Background
Physicians are a cornerstone of any healthcare system. The growth and aging of Israel’s population is increasing the demand for medical services and physicians. However, the rate of physicians per thousand population in Israel is low relative to the OECD average, and many physicians are expected to retire in the coming years.
The main source of physicians in the coming decades will be the current and future pool of medical residents, and therefore it is important to understand the process a physician undergoes starting from graduation and obtaining a medical license until the beginning of his or her residency.
Training a physician takes many years and consists of a number of stages, one of the most important being acceptance to a medical residency. The shortage of medical personnel calls for steps to reduce the time until physicians are able to integrate within the system as residents.
Candidates for residencies need to be proactive in securing a residency slot by approaching specific department heads on their own. This is unlike the process for placement of an intern which involves a lottery carried out by the Ministry of Health. It begins sometime during the final academic year in medical school and can take several years. In Israel, there is no central planning of residency placements; essentially, the number of positions for residency is determined by the clinical departments that have been approved for residency and according to their capacity. As such, there are lacunae in the information used by the Ministry of Health to plan residency positions in Israel, and consequently, candidates for residency are faced with uncertainty.
In response to this situation, the Ministry of Health approached the Myers-JDC-Brookdale Institute and requested a study to examine the barriers delaying the start of residency for physicians after receipt of an Israeli medical license.
Objectives
- To examine the length of time between obtaining a medical license and the actual start of a residency:
- According to the background characteristics of the license recipients.
- According to specialization.
- To identify factors that can facilitate the rapid placement into residencies as well as barriers and stages that delay the process.
- To identify the extent to which reducing barriers and removing stages that delay residency placement might contribute to addressing the shortage of medical personnel.
Methods
The study was conducted using mixed research methods and included both qualitative and quantitative components.
The quantitative component analyzed existing administrative data available to the Ministry of Health, which includes information (sociodemographic characteristics, medical school and year of the license) regarding 18,480 medical license recipients in Israel who are neither army medical doctors in training nor new immigrants and who received their licenses between 2000 and 2022, as well as data on residencies. (The analysis did not include army medical doctors in training and new immigrants because they follow a different training route). The administrative data include information on license recipients and of residences, starting from January 2000. The information was last updated in July 2023.
The qualitative section included semi-structured in-depth interviews conducted between January and August 2023 mainly via Zoom among three groups: senior physicians responsible for or involved in the acceptance of residents, second-year residents, and physicians who have been waiting for an extended period for a residency though not by choice. The senior doctors interviewed for this study are working in hospitals in both the center and the periphery, in a variety of departments. The doctors who were interviewed while waiting for a residency have diverse backgrounds with respect to gender, population group (Jews and Arabs), and country of study (Israel or abroad). The residents are training in hospitals in both the center and the periphery and the period they waited or were waiting for placement varied (less than a year or more than a year). All of the respondents were asked to describe how they envisioned an ideal placement process. In addition, the senior doctors were asked about the management of resident intake, the strengths of the process and the barriers to its implementation. The residents and those waiting for placement were asked to describe the process of residency search, their satisfaction with the process and its weak points.
Main Findings
The breakdown of the administrative data by gender and population group was 40% female, and 59% Jewish. The average age at the time of receiving the license was 31 years. The median waiting time until the start of the residency was 4 months, and the average waiting time was 8 months, with a standard deviation of 11 months.
The analysis of the data and the interviews generated the following insights:
- The internship year is critical in the placement process.
- The process of getting accepted to a residency is not formalized and is not sufficiently clear to either the residency candidates or the senior physicians.
- The sociodemographic characteristics of the residency candidates do not have a significant impact on the pace and rate of residency starts, except for type of medical school in the case of Arab candidates: The waiting time for residency for Arab doctors who had graduated from foreign medical schools was longer than for the rest of the candidates and their rate of starting residency is lower – 71% of them start residencies within five years from receiving a license as opposed to more than 90% of doctors who are either Jews or non-Jews who graduated from universities in Israel.
Recommendations
- Publishing information about vacant residency positions on the national level – The manner in which vacant positions are publicized needs to be optimized with respect to timing and platform, in order that the information becomes accessible to every candidate who wishes to apply for a position.
- Developing a guidance program for undecided physicians during and after their internship – Providing guidance to candidates with regard to suitable residency positions will significantly reduce waiting times and thereby also the mental distress of the waiting candidates, as well as assist the system in quickly filling residency positions.
- Transparency of acceptance criteria – It is recommended that the acceptance process for residencies in the departments and hospitals be formalized. It should be determined what the process includes, if there is a committee and what is its composition, whether an interview is conducted, etc. It is also recommended that the acceptance criteria for the various residencies be formulated and publicized.
- Regulation of placement in vacant positions – Consideration should be given to a reform in the residency placement process, so as to create a system with a central control mechanism that will ensure that enough physicians apply to specialties that are a national priority and that no significant surplus develops in any specialties.
- Expanding opportunities for exposure to the departments during medical school – It is recommended that changes be made to the curriculum for the clinical years of study for students in Israel and that there be greater opportunity for exposure to the departments during the internship year, beyond the limited exposure currently available, and that it should include departments beyond the five mandatory ones. In addition, options should be created for short-term employment opportunities that will replace the “observation period” that was in place in the past.
- Training of graduates from “not accredited foreign institutions” – At the time of writing, there were several thousand graduates from foreign medical schools that have low professional standards who have not yet started their residency; in the coming years, several hundred more are expected to complete their studies at those medical schools. Some of these physicians can be absorbed into the system, which is in desperate need of physicians, if they are properly trained after returning to Israel. Therefore, it is recommended that a comprehensive training program be created for these physicians and that criteria for those who will be included in it are formulated.
Citing suggestion: Burger, A., Ben Meir, E., & Maoz Breuer, R. (2024). Delays in the start of residency for physicians after receipt of an Israeli medical license. RR-016-24. Myers-JDC-Brookdale Institute. (Hebrew)