The word “overload” is barely adequate to describe what happened at the Internal Medicine B department at Ziv Medical Center in Safed during the hours that this Shomrim reporter spent being shown around the facility. Over the course of less than 24 hours, the department admitted 18 new patients, the oldest of whom was a 107-year-old woman.

“What’s going on? Did a bus drop off patients?” asked Prof. Raymond Farah, the head of the department, at the morning meeting when the single resident who was on duty overnight presented the new patients from his shift.

“From yesterday at three o’clock in the afternoon, it’s been one admittance after another,” the resident replied, adding: “Three times more than any other hospital our size.”

Ziv Medical Center, which serves close to 300,000 people from the Golan Heights, the Upper Galilee and the Eastern Galilee, has just two internal medicine departments. The Poriya Hospital, which is located a 40-minute drive away and which serves a similar number of people from Tiberias, the Jordan Valley and the Lower Galilee, also has just two such departments. “We get an average of between 10 and 15 new patients a day in our internal medicine departments – which is crazy,” says Dr. Eyal Fuchs, director of internal medicine at Poriya, describing a similar situation at his hospital. “The on-duty physician never sleeps. The on-duty physicians often tell me that they only managed to give a patient urgent instructions or life-saving drugs, but that they simply didn’t have time to review what other drugs they take, to look at their scans or to study their casefile. There’s a lot of talk about not having enough time for all that – and I can’t say anything.”

What is the significance of a single resident being responsible for the intake of a two-digit number of new patients during their shift? We asked Prof. Farah during a tour of his department. “You could miss something,” he replied. “You don’t have time to talk to the patients because you have to rush to the next intake.” Farah stops next to the ward for elderly patients, which is adjacent to the nurses’ station. “Right now, we have six patients who are on ventilators and each of them needs the doctor. “We have a full team of nurses but just one resident, who is also responsible for intakes and for the whole department, including all the patients. The situation is dire.”

The chronic shortage of medical staff at internal medicine departments at hospitals in Israel’s peripheries is nothing new. Now, however, everyone with hands-on experience of the crisis admits that it is worse than ever. In fact, if we borrow from the terminology of the past few weeks, it’s an existential problem, especially given the Ministry of Health’s decision in March to shorten medical school graduates’ residency period. According to senior doctors in these departments, that decision will increase the workload to even more unbearable levels, will severely harm the treatment patients receive and will exacerbate the already growing gulf between medical treatment in the center of the country and in the peripheries.

“My situation is terrible. We’re on the verge of collapse. For the past week, I have been the only senior physician in a department that has six patients waiting in the corridor for beds every morning and a shortage of residents,” wrote the director of one of the internal medicine departments at Soroka Hospital in Be'er Sheva in a private WhatsApp group for senior physicians. The group provides them with a forum in which to express their frustration at the healthcare system, which seems oblivious to the major crisis they are experiencing.

A colleague from Ashkelon’s Barzilai Medical Center shared that, “of the nine residents in the department, I only have two residents at the morning meeting. The manpower is limited, the occupancy rate keeps going up and it’s taking longer to extract blood. No one has any patience.” The director of internal medicine at the Galilee Medical Center in Nahariya called on his colleagues to ignore the new Ministry of Health plan – even if that means breaking the law – since “the conscience of a department director should guide him more than regulations.”

“What happens in practice is that a resident who is part of the pilot scheme is not at the hospital for between 40 and 50 percent of their monthly work days. When we run tests and perform scans."

‘Instead of narrowing the gap, it’s just getting wider’

The Ministry of Health first unveiled its plan to shorten medical residencies in September 2023, around a month before the outbreak of the war. It was defined as a pilot and implemented in the internal medicine departments of hospitals in the peripheries: The Galilee Medical Center in Nahariya, Ziv Medical Center in Safed, the Emek Medical Center in Afula, the Tzafon Medical Center in Poriya, Soroka in Be'er Sheva, Barzilai in Ashkelon and both of the hospitals in Nazareth.

The Ministry of Health presented it as part of an overall plan aimed at reducing the gaps between medical service in the center of the country to that offered in the peripheries and came after residents complained about working countless shifts. It sought to improve working conditions and alertness and to encourage young doctors to flock to hospitals in the peripheries. It took less than two years for these admittedly lofty ambitions to come crashing down on the hard ground of reality, with internal medicine department directors declaring it an unmitigated disaster and demanding that the plan be curtailed immediately.

“Instead of narrowing the gap between the periphery and the center of the country, all they did was make it worse,” Farah says. “There’s no training and there’s no clinical teaching. I can’t hold clinics when there are 40 patients in the department, including those in serious condition, and there is just one doctor or two at most. But, first and foremost, it harms the patients. As soon as the pilot was launched, the war broke out and most of the population [of northern Israel] was evacuated, so we did not start to feel the huge damage. Now they are back home and it’s a total catastrophe. The departments are full and don’t have enough doctors.”

While the explanation may be a little technical, in order to demonstrate how the new plan deepened the manpower crisis, it is important to understand the structure of personnel in internal medicine departments in the peripheries. At the Ziv Medical Center, for example, the internal medicine department provides two on-duty residents to the emergency room and a third on other wards. These shifts start at 4 P.M. and continue until the next morning. “During the daytime, I am ‘short’ three residents: two have just finished a shift in the ER and the third is on another ward,” Dr. Hepzi Green – the secretary of the Israeli Society of Internal Medicine and director of one of the internal medicine departments at Barzilai – explains. “Because of this reform, the on-duty physicians are not present the morning before their shifts [or the morning after], so, in effect, six residents are missing from the department during key working hours.”

At the Tzafon Medical Center in Poriya, residents from the internal medicine department also keep the ICU department afloat thanks to the shifts they serve there. The price: eight missing residents in the internal medicine departments. “Add to that pregnancies, reserve duty, study leave and rotations [each resident must spend one year away from the internal medicine department] – and who’s left on the department during the morning hours? Half of the given manpower is absent, because they didn’t increase the number of residents,” Green explains.

“In order to compensate for the lack of manpower during the morning, I needed four doctors instead of two,” says Poriya’s Dr. Fuchs – who was ‘compensated’ for the detrimental effect of the program with two extra residents. “Instead of there being five residents in the morning, which is the minimum you need at that time of day to treat 40 patients, I have three or four – and sometimes just two residents. There was a shortage beforehand and then this pilot significantly reduced manpower during the day.”

Fuchs adds: “What happens in practice is that a resident who is part of the pilot scheme is not at the hospital for between 40 and 50 percent of their monthly work days – which are Sunday to Thursday – between the hours of 8 A.M. and 4 P.M. That is when most of the department’s activity takes place, when we run tests and perform scans. That’s when most of the significant clinical work gets done. Everything beyond on-duty cases, which are always emergencies.”

“When a resident arrives for their shift at 1 P.M.,” another internal medicine department director explains, “they are half-scarecrow, half-babysitter. And then the shift from 4 P.M. until the next morning starts; the next morning, they simply hand over the department and nothing more. You won’t see them again until the next day. There are situations where they are on duty on Monday and Wednesday – and that’s the end of their week.”

Like Prof. Farah, Dr. Fuchs also believes that the professional damage will also be severe in the long-term. “Their training is being severely undermined,” he says. “During the two years they are at work, they are supposed to finish their residencies and be experts in internal medicine – which is the pinnacle of professional knowledge – and from there they can enjoy a three-decade career in internal medicine and treat everyone.”

“Graduates of universities in the center or advanced med schools overseas do not want to work here. They would come here for their residencies, cry the whole time and the moment it was over – they fled.”

There’s ‘residencies’ and then there’s ‘residencies in the peripheries’

It is no coincidence that the pilot scheme was launched in hospitals in the peripheries, where patients already receive a lower standard of care than in the center of the country. This is constantly reflected in indices published by the Ministry of Health, which show that the patient-doctor ratio in the peripheries is dramatically lower than in the center. In the north, there are 2.38 doctors for every 1,000 residents; in the south, there are just 1.92 doctors for every 1,000 residents. In Tel Aviv, residents enjoy a ratio of 4.97 doctors for every 1,000 residents. Unsurprisingly, this has a direct impact on life expectancy: in the periphery, it’s 81.3 years, compared to 84 in the center.

The pilot program to shorten medical residencies was intended to shift the balance by encouraging residents to work in internal medicine departments in Israel’s periphery. In practice, however, it only widened the existing gaps.

"The group pushing for the reform – Mirsham, the Medical Residents Organization of Israel – primarily represents physicians in the center of the country," says Dr. Fuchs. "There are hardly any members from hospitals in the periphery. They decided this plan was a good idea, but they’re not the ones living with its consequences. Not a single Mirsham doctor has experienced the damage it has caused to training or to the daily work in these departments."

The result, according to Dr. Green, is that “there are two residencies: there are residencies in the center of the country, where they have four on-duty shifts a month, because there is enough manpower; and there’s the residencies in the peripheries, where you do six or seven of these shifts and residents spend half the month away from the department, which means they see fewer patients.”

The professional gaps, according to Green and her colleagues at the Israeli Society of Internal Medicine, are also demonstrated by the following figures: just 27 percent of the internal medicine residents in the peripheries passed their exams at the first time of asking last year, compared to more than 80 percent in the center. This gap is not merely linked to the number of on-duty shifts, but also to the quality of residencies in the periphery compared to the center, as well as the fact that, instead of strengthening the professional training of residents in the peripheries, the healthcare system has made undermined the very people who need help the most.

“The least affluent members of Israeli society who study medicine do so at the weakest places,” Dr. Green explains. “Most of the residents in the peripheries graduated from medical school overseas. Many of them come from schools that have such poor records that Israeli hospitals will soon no longer be able to hire their graduates” because of the so-called Yatziv Reform to regulate medical studies at faculties abroad. According to Green, some 800 Israeli students graduate from these schools every year – the vast majority of them from Arab society. “Graduates of these overseas medical schools are the ones who, for the most part, work at internal medicine departments in the peripheries,” she adds.

“Graduates of universities in the center of the country or advanced med schools overseas do not want to work here,” confirms one Arab resident at the Ziv Medical Center. “They would come here for their residencies, cry the whole time and the moment it was over – they fled. They were offered bonuses of 300,000 shekels, 500,000 shekels, a long-term plan – but they didn’t want to stay here. Just look at the two internal medicine departments here. There are no Hebrew speakers. We want, but people don’t want to live in the peripheries; everyone’s moving to the center. In Poriya, Ziv, Nahariya – 90 to 95 percent are Arabs who live here.”

“When I started my residency here, I was amazed by the gaps,” says one physician in the north, who is the only Jewish Israeli among the residents in her department. “I used to get home and cry all day. I don’t want to say that I got used to it or that something changed a little, because the gaps are very wide. I am the first ever resident in this department who studied in Tel Aviv. The department has been running for decades. I chose to come here with motivation and desire, but it depends on what kind of day I’ve had. Today I am in a good place, but there are days when I tell myself that I would overturn the table and would drive every day to Rambam [teaching hospital in the Bat Galim neighborhood of Haifa].”

“Given how internal medicine works in Israel – with one internal medicine department that looks after a wide variety of ailments and patients with different diagnoses – it is a concept that does not exist in Eastern Europe and even in some hospitals in Western Europe,” Dr. Green explains. “So, they do not learn to work with this system of medicine; they are not familiar with the medical textbooks or clinical thinking. They start from a lower place than a fourth-year student in an Israeli hospital. Not in terms of motivation or intelligence, but purely in the sense that we have to teach them differently.”

“There are some wonderful people there, who learn very quickly,” says the director of one internal medicine department in the peripheries, “but the problem is the quality of their studies. I have excellent doctors there, but when you take the general level, you’ve got a serious problem.”

Just 27 percent of the internal medicine residents in the peripheries passed their exams at the first time of asking last year, compared to more than 80 percent in the center.

Personal life improved; professional life deteriorated

While the internal medicine department directors appear to be unanimous in their opinion that the pilot should be scrapped, what about the residents themselves? They launched a public campaign lasting from April 2020 to August 2023, during which they held vocal demonstrations and even went out on strike to protest their unbearable workload, which sometimes included 26-hour shifts. The plan, which shortens on-duty shifts to 21 hours and which was signed when Nitzan Horowitz was minister of health, was supposed to rectify the problem and improve the quality of life for medical residents.

“Shortening the shifts was very significant – not only to my own personal welfare, but also to my children, whom I can now take to kindergarten and school in the morning, and to my relationship, my daily life and my studies,” says one resident who started her residency at Poriya some three months ago. “Having said that, I must admit that getting a glimpse at the situation during the temporary suspension of the program [in June, when the Ministry of Health made concessions ahead of the residents’ exams] gave me a different perspective on things. I feel like I am more present in the department and understand what is happening more.

“Next week, for example, I am on duty on Sunday and Wednesday. That means that I will not be here on Sunday morning or Wednesday morning. I’m also not here on Monday and Thursday mornings, because I have just finished duty shifts. So, for an entire week, I am only working in the department during daytime hours on Tuesdays, which is pretty crazy for a new resident who needs to learn how internal medicine departments work.”

She adds: “It makes it very hard and scary when I arrive in the afternoon for my shifts and I don’t know the department. I am less familiar with the patients, some of whom have complex conditions and are on ventilators. I can get a call at 10 o’clock at night telling me that the patient in Room Seven is crashing but I would go in there totally unprepared because I don’t know the patient. That’s not to say that if I arrived at 8 A.M. I would know the patient’s file intimately, but it increases the chances.”

Similar sentiments were expressed by a physician currently interning at the internal medicine department at the Ziv Medical Center. “I benefit from shorter shifts when I am on duty, but on days when I am not, all of the work is divided between two doctors and, on some occasions, there’s just one physician to handle the whole department. Imagine that I am with a senior doctor – assuming that he or she is free – doing the rounds and visiting 42 patients. You can spend between three and five minutes with each patient and there are times when you won’t get to them all. It’s not right, but it happens. During the visit itself, you’re on the computer most of the time, peering at the patient from behind the monitor. It’s almost like online medicine. In contrast, when you’re calm and you have a reasonable number of patients to visit, you can give better treatment and conduct a physical examination.”

“Let me give you an example,” he adds. “There was a patient who I diagnosed as suffering from pneumonia. It was during a stressful and busy period. It was only the next day, when I was less stressed and I went to see her that I felt that something was wrong. I lifted her gown and performed a lumbar puncture – and she leapt from the bed in pain. We took her off for a CT scan and we discovered that one of her vertebrae was severely damaged and purulent. It wasn’t pneumonia.”

“When three or four residents are not in the department, the workload is crazy,” says one of the residents at Poriya. “And that means a significant decline in the quality of care. It makes a huge difference if I see four patients a day or if I have to see a dozen. The fewer patients I see, the better I can understand their needs, order more tests for them and consult with other doctors. When I have 10, I’m chasing my own tail just to get everything done. Sometimes, I extend a patient’s hospitalization because I didn’t have time to treat them. I tell them to stay one more night simply because I didn’t get to them.”

“I want excellent doctors in internal medicine departments," Fuchs says. "I don’t want there to be mediocre doctors who stayed simply because they didn’t have a better option".

“Instead of narrowing the gap between the periphery and the center of the country, all they did was make it worse,” Farah says. “I can’t hold clinics when there are 40 patients in the department."

‘Every morning, I look for the doctors’

On the desk in Prof. Farah’s office is a printed list of the names of the 13 patients who died in his department over the past year. “I don’t have the manpower to be able to sit and sum things up, so it will wait,” he says, unable to conceal the desperation in his voice. That morning, minutes before we met, another patient died; he didn't even have time to add her name to the list – and he was visibly upset. “I have a gut feeling that we’re going to see an unusual wave of morbidity in the coming months. There’s no research to back that up,” he stresses, “but we can feel it. We see more and more people dying.”

Next year will be Prof. Farah’s 20^th as director of the department. The walls of his office are packed with certificates and letters of thanks from patients, IDF units and senior Ministry of Health  officials, lauding him for his contribution. Notwithstanding the embrace from the medical establishment, Farah finds it hard to keep the anger he feels toward the Ministry of Health inside: “The situation here is not pleasant,” he says, with uncharacteristic understatement. “The Ministry of Health doesn’t understand that; the officials there do not know what’s happening on the ground. They have to come and see what’s going on here.”

A few minutes later, during the department’s morning meeting – a snippet of which was described above – we could clearly see what “not pleasant” actually meant. Sitting around the table were just six physicians – half of the normal number. “I arrive at the morning meeting and every day I have to ask who is on duty; every morning I’m looking for the doctors.”

According to internal medicine department directors, the Ministry of Health realizes that the planned reform has failed but officials are afraid to admit so by canceling it. “They know it’s problematic,” says Dr. Green. “After all, the Ministry of Health sent out a letter ahead of the first round of end-of-year exams in June, saying that if there are departments experiencing problems, they can send requests and get permission to suspend the plan to shorten residencies.”

These directors are also angry with the Israel Medical Association, which supported the plan – despite opposition from most of the professional organizations that make up the IMA. They are also angry with the IMA’s scientific council, which they accuse of allowing the government to harm doctor training. “Changing the residency model was a mistake because the main goal was not the best interests of the patient or the quality of care (…) We call on the government to annul the reform in the peripheries,” the heads of the organizations with the IMA wrote in an open letter some six months ago to IMA chair, Prof. Zion Hagay.

Like his colleagues, Dr. Fuchs also calls for the reform to be rolled back and, if that is not possible, he says, the government should reduce the number of on-call shifts and add more manpower. It is especially important, he says, to give support to senior physicians. “We have to make sure they don’t flee, because the good ones leave and the mediocre ones stay,” he says. “I want excellent doctors in internal medicine departments. I don’t want there to be mediocre doctors who stayed simply because they didn’t have a better option. I want them to want to stay here – in terms of salary, in terms of conditions, title and potential to do more things. We have to build a plan that will give them a reason, desire and something to aspire to – not just a stepping stone.”