social functions of medical licensing: a case study of soviet immigrant physicians in israel

Sot. SCI. Med. Vol. 20, No. 9, pp. 901-909, 1985 0277- 9536!‘85 $3.00 + 0.00 Prmted in Great Bntam Pergamon Press Ltd

SOCIAL FUNCTIONS OF MEDICAL LICENSING: A CASE STUDY OF SOVIET

IMMIGRANT PHYSICIANS IN ISRAEL

JUDITH T. SHUVAL

Hebrew University of Jerusalem, Program in Medical Sociology, P.O. Box 1172, Jerusalem, Israel

rNTRODUCTION

The apparent purpose of licensing physicians for practice is to assure a desired quality of medical care and to prevent practice by unqualified persons. Society thus provides protection for lay people at a time when they are thought to be vulnerable and dependent. In the course of medical treatment patients may reveal information of a private and intimate nature to their physician thereby endowing him with unintended power and control over them. Licensing, in assuring acceptable formal training and knowledge, is intended to protect lay persons from potential exploitation because it assumes that knowledge and skill in the practice of medicine are not only technical qualities but are accompanied by adherence to norms of service which place the patient’s well-being at the top of the practitioner’s priorities. In the quid pro quo in which society endows physicians with power, prestige and material rewards, it is assumed that these professionals will in return not only provide technical skills for persons who need them, but will do so within a framework of other-oriented norms which remove doubt or suspicion of possible exploitation from the minds of lay clients.

While the above may serve as the manifest functions of licensing, a sociological view of the process suggests a number of additional functions, some of them latent. While not all are consciously perceived, they are generally intended. It is the purpose of this paper to explore some of these.

The licensing of immigrant physicians throws these issues into sharp focus and reveals the goals and consequences of licensing in an unambiguous light. This is because the processes ofattaining permission to practice medicine in a new society by persons who already had been so licensed elsewhere reveals the nature of the process more clearly than in the case of local medical school graduates for whom the institutionalized procedures are fairly routine.

This paper will draw on a broad sociological study of Soviet immigrant physicians in Israel which provides a detailed analysis of the processes of their entry into the medical care system [l 1. Selected material on licensing will be presented here in an attempt to elucidate the more general nature of its functions.

SOME FUNCTIONS OF MEDICAL LICENSURE

Processes of licensing control not only the quality, but also the quantity of medical practitioners in a society [2,3]. Conditions for licensing are far from

absolute even within a given social system. In fact they are flexibly adapted to market needs to increase or decrease the number of practitioners in the system at any given time. One example of such flexibility in standards and adjustment to the demand and supply of medical personnel may be seen in the changes in licensing procedures for foreign medical graduates in the United States in recent years.

After World War II the United States began to encourage educational exchange and growing numbers of foreign trained doctors entered that country. At that time licensure was granted to graduates of thirty- nine specific foreign medical schools, largely European, which were identified by the Council on Medical Education of The American Medical Association and The Executive Council of the American Medical Colleges as equivalent in standard to most American medical schools. However in time this procedure was criticized for its European bias and non-inclusion of Asian medical schools in the preferred list. In 1958 the Educational Council for Foreign Medical Graduates (ECFMG) began to administer a standard examination to all foreign trained physicians [4]. This consisted of multiple choice questions used in tests administered to American medical students. The ECFMG examination, while serving to standardize the basic level of knowledge of physicians licensed to practice in the United States did not act as a severe deterrant to many and did not filter out many foreign medical school graduates: e.g. 70 y0 of those who took the exam passed it on their first try [S]. At that time the United States was interested in encouraging the entry of foreign medical graduates because of severe shortages of doctors in certain segments of the medical care system.

However in 1977 when the need for foreign trained physicians diminished in the United States, the examination for licensure was up-graded and stiffer standards were imposed on foreign medical graduates largely in response to a changed market situation in which there was no longer a dramatic shortage of physicians [5]. Thus it may be seen that the mechanism used to control quality is not an absolute one but reflects situational constrains of the medical care system [6]. In Australia Kunz feels that the obstacles placed in the path to licensure of immigrant physicians have been determined by self-protective motives ofthe local medical profession as much as by an interest to ensure quality of practice [7].

In addition to controlling the number of physicians who enter practice, licensing also serves to allocate them to different sectors of the health care system.

901

902 JUDITH T. SHUVAL

Such allocation takes place along several dimensions: geographical, form of practice setting, status level and specialty area. As a gate-keeping process, licensing can prevent incursion by newcomers on areas viewed as more desirable in which veteran practitioners are already, or seek to be, located.

Social values of the society are expressed through the licensing procedure. An example is one of the central values of Israeli society concerning the acceptance and encouragement of Jewish immigration: the arrival and integration of immigrants is viewed in Israel as the very ruison d’he of the society. The result has been an open-door policy which has not been tempered by pragmatic considerations of economic need or job availability. Thus despite the fact that Israel ischaracterized by the highest doctor/population ratio in the world (l/351) [8], there has never been any reservation about the importance of admitting immigrant physicians and integrating them into the medical care system. It will be seen that the procedure for licensing in Israel reflects these values by providing quick employment in an effort to promote integration and prevent emigration.

An additional function of the licensing process is to re-assure local professionals of their own status and high quality of practice. By imposing standards of alleged excellence and conversely, by denigrating others, the local profession asserts itw own elitism. Medicine is characterized by a long-standing tradition of elitism but its credibility requires periodic, visible mechanisms of reinforcement so that reference groups-veteran practitioners, laypersons and incumbents ~ are strengthened in their belief that this tradition persists and is actively viable. Immigrant physicians requesting licensure may be perceived as a threat to quality practice: like an exclusive club, the medical profession uses licensing as a gate-keeping mechanism to control entry.

In sum the social functions of licensing to be demonstrated are the following:

(a) Quality maintenance (b) Quantity control (c) Allocation of personnel (d) Expression of social values (e) Maintenance of professional elitism

STUDY POPULATION

In order to demonstrate the functions of medical licensing data will be drawn from a sociological study which examined the processes of entry of a group of Soviet immigrant physicians into the medical care system in Israel. That study considers the immigrant physician against the background of the Soviet health care system in which he was socialized and examines his encounter with a differently structured system in Israel [ 11.

Since the early 1970s over 162,000 Jews migrated to Israel from the Soviet Union. Among these were over 1250 physicians. The specific set of data to be considered here focus on those immigrant physicians among the above who arrived in Israel in 1972. These were interviewed in 1975, a period of 3 years during which they were all employed in their profession. This period was viewed as sufficient for newcomers to acquaint themselves with the system and to deal with

pressing, early problems of adaptation; however newness and immigrant status are still clearly evident to the individual and to relevant reference groups.

Of 405 Soviet physicians who arrived in Israel in 1972, 19 (5 %) had left Israel by 1975. This proportion of emigrants is the same as that found in 1975 among all immigrants from the Soviet Union who arrived in 1972 [9]. There were therefore 386 immigrant physicians in 1975 who were eligible for the study.

298 were interviewed either in their homes or clinics. These do not constitute a sample but rather 77 ‘;, of the total population under study. After several attempts the remainder were not interviewed because addresses were inaccurate or they were unavailable. Eight persons (2 y,,,) refused to be interviewed.

Subjects dealt with in the interview concerned entry into the health care system and are reported elsewhere [ 11. This paper concerns processes of licensing and is based on both open and closed questions on that subject.

In addition, qualitative data were gathered ;n open interviews with 25 Israeli physicians in different parts of the country who served as supervisors of immigrant doctors during their early period in the country.

MEDICAL LICENSURE IN ISRAEL

The mechanism for licensing immigrant physicians in Israel parallels the more general procedure for medical licensure. It involves a two-stage process:

(I) to establish formal professional qualifications for general medical practice;

(2) to establish qualification for specialty practice. At the first stage, after the immigrant physician has

shown competence in the Hebrew language, the Licensing Authority of the Ministry of Health examines the credentials attesting to basic medical training. If completion of studies at one of the medical schools listed by the World Health Organization can be demonstrated, a one year license is granted for general practice. Documents are subjected to cautious scrutiny and in the case of Soviet immigrants, a work card on which a person’s occupational history is recorded by dates and job description, may serve as additional verification for medical status. When doubt exists as to the validity of these documents, the Ministry of Health re-checks the claimant’s medical school diploma; in some cases confirmation from the Soviet authorities is obtained to demonstrate that an individual did in fact complete medical school. This is the same general procedure as that used to establish the credentials of refugee physicians after World War II [IO].

Since all immigrant physicians are employed in one of the medical care organizations, they are all subject to collegial evaluation. At the end of one year, the immigrant physician’s supervisor is required to evaluate professional performance; if this evaluation is positive, the immigrant is granted a license for general practice. Practically all of the Soviet immigrant physicians, who received a one year license, were eventually licensed for general practice.

This first stage of licensure for general practice needs to be viewed in the context of the Israeli health care system in which virtually all physicians practice in salaried posts in one of the medical care organizations

Social functions of medical licensing 903

[ 1,l I- 15 1. Physicians are employed by one of the sick funds, by one of the hospitals run by the Ministry of Health or by one of the other health care organizations. While there is some private practice, it is used by a relatively small proportion of the population and those physicians who practice privately do so on a part-time basis in addition to their full-time salaried position. Exposure to collegial scrutiny and evaluation is therefore maximal and plays a major functional role in the first stage of licensure.

At the second stage, qualification for licensure in a medical specialty is determined by the Scientific Council of the Israel Medical Association. The gate- keeping process involves a critical scrutiny of the immigrant physician’s qualifications and training to make certain they reach the local standard. In the case of the Soviet immigrant physicians, the process is complicated by the multi-tiered system of specialization in the Soviet Union and the different forms of training required for each. Extra courses which are individually tailored to the immigrant physician’s background may be required at this stage. Depending on individual background and experience, examinations may be required.

COMPARATIVE STRUCTURE OF MEDICAL EDUCATION AND SPECIALIZATION

In the present case study of Soviet immigrant physicians in Israel, the social functions of licensing need to be viewed against the systems of medical education and training for specialization that prevail in the two societies. As will be seen these differ considerably.

There are 92 medical schools in the Soviet Union of which only 9 are attached to universities. On the whole there is a preference in the U.S.S.R. for locating applied studies at institutes rather than at universities and graduates are granted a ‘diploma’ rather than a degree [16]. Thus the emphasis during medical education is practical and less oriented to the pure science background or research component of medical practice.

Until 1955 the medical school course lasted 5 years but at that time it was lengthened to 6 years. In 1966 a further year of required internship was added. Less than 20% of the immigrant physicians in this study were trained during the period when a year of internship was a required part of the training curriculum. Forty-six percent completed their training before 1955 when the curriculum lasted only 5 years. The upheavals of World War II and its aftermath were felt by 40% who underwent their medical training during that period. So that on the whole it can be said that the immigrant physician’s training was somewhat shorter than many of their Israeli colleagues.

Students in the U.S.S.R. are admitted to medical school upon completion of 11 years of primary and secondary school. Admission is highly competitive and ratios of admission range from l/5 to l/15, depending on the medical school. Preference is given to people who worked in allied health professions: 20% of medical students are former feldshers [17]. An additional 10% are foreigners from developing countries [16]. Groups to which preference is given vary from time to time [18-201.

A major effort has been exerted in the Soviet Union to augment the physician population rapidly by admitting large numbers of students to medical school. In the late 1960s the average entering class numbered 330 as contrasted to 88 in the U.S. and 64 in Britain [ 191. Such large classes necessarily limit the quality of teaching: a group of Western visitors to the U.S.S.R. noted that in laboratories students were only able to observe rather than participate themselves [21]. Furthermore the concentration of research in special institutes rather than in the medical schools, means that students have little exposure to basic research during their training.

A high proportion of Soviet physicians are women (70% in 1975). This percentage will decrease in the future since a deliberate attempt is being made to increase the proportion of males in the medical student population [16]. In 1976 only 56% of the medical students were women.

After completing their training, graduates of Soviet medical schools are required to practice for 3 years in areas in need of medical personnel. In fact many apparently evade this obligation or succeed in influencing the location of their post. These are often married women graduates who may not be separated from their spouses during this service [16].

Specialization begins early in the Soviet system of education. At entry to professional school the Soviet student chases one of four career lines in health: general medicine (therapy), pediatrics, public health or dentistry (stomatology). During the first 2 years the curricula for these programs are similar and include chemistry, biology, physics, anatomy, histology, physiology and Marxism. Beginning with the third and fourth years of study the curriculum differs for each of these areas. During the sixth year students specialize in a specific area of practice which they continue during internship. Before establishment of the required internship, graduates were licensed to practice after 6 years and were then considered first level specialists. More recently specialization has continued during the internship year so that graduates have an additional year of specialization before starting practice as first level specialists. This is called the ‘subordinatura’ level of specialization and is based on an early streaming process during the course of medical school training. Large numbers of physicians practice as specialists after the subordinatura.

After completing 3 years of service, physicians may attain specialty status by attending post-graduate courses in a specialty field. Time off from their regular job is provided for such additional training and over a period of several years specialty status may be attained and a certificate to that effect provided.

After completion of their 3 year service, young physicians may, if they wish, enter a formal program of specialization: the ‘ordinntura’. This involves a 2 year program of supervised clinical training in one of the specialty areas.

An alternative, more ambitious formal specialization program is the ‘aspirantura’ which can also be entered after the 3 year service period. The aspirantura involves 3 years of intensive clinical work in a specialty area, a research project, a thesis and an examination. It is geared for physicians seeking senior posts or academic careers. Upon completion of the aspiran-


tura, specialists are accorded the title ‘Candiate for Medical Science [ 19,161.

An even higher level of specialization can sub- sequently be acquired after several years of additional specialization and completion of a much more elaborate thesis. This highest level is called ‘Doctor of Medical Science’.

Four percent of the immigrant physicians in the present study had completed the aspirantura, 1 1 “/, the ordinatura, 7 y0 had some other form of specialization and 59 7: reported that they had attained specialty by post-graduate courses. Nineteen percent of the immigrant doctors stated that they had no recognized specialty status in the Soviet Union. The latter group may be responding in terms of the perceived system of specialization in Israel since virtually all physicians in the Soviet Union are considered specialists. In its efforts to up-grade the level of medical care, the Soviet Union structured its entire system of medical care in terms of specialty practice and in effect eliminated the role of generalist in medicine [22].

The general trend in the Soviet Union toward narrow specialization in the occupational sphere is expressed by excessive splintering and proliferation of specific areas of medical practice which numbered 173 in 1969. Recognizing this trend as excessive, 51 specialties were recognized in 1970 [23, 161. But many of the immigrant physicians in the study had been in practice prior to the 1970 consolidation of specialties and continued to view themselves as specialists in specific, narrow areas of practice to which they had devoted many years of professional work.

An interesting example of an area which is highly developed in the Soviet Union, but is only marginal in Israel, is balneology : the curative use of spas and baths for prevention and therapy. There is widespread use in the U.S.S.R. of therapeutic mud and mineral waters for both baths and drinking. Large rest homes and sanatoria are available and are widely recommended by physicians for a great variety of ailments. It has been suggested that these forms of treatment are at least to some extent functional equivalents of tranquilizers which are widely prescribed in Western countries [24].

Furthermore some of the specialty areas recognized in the Soviet Union are differently defined or categorized in Israel. In some cases they simply do not exist. Among these unfamiliar medical specialties, Ryan lists specialists in infectious diseases, dietitian, physiotherapist, laboratory specialist, specialist in general or communal hygiene. While some of these areas of practice exist in the West and in Israel, they are generally not carried out by physicians [ 161.

Turning to the Israeli system of medical education, we find a different picture [25]. Basic medical education in Israel is a 7 year process. Students are admitted on the basis of their average grade on the nationally administered secondary school matricu- lation examinations and only top achievers are permitted to apply. Stringent selection from this pool is carried out by each of the four medical schools by means of a variety of intelligence and personality tests. Over 1000 young people apply each year for about 230

*A somewhat different curriculum exists at the Beersheba Medical School [26].

places; the ratios of admission vary among the schools depending on the number of applicants to each.

All medical schools are affiliated to universities. Students are exposed to a rigorous science-based academic program as well as a large amount of research that is on-going by teaching staff, both pre- clinical and clinical.

The 7 year period is divided into four sub-periods: one pre-medical year in which basic sciences and some social science are taught; two pre-clinical years during which subjects include anatomy, physiology, biochem- istry, pharmacology, pathology, growth and development and epidemiology; three clinical years during which students rotate in small groups through different clinical departments. During the sixth clinical year they take the final examinations and, upon passing them, are given the title ‘Doctor’ and a temporary license to practice*. In order to obtain a permanent license they must complete a final year of internship in a recognized hospital. The internship is structured on a rotating basis: 3 months of internal medicine, one additional month in a sub-specialty of internal medicine, 2 months in general surgery, I month in orthopedic surgery, 1 month in traumatology, 2 months in pediatrics and 2 (sometimes 3) months in elected departments. The deliberately designed rotating system is not intended to produce specialists at the end of internship.

Completion of internship provides a license to practice but gives no specialty status, Specialization begins after internship and involves between 3+&54 years of additional clinical training in a specific field under the supervision of senior specialists. National examinations (Boards) which must be passed before the physician is recognized as a specialist, were required from 1973, and are controlled by the Israel Medical Association. Prior to that date competence was established by the supervising specialist. Specialty status has been conservatively controlled by the profession and every effort has been made to maintain the highest standards. There are no intermediate levels of specialization although some fields require longer periods of training than others. Virtually no graduates of Israeli medical school start practice without continuing their training in a residency program.

In Israel the proportion of women in the medical schools has consistently been about 20 “/L. The pool of applicants has also included about 207; wcmen so there is no evidence of the overwhelming feminization of the medical profession from new recruits [25]. Although the newest medical school in Beersheba has tended to admit relatively more women, their small classes are unlikely to contribute markedly to the general gender ratio in the professional population.

In sum it would seem that the general level of medical education to which most of the immigrant physicians were exposed in the Soviet Union was shorter, less science-based, and less research-oriented than medical school training has been in Israel since medical schools were opened there in the early 1950s. Compared to graduates of Israeli medical schools, most Soviet physicians have been trained in larger classes, had less direct laboratory experience and less individually oriented bedside teaching. However those Soviet doctors who worked in central, elite medical institutions were more likely to be exposed to newer


techniques and equipment than the majority who worked at the local or district level. It is also worth noting that many Israeli physicians have traveled and taken post-graduate training in Western countries; their exposure to the professional literature and to recent medical developments is considerable.

PERCEIVED QUALITY OF SOVIET MEDICAL CARE

Observers of the Soviet medical care system note that some Soviet physicians are comparable to the best in any part of the world, particularly in such fields as orthopedics and ophthamology. Certain of the facilities, for example the Bakuley Institute of Cardio- vascular Surgery, use the most sophisticated medical equipment and enjoy unrivaled reputations in their fields. At the same time medical care on the primary and hospital levels is in many cases strikingly underdeveloped and is characterized by low-level equipment, chronic shortages of basic medical necessities, inadequate pharmaceuticals and poor physical facilities. The system contains widely contrasting levels of practice ranging from superior for selected, privileged sectors, to mediocre or below standard, depending on the setting and the population being served [ 16,27-3 11. Immigrant physicians in Israel practised in a wide variety of such setting in the Soviet Union and their experience was naturally conditioned by the nature of the specific medical institutions in which they worked there.

Most of the Israeli doctors with whom open interviews were conducted during the course of the research, expressed doubts concerning the quality of medical practice in the Soviet Union and were of the opinion that these immigrant physicians generally do not measure up to the level of medical practice in Israel. “. They’ve got to change the medicine they learned in the Soviet Union.. We’ve got to bring them up-to-date.. Very few are up to the standards of our practice here.. .”

With probing most Israeli physicians interviewed showed some awareness of regional and institutional variation in the Soviet Union and admitted that this could be relevant to the quality of the professional background of the immigrant physicians. But on the whole a negative stereotype concerning the quality of Soviet medicine is widespread among Israeli practitioners. Like other stereotypes, this one contains a kernel of truth, although there is no systematic empirical evidence in Israel for lower quality of practice among Soviet immigrant physicians. In one of the few empirical studies in this general area, U.S. medical graduates were compared with foreign medical graduates working in the U.S. in terms of their supervisors’ ratings: the foreign physicians were rated lower in all specialty training programs except for surgery [32-341. Margulies et al. also reported lower quality practice among foreign medical graduates in the United States [35]. On the other hand Knobel points out that the quality of immigrant physicians’ professional performance is a function of the level of development and Westernization of their country of origin [36]. In general, there is little consensus concerning the criteria for evaluation nor can the evaluators pre-judged attitudes be separated out.

Although the evidence in Israel is based on a small sample, the stereotype appears to be widely generalized and is accompanied by little scrutiny of the empirical evidence that is available, i.e. the de facto practice and knowledge of the immigrant practitioner. Stereotyping tends to block the consideration of contrary evidence and is accompanied by affect which inevitably conditions the evaluation process [3, 5, 7, 371. Instead ofjudging individual immigrants on their personal merits, there is a tendency first to attribute the stereotype and seek empirical evidence for its confirmation. There would seem to be little doubt that widespread attitudes of this sort exist in both professional and lay populations.

LICENSING OF IMMIGRANT PHYSICIANS

Recognition of their professional status is a prominent issue for all immigrant physicians and especially for those from the Soviet Union for whom such status carries particularly high salience. Voronel [38] has discussed the centrality of work in Soviet culture and its unique salience for professionals. The need for unambiguous status in a society in which there are widespread doubts concerning the quality of their professional qualifications make this issue a critical one for Soviet immigrants. Smith [28] notes that there is a long history in Russia of sensitivity to the nuances of the pecking order. Its equalitarian ideology has not prevented the Soviet system from differentiating and emphasizing gross and minute differences of rank which are expressed in power, title, privileges and prestige [28]. This tradition has heightened the sensitivity of immigrant physicians to the recognition of their occupational status in Israel.

Within 5 months of their arrival in Israel, 62 % of the immigrant physicians were licensed to practice general medicine. By the time 9 months had passed, 90 ‘A were so licensed. In 1975, 3 years after their arrival, all were practicing but only 33 % were licensed to practice in their specialty. This is a lower percentage than that reported among immigrant scientists to Israel, 76 % of whom reported that they were employed in their field of specialization [39].

Those whose specialty status was not recognized frequently found it difficult to comprehend how they could be licensed for genera1 practice but not for the field in which they perceived themselves to excel. Indeed there was a good measure of exasperation among practitioners as they tried to make their way in the Israeli medical care system which on the one hand provides them with professional employment but at the same time shows reluctance or delay in recognizing their specialty status.

“. . Why don’t they recognize my specialization? I’ve been in practice for over twenty years.. Why do they delay giving me an answer?. They asked for all the documents; I sent them in but still no answer.. If they recognize us as doctors, why don’t they recognize us as specialists? I’ve taken specialty courses and have worked in my field for 10 Yeats., .“.

Table 1 presents the specialties practiced in the Soviet Union by immigrant physicians in the population under study. It may be noted that several specialties listed do not exist as such or as separate areas, of practice in Israel: physiotherapy (is not


Table I. Medical specialties of Soviet immigrant physicians in the Soviet Union and percentage licensed as specialists in Israel, 1975

Y0 Licensed as :‘, Among specialists

Specialty in the U.S.S.R. specialties in Israel

Internal medicine 79 27 19 Medicine 47 21 Endicrinology II 18 Cardiology 8 13 Tuberculosis IO

Surgery 27 9 37 Urology 12 33

Neurology 8 3 63 Psychiatry 18 6 56 Pediatrics 27 9 19 Obstetrics-Gynecology I8 6 II Eye, Ear, Nose and Throat 18 6 56 Ophthamology IO 3 30 Dermatology 7 2 71 Anesthesiology 5 2 80 Roentgenology 12 4 25 Speaalties not recogmzed in Israel 13 4

Physiotherapy I _ Traumatology 1 Laboratory medicine 6 2 Public health 1 Infectious diseases 2 I Legal medicine 2 I

No speaalty 53 19 No information 3 I Total 298 100 33

practised by physicians), traumatology, laboratory medicine, infectious diseases. There were also IO tuberculosis specialists who are grouped with the internists in Table 1. Only 19 % declared that they had not been recognized as specialists before immigrating but these physicians may be responding in terms of their perception of Israeli standards of practice since, as noted, virtually all Soviet doctors tend to view themselves as specialists.

It is of interest to observe the licensing of specialists in Israel by specialty in the Soviet Union even though the small numbers in each category require caution in interpretation. This is also shown in Table 1. Over half of those who had practised in anesthesiology, dermatology, neurology, phsychiatry and eye, ear, nose and throat specialties were licensed as specialists by 1975. To some extent this may reflect more positive evaluation by the Israel authorities of the level of practice in these fields in the Soviet Union. However in some cases, such as anesthesiology, it reflects a shortagein the medical care system of specialists in this field. Relatively infrequent recognition was granted to physicians who were specialists in obstetrics+ gynecology and in various internal medicine specialties which tend to be saturated in Israel.

The specialty backgrounds of the immigrant physicians are of course not necessarily attuned to specific needs of the medical care system. As noted Israel has the highest doctor/population ratio in the world. However, as in other countries, there is poor geographical distribution with the non-urban areas under-staffed; furthermore the community clinics are serviced by relatively old physicians while the younger graduates of Israeli medical schools generally opt for hospital positions [ 13 1.

Sixty percent of the immigrant physicians were employed at the time of the study in community clinics.

On the whole these physicians were less frequently licensed as specialists than their colleagues who were employed in hospitals. What is most important is that, despite the large absolute number of physicians in Israel, certain areas of specialization are characterized by shortages of physicians. Such shortages are quickly filled in a small country where the total number needed in any one field is relatively small. However in 1975 the following areas of practice lacked physicians: roentgenology, geriatrics, physical medicine, family medicine and-as already noted, anesthesiology. Retraining courses were offered in these fields in an attempt to channel immigrant physicians to areas of practice in which there were shortages of medical personnel. Some of these areas have been traditionally shunned by graduates of Israeli medical schools so the immigrants fill a real need by retraining for them [25 1. In 1975,5 “; of the immigrant physicians reported that they had participated in courses aimed to change their specialty. Twenty-two percent participated in other retraining courses geared to up-grade their medical background.

Licensure of immigrant physicians for specialty practice is strongly correlated with the form and rank of the specialty practiced in the Soviet Union. Because of variation in titles of specialties and their excessive differentiation, Table 2 makes use of the formal ranks used in the Soviet Union. Forty percent of the immigrant physicians in the population studied held one of the two highest ranks of specialization in the Soviet Union. This rank order is recognized by the Israeli gate-keepers: there is a sharp decline in licensing from those of the highest rank, 83 y/o of whom were licensed as specialists, to the first rank only 40 ‘;,, of whom received that recognition during the first three years in Israel. The sharp and systematic decline in the percentages licensed seen in Table 2 reflects some doubts among the Israeli gatekeepers about the quality of Soviet medicine especially in its lower ranks.

DISCUSSION

The entry of migrant professionals into a society, necessitates the activation of mechanisms for control of the quality of practice. With regard to physicians, who carry a critical responsibility for the safety and welfare of their patients, there is particular societal concern to assure an adequate standard and quality of practice by persons trained in a system which differs from the local one. Medical licensure seeks to answer to these needs but it fulfills other social functions as well [40]. The research in Israel demonstrates a set of

Table 2. Licensing of specialty status in Israel by rank of speaalty in the U.S.S.R. (N = 298)

Specialty rank 1” the U.S.S.R.

Highest First Second Third Specialty practice

without formal rank No speaalty

“,, I” U.S.S.R. rank licensed as speciahsts

“, in rank in Israel I” 1975

IO x3 30 40 12 27 9 14

20 x 19

100

*These are formal ranks in the SOWCI system


licensure procedures which reflect certain values and situational constrains of that society. These may be viewed as a means to reconcile two fundamental value themes; on the one hand a need to provide prompt employment for immigrants in jobs that will be acceptable to them and on the other a need to maintain a high quality of professional practice in accordance with the standards of the best scientific knowledge currently available. Neither of these value themes can be compromised too far and the research points to mechanisms in the system which are geared to meet the needs of both. Indeed there is evidence for cross pressures exerted by various interested parties ~ the medical profession, the official bodies concerned with absorption of immigrants and the immigrant physicians themselves-to reconcile these themes. Some conflict has been observed in the system although it has remained relatively unobtrusive [41,1 1. The most visible form this has taken has been in periodic protests by immigrant physicians demanding specialty status and claiming that the licensing authorities are unfair or ignorant of the nature of Soviet or other medical standards. Accusations of slow, bureaucratic procedures have also been made.

The licensure mechanisms in Israel reflect the open- door policy which admits Jewish immigrants from many countries of origin freely with no regard for their occupational or other qualifications and seeks to integrate them economically and socially into the society. It is based on a long history of immigration which has consistently admitted large numbers of professionals trained in widely different cultural traditions for whom a uniform system ofexaminations would be problematic. Particularly when such professionals arrive at mid- or late-career stages, examinations could serve as a major deterrent to successful entry into the occupational system. Formal completion of medical studies at a recognized medical school, while undoubtedly permitting some un- evenness in professional background, serves as a functional mechanism to deal with this issue: it is a universalistic criterion, it provides employment oppor- tunities, it assures a basic minimum of practice skills thus affording protection to the patient population, but it limits the practitioner to general practice and therefore, to a lower status position in the system. Furthermore it allocates immigrant physicians to community practices which are viewed as less desirable by graduates of Israeli medical schools and in many cases places immigrants in less attractive geographical settings which are otherwise not provided with medical personnel.

Some control on quality is exercised at this stage of licensure by collegial supervision. As noted, the basic license for general practice is granted quickly in most cases but is provisional for 1 year during which time the immigrant physician is placed in a practice where he is subject to supervision of an Israeli colleague. Only after 1 year when that supervisor indicates his approval of the standard of medical practice, is a license for general practice provided.

This stage of licensure, which most closely expresses the general societal value of the ‘open door’ for immigrants, is implemented by the Ministry of Health. Thus it expresses a policy reflecting a general societal value rather than one associated with any one sector or

professional group, e.g. the medical profession. The division of authority with regard to the two stages of licensing is expressive of the duality of the two themes referred to above. At the first stage the emphasis is on the first theme-which is critical to the very raison d’etre of the society and the quality issue is to some extent compromised in the interest of the value theme. But that compromise is controlled by the allocation process which results in most immigrant physicians practicing in the primary care sector.

However the second stage -licensing for specialty practice-is perceived as the heart of the quality issue. Here the medical profession is the gate-keeping authority exercising control. After the demands of the first basic value issue have been met, the profession has taken upon itself to exercise stringent control of licensing for specialty status. There has never been any question as to the authority of the Israel Medical Association to appoint its Scientific Council to control licensure for specialty status. Its authority is derived from government regulations delegating that authority to it. Indeed the government prefers to delegate the authority for such licensing to the profession which thus assumes responsibility for the quality of specialty practice. Although the Ministry of Health provides the formal license for specialty status, this may be viewed as a technicality since it does so only on the recommendation of the Israel Medical Association. The Scientific Council of the Israel Medical Association operates autonomously without governmental interference or influence in administering examinations. It is also authorized in appropriate cases to grant specialty status to qualified immigrant physicians without examinations. As noted, pressures on this body have come occasionally from groups of immigrant physicians who have resorted to court procedures when they have been refused specialty status; however the basic authority of the Israel Medical Association has not been questioned.

Basically the two authorities, governmental and professional, have collaborated to attain the two goals: employment of professionals and maintenance of quality practice. There has been general consensus on the importance of both goals: the medical profession has never suggested limiting the entry of immigrant physicians nor has the government questioned or interfered in the standards set by the Israel Medical Association for specialty status. In a society which traditionally accords high status to physicians, there has been little difficulty for the profession to maintain its elitism and authority in its own sphere.

It is clearly at the second stage that critical quality control is exercised and licensure granted with extreme caution and restraint. This contrasts sharply with the almost automatic licensure granted for general practice at the first stage. Since the nature of specialty practice in the Soviet Union is so different from that practised in Israel, examination of credentials and experience involve a painstaking process that is characterized by conservatism. Extra training is frequently required as are examinations. No compromises and little flexibility to soften the entry of immigrant physicians into practice are encouraged at the second stage.

There is some evidence that the reverse may be the case. The widespread stereotyping with regard to

908 JUDITH T. SHUVAI

Soviet physicians may be interpreted in this light. Such a pattern is not unique to Israel and has been reported in other countries having experience with immigrant physicians, e.g. the United States and Australia [3, 7, 37, 51. As in the case of all stereotypes, positive or negative, attitudes are polarized, overgeneralized and rigidly structured so that qualities that negate the stereotype are either ignored or viewed as idio- syncratic. Analysis of the medical care system of the Soviet Union indicates that there is a central core of truth to parts of this negative evaluation, but in many cases it has been generalized beyond the level of objective judgement. The quality ofmedical care in the Soviet Union is mixed and characterized by extreme contrasts in quality, depending on its setting and on the population it serves.

However, in making judgements of their immigrant colleagues and decisions concerning licensure for specialty practice, there is frequently little consideration by Israeli gate-keepers of the differences in level and experience of Soviet immigrant physicians which are associated with the nature of their employment setting in the U.S.S.R., most importantl: its position within the hierarchy of the Soviet medical care delivery system. Furthermore, in demanding the highest standards of performance of immigrant physicians, there is a tendency to ignore the variation in quality of medical care that prevails in many segments of the system among veteran Israeli practitioners as well. In fact some of them were trained in medical schools that were not too different from the ones in which the immigrant physicians were trained in the Soviet Union.

More general consideration of the functional role of stereotypes indicates that they serve important needs of both professionals and laypersons who hold them. Thus they may be viewed as a mechanism to reinforce an image of the high quality of the prevailing medical care in the society. In this manner they assert the elitism of the veteran practitioner Cwhis newcomers and reassure the lay population that the medical care it has been receiving is indeed of the highest standard. Looked at from this viewpoint, the stereotype is a protective mechanism which reveals as much or more about those who hold it as about the group it describes.

Stereotyping, largely negative, appears to be a general response of host groups to newcomers and can be expected in most migration situations. By highlighting negative qualities and blocking perception of positive ones, stereotypes serve the needs of those who hold them but impede the entry of newcomers into the social system by placing them on the defensive with a constant need to demonstrate competence in knowledge and practice.

This study did not include measures of the quality of clinical practice and we are therefore unable to judge the objective quality of medical care delivered by Soviet immigrant physicians. But, given the social and psychological bases for stereotyping, we may assume that on the whole the quality of care is likely to be better than is suggested by the stereotype. This does not imply any absolute level or indicate its level in comparison to other physicians.

In sum, data concerning licensing of immigrant physicians in Israel have demonstrated that the

licensing process fulfills a number of social functions in the social system. While quality control is the one that is most prominently referred to .in legitimizing the process, licensing also serves to control the quantity of practitioners in a society and their allocation in space, status and settings of practice. Furthermore it acts as a vehicle to express general values ofa society which may have little direct association with the medical profession per se. Licensing has also been shown to be a mechanism which reinforces the solidarity of specific groups-in this case the medical profession---by re- asserting its elitism. The latter serves a function for reference groups of the profession by bolstering confidence in its standards and quality. Sentiments and affect -in the form of stereotypes and prejudice-which pervade a society, temper the licensing processes in affecting decision-making processes.

These functions do not necessarily complement each other; indeed there is tension between the need to integrate immigrants into the profession and the need to maintain standards and quality of medical practice. The system seeks a balance among the conflicting themes that pervade it and the licensing scheme devised may be viewed as a reflection of the compromises developed.

The findings of the Israeli case study may be generalized to other situations where there is migration of physicians.

Most societies view in-migration as instrumental to their economic or social needs and attempt to regulate admission of newcomers accordingly. Israel views immigration as so desirable in terms of its needs and goals, that it has never limited entry for those included in the Law of Return. Thus its overall acceptance of immigrants is probably more pronounced than is the case in other countries. But even in that context, migrant physicians undergo processes of occupational and social adjustment that generally parallel those in societies that are more selective in their admission of immigrants. Structurally it would seem that these processes are independent of specific situational contexts.

Initial employment of physicians is likely to be in less desirable positions in the health care system. The attainment of more desirable professional status, such as specialty status or a more favorable location of practice, involves a process of overcoming certain gate- keeping obstacles which are generally controlled by the profession or the government and which are frequently formidable. Such obstacles are overtly legitimized by alleged quality control, but are permeated with informal mechanisms geared to maintain the elitism and power of the authority controlling them.

The latter’s power in the society may be expressed in processes of negative stereotyping of irnmigrant physicians which the lay public is hard-put to reject in view of the status and expertise of the authorities. By accepting the stereotype, the public may become an unwitting collaborator of the profession in blocking the entry of immigrant physicians. In situations of real need for additional medical manpower, this col- laboration can be dysfunctional from a general, societal point of view.


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