Hadassah in Crisis

It’s been a long time since I wrote anything, and in truth that was because life has trundled on, at a pleasant enough pace, with nothing hugely eventful to describe.

But today some strange things have been going on at Hadassah Hospital, so here goes:

Last night it emerged that the Finance Ministry has applied to the courts to put Hadassah into some sort of administration.

All Hadassah’s debts ($200m of them) will be cancelled. That’s the good news.

The bad news for us is that those debts include the salary they owe us for our work in January. In other words, we won’t be paid for this past month.

They also will enforce a 10% pay cut on all doctors, nurses and non-clinical staff. The pay cuts are likely to be even higher for doctors who do private work in the hospital.

As a result, the doctors committee declared a strike: from today we will reduce to weekend skeleton staffing levels, with operating theatres only doing emergency, cancer and obstetric surgery. Even that work is likely to be unpaid, with no guarantee that the “weekend” on-call team will ever see any salary for their time.

The impact on Jerusalem could be bad. There are three hospitals in West Jerusalem – Hadassah Ein Karem (the big teaching centre to the west), Sha’arei Tzedek (towards the centre) and Hadassah Mt Scopus (near East Jerusalem). Two of those are Hadassah owned and affected by the strike. That means that the only hospitals providing neurosurgery (including neurological major trauma), plastics and burns, liver transplants and whole bunch of other services, for the 1.2m inhabitants of Jerusalem plus significant amounts of the West Bank, are going to be effectively closed.

That’s the objective facts.

The question is how did we got to this situation?

Over the last few decades Hadassah has been haemorrhaging money, especially after negotiating a very bad deal with the HMOs for reimbursement. We just about survived due to the generosity of the Hadassah Women’s Organisation in the US. But after Madoff the HWO said they could no longer support our running costs and we started running up debts.

Last spring our Chief Exec resigned and a new guy called Avigdor Kaplan arrived. As far as I could see he acted decisively, proposing voluntary 5% cuts in salary for all employees to save the hospital, plus the loss of 200 jobs. The doctors committee reluctantly agreed; the nurses agreed to 2.5%, the workers committee (non-clinical) refused and went on strike. During that strike the picketed the hospital and even physically assaulted doctors who crossed the line to treat their patients.

It was clear there would be repercussions, and since then we have had several months were we were paid 80%, 50% and 50% of our salary on time, with the rest arriving later. But it always arrived.

No we are in a position where even that may not be happening.

In addition, Hadassah doctors had various forms of grant money held in hospital bank accounts. That includes research grants, personal grants awarded to Junior Doctors from the government, and funds from private practice. All those grants have recently been simply taken by the hospital into the central pot.

What about the future?

My fear is that the government will consider the things that make Hadassah great, to be non-affordable luxuries. Things like support for research, both financial and in terms of flexible working hours; good salaries (many doctors earned better than they would in purely government hospitals) etc.

These (especially the research) were also the reasons that I chose Hadassah over other hospitals.

Hadassah used to be known to be the best hospital in Israel by a mile. The heads of every anaesthesia department in the country were trained at Hadassah. That reputation has been slipping for close to a decade, and we now have very stiff competition from a number of places, but we felt that with determination we could regain/retain the top position.  However there is a real risk Hadassah may be stripped bare now, and become little more than a DGH.

That would be a shame for everyone.

For the moment we have been asked to remain loyal to Hadassah, and I will respect that request. I’m in the fortunate position of not having a family to support, and not having to worry about where my next meal will come from. But having said all that, when I moved to Israel, I came to the best place I could find to learn anaesthesia at the highest level Israel could offer, and perhaps contribute to medical research at that centre. If Hadassah ceases to be that place, a lot of us will start to wonder if our dreams can be fulfilled elsewhere.

A momentous day, and a question of Consent

I can’t start this posting without first mentioning my huge pride in my little sister, Becca.

On Wednesday, Becca is due to marry Ron, a wonderful man who everyone in the family adores. Now you might imagine that for the last weeks leading up to the wedding she has been focussing on all the planning for such a momentous event. In fact, she has been sitting university exams in architecture, and excelling: scoring in the top ranks of her year-group including a recent 100%. And as if that’s not enough, she decided to make her own wedding dress, because life just isn’t sufficiently busy.

But her trailblazing isn’t new. Becca was the first member of our family to make aliyah, about 5 years ago, and being our here without family, and initially without a job, had the most challenging time of it. She showed it could be done, which was no small part in encouraging the rest of us to give it a go.

I wanted to find a link to the other thing I’ve been thinking about, but I can’t so apologies for the clash in theme.

The question I had was why is there such a difference in attitudes in consent in the UK vs. Israel?

I first noticed this when I opened a bank account. In Jerusalem, I was asked to sign about 13 pages of forms, each one with dense text. When I asked what I was signing, or for an English copy, I never got a proper answer, except that it is necessary to get an account. I know that in the UK we do also sign saying “we have read the terms and conditions”, but that seems less frightening than signing 13 pages individually, each confirming that I giving away some other right.

This would all be no more than an intellectual curiosity, except that I’ve found it’s started to affect how I explain anaesthesia to patients at work.

So compare the way one surgeon tried to consent my patient, in the theatres reception:

“You want anaesthesia? Please sign here.”

(handing patient a page of dense A4 text listing all the risks of GA, including everything from pain to Malignant Hyperthermia and Death)

..to the way the nice young British immigrant doctor (Yours Truly) put it:

“Now to explain what will happen in the OR. (explanation of arriving, getting oxygen mask, IV line and drugs to go to sleep, followed by wake up in the Recovery Ward).

“I have here the anaesthetic consent form. It lists all the very rare things that can occasionally happen under GA. I know it may sound frightening but anaesthesia is extremely safe nowadays.

“If after the operation you feel pain or nausea please let us know and we will give you extra medicines to help with that. Other than that, the much rarer things that occasionally happen in anaesthesia are:

Damage to teeth

Vomiting

Aspiration of vomit

Damage to Lungs;

Heart;

Liver;

Kidneys;

Allergies to medication

One in several thousand remember their surgery despite GA

One in 250,000 don’t wake up from anaesthesia, which is extremely rare.

Do you have any questions or anything I can explain better?

If you’re happy to go ahead, would you mind signing here and dating here.”

By the end of this, the patient is starting at my wide-eyed (literally. Do you know that people’s eyes genuinely do go wide when they are afraid?)

They all sign, but I never feel that I have eased their medical journey.

I have tried different wording; being humorous; likening the odds to crossing the street (which is a bit of a lie, I have no idea what the one-off risk of crossing a road, but I suspect it is actually less than 1:250,000). None of this works for me. They all seem petrified.

Is it a kindness to put them through this? And will it ultimately make any difference? After all, they are signing the same document that includes these risks and more. In other words, can ignorance be bliss?

I will keep experimenting with other ways of saying the same thing, and who knows, maybe some day I’ll find the magic formulae for an informed, confident and happy patient.

UN Human Rights Commission Report

Just read this article in Ha'aretz about the new UN report on the settlements:

http://www.haaretz.co.il/news/politics/1.1920000

It is undoubtedly true that the UN Human Rights Commission is a joke. That it is full of countries with atrocious human rights records, and that it is more than a little bizarre the way that it focusses on Israel, rather than far more serious violations elsewhere.

However, there is still the possibility that they occasionally will speak the truth.

The settlements are unfortunately a breach of international law, because you are not allowed to transfer your population into "occupied territory". Israel has no choice but to consider the territory to be "occupied" because we don't can't extend the vote to the hostile palestinian population, but to call it Israel and not give them the vote would be true apartheid.

Worse than that: settlements seem to be the only weak spot Israel has with regards to the International Criminal Court (this was pointed out to me by an Israel lawyer friend). The ICC only intervenes if the local country's legal system is unwilling or unable to investigate a case. We have shown that we can prosecute our politicians (normally for fraud or rape), that we can prosecute soldiers in the cases of them violating human rights, but the courts have never looked at the legality of *all* settlements, and are unlikely to be able to do so. So the ICC is in a strong position to step in.

In the end, I am confident we will solve the problem in the West Bank, and withdraw from most of it:

We may do it through a negotiated settlement, having found a "partner" who can deliver.

We may do it because our conscience as a people compels it.

We may do it under pressure from foreign governments and international bodies, friendly and less friendly.

We may do it due to some economic and social boycott, similar to that seen against South Africa.

We may do it in the face of a serious uprising, unwilling to pay the cost in lives, as we did in Lebanon.

I hope for my country sake that we pick our time well, and leave under the best possible circumstances.

Shabbat Shalom

The Army

For the last several months I have been troubled by the question of army service, and it has all felt much more acute with the current conflict. I hesitated about writing about it, partly because I still don’t have an answer, and partly because it seems like a personal issue and wouldn’t be of general interest. But it does touch on a topical Israeli matter, so I thought I’d see how it goes…

I also wrote a bit at the end about my personal views about what’s going on in Gaza (and all of Israel up to Tel-Aviv and Jerusalem).

As an immigrant doctor I am officially due to be conscripted for 18 months as a Medical Officer. I would then serve up to 1 month every year of “Millu’im” (reserve duty) until I’m 45, and be available for call-up in times of war. What is unusual about my situation is that I am being given the choice whether I want to do this (partly due to an army administrative c*#k-up). And so the big question for me is whether to volunteer?

Service in the army has historically been a big deal here: It forms an old-boys network, as proven by the number of prime ministers, cabinet ministers, and even hospital senior managers who served together in elite units.

It has also been a great social leveller: unlike Eton, Oxford and Cambridge, admission into the elite combat units tended to be from all strata of society, e.g. the current leader of the opposition (Mofaz) came from a classically under-privileged background but served as an officer in Sayeret Matkal before starting his political career.

Conversely not serving was a sign of either physical/psychological illness, or shirking of civic duty.

However, much of that has changed. Less than 50% of those who could serve actually do, and employers are no longer allowed to ask about service at interviews.

So why consider volunteering? (Or as Israelis put it: “Are you crazy?!”)

The truth is, it can’t be because the 18 months are fun or heroic. A friend (Adam Albert) wrote an excellent and funny blog describing his time as an army doctor (http://www.adndeb.blogspot.co.il), and it is tough and demoralizing: 120 hour weeks playing GP to essentially healthy, whinging 19 year olds. And I have a huge amount of respect for Adam in managing to get through it.

I am also not sure in my specific circumstance that it can be justified as being the best service to the country:

The head of my department has been suggesting various projects (e.g. research) I could do at Hadassah, some of which could definitely be more useful to Israel. In contrast, I am hardly the greatest physical athlete, or combat soldier.

Those arguments against service may well win in the end, but there still seem to be a few in favour that I haven’t been able to get around:

Firstly, it is still a big right of passage shared by most Israelis. Everyone has stories of their army service, and everywhere you go, you see people in uniform. To be Israeli and not have served makes me feel like I have missed out on a big part of what being Israeli (unfortunately) is.

Secondly, there’s no getting round the fact that it is a duty. If I volunteer and the army (unbelievably) chooses to place me in Hadassah doing research, that would be their choice. But as Ze’ev, a former boss of my mum’s put it: “Israeli men don’t use their time “usefully”; they serve their country for 3 years”.

Finally, and perhaps most positive of the reasons, is the prospect of better jobs in the future. During Milu’im you can get assigned to more special units, and I know of doctors who currently or in the past have served in such units as 669 (combat search-and-rescue/civilian helicopter evacuation), Alpianistim (the alpine trained troops in the Golan), Sayeret Egoz (elite unit of Northern Command), and Sayeret Matkal (the most elite unit in Israel and amongst the best in the world). But to do those, you must do your time as an ordinary doctor for 18 months first.

That is currently where I am at. I have agreed with my Head of Department that I will do 2 years of pure clinical training, and then we’ll see. I am currently edging towards volunteering at that stage, but the opposing pressures are great.

I know this is getting long, but I feel that I can’t finish without mentioning my experience of the recent conflict.

To start with, I wanted to say something about the political question: Was Israel right to enter into Operation Pillar of Cloud?

I see myself as firmly on the Left of the political spectrum. I believe that the Palestinians have a right to their own country and that it is in Israel’s interests for it to be independent and prosperous. My Right-leaning friends often object that the Palestinians will just use their country as a base to launch rockets, and my (admittedly slightly cynical) response is: “that’s fine”. They would then be treated like any other country that chose to launch rockets at a neighbour - it would be an act of war, and may the best army win.

Ever since I arrived here the newspapers report almost daily counts of rockets hitting towns in Israel, and they increased markedly in recent weeks. I don’t expect the British media to have covered that (it’s hardly of interest to most Brits), but it does give some context.

If we on the Left are serious about the Palestinians getting a state, than we must also be serious about that state being held accountable.

Leaving politics aside, my own experience of the war has been thankfully minor. Jerusalem has had one rocket attack, and I happened to be on holiday in the North at the time. My sister on the other hand, in Tel Aviv, has had frequent air-raid sirens and temporarily moved out of her flat to her friend’s, because it has a reinforced room.

What I did see was huge movements of troops and armoured vehicles when we were travelling on the roads (I won’t name units and where they were going on the internet). The whole atmosphere has also changed. Everyone is talking about the conflict, and some people with real anxiety.

At the moment, there is talk of a cease-fire but it’s all very vague. Let’s hope that calm will finally come to this region once and for all.

P.S. Since writing this we had another rocket hit the Jerusalem area this afternoon. I was in clinic at the time and didn’t hear the sirens (either a worrying sign about local civil defence measures, or a positive sign of how much stone and concrete was between me and the outside world!)

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.