Monday, 10 September 2012

Medicine in Israel

So, I have now been working as an Israeli doctor for precisely 1 week and 1 day, which puts me in the perfect position to make sweeping generalisations about medicine in Israel, without the complication of experience to prove me wrong. So here goes..

But first of all, a bit about where I’m working.
Hadassah Hospital is the biggest teaching hospital in Jerusalem, and provides a whole range of specialties, including being the neurosurgical and cardiothoracic surgical centre for the area. We therefore get lots of trauma cases. We also cover a diverse population including much of the West Bank, and the Ultra Orthodox population of Jerusalem.

For the first month they have put me on the Intensive Care Unit, as a way to learn how the system in Israel works, before letting me lose as an independent anaesthetist. In 2 months time I will sit an exam, and if all goes well, will start to fly solo after that.

Now for my observations and generalisations:

Generalisation Number 1:   Medical care is hyper-specialised.
We run the “General ICU”, but there is a separate “Medical ICU” (for sick medical patients), “Neurosurgical ICU” (lots of head injuries), “Cardiothoracics ICU”, “Vascular Surgical ICU”, etc..
This means that we tend not to see the kind of multi-organ failure, medical patients that you would see in a typical British ICU.

Services are contracted out in a big way too, so when we saw a small pneumothorax (collapsed lung) on a chest X-ray, we call the cardiothoracic surgeons and they put a tube in for us (rather than do it myself as I did in England). If a patient complains of chest pain (despite minimally elevated troponin and ribs being tender), you call the cardiologist, etc..

This does seem to reduce slightly from the aura of the Intensivist as the Ultimate Physician who can treat the sickest of the sick (the hallowed status I was hoping to achieve). That title probably goes to the physicians in the Medical ICU.

Number 2:   Israelis use trade names in a huge way – which drives me crazy!
It is true that the human body is the same everywhere, and even that the treatments don’t differ so much between countries, but all that is useless if you have no idea what medical they are talking about.
We discuss how much Dantoin a head injury patient gets; most of our patients are on Lasix; all of them are on Nexium; Anyone in pain gets Optalgin (or Acamol); Patients who are agitated get Klonopin or Haldol; And if their heart is beating too fast they get Deralin or Neobloc.

It turns me into a clueless lump on ward rounds, where I am busily checking my iPhone for every medication mentioned.

Number 3:   Patient Autonomy is far more important here
In the UK:
We talk about the patient being given all the information, and making the decisions. In fact, we rarely allowed them to see investigation results, and only after we had vetted them. Getting hold of your notes took months, and you had to pay for it. The reason: Doctors know best, and patients will only get confused if they get results without explanations.

In Israel:
All GP blood results go on an online system which the patient can check from home. They would expect to discuss them with their GP, but it is not uncommon for them to read them and seek second opinions. So I get calls from family members asking why their TSH is fractionally elevated (with no symptoms and normal T4), or what to do about a minimally low folate (with no anaemia).

Similarly Do Not Resuscitate decisions seem to genuinely involve asking the family whether they want resuscitation to be carried out, as opposed to in England, where I always went into such discussions with a strong opinion of my own whether resuscitation was appropriate (generally not, if I am bringing up the subject).

Number 4:   End of life care never seems to end.
I don’t know if this is due to religious sensitivities, but there seems to be very little sense of limiting care.
So everyone (including patients in their 90s with cancer and multiple medical problems) are automatically taken to Intensive Care if they are sick, where they are given everything at our disposal. They get intubated, ventilated, started on inotropes (powerful drugs to push their heart and organs to the limits), and get full CPR. Do Not Resuscitate Decisions are very rare.

The result: frail patients spending months or years on ventilators with no chance of recovery.
Basic medical wards have their own ventilated patients, and Herzog Hospital provides entire wards for these patients to receive continuing care after they leave us.

Anyway, I don’t know how many of the non-medics will have got this far, but I thought I’d end on a bitter-sweet story from today.
We received a 22 year old girl from Ramallah with an aggressive cancer in her chest (metastatic osteosarcoma). She had a cardiac arrest on our ICU and we got her back – something which I am not at all sure was the right course of action, (but see Number 4 above).
I volunteered to sit down and break the bad news to the family, along with another trainee, Tamer (an new trainee from Bethlehem who fled from Egypt in the troubles and is now in Hadassah), who translated.
After those sorts of conversations you always feel a bit hollow inside, even though the family were extremely understanding, and even thanked us for the care we are giving her!

On the way home, on an impulse, I got off the bus a couple of stops early, and discovered another of the benefits to working here:

I stepped off the road and found myself walking for 45 minutes down slopes of Jerusalem Pine trees, towards the ancient village of Ein Karem, and the Russian Basilica there. The valley opens out before you, with Hadassah Hospital sitting like a medieval castle overlooking it all.
These photos really don’t do it justice, but after 45 minutes you can’t help but feel like your head is cleared, and you are ready to return to civilisation.


  1. Wow. Interesting to read your thoughts and day-to-day. Especially enjoyed the photos.

  2. from what I have heard from my American resident friends, it sounds like all the things you mentioned are very similar to there... do share the pros of the system as well when you come across them ;)