministry of Health and director of the NY/American MD program at the Tel Aviv University's Sackler Faculty of Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise.

A perfect storm has brewed that is causing most countries to take a good hard look at their healthcare systems and workforce needs. On the one hand, the patient burden is increasing. Advances in modern medicine are helping people live longer with more complex and chronic diseases. On the other hand, those advances are more difficult to sustain. Medical innovation has caused a significant rise in the cost of healthcare delivery and created a need for a specialized workforce. The philosophy of healthcare is also changing toward team-based medicine. The focus has shifted toward increasing quality, safety, and patient-centered care.

With these goals in mind, Israel has been trying to develop its own physician assistant (PA) profession. Israel predicts a significant lack of physicians in the near future. Many of the physicians who emigrated in the 1990s from the former Soviet Union will soon be retiring. Several of the medical specialties are already in distress and need an urgent boost in manpower.

Just like the United States did, Israel is encountering various political and legislative obstacles to creating a PA profession. In 2009, a white paper developed by the Israeli Medical Association (the physician professional organization) stated its opposition to establishing a PA profession in Israel, suggesting instead that the country “reexamine its investments into the existing physician professions.”1

Swinging the pendulum back was a 2010 report from the Israel Ministry of Health's Healthcare Workforce Committee, which recommended “an investigation into the possibility of developing a model in Israel... similar to physician assistant, nurse practitioner, anesthesia assistant...” with the expectation that these healthcare providers would “increase the quality of the clinic and the productivity of the physician, the clinic, and the hospital and clear up time for the physician.”2

Finally, the former director general of the Israel Ministry of Health, Roni Gamzu, convened a PA committee that was chaired by Arnon Afek and Gil Fire. Their first meeting took place in August 2012 and their final recommendation was published in July 2013.3

The five specialty areas identified as having the greatest workforce need were anesthesiology, emergency medicine, surgery, internal medicine, and pathology. The committee considered several ways to address the physician gap, including models such as the American PA and NP, or creating a new healthcare profession.

The committee determined that most of the clinical needs of these specialties can be met by creating a job in which a skilled professional monitors and manages patients of varying degrees of acuity, provides routine medical care, and acts as a case coordinator/liaison between the various healthcare team members. Specifically for pathology, a laboratory worker or a foreign medical school graduate who didn't pass the Israeli licensing examination can be used. The legislative process for PAs in pathology was recently completed, and the Ministry of Health is preparing the training program for the first group.4 The legislative process for creating PAs in emergency medicine and anesthesiology also is expected to be complete this year.

Creating a new profession from scratch is not an easy task in any country. The philosophy that the Israel Ministry of Health has decided to embrace involves using an existing profession and expanding on its current role. This would be an easier and faster legislative route than making something brand new. Therefore, according to the Ministry of Health's recommendations, the new PAs will likely be paramedics who are given additional education and training in order to fit their new role. They will start by only practicing within the specialties outlined, with the hope that the profession can naturally evolve over time. We can find parallels to this quandary in the early days of the American PA program—military medics were called upon to create this profession and garner support for legislation. The hope in Israel is that these special paramedics-turned-PAs will evolve naturally into their new role and create a culture of acceptance and appreciation in the healthcare workforce. Their growth should lead to the creation of legislative advances, professional associations, and expanding academic programs.

No one-size-fits-all solution exists to address global healthcare needs. Every country faces its own set of challenges. Many of the growing pains that other countries encounter can be predicted by reading the history of the American PA profession. Born out of the necessity to fill a need and opposed by legislative obstacles, fear, and protectionism, PAs worldwide have proven themselves to be resilient and have grown to become indispensable players on the modern healthcare team.

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1. Israeli Medical Association. Preparing for the healthcare of tomorrow. 2009. [Hebrew] Accessed September 5, 2014.
2. Israel Ministry of Health. Report of the planning committee of the Israeli healthcare workforce. 2010. [Hebrew] Accessed September 5, 2014.
3. Israel Ministry of Health. Report of the physician assistant committee. 2013. [Hebrew, subscription required] Accessed September 5, 2014.
4. Israel Ministry of Justice. Physician regulations (corrections). 2014. [Hebrew] Accessed September 5, 2014.
© 2014 American Academy of Physician Assistants.