November 1, 2018
A group of Fellows from the American College of Surgeons (ACS) visited Israel in April. The purpose of the trip was to learn about the development of surgery and the state of surgical services, the challenges and advances in the delivery of surgical and health care services, approaches to civilian and military trauma, and health care financing in Israel.
Sunset over the Mediterranean (Tel Aviv)
Our first stop was in Tel Aviv, where we met with Yoram Kluger, MD, FACS, chair, division of surgery, Rambam Medical Center, Haifa, and president, Israeli Surgical Association (ISA), who described the graduate medical education (GME) structure in Israel. The Israeli National Health System is centrally regulated by the department of health, which requires, by law, that the population’s mandatory health care services be free to all. Taxes and major philanthropic donations support the public hospitals and smaller private facilities. There are no designated military hospitals. The largest public centers are in Tel Aviv, Haifa, Safed, and Jerusalem, where Israeli, Arab, and Druze physicians work side by side.
Acknowledging the influence of the ACS on surgical practice (including early recommendations for establishing a GME system and the modernization of surgical concepts), Dr. Kluger reviewed Israel’s GME structure for general surgery. A total of 30 residencies, most affiliated with hospitals rather than universities, are distributed throughout the country. Training is for six years, including six months of mandatory research, with examinations that occur at the midpoint and on completion of the program.
Qualification for fellowship training is a primary goal for residents. Many Israeli graduates seek fellowship training in the U.S. but find these opportunities difficult to obtain. Some in-country fellowships for trauma and colorectal specialization are well established, whereas fellowships in breast, metabolic (bariatric), and endocrine are in development. The ISA is responsible for accrediting general surgery residencies and fellowships, essentially combining the roles of the ACS, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery into a single entity. Parallel accreditation for orthopaedics, urology, and otolaryngology training is overseen by the individual specialties.
A wall at a Tel Aviv school: the inscription “Love” in Hebrew and in Arabic
Because of Israel’s mandatory armed forces service requirement, the average age of a first-year medical student is 24 years old, and the average age of a first-year resident is 29 years old. Approximately 25 percent of general surgery residents are women. The apprenticeship model for training is slowly shifting to a proficiency model, which will include milestones (certain skills that need to be attained at certain points in training), management courses for those surgeons who aspire to leadership positions, and assessment of interactive skills. Continuing medical education is not mandatory but is being implemented for practicing physicians.
Next we visited Chaim Sheba Medical Center in Tel Aviv, where we were greeted by Prof. Mordechai Gutman, MD, FACS, director of surgery; Prof. Aviram Nissan, MD, director of surgical oncology; Yoram Klein, MD, director of trauma and critical care surgery; Goldes Yuri, MD, deputy director, department of general surgery; David Goitein, MD, senior physician, surgical oncology department, and head, bariatric and metabolic surgery unit; and Danny Rosin, MD, FACS, department of general surgery and transplantation. Chaim Sheba Medical Center, or “Sheba Town” as it is commonly known, is the largest hospital in Israel and a tertiary referral center operated under the ministry of health. The facility has a hotel for out-of-town patients and their families, and two shopping malls. It houses 1,700 beds, 35 of which are in the intensive care unit (ICU). The surgical specialties practiced at Sheba Town include trauma, critical care, bariatrics, surgical oncology, hepatobiliary, and minimally invasive surgery.
For trauma and critical care, the hospital largely relies on telemedicine. It is the only medical center in Israel that has the capability to provide critical care via an audiovisual platform. Unfortunately, the demand for surgical critical care providers does not meet the availability of providers, so telemedicine is a critical component of care in Israel. The platform uses software that can be accessed via a laptop or a smartphone, and includes a high-definition camera and options for stethoscope, otoscope, and ultrasound capabilities. The platform also allows for services beyond critical care, including access to general surgery resources, specialty consultation for the military, pediatric critical care, as well as trauma consultation in remote areas. Medical records are kept electronically.
Sheba’s mass casualty preparedness plan is well structured, with coordination between the ministry of health and other hospitals. Because Israel has no military hospitals, all medical centers provide care to military personnel. The Ministry of Health supervises annual drills for trauma, toxicology, and radiation casualties; natural disaster drills are not included. Chaim Sheba Medical Center is not currently fortified, but plans are under way to provide for underground relocation during missile attack of the following key areas: emergency department, operating room (OR), ICU, and maternity units.
In surgical oncology, Chaim Sheba Medical Center offers chemotherapy (intraarterial and intraperitoneal in addition to conventional chemo); immunotherapy (adaptive cell therapy, second only to the Rosenberg lab at the U.S. National Cancer Institute, Bethesda, MD); isotope therapy, including selective internal radiation therapy (also known as SIRT) and yttrium-90 (also known as Y-90); ablation therapy (including radiofrequency, microwave, irreversible electroporation, focused ultrasound); and radiation (intraoperative brachytherapy). The facility is also in the process of obtaining a mobile linear electron beam accelerator, which will merge magnetic resonance imaging (MRI) and ultrasound images for use intraoperatively. Health care providers at the Chaim Sheba Medical Center have done more than 600 HIPEC (hyperthermic intraperitoneal chemotherapy) cases, with a goal of 100-plus cases in 2018; cases include mesothelioma and colorectal cases. The facility also has a basic science research lab where researchers are investigating intracellular targets and are in the process of developing a peptide nucleic acid biomarker in colon cancer. Sheba has a peritoneal surface malignancies program where surgical teams from Israel and other countries are trained.
The department of surgery has nine surgeons on staff, and three are women. All surgeons take general surgery call regardless of their subspecialty. Sheba’s physicians are paid a salary, and the public hospital system in Israel is such that one of the four Israeli health maintenance organizations pays a flat fee per inpatient day per patient regardless of interventions or studies performed. There are 25 general surgery residents (with varying numbers in different postgraduate levels). The hospital has no formal surgical fellowship training programs; however, a pilot training program is under way for surgical oncology with the goal to develop a formal program, which would include a one-year training rotation through different hospitals in Israel and one year of training in surgical oncology at a U.S. center. The pilot training program has established collaborations between Chaim Sheba Medical Center and Albert Einstein Hospital and Mount Sinai hospitals in New York, NY, with goals to expand collaboration with other medical centers in the U.S. and Europe. Medical students from Tel Aviv University and St. George University, Nicosia, rotate through Sheba. Chaim Sheba Medical Center has one of the best simulation centers in the world.
From left: ACS Past-Presidents Drs. Townsend and Pellegrini, and ACS Excecutive Director David Hoyt, MD, FACS, with Ms. Hyams in the Rambam Hospital underground emergency OR
Prof. Amos Etzioni, MD, director, Ruth Rappaport Children’s Hospital, Haifa, provided us with a broad overview of the extensive Rambam Health Care campus, northern Israel’s largest medical campus, 40 kilometers from Israel’s border with Lebanon. Rambam Health Center is the referral center for 12 district hospitals, serving more than 2 million people. It has 960 hospital beds and 51 ambulatory center beds, and it employs more than 1,000 physicians and 1,600 nurses. The medical center provides cutting-edge care, including more than 900 procedures conducted robotically per year. It also offers three-dimensional printing for craniofacial reconstructions and provides advanced brain therapeutics, such as MRI-guided focused ultrasound for essential tremor and Parkinson’s.
Gila Hyams, RN, MA, center director, Teaching Center for Trauma Systems, Emergency and Mass Casualty Events, and director, nursing, provided an overview of the trauma hospital system and mass casualty plan. Rambam Health Care is the largest Level I trauma center in Israel, treating approximately 800 severely injured trauma patients (with an injury severity score greater than 16) annually. Furthermore, given its location in northern Israel, Rambam has experienced firsthand the need to be prepared to operate while under attack. In the summer of 2006, during the second Lebanon war, Rambam treated 792 soldiers and 538 civilian casualties while under fire. Notably, more than 60 rockets struck within a half-mile radius of the hospital, and as a result of this experience, in 2009 hospital administrators commissioned the construction of an underground hospital.
In 2014, the Sammy Ofer Fortified Underground Emergency Hospital opened. In times of peace, the three-level parking garage houses 1,500 cars. However, the parking garage can be converted to a 2,000-bed hospital within 72 hours. This hospital is fortified against bombings and chemical warfare with thick walls and 12 doors with varying degrees of decontamination. The hospital houses ORs, delivery rooms, 35 ICU beds, and a full laboratory. Computed tomography (CT) and MRI equipment can be lowered down to the facility by a specially constructed elevator. The underground emergency hospital has its own water and electrical supply, as well as stockpiled food rations.
Tal Salomon, MD, chief of surgery; Alexander Braslasky, MD, head of the trauma unit; and David Fuchs, head nurse, trauma, gave the College delegation an overview of the Ziv Medical Center, Safed, which is located 19 miles from the Syria border and seven miles from the Lebanon border. The hospital plays a strategic role in delivering health care to the residents of northern Israel, which include Jews, Muslims, Christians, and Druze, as well as military personnel, United Nations (UN) peacekeepers, and Syrian civilians who cross the border in search of lifesaving procedures. Since the Syrian war began in 2011, approximately 500,000 people have died and more than 1.5 million have been wounded. Most Syrian medical personnel have departed the area, leaving the country with no structured medical care. A large portion of the trauma is orthopaedic, although surgeons at Ziv Medical Center also have treated extensive abdominal trauma patients who require multiple operations, prolonged ICU stays, and lengthy hospital admissions. The cost of this care is absorbed by the Israeli government or through charitable donations.
The challenges in treating Syrian patients are many, including language barriers, unaccompanied minors, and the possible presence of explosive devices in their clothing. To address these issues, the medical center has a Syrian-speaking social worker immediately present during the acute care of the patients, and a total body CT scan is performed on all injured patients arriving in the emergency room.
Ziv Medical Center’s multiethnic staff is on a war footing and the hospital has been struck by missiles in the past. Training includes massive casualty preparedness and the proper use of gas masks in the event of a chemical weapons attack. The hospital has underground capability and an auditorium that can be rapidly converted into an ICU for 200 patients.
The hospital started the Good Neighborhood Project at the end of 2016. Every two weeks, 25 children and their mothers are transported from Syria and are given basic health care, including vaccination, ophthalmology, and otolaryngology services.
Our last meeting in Israel was with Ofer Merin, MD, cardiothoracic surgeon, chief of the trauma unit, the ICU, and the ORs at Shaare Zedek Medical Center. Dr. Merin is also commander, Israeli Defense Force Mobile Field Hospital.
Technion-Israel Institute of Technology, from left: Dr. Jimenez, Ms. Jimenez, Dr. Salcedo-Wasicek, Dr. Langdale, Dr. Pellegrini, Professor Wolf, Dr. Townsend, Dr. Hoyt (behind), and Dr. Oyentunji
The Shaare Zedek Medical Center is a Level I trauma hospital with 1,000 beds. The hospital has a large obstetrics department, delivering approximately 20,000 babies a year. The medical center treats 3,000 trauma patients annually, mostly from motor vehicle accidents and terrorism. Dr. Merin explained that these patients typically present in waves. Victims of suicide bombers and bus bombs were common 15 years ago, whereas seven to eight years ago, cars driven into groups of people became a frequent means of terrorism. More recently, Dr. Merin and his colleagues have been treating victims of stabbings carried out by younger terrorists. These stabbings usually involve the upper body and cause major damage to the head, neck, and thorax. The problem is that the perpetrator is often stopped by the police using lethal force, and both the victim and the terrorist arrive at the trauma unit, where they have to prioritize the care given to both patients according to the severity of the injuries. Sometimes it is the perpetrator who will receive the most expedient care and require the most resources. This scenario is difficult for the victim, the family, and the health care workers. For this reason, the teams debrief after each incident to allow members to communicate their concerns and frustrations.
The Israeli Defense Force mobile field hospital has been deployed for international disasters. This team was present in Haiti in 2010 and was the first unit to have a functional OR within 72 hours of the earthquake. Approximately 200 health care workers treated more than 1,000 injured patients and performed 300 operations. At the end of the two-week deployment, they donated their equipment to the local physicians. The World Health Organization recognized the Israeli Defense Force Mobile Field Hospital for its work and awarded it the Type 3 score, the highest rating that the UN uses to rate foreign medical assistance in times of disaster.
In front of the Jaffa Gate, from left: Dr. Oyentunji, Dr. Langdale, Dr. Kao, Dr. Townsend (behind), Ms. Townsend, Ms. Weymuller, Mr. Wasicek, Dr. Wasicek, Ms. Pellegrini, Dr. Weymuller (behind), Dr. Pellegrini, Ms. Russell, Ms. Jimenez, and Dr. Jimenez
Our site visits served to demonstrate that although the people of Israel must constantly be prepared for warfare, they do not let this weaken their creative spirit or their technological progress. During our visit to the Technion–Israel Institute of Technology, Alon Wolf, PhD, associate professor, mechanical engineering, described many exciting projects at the institute, including the development of flexible, steerable scope technology and a three-dimensional printed hand prosthesis for children. Israel is at the forefront of entrepreneurial startups and this was demonstrated by Start.il, an organized group based in Tel Aviv that supports new startups.
With our charismatic guide Amir Orly, we learned about the history of Israel in the old port city of Jaffa, the Independence Hall, the ruins of Caesarea, the different quarters of the city of Jerusalem, and the ancient fortress of Masada. We were moved by Yad Vashem, Israel’s official memorial to the victims of the Holocaust, and we participated in the country’s Holocaust Remembrance Day with a two-minute silence across the nation to remember the 6 million Jews who were killed during World War II. We visited a kibbutz, the temples, and the Western Wall, floated in the Dead Sea, drove along the Sea of Galilee, shared Sabbath dinner with our gracious hosts Chaim and Simi Landau, and enjoyed the wonderful Israeli cuisine. But above all, we discovered a nation of strong, friendly, caring, generous people who are deeply proud of their health care system, as well as their country.