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A Study of the Workforce in Emergency Medicine in Israel: 2003
The Journal of Emergency Medicine, Vol. 33, No. 4, pp. 433– 437, 2007 Copyright © 2007 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/07 $–see front matter
doi:10.1016/j.jemermed.2007.04.016
International Emergency Medicine
A STUDY OF THE WORKFORCE IN EMERGENCY MEDICINE IN ISRAEL: 2003 Michael J. Drescher,
MD,*†
Limor Aharonson-Daniel, PhD,‡ Bella Savitsky, and Kobi Peleg, PhD, MPH‡
MPH,‡
Joseph Leibman,
MD,§
*Department of Emergency Medicine, Sheba Medical Center, Tel Hashomer, Israel, †Division of Emergency Medicine, Hartford Hospital, Hartford, Connecticut, ‡Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel, and §Department of Emergency Medicine, Bikur Cholim Hospital, Jerusalem, Israel Reprint Address: Michael J. Drescher, MD, Division of Emergency Medicine, Hartford Hospital, Hartford, CT 06102
placed on increasing EM staff and resident positions. The need seems most acute in medium-sized hospitals and during off hours and weekends. © 2007 Elsevier Inc.
e Abstract—Emergency Medicine (EM) was officially recognized as a specialty in Israel in 1999. In 2003 the first nine Israeli trained emergency physicians (EPs) were certified. This survey was undertaken to assess current staffing of Emergency Departments (ED) in Israel and to attempt to estimate future staffing needs for EPs. A survey was sent to all ED directors at general hospitals in Israel. We asked questions relating to staffing by number of physicians, type and level of training, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Twenty-four of 25 (96%) EDs responded. There were 59 EM specialists registered in Israel; there were 37 EM residents. EDs reported a total of 1,872,500 visits annually. Emergency care is otherwise given by specialists and residents in other fields, and non-specialist physicians. At large hospitals there is an average of 2.5 EM specialists during daytime hours, and another four specialists of other types on duty. During the night in large hospitals, there is an average of <1 specialist of any kind (typically not EM) on duty. In most EDs, care is turned over to non-specialists (residents and others) during evenings and nights. The recognition of the need for Emergency Medicine as a specialty in Israel has not as yet translated into care of emergencies by EPs for most patients. To adequately staff EDs with physicians trained in EM, an emphasis needs to be
e Keywords—workforce; Emergency Medicine; Israel; staffing; international
INTRODUCTION Background In 1992, the Israeli Association for Emergency Medicine (IAEM) was formed to further emergency care and the professional status of Emergency Medicine (EM) in Israel (1). In 1999, after a period of investigation and a concerted effort by the existing leadership of the IAEM, Emergency Department heads from around the country, and with help from leaders in EM abroad, the Israeli Ministry of Health officially recognized EM as a specialty (2). Criteria for specialist status were published, as were a curriculum and site conditions for training programs in EM. In November of 2003, the first cohort of nine Israeli trained emergency physicians (EPs) successfully passed the certification examination given by the Israeli Association for Emergency Medicine under the aegis of the Scientific Council of the Israeli Medical Association (IMA).
Presented as an abstract at the Research Forum, American College of Emergency Physicians, San Francisco, California, October 2004.
RECEIVED: 7 October 2005; FINAL ACCEPTED: 8 November 2006
SUBMISSION RECEIVED:
8 June 2006; 433
434
M. J. Drescher et al.
Importance With the recognition of the specialty of Emergency Medicine in Israel, and the inception of training programs, there is a need to estimate the demand for EPs. This estimate needs to be based on current workforce and work practices, and anticipated future needs.
Goals of this Investigation This study aims to examine the existing workforce of physicians working in Emergency Departments (EDs) in Israel, to better delineate the need for EM specialists in the future.
Figure 1. Number of full-time physicians staffing Emergency Departments in Israel by hospital size.
Characteristics of Study Subjects METHODS Setting In July of 2003, we performed a study of the workforce of all 25 general hospitals with EDs countrywide in Israel.
There were 7 small, 11 medium, and 6 large hospitals in the study. Average annual ED census for each group was 39,000, 88,500, and 104,500, respectively.
Main Study Results Study Design We conducted a cross-sectional survey designed to assess the numbers, level of training, and specialty (if any) of physicians working in EDs. We further asked about differential staffing at various times during the day and the week. Additional questions regarding ED and hospital size, and ED census were included. The survey was adapted from a previously published workforce study (3). Hospitals were divided into three groups by number of beds, as follows: small (up to 399 beds), medium (400 – 699 beds), and large (700 beds and up). We sent the survey to the directors of EDs in all general hospitals in the country that have EDs. If surveys were not initially returned, telephone call follow-up was done to encourage participation. Data were entered using SAS statistical software (SAS Institute Inc., Cary, NC), which was subsequently used for data analysis. We stratified the data by physician type, shift, and hospital size. This study was exempt from Institutional Review Board approval as it did not involve human subjects or their records.
RESULTS Twenty four of 25 (96%) survey instruments were returned.
We found that there were a total of 140 physicians employed full time by the ED over all the hospitals. There were another 94 physicians employed part time by the ED. Of these, 59 were certified Emergency Medicine specialists. Other specialties represented were mainly internists, surgeons and orthopedists. The average number of full-time physicians of all types employed by the ED— by hospital size—is shown in Figure 1. These numbers do not include other physicians working in the ED, either “on call” or “covering” the ED for other departments. The number of full-time physicians working in the ED varies by hospital size disproportionately to the difference in ED census, with medium-sized hospitals having the lowest full-time staff-to-visit ratio (Figure 1). The number of physicians actually working (whether belonging to the ED or to other departments) in the ED and the type of physician by level of training and specialty vary from shift to shift and from weekday to weekend (Figure 2). Throughout the country, there are essentially no EM specialists on duty during the night shift and very few during the evening. On an average weekday in Israel, in all EDs, there were 51 EM specialists working the day shift, five working the evening shift, and an average of 1.5 EM specialists on the night shift in the country at large.
Emergency Medicine Workforce in Israel
Figure 2. Average daily number of physicians staffing Emergency Departments in Israel by specialty and hospital size.
DISCUSSION It is clear from our findings that, by and large, the practice of EM in Israel is still done by non-EM-trained or certified physicians. Often, these are specialists in other fields on the ED staff, but just as often, and especially during nights and weekends, the care of patients in the ED is left to unsupervised residents in various specialties, at various stages of their training, or to physicians without specialist status who are not in a training program. In addition, there is no official structure as yet for employing physicians during evenings and nights other than the system of “taking call” in the ED from 4:00 p.m. to 8:00 a.m. the next day on weekdays, 1:00 p.m. to 8:00 a.m. on Fridays, and 8:00 a.m. to 8:00 a.m. (24 h) on the Jewish Sabbath (Saturday). Therefore, the typical physician staffing the ED during most of the hours of the week is a resident physician at some level of training in one of several non-EM specialties, who is working a 16-h shift after having already worked 8 h in his own department. The shortage of full-time EPs (of any specialty) seems to be worst in the medium-sized hospitals. There, the average number of full-time physicians employed in the ED is 5.3. This is in contrast to large hospitals, where the average ED census is only 18% more but there are nearly double (9.3 per ED) the average number of phy-
435
sicians employed full-time in the ED. This would imply an even greater dependency on physicians from other departments to staff the ED than in the larger centers. The number of ED physicians per ED visit seems to be small relative to that reported by Moorhead et al. in their study of the workforce in EM in the United States (3). There the authors report finding an average 7.85 physicians (needed to fill 5.29 full-time positions) scheduled to staff the ED with an average of 23,912 ED visits (3). In our sample, we found 140 full-time ED physicians (of all levels and specialties) in 24 hospitals (average 5.8) caring for an average of 78,000 ED visits annually. This does not include physicians (typically residents) assigned to cover the ED “on call” during evenings, nights, and weekends—which is the rule in most, if not all, Israeli hospitals. It would seem that these physicians, caring for patients in the ED as described above but not counted as ED staff, account for much of the discrepancy. It is also possible that the physician-patient ratio is larger in Israel than in US Emergency Departments. Various estimates have been published on the need for EPs for a given population. One formula is based on the number of ED visits in a given area (4 – 6). Another formula estimates staffing needs according to the number of EDs in a given area (7). By these formulas, given approximately 2 million annual visits to 25 EDs in Israel, the number of full-time EPs needed to adequately staff an ED that is open around the clock would be 400 and 118, respectively. Clearly, these estimates are incongruous, and the latter most likely reflects a situation in which small EDs are covered by a single physician at any given time. This is not relevant to the situation in Israel, where even EDs at small hospitals see a median of 47,000 annual visits (mean number of visits, 39,000). These formulas have been shown in other circumstances also to underestimate the need for ED coverage (8). The ratio of EPs in the United States relative to the population has been estimated at 1 per 10,000 population. The equivalent ratio in Israel would call for approximately 600 EPs at any given time for the population of 6 million (9). In contrast, according to a recent government publication from the United Kingdom, there are 600 EPs at the consultant or attending level in all of England, caring for 16.5 million ED patients. This reflects a model of emergency care that relies heavily on Nurse Practitioners, General Practitioners, and specialist consultants from other departments. It does not include physicians in training (10). Assuming a parallel ratio and model of care in Israel would require only approximately 72 senior EPs at any one time. However, the British Faculty of Accident and Emergency Medicine has estimated a need for one consultant (attending or senior) EP per 12,000 patient visits. This is assuming a chiefly
436
supervisory and administrative role (11). A similar model in Israel would require about 166 senior EPs. Emergency Medicine is, as is Medicine in general, practiced and organized differently from country to country and area to area. And within each country, EM is developing at various paces and in different directions over time. The following are some examples in the context of which one may compare the development of EM in Israel: ● In Japan, as of 2001, there was no recognized specialty of Emergency Medicine, however, there are physicians specially trained in acute care and certified by the national professional organization, focusing primarily on trauma. The concept of a dedicated Emergency Department, as it is known in the west, reportedly does not exist, and there is no obligation on the part of a physician to accept a patient for emergency care if he does not feel, for whatever reason, that he can properly care for the patient, often requiring ambulances to circulate and make multiple requests before finding an accepting institution (12). ● The Netherlands, about two and a half times the size of Israel by population, with a generally advanced level of medical care, seems to be at a comparable stage of development in EM to that of Israel. As of 2001, the specialty of EM had been officially recognized and the Anglo-American model curriculum adopted, but in only two of 126 hospitals was there a permanent staff of emergency physicians. Otherwise, patients in the ED were cared for by rotating residents in various specialties without direct onsite attending supervision. At that time, there were four hospitals with residencies in EM with a total of 14 residents. Emergency nurses who are permanently assigned to the ED play a large role in the delivery of emergency care (13). ● Emergency Medicine in Hungary, a country of about 10 million, has moved in recent years from the previous Soviet model of health care, where there were essentially no EDs, but rather General Admitting Departments that were understaffed and underequipped for the work of a modern ED. As of 2001 there were only nine EDs in the country, at least one of which was staffed with full-time physicians from various specialties. Training in EM is at the fellowship level or may be done as a combined EM/Internal Medicine program. Until recently, however, traumatology was not considered part of the scope of Emergency Medicine (14). ● In Switzerland, with 7 million residents and a technologically and organizationally advanced medical system, there is great variation in the training of caregivers in the ED. The level of training of physicians working in EDs varies largely and depends mainly on the size of hospitals and internal policies. In larger hospitals, ED physicians are often specialists, certified
M. J. Drescher et al.
in emergency or intensive care. In smaller hospitals, ED care is usually provided by residents without formal, postgraduate emergency care qualifications, closely supervised by higher-qualified physicians (attendings or seniors). Residents have usually attended qualified in-house training, although supervision is not always optimal (15). A recent study in Switzerland showed that, among other interventions, improving supervision of inexperienced physicians and instituting specific training in EM topics for physicians in the ED improved triage categorization, and decreased time intervals to care in 12 EDs in Switzerland (16). Two broad visions of emergency medical care have been described, the Anglo-American and the European models. The former is based on specially trained hospitalbased physicians to deliver a broad range of services for all patients presenting to a separate Emergency Department. In contrast, the European model focuses on delivering resuscitative care in the field; this care is usually provided by anesthesiologists, with subsequent triage of patients directly to specific specialty services for definitive care (17). Emergency Medicine in Israel seems to be following the Anglo-American model. Within that model, however, there is still debate among Israeli EPs as to the future direction of EM in Israel. Some would favor the British model, with relatively few senior EPs, whereas others favor the North American model, in which certified senior EPs being present and responsible for patient care at all hours is the standard. Nonetheless, the Israeli medical establishment, in its recognition of the specialty of EM with its attendant training, curriculum, and certification examinations, has established a standard of EM to be met. In November of 2003, the first cohort of Israeli trained EM residents sat for their written and oral certification examinations and the first group of nine Israeli home-grown EPs went into practice. At the time of this survey, there were 59 certified EM specialists in Israel to care for the nearly 2 million patients in the ED annually. Most of these EM specialists were recognized in the “grandfather period” due to experience working in or directing EDs. This track to specialization has effectively been closed. The coverage of these specialists is not uniform, with their presence in the ED heavily weighted to weekday day shifts and absent or nearly so on nights and weekends. LIMITATIONS Our data were collected from department heads. Although assurances were given that the data would be kept confidential, except in the aggregate, it is possible that fear of making workforce data public, for whatever rea-
Emergency Medicine Workforce in Israel
son, may have caused respondents to answer inaccurately. A more rigorous investigation including site visits would guard against this to some extent. We did not inquire as to the variability of staffing given the dependence on extra-departmental staff, or day-to-day problems in filling shifts with physicians for this or other reasons. The dependence on physicians from outside the department may cause considerable variability in staffing, which may not be reflected in the survey reports. More detailed demographics on emergency physician age and expected work longevity would be of interest. CONCLUSION Emergency Medicine is recognized in Israel as a distinct specialty within the house of Medicine. It has not, however, defined a national standard in terms of its status in the hospital, scope of practice, etc. There seems to be a shortage of EPs, especially during off hours. Given the number of EM specialists currently certified and the distribution of specialists on duty over the course of the day and night, the odds are against any given patient being cared for in the ED by an EM specialist. Whether or not the public and political leadership in Israel see ED staffing as a major public health issue will determine whether resources will be channeled so that there will be more EM specialists caring for patients with emergencies, whenever they may present. REFERENCES 1. Waisman Y, Amir L, Or J. Emergency medicine in Israel: state of the art. Ann Emerg Med 1995;26:640 –2.
437 2. Halpern P, Steiner I. Development of emergency medicine programs in Israel and Canada: a tale of two countries. CJEM 2002; 4:218 –23. 3. Moorhead JC, Gallery ME, Hirshkorn C, et al. A study of the workforce in emergency medicine: 1999. Ann Emerg Med 2002; 40:3–15. 4. Mills P. The emergency department: organization and staffing. In: Schwartz GR, ed. Principles and practice of emergency medicine, 2nd edn. Philadelphia: Saunders; 1986:622–5. 5. Hannas RR. Staffing the emergency department. Hospitals 1973; 47:83– 6. 6. Van de Leuv JH. Physician staffing in management of emergency services. Rockville, MD: Aspen Publishers; 1987:33– 8. 7. Gallery ME, Allison EJ, Mitchell JM, Williams R. Manpower needs in academic emergency medicine. Ann Emerg Med 1990;9: 107–10. 8. Haase CE, Lewis LM, Kao B. Do estimates of emergency physician workforce underestimate current needs? Ann Emerg Med 1996;28:666 –70. 9. Holliman CJ, Wuerz RC, Chapman DM, Hirshberg AJ. Workforce projections for emergency medicine: how many emergency physicians does the United States need? Acad Emerg Med 1997;4: 725–30. 10. Alberti G. Transforming emergency care in England. Department of Health, October 2004. Available at: www.dh.gov.uk/ publications. Accessed July 25, 2007. 11. Workforce in emergency medicine. Faculty of Accident and Emergency Medicine. Available at: http://www.emergencymed.org.uk/ CEM/Background/workforce%202004.asp. Accessed July 25, 2007. 12. O’Malley RN, O’Malley GF, Ochi G. Emergency medicine in Japan. Ann Emerg Med 2001;38:441– 6. 13. de Vries GMJ, Luitse JSK. Emergency medicine in The Netherlands. Ann Emerg Med 2001;38:583–7. 14. Nemeth J, Piko K. Emergency medicine in Eastern Europe: the Hungarian experience. Ann Emerg Med 2001;37:399 – 401. 15. Osterwalder JJ. Emergency medicine in Switzerland. Ann Emerg Med 1998;32:243–7. 16. Schwappach DLB, Blaudszun A, Conen D, Ebner H, Eichler K, Hochreutener MA. “Emerge”: benchmarking of clinical performance and patients’ experiences with emergency care in Switzerland. Int J Qual Health Care 2003;15:473– 85. 17. Kirsch TD. Emergency medicine around the world. Ann Emerg Med 1998;32:237– 8.
doi:10.1016/j.jemermed.2007.04.016
International Emergency Medicine
A STUDY OF THE WORKFORCE IN EMERGENCY MEDICINE IN ISRAEL: 2003 Michael J. Drescher,
MD,*†
Limor Aharonson-Daniel, PhD,‡ Bella Savitsky, and Kobi Peleg, PhD, MPH‡
MPH,‡
Joseph Leibman,
MD,§
*Department of Emergency Medicine, Sheba Medical Center, Tel Hashomer, Israel, †Division of Emergency Medicine, Hartford Hospital, Hartford, Connecticut, ‡Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel, and §Department of Emergency Medicine, Bikur Cholim Hospital, Jerusalem, Israel Reprint Address: Michael J. Drescher, MD, Division of Emergency Medicine, Hartford Hospital, Hartford, CT 06102
placed on increasing EM staff and resident positions. The need seems most acute in medium-sized hospitals and during off hours and weekends. © 2007 Elsevier Inc.
e Abstract—Emergency Medicine (EM) was officially recognized as a specialty in Israel in 1999. In 2003 the first nine Israeli trained emergency physicians (EPs) were certified. This survey was undertaken to assess current staffing of Emergency Departments (ED) in Israel and to attempt to estimate future staffing needs for EPs. A survey was sent to all ED directors at general hospitals in Israel. We asked questions relating to staffing by number of physicians, type and level of training, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Twenty-four of 25 (96%) EDs responded. There were 59 EM specialists registered in Israel; there were 37 EM residents. EDs reported a total of 1,872,500 visits annually. Emergency care is otherwise given by specialists and residents in other fields, and non-specialist physicians. At large hospitals there is an average of 2.5 EM specialists during daytime hours, and another four specialists of other types on duty. During the night in large hospitals, there is an average of <1 specialist of any kind (typically not EM) on duty. In most EDs, care is turned over to non-specialists (residents and others) during evenings and nights. The recognition of the need for Emergency Medicine as a specialty in Israel has not as yet translated into care of emergencies by EPs for most patients. To adequately staff EDs with physicians trained in EM, an emphasis needs to be
e Keywords—workforce; Emergency Medicine; Israel; staffing; international
INTRODUCTION Background In 1992, the Israeli Association for Emergency Medicine (IAEM) was formed to further emergency care and the professional status of Emergency Medicine (EM) in Israel (1). In 1999, after a period of investigation and a concerted effort by the existing leadership of the IAEM, Emergency Department heads from around the country, and with help from leaders in EM abroad, the Israeli Ministry of Health officially recognized EM as a specialty (2). Criteria for specialist status were published, as were a curriculum and site conditions for training programs in EM. In November of 2003, the first cohort of nine Israeli trained emergency physicians (EPs) successfully passed the certification examination given by the Israeli Association for Emergency Medicine under the aegis of the Scientific Council of the Israeli Medical Association (IMA).
Presented as an abstract at the Research Forum, American College of Emergency Physicians, San Francisco, California, October 2004.
RECEIVED: 7 October 2005; FINAL ACCEPTED: 8 November 2006
SUBMISSION RECEIVED:
8 June 2006; 433
434
M. J. Drescher et al.
Importance With the recognition of the specialty of Emergency Medicine in Israel, and the inception of training programs, there is a need to estimate the demand for EPs. This estimate needs to be based on current workforce and work practices, and anticipated future needs.
Goals of this Investigation This study aims to examine the existing workforce of physicians working in Emergency Departments (EDs) in Israel, to better delineate the need for EM specialists in the future.
Figure 1. Number of full-time physicians staffing Emergency Departments in Israel by hospital size.
Characteristics of Study Subjects METHODS Setting In July of 2003, we performed a study of the workforce of all 25 general hospitals with EDs countrywide in Israel.
There were 7 small, 11 medium, and 6 large hospitals in the study. Average annual ED census for each group was 39,000, 88,500, and 104,500, respectively.
Main Study Results Study Design We conducted a cross-sectional survey designed to assess the numbers, level of training, and specialty (if any) of physicians working in EDs. We further asked about differential staffing at various times during the day and the week. Additional questions regarding ED and hospital size, and ED census were included. The survey was adapted from a previously published workforce study (3). Hospitals were divided into three groups by number of beds, as follows: small (up to 399 beds), medium (400 – 699 beds), and large (700 beds and up). We sent the survey to the directors of EDs in all general hospitals in the country that have EDs. If surveys were not initially returned, telephone call follow-up was done to encourage participation. Data were entered using SAS statistical software (SAS Institute Inc., Cary, NC), which was subsequently used for data analysis. We stratified the data by physician type, shift, and hospital size. This study was exempt from Institutional Review Board approval as it did not involve human subjects or their records.
RESULTS Twenty four of 25 (96%) survey instruments were returned.
We found that there were a total of 140 physicians employed full time by the ED over all the hospitals. There were another 94 physicians employed part time by the ED. Of these, 59 were certified Emergency Medicine specialists. Other specialties represented were mainly internists, surgeons and orthopedists. The average number of full-time physicians of all types employed by the ED— by hospital size—is shown in Figure 1. These numbers do not include other physicians working in the ED, either “on call” or “covering” the ED for other departments. The number of full-time physicians working in the ED varies by hospital size disproportionately to the difference in ED census, with medium-sized hospitals having the lowest full-time staff-to-visit ratio (Figure 1). The number of physicians actually working (whether belonging to the ED or to other departments) in the ED and the type of physician by level of training and specialty vary from shift to shift and from weekday to weekend (Figure 2). Throughout the country, there are essentially no EM specialists on duty during the night shift and very few during the evening. On an average weekday in Israel, in all EDs, there were 51 EM specialists working the day shift, five working the evening shift, and an average of 1.5 EM specialists on the night shift in the country at large.
Emergency Medicine Workforce in Israel
Figure 2. Average daily number of physicians staffing Emergency Departments in Israel by specialty and hospital size.
DISCUSSION It is clear from our findings that, by and large, the practice of EM in Israel is still done by non-EM-trained or certified physicians. Often, these are specialists in other fields on the ED staff, but just as often, and especially during nights and weekends, the care of patients in the ED is left to unsupervised residents in various specialties, at various stages of their training, or to physicians without specialist status who are not in a training program. In addition, there is no official structure as yet for employing physicians during evenings and nights other than the system of “taking call” in the ED from 4:00 p.m. to 8:00 a.m. the next day on weekdays, 1:00 p.m. to 8:00 a.m. on Fridays, and 8:00 a.m. to 8:00 a.m. (24 h) on the Jewish Sabbath (Saturday). Therefore, the typical physician staffing the ED during most of the hours of the week is a resident physician at some level of training in one of several non-EM specialties, who is working a 16-h shift after having already worked 8 h in his own department. The shortage of full-time EPs (of any specialty) seems to be worst in the medium-sized hospitals. There, the average number of full-time physicians employed in the ED is 5.3. This is in contrast to large hospitals, where the average ED census is only 18% more but there are nearly double (9.3 per ED) the average number of phy-
435
sicians employed full-time in the ED. This would imply an even greater dependency on physicians from other departments to staff the ED than in the larger centers. The number of ED physicians per ED visit seems to be small relative to that reported by Moorhead et al. in their study of the workforce in EM in the United States (3). There the authors report finding an average 7.85 physicians (needed to fill 5.29 full-time positions) scheduled to staff the ED with an average of 23,912 ED visits (3). In our sample, we found 140 full-time ED physicians (of all levels and specialties) in 24 hospitals (average 5.8) caring for an average of 78,000 ED visits annually. This does not include physicians (typically residents) assigned to cover the ED “on call” during evenings, nights, and weekends—which is the rule in most, if not all, Israeli hospitals. It would seem that these physicians, caring for patients in the ED as described above but not counted as ED staff, account for much of the discrepancy. It is also possible that the physician-patient ratio is larger in Israel than in US Emergency Departments. Various estimates have been published on the need for EPs for a given population. One formula is based on the number of ED visits in a given area (4 – 6). Another formula estimates staffing needs according to the number of EDs in a given area (7). By these formulas, given approximately 2 million annual visits to 25 EDs in Israel, the number of full-time EPs needed to adequately staff an ED that is open around the clock would be 400 and 118, respectively. Clearly, these estimates are incongruous, and the latter most likely reflects a situation in which small EDs are covered by a single physician at any given time. This is not relevant to the situation in Israel, where even EDs at small hospitals see a median of 47,000 annual visits (mean number of visits, 39,000). These formulas have been shown in other circumstances also to underestimate the need for ED coverage (8). The ratio of EPs in the United States relative to the population has been estimated at 1 per 10,000 population. The equivalent ratio in Israel would call for approximately 600 EPs at any given time for the population of 6 million (9). In contrast, according to a recent government publication from the United Kingdom, there are 600 EPs at the consultant or attending level in all of England, caring for 16.5 million ED patients. This reflects a model of emergency care that relies heavily on Nurse Practitioners, General Practitioners, and specialist consultants from other departments. It does not include physicians in training (10). Assuming a parallel ratio and model of care in Israel would require only approximately 72 senior EPs at any one time. However, the British Faculty of Accident and Emergency Medicine has estimated a need for one consultant (attending or senior) EP per 12,000 patient visits. This is assuming a chiefly
436
supervisory and administrative role (11). A similar model in Israel would require about 166 senior EPs. Emergency Medicine is, as is Medicine in general, practiced and organized differently from country to country and area to area. And within each country, EM is developing at various paces and in different directions over time. The following are some examples in the context of which one may compare the development of EM in Israel: ● In Japan, as of 2001, there was no recognized specialty of Emergency Medicine, however, there are physicians specially trained in acute care and certified by the national professional organization, focusing primarily on trauma. The concept of a dedicated Emergency Department, as it is known in the west, reportedly does not exist, and there is no obligation on the part of a physician to accept a patient for emergency care if he does not feel, for whatever reason, that he can properly care for the patient, often requiring ambulances to circulate and make multiple requests before finding an accepting institution (12). ● The Netherlands, about two and a half times the size of Israel by population, with a generally advanced level of medical care, seems to be at a comparable stage of development in EM to that of Israel. As of 2001, the specialty of EM had been officially recognized and the Anglo-American model curriculum adopted, but in only two of 126 hospitals was there a permanent staff of emergency physicians. Otherwise, patients in the ED were cared for by rotating residents in various specialties without direct onsite attending supervision. At that time, there were four hospitals with residencies in EM with a total of 14 residents. Emergency nurses who are permanently assigned to the ED play a large role in the delivery of emergency care (13). ● Emergency Medicine in Hungary, a country of about 10 million, has moved in recent years from the previous Soviet model of health care, where there were essentially no EDs, but rather General Admitting Departments that were understaffed and underequipped for the work of a modern ED. As of 2001 there were only nine EDs in the country, at least one of which was staffed with full-time physicians from various specialties. Training in EM is at the fellowship level or may be done as a combined EM/Internal Medicine program. Until recently, however, traumatology was not considered part of the scope of Emergency Medicine (14). ● In Switzerland, with 7 million residents and a technologically and organizationally advanced medical system, there is great variation in the training of caregivers in the ED. The level of training of physicians working in EDs varies largely and depends mainly on the size of hospitals and internal policies. In larger hospitals, ED physicians are often specialists, certified
M. J. Drescher et al.
in emergency or intensive care. In smaller hospitals, ED care is usually provided by residents without formal, postgraduate emergency care qualifications, closely supervised by higher-qualified physicians (attendings or seniors). Residents have usually attended qualified in-house training, although supervision is not always optimal (15). A recent study in Switzerland showed that, among other interventions, improving supervision of inexperienced physicians and instituting specific training in EM topics for physicians in the ED improved triage categorization, and decreased time intervals to care in 12 EDs in Switzerland (16). Two broad visions of emergency medical care have been described, the Anglo-American and the European models. The former is based on specially trained hospitalbased physicians to deliver a broad range of services for all patients presenting to a separate Emergency Department. In contrast, the European model focuses on delivering resuscitative care in the field; this care is usually provided by anesthesiologists, with subsequent triage of patients directly to specific specialty services for definitive care (17). Emergency Medicine in Israel seems to be following the Anglo-American model. Within that model, however, there is still debate among Israeli EPs as to the future direction of EM in Israel. Some would favor the British model, with relatively few senior EPs, whereas others favor the North American model, in which certified senior EPs being present and responsible for patient care at all hours is the standard. Nonetheless, the Israeli medical establishment, in its recognition of the specialty of EM with its attendant training, curriculum, and certification examinations, has established a standard of EM to be met. In November of 2003, the first cohort of Israeli trained EM residents sat for their written and oral certification examinations and the first group of nine Israeli home-grown EPs went into practice. At the time of this survey, there were 59 certified EM specialists in Israel to care for the nearly 2 million patients in the ED annually. Most of these EM specialists were recognized in the “grandfather period” due to experience working in or directing EDs. This track to specialization has effectively been closed. The coverage of these specialists is not uniform, with their presence in the ED heavily weighted to weekday day shifts and absent or nearly so on nights and weekends. LIMITATIONS Our data were collected from department heads. Although assurances were given that the data would be kept confidential, except in the aggregate, it is possible that fear of making workforce data public, for whatever rea-
Emergency Medicine Workforce in Israel
son, may have caused respondents to answer inaccurately. A more rigorous investigation including site visits would guard against this to some extent. We did not inquire as to the variability of staffing given the dependence on extra-departmental staff, or day-to-day problems in filling shifts with physicians for this or other reasons. The dependence on physicians from outside the department may cause considerable variability in staffing, which may not be reflected in the survey reports. More detailed demographics on emergency physician age and expected work longevity would be of interest. CONCLUSION Emergency Medicine is recognized in Israel as a distinct specialty within the house of Medicine. It has not, however, defined a national standard in terms of its status in the hospital, scope of practice, etc. There seems to be a shortage of EPs, especially during off hours. Given the number of EM specialists currently certified and the distribution of specialists on duty over the course of the day and night, the odds are against any given patient being cared for in the ED by an EM specialist. Whether or not the public and political leadership in Israel see ED staffing as a major public health issue will determine whether resources will be channeled so that there will be more EM specialists caring for patients with emergencies, whenever they may present. REFERENCES 1. Waisman Y, Amir L, Or J. Emergency medicine in Israel: state of the art. Ann Emerg Med 1995;26:640 –2.
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