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The Journal of Emergency Medicine, Vol. 33, No. 4, pp. 433–437, 2007Copyright © 2007 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/07 $–see front matter

doi:10.1016/j.jemermed.2007.04.016

InternationalEmergency Medicine

A STUDY OF THE WORKFORCE IN EMERGENCY MEDICINE IN ISRAEL: 2003

Michael J. Drescher, MD,*† Limor Aharonson-Daniel, PhD,‡ Bella Savitsky, MPH,‡ Joseph Leibman, MD,§and Kobi Peleg, PhD, MPH‡

*Department of Emergency Medicine, Sheba Medical Center, Tel Hashomer, Israel, †Division of Emergency Medicine, HartfordHospital, Hartford, Connecticut, ‡Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for

Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel, and §Department of Emergency Medicine,Bikur Cholim Hospital, Jerusalem, Israel

Reprint Address: Michael J. Drescher, MD, Division of Emergency Medicine, Hartford Hospital, Hartford, CT 06102

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Abstract—Emergency Medicine (EM) was officially rec-gnized as a specialty in Israel in 1999. In 2003 the first ninesraeli trained emergency physicians (EPs) were certified.his survey was undertaken to assess current staffing ofmergency Departments (ED) in Israel and to attempt tostimate future staffing needs for EPs. A survey was sent toll ED directors at general hospitals in Israel. We askeduestions relating to staffing by number of physicians, typend level of training, and differential staffing by time of theay and week. In addition, we inquired as to the census,tructure, hospital resources available, and size of the ED.wenty-four of 25 (96%) EDs responded. There were 59M specialists registered in Israel; there were 37 EM res-

dents. EDs reported a total of 1,872,500 visits annually.mergency care is otherwise given by specialists and resi-ents in other fields, and non-specialist physicians. At largeospitals there is an average of 2.5 EM specialists duringaytime hours, and another four specialists of other typesn duty. During the night in large hospitals, there is anverage of <1 specialist of any kind (typically not EM) onuty. In most EDs, care is turned over to non-specialistsresidents and others) during evenings and nights. Theecognition of the need for Emergency Medicine as a spe-ialty in Israel has not as yet translated into care of emer-encies by EPs for most patients. To adequately staff EDsith physicians trained in EM, an emphasis needs to be

Presented as an abstract at the Research Forum, Americanollege of Emergency Physicians, San Francisco, California,ctober 2004.

ECEIVED: 7 October 2005; FINAL SUBMISSION RECEIVED: 8

CCEPTED: 8 November 2006

433

laced on increasing EM staff and resident positions. Theeed seems most acute in medium-sized hospitals and dur-

ng off hours and weekends. © 2007 Elsevier Inc.

Keywords—workforce; Emergency Medicine; Israel;taffing; international

INTRODUCTION

ackground

n 1992, the Israeli Association for Emergency MedicineIAEM) was formed to further emergency care and therofessional status of Emergency Medicine (EM) in Is-ael (1). In 1999, after a period of investigation and aoncerted effort by the existing leadership of the IAEM,mergency Department heads from around the country,nd with help from leaders in EM abroad, the Israeliinistry of Health officially recognized EM as a spe-

ialty (2). Criteria for specialist status were published, asere a curriculum and site conditions for training pro-rams in EM. In November of 2003, the first cohort ofine Israeli trained emergency physicians (EPs) success-ully passed the certification examination given by thesraeli Association for Emergency Medicine under theegis of the Scientific Council of the Israeli Medicalssociation (IMA).

2006;

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mportance

ith the recognition of the specialty of Emergency Med-cine in Israel, and the inception of training programs,here is a need to estimate the demand for EPs. Thisstimate needs to be based on current workforce andork practices, and anticipated future needs.

oals of this Investigation

his study aims to examine the existing workforce ofhysicians working in Emergency Departments (EDs) insrael, to better delineate the need for EM specialists inhe future.

METHODS

etting

n July of 2003, we performed a study of the workforce ofll 25 general hospitals with EDs countrywide in Israel.

tudy Design

e conducted a cross-sectional survey designed to as-ess the numbers, level of training, and specialty (if any)f physicians working in EDs. We further asked aboutifferential staffing at various times during the day andhe week. Additional questions regarding ED and hospi-al size, and ED census were included. The survey wasdapted from a previously published workforce study3). Hospitals were divided into three groups by numberf beds, as follows: small (up to 399 beds), medium400–699 beds), and large (700 beds and up). We senthe survey to the directors of EDs in all general hospitalsn the country that have EDs. If surveys were not initiallyeturned, telephone call follow-up was done to encouragearticipation. Data were entered using SAS statisticaloftware (SAS Institute Inc., Cary, NC), which was sub-equently used for data analysis. We stratified the data byhysician type, shift, and hospital size. This study wasxempt from Institutional Review Board approval as itid not involve human subjects or their records.

RESULTS

wenty four of 25 (96%) survey instruments were

eturned. t

haracteristics of Study Subjects

here were 7 small, 11 medium, and 6 large hospitals inhe study. Average annual ED census for each group was9,000, 88,500, and 104,500, respectively.

ain Study Results

e found that there were a total of 140 physiciansmployed full time by the ED over all the hospitals.here were another 94 physicians employed part time by

he ED. Of these, 59 were certified Emergency Medicinepecialists. Other specialties represented were mainlynternists, surgeons and orthopedists. The average num-er of full-time physicians of all types employed by theD—by hospital size—is shown in Figure 1. Theseumbers do not include other physicians working in theD, either “on call” or “covering” the ED for otherepartments. The number of full-time physicians work-ng in the ED varies by hospital size disproportionatelyo the difference in ED census, with medium-sized hos-itals having the lowest full-time staff-to-visit ratioFigure 1).

The number of physicians actually working (whetherelonging to the ED or to other departments) in the EDnd the type of physician by level of training and spe-ialty vary from shift to shift and from weekday toeekend (Figure 2). Throughout the country, there are

ssentially no EM specialists on duty during the nighthift and very few during the evening. On an averageeekday in Israel, in all EDs, there were 51 EM special-

sts working the day shift, five working the evening shift,nd an average of 1.5 EM specialists on the night shift in

igure 1. Number of full-time physicians staffing Emergencyepartments in Israel by hospital size.

he country at large.

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Emergency Medicine Workforce in Israel 435

DISCUSSION

t is clear from our findings that, by and large, theractice of EM in Israel is still done by non-EM-trainedr certified physicians. Often, these are specialists inther fields on the ED staff, but just as often, and espe-ially during nights and weekends, the care of patients inhe ED is left to unsupervised residents in various spe-ialties, at various stages of their training, or to physi-ians without specialist status who are not in a trainingrogram.

In addition, there is no official structure as yet formploying physicians during evenings and nights otherhan the system of “taking call” in the ED from 4:00 p.m.o 8:00 a.m. the next day on weekdays, 1:00 p.m. to 8:00.m. on Fridays, and 8:00 a.m. to 8:00 a.m. (24 h) on theewish Sabbath (Saturday). Therefore, the typical physi-ian staffing the ED during most of the hours of the weeks a resident physician at some level of training in one ofeveral non-EM specialties, who is working a 16-h shiftfter having already worked 8 h in his own department.

The shortage of full-time EPs (of any specialty) seemso be worst in the medium-sized hospitals. There, theverage number of full-time physicians employed inhe ED is 5.3. This is in contrast to large hospitals, wherehe average ED census is only 18% more but there are

igure 2. Average daily number of physicians staffing Emer-ency Departments in Israel by specialty and hospital size.

early double (9.3 per ED) the average number of phy- p

icians employed full-time in the ED. This would implyn even greater dependency on physicians from otherepartments to staff the ED than in the larger centers.

The number of ED physicians per ED visit seems toe small relative to that reported by Moorhead et al. inheir study of the workforce in EM in the United States3). There the authors report finding an average 7.85hysicians (needed to fill 5.29 full-time positions) sched-led to staff the ED with an average of 23,912 ED visits3). In our sample, we found 140 full-time ED physiciansof all levels and specialties) in 24 hospitals (average 5.8)aring for an average of 78,000 ED visits annually. Thisoes not include physicians (typically residents) assignedo cover the ED “on call” during evenings, nights, andeekends—which is the rule in most, if not all, Israeliospitals. It would seem that these physicians, caring foratients in the ED as described above but not counted asD staff, account for much of the discrepancy. It is alsoossible that the physician-patient ratio is larger in Israelhan in US Emergency Departments.

Various estimates have been published on the need forPs for a given population. One formula is based on theumber of ED visits in a given area (4–6). Anotherormula estimates staffing needs according to the numberf EDs in a given area (7).

By these formulas, given approximately 2 millionnnual visits to 25 EDs in Israel, the number of full-timePs needed to adequately staff an ED that is open around

he clock would be 400 and 118, respectively. Clearly,hese estimates are incongruous, and the latter mostikely reflects a situation in which small EDs are coveredy a single physician at any given time. This is notelevant to the situation in Israel, where even EDs atmall hospitals see a median of 47,000 annual visitsmean number of visits, 39,000). These formulas haveeen shown in other circumstances also to underestimatehe need for ED coverage (8).

The ratio of EPs in the United States relative to theopulation has been estimated at 1 per 10,000 popula-ion. The equivalent ratio in Israel would call for approx-mately 600 EPs at any given time for the population of

million (9). In contrast, according to a recent govern-ent publication from the United Kingdom, there are

00 EPs at the consultant or attending level in all ofngland, caring for 16.5 million ED patients. This re-ects a model of emergency care that relies heavily onurse Practitioners, General Practitioners, and specialist

onsultants from other departments. It does not includehysicians in training (10). Assuming a parallel ratio andodel of care in Israel would require only approximately

2 senior EPs at any one time. However, the Britishaculty of Accident and Emergency Medicine has esti-ated a need for one consultant (attending or senior) EP

er 12,000 patient visits. This is assuming a chiefly

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436 M. J. Drescher et al.

upervisory and administrative role (11). A similarodel in Israel would require about 166 senior EPs.Emergency Medicine is, as is Medicine in general, prac-

iced and organized differently from country to country andrea to area. And within each country, EM is developing atarious paces and in different directions over time. Theollowing are some examples in the context of which oneay compare the development of EM in Israel:

In Japan, as of 2001, there was no recognized spe-cialty of Emergency Medicine, however, there arephysicians specially trained in acute care and certifiedby the national professional organization, focusingprimarily on trauma. The concept of a dedicatedEmergency Department, as it is known in the west,reportedly does not exist, and there is no obligation onthe part of a physician to accept a patient for emer-gency care if he does not feel, for whatever reason,that he can properly care for the patient, often requir-ing ambulances to circulate and make multiple re-quests before finding an accepting institution (12).The Netherlands, about two and a half times the sizeof Israel by population, with a generally advancedlevel of medical care, seems to be at a comparablestage of development in EM to that of Israel. As of2001, the specialty of EM had been officially recog-nized and the Anglo-American model curriculumadopted, but in only two of 126 hospitals was there apermanent staff of emergency physicians. Otherwise,patients in the ED were cared for by rotating residentsin various specialties without direct onsite attendingsupervision. At that time, there were four hospitals withresidencies in EM with a total of 14 residents. Emer-gency nurses who are permanently assigned to the EDplay a large role in the delivery of emergency care (13).Emergency Medicine in Hungary, a country of about10 million, has moved in recent years from the previ-ous Soviet model of health care, where there wereessentially no EDs, but rather General Admitting De-partments that were understaffed and underequippedfor the work of a modern ED. As of 2001 there wereonly nine EDs in the country, at least one of which wasstaffed with full-time physicians from various specialties.Training in EM is at the fellowship level or may be doneas a combined EM/Internal Medicine program. Untilrecently, however, traumatology was not considered partof the scope of Emergency Medicine (14).In Switzerland, with 7 million residents and a techno-logically and organizationally advanced medical sys-tem, there is great variation in the training of caregiv-ers in the ED. The level of training of physiciansworking in EDs varies largely and depends mainly onthe size of hospitals and internal policies. In larger

hospitals, ED physicians are often specialists, certified f

in emergency or intensive care. In smaller hospitals,ED care is usually provided by residents without for-mal, postgraduate emergency care qualifications,closely supervised by higher-qualified physicians (at-tendings or seniors). Residents have usually attendedqualified in-house training, although supervision is notalways optimal (15). A recent study in Switzerlandshowed that, among other interventions, improvingsupervision of inexperienced physicians and institut-ing specific training in EM topics for physicians in theED improved triage categorization, and decreasedtime intervals to care in 12 EDs in Switzerland (16).

Two broad visions of emergency medical care haveeen described, the Anglo-American and the Europeanodels. The former is based on specially trained hospital-

ased physicians to deliver a broad range of services forll patients presenting to a separate Emergency Depart-ent. In contrast, the European model focuses on deliv-

ring resuscitative care in the field; this care is usuallyrovided by anesthesiologists, with subsequent triage ofatients directly to specific specialty services for defin-tive care (17). Emergency Medicine in Israel seems toe following the Anglo-American model.

Within that model, however, there is still debate amongsraeli EPs as to the future direction of EM in Israel. Someould favor the British model, with relatively few seniorPs, whereas others favor the North American model, inhich certified senior EPs being present and responsible foratient care at all hours is the standard.

Nonetheless, the Israeli medical establishment, in itsecognition of the specialty of EM with its attendantraining, curriculum, and certification examinations, hasstablished a standard of EM to be met. In November of003, the first cohort of Israeli trained EM residents sator their written and oral certification examinations andhe first group of nine Israeli home-grown EPs went intoractice. At the time of this survey, there were 59 certi-ed EM specialists in Israel to care for the nearly 2illion patients in the ED annually. Most of these EM

pecialists were recognized in the “grandfather period”ue to experience working in or directing EDs. This tracko specialization has effectively been closed. The cover-ge of these specialists is not uniform, with their pres-nce in the ED heavily weighted to weekday day shiftsnd absent or nearly so on nights and weekends.

LIMITATIONS

ur data were collected from department heads. Al-hough assurances were given that the data would be keptonfidential, except in the aggregate, it is possible that

ear of making workforce data public, for whatever rea-

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Emergency Medicine Workforce in Israel 437

on, may have caused respondents to answer inaccu-ately. A more rigorous investigation including site visitsould guard against this to some extent. We did not

nquire as to the variability of staffing given the depen-ence on extra-departmental staff, or day-to-day prob-ems in filling shifts with physicians for this or othereasons. The dependence on physicians from outside theepartment may cause considerable variability in staff-ng, which may not be reflected in the survey reports.

ore detailed demographics on emergency physiciange and expected work longevity would be of interest.

CONCLUSION

mergency Medicine is recognized in Israel as a distinctpecialty within the house of Medicine. It has not, how-ver, defined a national standard in terms of its status inhe hospital, scope of practice, etc. There seems to be ahortage of EPs, especially during off hours. Given theumber of EM specialists currently certified and theistribution of specialists on duty over the course ofhe day and night, the odds are against any given patienteing cared for in the ED by an EM specialist. Whetherr not the public and political leadership in Israel see EDtaffing as a major public health issue will determinehether resources will be channeled so that there will beore EM specialists caring for patients with emergen-

ies, whenever they may present.

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