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Credentialling immigrant physicians in Israel
Health & Place, Vol. 4, No. 4, pp. 375±381, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 1353-8292/98/$ - see front matter
PII: S1353-8292(98)00028-8
Credentialling immigrant physicians in Israel Judith T. Shuval
Department of Sociology and Anthropology, Hebrew University of Jerusalem, Jerusalem, Israel
Credentialling of immigrant physicians is discussed in the context of two sets of high-priority values which have remained constant in Israel since its founding: (a) an open, non-selective migration policy which has resulted in the entry of thousands of immigrant physicians, (b) the high priority accorded to quality health care. These values and their social implications are discussed in terms of the licensing procedures before 1988 and after that date when more stringent procedures were initiated. These processes are discussed with special reference to the large number of immigrant physicians that have come to Israel from the former Soviet Union since 1989. # 1998 Elsevier Science Ltd. All rights reserved Keywords: immigrant, physicians, licensing, credentialling, Israel, migration, professions, latent functions, Soviet medicine, Soviet Union
Theoretical background At ®rst glance it would appear that the principal function of medical licensing is to ensure a desired quality of medical care and to prevent practice by unquali®ed persons, thus providing protection for lay people at a time when they are thought to be vulnerable and dependent. In assuring acceptable formal training and knowledge, the licensing procedure protects people from possible exploitation because it assumes that knowledge and skill as re¯ected in qualifying examinations are accompanied by norms of service that place the patient's welfare at the top of the physicians priorities. Doubts as to the meaningfulness of this norm have been expressed by neo-Weberian and Marxist critics who have pointed to the self-interest of the professions which over-ride a service orientation. However, recent research suggests that altruism probably does play an important role in controlling contemporary professional performance even though it may not take quite the same form suggested by the early functional theorists (Stacey, 1992; Vaughan, 1992; Saks, 1995). *Corresponding author. Tel.: +00-972-2-566-0429; Fax: +00972-2-566-0429; E-mail: [email protected].
Sociologists have pointed to the fact that the above refers to the manifest functions of medical licensing. At the same time, there are a number of additional functionsÐsome of them no less important than quality controlÐwhich are also served by the licensing process. Licensing is a gate-keeping procedure that protects local practitioners from competition by persons de®ned by them as unquali®ed. In addition licensing controls the number of practicing physicians in a given geographical area as well as the distribution of medical personnel in practice settings. All of these are directed to maintaining the medical profession's area of control which is what provides professions with their power and authority. Licensing can be viewed as a political process in which the discourse re¯ects various groups' competition for strategic control over jurisdiction and autonomy. Processes of credentialling are a mechanism which monitors and limits access to speci®c occupational positions in a society. Thus professions already established utilize strategies to retain power and do so by means of exclusionary closure or control of knowledge and performance (Larson, 1977; Abbott, 1988; Witz, 1992; Svensson, 1996). Merton's classic discussion of manifest and latent functions distinguished between intended 375
Credentialling immigrant physicians in Israel: J. T. Shuval
and unintended consequences of a social process as well as between ``the end-in-view and the functional consequences of action''. He indicated that latent functions are ``neither intended nor recognized'' (Merton, 1949, p. 51). Well before Merton's classic statement, George H. Mead (1918) provided an early kernel of the notion of latent function by noting the multiple functions of collective hostility toward law-breakers and referred speci®cally to the importance such hostility plays in promoting social solidarity in the community by providing a common, visible object on which hostility can be focused (Mead, 1918). Thomas and Znaniecki (1918) discuss the explicit, instrumental purposes of social institutions providing services for immigrants but also refer to the importance of their other functions which are frequently no less important. Deconstruction of the medical licensing process points to important functions that are not manifest but at the same time are not unintended or unrecognized. Manifest and latent functions may compete with each other and be expressed unequally (Orzack, 1980; Shuval, 1985). An important latent function that is not always recognized is the role of the licensing process in expressing and reinforcing social values of a society. This paper seeks to demonstrate how medical licensing procedures re¯ect the simultaneous and not always equal function of quality control and value reinforcement. The licensing of immigrant physicians to Israel serves as a case study which shows the shifting priority of these functions in response to structural changes in the society. We will also suggest that latent functions are not necessarily unintended or unrecognized. The medical licensing procedures in Israel re¯ects the high priority of the open-door policy which admits Jewish immigrants from many countries of origin freely with no regard for their occupational or other quali®cations and seeks to integrate them economically and socially into the society. In practice, this value has over-ridden virtually all other values and goals of the society with the exception of security needs. By way of contrast to other societies where migration has been controlled in terms of economic need, excesses and shortages in the labor force, levels of unemployment, pressures of interest groups and health criteria (Rose, 1969; Yochum and Agarwal, 1988; Zolberg, 1989), in Israel it has been assumed that the society must seek ways of integrating immigrants into the social and economic structure of the society regardless of the cost (Shuval and Bernstein, 1996a,b, 1997). A second value re¯ected in the licensing procedure is associated with the high priority accorded to health in the society and is expressed in the importance attached to maintaining quality health care in an eort to approximate the most 376
exacting Western standards. This value is reinforced by selective admission to Israeli medical schools, a rigorous curriculum in those schools, an eort to approximate the highest standards of Western medicine in theory and in practice, a pronounced elitism of the medical profession and high expectations of the lay population with regard to health care services (Shuval, 1992; Shuval and Bernstein, 1996a). The mechanisms by which these values have been simultaneously retained lean on contemporary patterns in the structuring of the professions. All of the latter, and especially medicine, have been characterized by on-going processes of increasing dierentiation and segmentation which have resulted in a rapidly multiplying number of `sub-professions' each focusing on a dierent specialty or sub-specialty. Klein (1993) has noted that these sectors attain autonomy and each pursues its own interests. These sub-specialties are ranked in terms of their perceived prestige by members of the professions themselves whose attitudes and behavior are generally reproduced in the lay populations' views (Haerty and Light, 1995). In the course of this rank ordering, formal training for a specialization is taken as a sine qua non for upper status practiceÐa process which leaves the non-specialist at the bottom of the ranked specialties. In such a context, medical practice in the primary care system without further training for a specialty enjoys the least social prestige and remuneration. This is what Riska (1996) has termed the `trivialization' of primary care since that form of practice is in many cases performed by practitioners who have not continued with formal training for a specialization. It is likely that the `generalism' associated with primary care has been one of the causes for the low status ranking of family practice despite the fact that this ®eld is a recognized medical specialty in many societiesÐrequiring three to 4 years of post medical-school training for accreditation. In the Israeli context, this system of dierentiation and ranking has been utilized to retain the elitism of the veteran medical profession by placing most of the immigrant physicians in primary care practice, in most cases without specialty training. This allocative process is bolstered by a licensing procedure which is structured to channel veterans and immigrants into status-differentiated positions in the medical care system.
Empirical data The empirical data on which our analysis is based concerns the licensing of physicians in Israel in two periods: before 1988 and, in view of the changes introduced at that date, after 1988.
Credentialling immigrant physicians in Israel: J. T. Shuval
Licensing procedure until 1988 Immigrant physicians have been coming to Israel during its entire history, including the period predating independence. Numbers have varied at dierent times depending on the numbers of doctors in various countries of origin who have chosen to immigrate. In seeking to reconcile the two high-priority values, a two-stage system of licensing was established which distinguishes between licensing for general practice and licensing for specialty status. The two values were expressed at both stages but were given dierent emphasis. The ®rst valueÐ regarding the need to provide employment in their profession for as many immigrant physicians as possibleÐwas given prominence in licensing for general practice; the second valueÐ control for high quality medical practiceÐwas emphasized in licensing for specialty status. In the interest of providing professional employment to as many immigrant physicians as possible, the society and its professional community were willing to accept the premise that ``a diploma is an internationally valid testimony of professional competence'' and that medicine is a `universal' ®eld which has few or no culturally determined characteristics (Coser, 1984; BarYosef and King, 1989, p. 190; Field, 1989). Thus a license for general practice was obtained by immigrant physicians upon demonstration of basic knowledge of Hebrew, presentation of formal credentials indicating completion of training at a recognized medical school and a year of work under supervision in a recognized hospital. No examination was required for general practiceÐbecause it was felt that professionals trained in widely dierent cultural settings, with varying lengths of practice experienceÐwould ®nd it dicult to confront a uniform licensing examination. It was assumed that on-going peer review of immigrant physicians' professional performance would control quality of practice. The second value was given prominence in the more stringent and formal quality control applied with regard to licensure for medical specialty status. Immigrants were required to pass the same qualifying examinations as those administered to Israeli medical graduates. The result of this two-stage licensing process was that virtually all immigrant physicians were licensed as general practitioners and in fact almost all were employed in their profession (Ofer et al., 1989, 1991). At the same time many of them experienced downward occupational mobility within the profession because they were not able to obtain specialty statusÐdespite the fact that they had practiced as specialists in their countries of origin. As in most Western societies, high professional status is associated in Israel
with specialty status. Among physicians who immigrated to Israel from the Soviet Union in the 1970s, almost all of whom had practiced previously as specialists, only 33% were licensed to practice in their former specialty after 3 years in Israel and 9 years after arriving that percentage rose to 40%. This is explained by the fact that their professional training was, in most cases, not viewed as acceptable in Israel (Shuval, 1983, 1985). It is worth noting that the eectiveness of peer review as a mode of quality control is seen in the fact that there has been very little evidence of unacceptable practice by immigrant physicians; neither have consumers voiced complaints regarding health care by immigrant doctors. Licensing procedure after 1988 During the 1980s there was a lull in immigration which made it possible for political and professional groups concerned with quality issues in medical practice to exert pressure to make the formal requirements for basic medical licensing more stringent. There was a widespread feeling among health care specialists and in the Israel Medical Association that the standard of medical practice among immigrant doctors and Israelis returning after training in medical schools abroad, wasÐwith some exceptionsÐlower than that viewed as acceptable in Israel. Thus the set of values having to do with the quality of medical practice was brought to the fore at a time when matters relating to the admission of immigrants and their employment were not on the active public agenda. This made it possible for the medical profession to exert pressure on the authorities to tighten quality control for basic medical licensure. The result was that in 1988Ðwell before the large scale immigration from the former Soviet Union began in 1989Ðthe ®rst stage of the licensure procedure was made more rigorous: after demonstrating language skills and credentials from a recognized medical school, immigrant physicians with less than 20 years of practice experience were required to pass a basic licensing examination which quali®ed them for general practice. Only those who had completed their medical training in the United States, Canada or South Africa were exempted from this examination. However, in consideration of the pro-migration policy, immigrant doctors with more than 20 years of experience were exempted from the examination; instead they were required to work for 6 months under supervision and then be examined orally by three veteran physicians before receiving a license for general practice. As previously, medical specialty status could be obtained subsequently after passing the same for377
Credentialling immigrant physicians in Israel: J. T. Shuval Table 1. Immigration of health personnel to Israel, 1989±1995 1989±91 399 666 9820 1070 7888 1063 957
Total Immigrants Physicians Dentists Nurses Paramedicals Pharmacists
1992 77 057 1430 170 1560 170 197
1993 76 805 1360 130 1784 200 170
1994 79 844 1100 120 1791 200 160
1995 76 361 880 84 1318 180 122
TOTAL 707 733 14 590 1574 14 341 1813 1606
Note: Data are from the Ministry of Absorption. and are based on the self-declared occupation of new immigrants and returning residents upon arrival. The Ministry of Health estimates that about 90 percent of the physicians and dentists are from the former Soviet Union. Source: Israel Ministry of Absorption, 1996.
mal examinations required in the past (Shuval and Bernstein, 1996a,b, 1997). The requirement of a formal licensure examination for general practice was geared to give greater emphasis to the second valueÐthe concern for high quality medicine. Like in other countries, it was assumed that an examination would weed out physicians who do not meet the required standard of practice. With the mass immigration from the former Soviet Union (Table 1), which brought some 13 000 physicians to Israel between 1989 and 1994, concern for their well-being and employment came to the fore and served to constrain the screening function of the examination. Israel has one of the highest MD/population ratios in the world: in 1994 the ratio of licensed physicians under the age of 65 was 363/100 000 (Table 2) (Rosen and Nirel, 1995). Despite this, the pro-migration ideology promoted widespread consensus that no eort should be spared to assist immigrant physicians to attain employment in their profession. Thus, in 1992 the number of years of practice experience required of those exempted from the formal examination was reduced from twenty to fourteen. This had the eect of reducing the size of the population required to sit for the licensing examination from 67% to about half. There was little public discussion or debate regarding this change nor were its implications for quality control raised. Those with more than 14 years of practice are required to work for 6 months in a Table 2. Physicians/100 000 population in Israel and in selected OECD countries 1988 Israel (1989) Germany Sweden Denmark France Holland United States Canada UK
289 290 290 270 260 240 230 220 140
363/100 000 in 1994
OECD JTS note: calculation of Person/MD: Israel 1994 = 275.
378
supervised practice setting; a high proportion of those who go through this process obtain a license for general practice. The pro-migration policy provides substantial publicly ®nanced assistance to those immigrant physicians required to sit for the licensure examination. They are provided with a 6-month preparatory course at public expense (about $2000 for each physician) to up-date their basic knowledge of medical technology and practice procedures. Participants receive ®nancial subsidies during the course and pay no tuition. The examination is oered in Russian. Research indicates that by the time they were in Israel 2.5 years, 78% of those immigrant physicians who sought licensure and were required to take the examination had succeeded in passing itÐsome after several attemptsÐand had obtained a license for general practice (Bernstein and Shuval, 1995). This indicates that the qualifying examination for general practice screens out only about 20% who are required to take it; of the latter, some try again and may obtain a license after additional trials (Table 3). In terms of its quality-control function, it should be noted that the existence of an examination probably discourages some less quali®ed immigrant physicians from seeking licensure. In fact, approximately 25% of those who declared upon arrival in Israel that they had been physicians in the former Soviet Union, did not seek to obtain a license for practice (Naveh and Nirel, 1995; Bernstein and Shuval, 1995). Not all of these opted out because of inadequate quali®cations; research indicates that those who did not initiate procedures for licensure were more likely
Table 3. Licensing of immigrant physicians from the former Soviet Union, 1989±1992 Applied to ministry of health for medical license Criterion of licensing examination clinical observation Received license for general practice Of those with license: applied for residency Source: Naveh and Nirel, 1995.
6,754 56% 44% 71% 73%
Credentialling immigrant physicians in Israel: J. T. Shuval
to be women and over the age of 55 (Bernstein and Shuval, 1995). But some may have been daunted by the prospect of a formal examination. In addition to its positive self-selection function, the examination and the preparatory course promote quality by encouraging study and up-dating of medical knowledge. Nevertheless, it is striking that after 2.5 years, the examination screened out only a ®fth of the population and we may assume that with repeated tries that percentage will be further reduced.
Discussion Procedures for licensing of physicians in Israel may be viewed as a means to reconcile two fundamental value-themes of the society: on the one hand, a need to provide employment for immigrants in appropriate jobs that are in accord with their prior occupational training and experience and, on the other, a need to maintain a high quality of professional practice in accordance with the standards of the best scienti®c knowledge currently available. Neither of these valuethemes can be compromised too far and their joint eect has been a licensure system that seeks to answer to both. The Israel case study points to the power of social values in constraining institutionalized mechanisms of quality control. Two powerful value systems have jointly in¯uenced the licensing procedures for immigrant physicians to Israel. Before 1988 the ®rst of theseÐthe need to provide employment in their professionÐwas emphasized in the ®rst stage of licensing for general practice while the second having to do with quality control was most prominent in the second stage of licensing for specialty status. Changes in the licensing procedures introduced in 1988 sought to tighten quality control with regard to the ®rst stage by requiring an examination for quali®cation. However, these changes have been constrained by pro-migration policies seeking to promote employment opportunities for immigrants. Paradoxically, these constraints result in a situation that is remarkably similar to the situation that prevailed before 1988. Quality control is stringently focused on licensing for specialty status while pro-migration values remain prominent in licensure for general practice. The licensing examination projects an image of quality control but in eect is a relatively weak screening mechanism. This is seen in the fact that after 2.5 years in Israel andÐin some casesÐnumerous attempts, fully 78% of those required to take the examination had passed it. Quality control at the general practice level is largely exercised by peers on an informal level much as it was before 1988. At the same time the elitism of the medical profession has been retained by maintenance of
the same selective admissions to Israeli medical schools, minimal changes in the rigorous curriculum of these schools and continuing eorts to approximate the highest, up-dated standards of research and technology of Western medicine. The large numbers of immigrant physicians has repeatedly led to proposals to reduce the numbers of students admitted to medical school but these have been rejected by leaders of the profession who have consistently asserted that graduates of Israeli medical schools are an elite that serves to maintain the high quality of medical practice. We may therefore conclude that the licensure examination may well serve important social functions having to do with immigrants' well being, such as providing those who pass with a sense of accomplishment and reinforcing their professional status and self-image; it also provides an opportunity to compete for the scarce residency posts that make possible the attaining of specialty status. It provides the society with a sense of con®dence that immigrant physicians trained outside of Israel have met up-dated standards of knowledge deemed necessary by the medical profession. The latter function has been most important in view of the large number of immigrant doctors from the former Soviet Union whose level of professional competence has been questioned (Shuval and Bernstein, 1996b, 1997). But in practice the licensure examination is a weak screening mechanism and ®lters out a relatively small proportion of those who seek licensure. This does not necessarily imply that the basic licensure examination should be abolished and the pre-1988 situation restored since, as noted, the examination ful®lls a number of important social and psychological functions. Its usefulness should be examined in terms of its relative costs and bene®tsÐbearing in mind the latent functions it provides. How may we explain the willingness of an elite, quality-oriented medical profession to accept what appears to be relatively lax quality control for the ®rst stage of basic medical licensing, i.e. for general practice? Indeed, the General Kupat HolimÐIsrael's largest sick fundÐhas sought to abolish `general practice' by establishing a residency program in `family medicine' which has given this ®eld the formal status of a medical specialty. Since 1972 this specialty has required 5 years of residency training and an additional 3 years of work in one of the General Kupat Holim primary care clinics. While a shrinking job market has caused increasing numbers of Israeli medical graduates to opt for a career in family medicine, the overall status priority of other specialties has not been diminished and for most local graduates the latter have been preferred when jobs have been available. It is 379
Credentialling immigrant physicians in Israel: J. T. Shuval
possible that family medicineÐdespite its specialty statusÐis tainted by the low-ranking `generalist' label. Furthermore, despite eorts by the General Kupat Holim to employ only recognized family practictitioners in its primary care clinics, there remain niches in the health care systemÐ and apparently in large numbersÐin which `generalists' (without medical specialties) can ®nd employment. Many of the immigrant physicians have found jobs in these niches. While at ®rst glance it might therefore seem that there is less concern in Israel than in other Western countries to maintain the autonomy and monopoly of the medical profession by means of exclusionary strategies, we would suggest that this is far from the reality. The concern with control and autonomy of the medical profession is no less strong in Israel than in other societies. However, the pro-migration value context has resulted in a dierent way of de®ning the boundaries of practice. The Israeli mode of handling thousands of newly arrived immigrant physicians has been to make it possible for the majority of them to obtain licenses for general practice while at the same time carefully controlling their entry into medical specialties. In consideration of the high priority of the pro-migration consensus and the need to provide employment, general practice has been made relatively accessible but is socially perceived as low in status. However, entry to high-status specialties is rigorously curtailed. By keeping alive the option for general practice in a social context that de®nes `real' medicine as specialty practice, Israeli policy serves a dual purpose: it avoids the unacceptable stance of seeking to limit the entry of immigrant doctors while minimizing the threat posed to the basic autonomy of the profession by a large in¯ux of professionals. It may be suggested that the medical licensure procedures followed, both before and after 1988, express an unverbalized belief of the medical profession in Israel that serious medical problems will inevitably be channeled to practitioners holding one of the long-accepted or new, narrowlyde®ned medical specialties. In an era of hyper medical specialization, the general practitioner is viewed as more of a gate-keeper than as a dispenser of high quality medical care. Viewed in these terms, rigorous quality control at that level is seen as expendable.
References Abbott, A. (1988) The System of Professions: an Essay on the Division of Expert Labour. University of Chicago Press, Chicago. Bar-Yosef, R. W. and King, J. V. (1989) Unemployed Professionals: the case of Immigrant Engineers from Soviet Russia to Israel. In Horowitz, T., editor. The Soviet Man in
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an Open Society. University Press of America, Lanham, MD. Bernstein, J. and Shuval, J. T. (1995) Occupational stability and change among immigrant physicians from the former Soviet Union to Israel. International Migration 33(1), 3±29. Coser, L. A. (1984) Refugee Scholars in America: their Impact and their Experiences. Yale University Press, New Haven. Field, M. (1989) Success and Crisis in National Health Systems: a Comparative Approach. Routledge, London. Haerty, F. W. and Light, D. W. (1995) Professional dynamics and the changing nature of medical work. Journal of Health and Social Behavior Extra issue, 132±153. Israel Ministry of Absorption (1996) Immigrant Absorption: Situation, Challenges and Goals. Israel Ministry of Absorption, Jerusalem. Klein, R. (1993) National Variations on International Trends. In Haerty, W. and McKinlay, J. B., editors. The Changing Medical Profession: an International Perspective, pp. 84± 101. Oxford University Press, New York. Larson, M. S. (1977) The Rise of Professionalism. University of California Press, Berkeley. Mead, G. H. (1918) The psychology of punitive justice. American Journal of Sociology 23, 577±602. Merton, R. K. (1949) Social Theory and Social Structure. Free Press, New York. Naveh, G. and Nirel, N. (1995) The Employment of Immigrant Physicians from the former Soviet Union: Preliminary Findings. JDC-Brookdale Institute of Gerontology and Human Development, in Hebrew. Jerusalem. Ofer, G., Vinokur, A. and Bar-Haim, Y. (1989) The Absorption and Economic Contribution of Immigrants from the USSR in Israel. In Horowitz, T., editor, 67-91. The Soviet Man in an Open Society. University Press of America, Lanham, MD. Ofer, G., Flug, K. and Kassir, N. (1991) The absorption in employment of immigrants from the Soviet Union: 1990 and beyond. Economic Quarterly 148, 135±171 In Hebrew. Orzack, L. H. (1980) Educators, practitioners and politicians in the European Common Market. Higher Education 9, 307±323. Riska, E. (1996) The Recon®guration of the Medical Profession: a Split Between the Geneticization and Trivialization of Medicine. Onati. Rose, A. (1969) Migrants to Europe. University of Minnesota Press, Minneapolis. Rosen, B. and Nirel, N. (1995) Immigration and Medical Manpower in Israel: Partial Questions and Answers. Jerusalem: Brookdale Institute of Gerontology and Human Development. In Hebrew, unpublished. Saks, M. (1995) Professions and the Public Interest: Medical Power, Altruism and Alternative Medicine. Routledge, London. Shuval, J. T. (1983) Newcomers and Colleagues: Soviet Immigrant Physicians in Israel. Cap and Gown Press, Galveston. Shuval, J. T. (1985) Social functions of medical licensing: a case study of Soviet immigrant physicians in Israel. Social Science and Medicine 20(9), 901±909. Shuval, J. T. (1992) Social Dimensions of Health: the Israeli Experience. Greenwood, Westport, Connecticut. Shuval, J. T. and Bernstein, J. (1996a) The dynamics of professional commitment: immigrant physicians from the former Soviet Union in Israel. Social Science and Medicine 42(7), 965±974. Shuval, J. T. and Bernstein, J. (1996b) Social Values and Health Policy: Immigrant Physicians in the Israeli Health Care System. In Carmon, N., editor, Immigrants: Liability or Asset: Innovative Research and Policy Implications, pp. 127±143. MacMillan, New York. Shuval, J.T. and Bernstein, J. (ed) (1997) Immigrant Physicians: Former Soviet Doctors in Israel, Canada and the United States. Greenwood, Westport, Connecticut.
Credentialling immigrant physicians in Israel: J. T. Shuval Stacey, M. (1992) Regulating British Medicine: the General Medical Council. John Wiley, Chichester. Svensson, L. G. (1996) From Professional Organization to Professionalism. Conference on ``Deconstructing Professions: Professional Identity and Professional Order in Comparative Perspective'', 25±26 April, 1996, Onati International Institute for the Sociology of Law, Onati, Spain, unpublished paper. Thomas, W. I. and Znaniecki, F. (1918) The Polish Peasant in Europe and America. University of Chicago Press, Chicago.
Vaughan, P. (1992) Secret Remedies in the Late Nineteenth and Early Twentieth Centuries. In Saks, M., editors. Alternative Medicine in Britain. Clarendon Press, Oxford. Witz, A. (1992) Professions and Patriarchy. Routledge, London and New York. Yochum, G. and Agarwal, V. (1988) Permanent labor certi®cation for alien professionals, 1975±82. International Migration Review 22, 265±281. Zolberg, A. (1989) The next waves: migration theory for a changing world. International Migration Review 23, 403± 430.
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PII: S1353-8292(98)00028-8
Credentialling immigrant physicians in Israel Judith T. Shuval
Department of Sociology and Anthropology, Hebrew University of Jerusalem, Jerusalem, Israel
Credentialling of immigrant physicians is discussed in the context of two sets of high-priority values which have remained constant in Israel since its founding: (a) an open, non-selective migration policy which has resulted in the entry of thousands of immigrant physicians, (b) the high priority accorded to quality health care. These values and their social implications are discussed in terms of the licensing procedures before 1988 and after that date when more stringent procedures were initiated. These processes are discussed with special reference to the large number of immigrant physicians that have come to Israel from the former Soviet Union since 1989. # 1998 Elsevier Science Ltd. All rights reserved Keywords: immigrant, physicians, licensing, credentialling, Israel, migration, professions, latent functions, Soviet medicine, Soviet Union
Theoretical background At ®rst glance it would appear that the principal function of medical licensing is to ensure a desired quality of medical care and to prevent practice by unquali®ed persons, thus providing protection for lay people at a time when they are thought to be vulnerable and dependent. In assuring acceptable formal training and knowledge, the licensing procedure protects people from possible exploitation because it assumes that knowledge and skill as re¯ected in qualifying examinations are accompanied by norms of service that place the patient's welfare at the top of the physicians priorities. Doubts as to the meaningfulness of this norm have been expressed by neo-Weberian and Marxist critics who have pointed to the self-interest of the professions which over-ride a service orientation. However, recent research suggests that altruism probably does play an important role in controlling contemporary professional performance even though it may not take quite the same form suggested by the early functional theorists (Stacey, 1992; Vaughan, 1992; Saks, 1995). *Corresponding author. Tel.: +00-972-2-566-0429; Fax: +00972-2-566-0429; E-mail: [email protected].
Sociologists have pointed to the fact that the above refers to the manifest functions of medical licensing. At the same time, there are a number of additional functionsÐsome of them no less important than quality controlÐwhich are also served by the licensing process. Licensing is a gate-keeping procedure that protects local practitioners from competition by persons de®ned by them as unquali®ed. In addition licensing controls the number of practicing physicians in a given geographical area as well as the distribution of medical personnel in practice settings. All of these are directed to maintaining the medical profession's area of control which is what provides professions with their power and authority. Licensing can be viewed as a political process in which the discourse re¯ects various groups' competition for strategic control over jurisdiction and autonomy. Processes of credentialling are a mechanism which monitors and limits access to speci®c occupational positions in a society. Thus professions already established utilize strategies to retain power and do so by means of exclusionary closure or control of knowledge and performance (Larson, 1977; Abbott, 1988; Witz, 1992; Svensson, 1996). Merton's classic discussion of manifest and latent functions distinguished between intended 375
Credentialling immigrant physicians in Israel: J. T. Shuval
and unintended consequences of a social process as well as between ``the end-in-view and the functional consequences of action''. He indicated that latent functions are ``neither intended nor recognized'' (Merton, 1949, p. 51). Well before Merton's classic statement, George H. Mead (1918) provided an early kernel of the notion of latent function by noting the multiple functions of collective hostility toward law-breakers and referred speci®cally to the importance such hostility plays in promoting social solidarity in the community by providing a common, visible object on which hostility can be focused (Mead, 1918). Thomas and Znaniecki (1918) discuss the explicit, instrumental purposes of social institutions providing services for immigrants but also refer to the importance of their other functions which are frequently no less important. Deconstruction of the medical licensing process points to important functions that are not manifest but at the same time are not unintended or unrecognized. Manifest and latent functions may compete with each other and be expressed unequally (Orzack, 1980; Shuval, 1985). An important latent function that is not always recognized is the role of the licensing process in expressing and reinforcing social values of a society. This paper seeks to demonstrate how medical licensing procedures re¯ect the simultaneous and not always equal function of quality control and value reinforcement. The licensing of immigrant physicians to Israel serves as a case study which shows the shifting priority of these functions in response to structural changes in the society. We will also suggest that latent functions are not necessarily unintended or unrecognized. The medical licensing procedures in Israel re¯ects the high priority of the open-door policy which admits Jewish immigrants from many countries of origin freely with no regard for their occupational or other quali®cations and seeks to integrate them economically and socially into the society. In practice, this value has over-ridden virtually all other values and goals of the society with the exception of security needs. By way of contrast to other societies where migration has been controlled in terms of economic need, excesses and shortages in the labor force, levels of unemployment, pressures of interest groups and health criteria (Rose, 1969; Yochum and Agarwal, 1988; Zolberg, 1989), in Israel it has been assumed that the society must seek ways of integrating immigrants into the social and economic structure of the society regardless of the cost (Shuval and Bernstein, 1996a,b, 1997). A second value re¯ected in the licensing procedure is associated with the high priority accorded to health in the society and is expressed in the importance attached to maintaining quality health care in an eort to approximate the most 376
exacting Western standards. This value is reinforced by selective admission to Israeli medical schools, a rigorous curriculum in those schools, an eort to approximate the highest standards of Western medicine in theory and in practice, a pronounced elitism of the medical profession and high expectations of the lay population with regard to health care services (Shuval, 1992; Shuval and Bernstein, 1996a). The mechanisms by which these values have been simultaneously retained lean on contemporary patterns in the structuring of the professions. All of the latter, and especially medicine, have been characterized by on-going processes of increasing dierentiation and segmentation which have resulted in a rapidly multiplying number of `sub-professions' each focusing on a dierent specialty or sub-specialty. Klein (1993) has noted that these sectors attain autonomy and each pursues its own interests. These sub-specialties are ranked in terms of their perceived prestige by members of the professions themselves whose attitudes and behavior are generally reproduced in the lay populations' views (Haerty and Light, 1995). In the course of this rank ordering, formal training for a specialization is taken as a sine qua non for upper status practiceÐa process which leaves the non-specialist at the bottom of the ranked specialties. In such a context, medical practice in the primary care system without further training for a specialty enjoys the least social prestige and remuneration. This is what Riska (1996) has termed the `trivialization' of primary care since that form of practice is in many cases performed by practitioners who have not continued with formal training for a specialization. It is likely that the `generalism' associated with primary care has been one of the causes for the low status ranking of family practice despite the fact that this ®eld is a recognized medical specialty in many societiesÐrequiring three to 4 years of post medical-school training for accreditation. In the Israeli context, this system of dierentiation and ranking has been utilized to retain the elitism of the veteran medical profession by placing most of the immigrant physicians in primary care practice, in most cases without specialty training. This allocative process is bolstered by a licensing procedure which is structured to channel veterans and immigrants into status-differentiated positions in the medical care system.
Empirical data The empirical data on which our analysis is based concerns the licensing of physicians in Israel in two periods: before 1988 and, in view of the changes introduced at that date, after 1988.
Credentialling immigrant physicians in Israel: J. T. Shuval
Licensing procedure until 1988 Immigrant physicians have been coming to Israel during its entire history, including the period predating independence. Numbers have varied at dierent times depending on the numbers of doctors in various countries of origin who have chosen to immigrate. In seeking to reconcile the two high-priority values, a two-stage system of licensing was established which distinguishes between licensing for general practice and licensing for specialty status. The two values were expressed at both stages but were given dierent emphasis. The ®rst valueÐ regarding the need to provide employment in their profession for as many immigrant physicians as possibleÐwas given prominence in licensing for general practice; the second valueÐ control for high quality medical practiceÐwas emphasized in licensing for specialty status. In the interest of providing professional employment to as many immigrant physicians as possible, the society and its professional community were willing to accept the premise that ``a diploma is an internationally valid testimony of professional competence'' and that medicine is a `universal' ®eld which has few or no culturally determined characteristics (Coser, 1984; BarYosef and King, 1989, p. 190; Field, 1989). Thus a license for general practice was obtained by immigrant physicians upon demonstration of basic knowledge of Hebrew, presentation of formal credentials indicating completion of training at a recognized medical school and a year of work under supervision in a recognized hospital. No examination was required for general practiceÐbecause it was felt that professionals trained in widely dierent cultural settings, with varying lengths of practice experienceÐwould ®nd it dicult to confront a uniform licensing examination. It was assumed that on-going peer review of immigrant physicians' professional performance would control quality of practice. The second value was given prominence in the more stringent and formal quality control applied with regard to licensure for medical specialty status. Immigrants were required to pass the same qualifying examinations as those administered to Israeli medical graduates. The result of this two-stage licensing process was that virtually all immigrant physicians were licensed as general practitioners and in fact almost all were employed in their profession (Ofer et al., 1989, 1991). At the same time many of them experienced downward occupational mobility within the profession because they were not able to obtain specialty statusÐdespite the fact that they had practiced as specialists in their countries of origin. As in most Western societies, high professional status is associated in Israel
with specialty status. Among physicians who immigrated to Israel from the Soviet Union in the 1970s, almost all of whom had practiced previously as specialists, only 33% were licensed to practice in their former specialty after 3 years in Israel and 9 years after arriving that percentage rose to 40%. This is explained by the fact that their professional training was, in most cases, not viewed as acceptable in Israel (Shuval, 1983, 1985). It is worth noting that the eectiveness of peer review as a mode of quality control is seen in the fact that there has been very little evidence of unacceptable practice by immigrant physicians; neither have consumers voiced complaints regarding health care by immigrant doctors. Licensing procedure after 1988 During the 1980s there was a lull in immigration which made it possible for political and professional groups concerned with quality issues in medical practice to exert pressure to make the formal requirements for basic medical licensing more stringent. There was a widespread feeling among health care specialists and in the Israel Medical Association that the standard of medical practice among immigrant doctors and Israelis returning after training in medical schools abroad, wasÐwith some exceptionsÐlower than that viewed as acceptable in Israel. Thus the set of values having to do with the quality of medical practice was brought to the fore at a time when matters relating to the admission of immigrants and their employment were not on the active public agenda. This made it possible for the medical profession to exert pressure on the authorities to tighten quality control for basic medical licensure. The result was that in 1988Ðwell before the large scale immigration from the former Soviet Union began in 1989Ðthe ®rst stage of the licensure procedure was made more rigorous: after demonstrating language skills and credentials from a recognized medical school, immigrant physicians with less than 20 years of practice experience were required to pass a basic licensing examination which quali®ed them for general practice. Only those who had completed their medical training in the United States, Canada or South Africa were exempted from this examination. However, in consideration of the pro-migration policy, immigrant doctors with more than 20 years of experience were exempted from the examination; instead they were required to work for 6 months under supervision and then be examined orally by three veteran physicians before receiving a license for general practice. As previously, medical specialty status could be obtained subsequently after passing the same for377
Credentialling immigrant physicians in Israel: J. T. Shuval Table 1. Immigration of health personnel to Israel, 1989±1995 1989±91 399 666 9820 1070 7888 1063 957
Total Immigrants Physicians Dentists Nurses Paramedicals Pharmacists
1992 77 057 1430 170 1560 170 197
1993 76 805 1360 130 1784 200 170
1994 79 844 1100 120 1791 200 160
1995 76 361 880 84 1318 180 122
TOTAL 707 733 14 590 1574 14 341 1813 1606
Note: Data are from the Ministry of Absorption. and are based on the self-declared occupation of new immigrants and returning residents upon arrival. The Ministry of Health estimates that about 90 percent of the physicians and dentists are from the former Soviet Union. Source: Israel Ministry of Absorption, 1996.
mal examinations required in the past (Shuval and Bernstein, 1996a,b, 1997). The requirement of a formal licensure examination for general practice was geared to give greater emphasis to the second valueÐthe concern for high quality medicine. Like in other countries, it was assumed that an examination would weed out physicians who do not meet the required standard of practice. With the mass immigration from the former Soviet Union (Table 1), which brought some 13 000 physicians to Israel between 1989 and 1994, concern for their well-being and employment came to the fore and served to constrain the screening function of the examination. Israel has one of the highest MD/population ratios in the world: in 1994 the ratio of licensed physicians under the age of 65 was 363/100 000 (Table 2) (Rosen and Nirel, 1995). Despite this, the pro-migration ideology promoted widespread consensus that no eort should be spared to assist immigrant physicians to attain employment in their profession. Thus, in 1992 the number of years of practice experience required of those exempted from the formal examination was reduced from twenty to fourteen. This had the eect of reducing the size of the population required to sit for the licensing examination from 67% to about half. There was little public discussion or debate regarding this change nor were its implications for quality control raised. Those with more than 14 years of practice are required to work for 6 months in a Table 2. Physicians/100 000 population in Israel and in selected OECD countries 1988 Israel (1989) Germany Sweden Denmark France Holland United States Canada UK
289 290 290 270 260 240 230 220 140
363/100 000 in 1994
OECD JTS note: calculation of Person/MD: Israel 1994 = 275.
378
supervised practice setting; a high proportion of those who go through this process obtain a license for general practice. The pro-migration policy provides substantial publicly ®nanced assistance to those immigrant physicians required to sit for the licensure examination. They are provided with a 6-month preparatory course at public expense (about $2000 for each physician) to up-date their basic knowledge of medical technology and practice procedures. Participants receive ®nancial subsidies during the course and pay no tuition. The examination is oered in Russian. Research indicates that by the time they were in Israel 2.5 years, 78% of those immigrant physicians who sought licensure and were required to take the examination had succeeded in passing itÐsome after several attemptsÐand had obtained a license for general practice (Bernstein and Shuval, 1995). This indicates that the qualifying examination for general practice screens out only about 20% who are required to take it; of the latter, some try again and may obtain a license after additional trials (Table 3). In terms of its quality-control function, it should be noted that the existence of an examination probably discourages some less quali®ed immigrant physicians from seeking licensure. In fact, approximately 25% of those who declared upon arrival in Israel that they had been physicians in the former Soviet Union, did not seek to obtain a license for practice (Naveh and Nirel, 1995; Bernstein and Shuval, 1995). Not all of these opted out because of inadequate quali®cations; research indicates that those who did not initiate procedures for licensure were more likely
Table 3. Licensing of immigrant physicians from the former Soviet Union, 1989±1992 Applied to ministry of health for medical license Criterion of licensing examination clinical observation Received license for general practice Of those with license: applied for residency Source: Naveh and Nirel, 1995.
6,754 56% 44% 71% 73%
Credentialling immigrant physicians in Israel: J. T. Shuval
to be women and over the age of 55 (Bernstein and Shuval, 1995). But some may have been daunted by the prospect of a formal examination. In addition to its positive self-selection function, the examination and the preparatory course promote quality by encouraging study and up-dating of medical knowledge. Nevertheless, it is striking that after 2.5 years, the examination screened out only a ®fth of the population and we may assume that with repeated tries that percentage will be further reduced.
Discussion Procedures for licensing of physicians in Israel may be viewed as a means to reconcile two fundamental value-themes of the society: on the one hand, a need to provide employment for immigrants in appropriate jobs that are in accord with their prior occupational training and experience and, on the other, a need to maintain a high quality of professional practice in accordance with the standards of the best scienti®c knowledge currently available. Neither of these valuethemes can be compromised too far and their joint eect has been a licensure system that seeks to answer to both. The Israel case study points to the power of social values in constraining institutionalized mechanisms of quality control. Two powerful value systems have jointly in¯uenced the licensing procedures for immigrant physicians to Israel. Before 1988 the ®rst of theseÐthe need to provide employment in their professionÐwas emphasized in the ®rst stage of licensing for general practice while the second having to do with quality control was most prominent in the second stage of licensing for specialty status. Changes in the licensing procedures introduced in 1988 sought to tighten quality control with regard to the ®rst stage by requiring an examination for quali®cation. However, these changes have been constrained by pro-migration policies seeking to promote employment opportunities for immigrants. Paradoxically, these constraints result in a situation that is remarkably similar to the situation that prevailed before 1988. Quality control is stringently focused on licensing for specialty status while pro-migration values remain prominent in licensure for general practice. The licensing examination projects an image of quality control but in eect is a relatively weak screening mechanism. This is seen in the fact that after 2.5 years in Israel andÐin some casesÐnumerous attempts, fully 78% of those required to take the examination had passed it. Quality control at the general practice level is largely exercised by peers on an informal level much as it was before 1988. At the same time the elitism of the medical profession has been retained by maintenance of
the same selective admissions to Israeli medical schools, minimal changes in the rigorous curriculum of these schools and continuing eorts to approximate the highest, up-dated standards of research and technology of Western medicine. The large numbers of immigrant physicians has repeatedly led to proposals to reduce the numbers of students admitted to medical school but these have been rejected by leaders of the profession who have consistently asserted that graduates of Israeli medical schools are an elite that serves to maintain the high quality of medical practice. We may therefore conclude that the licensure examination may well serve important social functions having to do with immigrants' well being, such as providing those who pass with a sense of accomplishment and reinforcing their professional status and self-image; it also provides an opportunity to compete for the scarce residency posts that make possible the attaining of specialty status. It provides the society with a sense of con®dence that immigrant physicians trained outside of Israel have met up-dated standards of knowledge deemed necessary by the medical profession. The latter function has been most important in view of the large number of immigrant doctors from the former Soviet Union whose level of professional competence has been questioned (Shuval and Bernstein, 1996b, 1997). But in practice the licensure examination is a weak screening mechanism and ®lters out a relatively small proportion of those who seek licensure. This does not necessarily imply that the basic licensure examination should be abolished and the pre-1988 situation restored since, as noted, the examination ful®lls a number of important social and psychological functions. Its usefulness should be examined in terms of its relative costs and bene®tsÐbearing in mind the latent functions it provides. How may we explain the willingness of an elite, quality-oriented medical profession to accept what appears to be relatively lax quality control for the ®rst stage of basic medical licensing, i.e. for general practice? Indeed, the General Kupat HolimÐIsrael's largest sick fundÐhas sought to abolish `general practice' by establishing a residency program in `family medicine' which has given this ®eld the formal status of a medical specialty. Since 1972 this specialty has required 5 years of residency training and an additional 3 years of work in one of the General Kupat Holim primary care clinics. While a shrinking job market has caused increasing numbers of Israeli medical graduates to opt for a career in family medicine, the overall status priority of other specialties has not been diminished and for most local graduates the latter have been preferred when jobs have been available. It is 379
Credentialling immigrant physicians in Israel: J. T. Shuval
possible that family medicineÐdespite its specialty statusÐis tainted by the low-ranking `generalist' label. Furthermore, despite eorts by the General Kupat Holim to employ only recognized family practictitioners in its primary care clinics, there remain niches in the health care systemÐ and apparently in large numbersÐin which `generalists' (without medical specialties) can ®nd employment. Many of the immigrant physicians have found jobs in these niches. While at ®rst glance it might therefore seem that there is less concern in Israel than in other Western countries to maintain the autonomy and monopoly of the medical profession by means of exclusionary strategies, we would suggest that this is far from the reality. The concern with control and autonomy of the medical profession is no less strong in Israel than in other societies. However, the pro-migration value context has resulted in a dierent way of de®ning the boundaries of practice. The Israeli mode of handling thousands of newly arrived immigrant physicians has been to make it possible for the majority of them to obtain licenses for general practice while at the same time carefully controlling their entry into medical specialties. In consideration of the high priority of the pro-migration consensus and the need to provide employment, general practice has been made relatively accessible but is socially perceived as low in status. However, entry to high-status specialties is rigorously curtailed. By keeping alive the option for general practice in a social context that de®nes `real' medicine as specialty practice, Israeli policy serves a dual purpose: it avoids the unacceptable stance of seeking to limit the entry of immigrant doctors while minimizing the threat posed to the basic autonomy of the profession by a large in¯ux of professionals. It may be suggested that the medical licensure procedures followed, both before and after 1988, express an unverbalized belief of the medical profession in Israel that serious medical problems will inevitably be channeled to practitioners holding one of the long-accepted or new, narrowlyde®ned medical specialties. In an era of hyper medical specialization, the general practitioner is viewed as more of a gate-keeper than as a dispenser of high quality medical care. Viewed in these terms, rigorous quality control at that level is seen as expendable.
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