Medical education in Israel 2016: five medical schools in a period of transition
© The Author(s). 2016
Received: 21 November 2015
Accepted: 30 August 2016
Published: 15 September 2016
We reviewed the existing programs for basic medical education (BME) in Israel as well as their output, since they are in a phase of reassessment and transition. The transition has been informed, in part, by evaluation in 2014 by an International Review Committee (IRC). The review is followed by an analysis of its implications as well as the emergent roadmap for the future.
The review documents a trend of modernizing, humanizing, and professionalizing Israeli medical education in general, and BME in particular, independently in each of the medical schools. Suggested improvements include an increased emphasis on interactive learner-centered rather than frontal teaching formats, clinical simulation, interprofessional training, and establishment of a national medical training forum for faculty development. In addition, collaboration should be enhanced between medical educators and health care providers, and among the medical schools themselves.
The five schools admitted about 730 Israeli students in 2015, doubling admissions from 2000. In 2014, the number of new licenses, including those awarded to Israeli international medical graduates (IMGs), surpassed for the first time in more than a decade the estimated need for 1100 new physicians annually. About 60 % of the licenses awarded in 2015 were to IMGs.
Israeli BME is undergoing continuous positive changes, was supplied with a roadmap for even further improvement by the IRC, and has doubled its output of graduates. The numbers of both Israeli graduates and IMGs are higher than estimated previously and may address the historically projected physician shortage. However, it is not clear whether the majority of newly licensed physicians, who were trained abroad, have benefited from similar recent improvements in medical education similar to those benefiting graduates of the Israeli medical schools, nor is it certain that they will benefit from the further improvements that have recently been recommended for the Israeli medical schools.
Inspired by the IRC report, this overview of programs and the updated physician manpower data, we hope the synergy between all stakeholders is enhanced to address the combined medical education quality enhancement and output challenge.
KeywordsBasic Medical Education Israel Medical Manpower Medical Education Reform
In 2009, reflecting on the impending inauguration of a fifth medical school, a brief overview of Basic Medical Education (BME) in Israel was published in Medical Teacher . During the relatively short time that has elapsed, marked changes in Israeli BME have been introduced and an extensive external expert evaluation has become available , allowing a fresh and critical view of the current status and future perspectives for Israeli BME. Changes in medical education are experienced globally with changes both in the prevailing educational paradigms (towards student centered, experiential instruction), and in healthcare realities (chronic diseases, ambulatory and prevention focus).
This paper begins with a brief overview of the Israeli medical system and a description of the five existing medical schools. The paper continues with an assessment of the state of BME in Israel in 2015-6 and its impact on the healthcare system, notably the issue of a physician shortage. The paper concludes with an attempt to critically evaluate Israeli BME and some thoughts for the future.
The authors are senior members of the five medical schools, who researched their institutions in order to supply up-to-date and precise reports according to a common, pre-designed framework. However, their reports represent their perspectives and are not always officially endorsed by their institutions.
Healthcare in Israel
Since 1995, Israelis have been covered by a national universal health insurance law under which all permanent residents are insured in one of four competing Health Funds . Life expectancy, infant mortality and many other health care indices in Israel are similar or better than average European indices . Health care expenditure was 8 % of GNP in 2014, below the Organization for Economic Cooperation and Development (OECD) average of 9.3 % . In 2016, the major challenges of the health care system include sustainability, physician supply, and lack of a primary care focus. For more extensive description of the Israeli system see also [1, 2, 6].
Israeli Medical Education
The number of students in the different programs in Israeli medical schools
Israeli MD students (per year, excluding English-language programs)
Foreign- English-language programs
Israelis returning after 3 years abroad
Graduate, entry level
Sackler, Tel Aviv
Hebrew Univ, Jerusalem
Goldman, Beer Sheva
Bar Ilan, Safed
In addition to the Hebrew-language Israeli programs, there are English-language programs in three Israeli universities. These recruited a total of about 170 students in 2015, mostly US citizens who return to their native country upon graduation and are not licensed to practice medicine in Israel, thus having minimal or no impact on Israeli physician numbers.
Overall, the current level of enrollment is still short of the need for 1000–1200 new physicians per year that was predicted by three official committees from 2002–20101 [7–11]. This figure was set to achieve a physician to population ratio at 2.9 per 1000, while accommodating both retirement and population growth, and assuming licensure of 285 IMGs per year.
Medical licenses granted
Difference from estimated requirement (1100 a year)
The standard Israeli BME program includes 6 years of medical school at the undergraduate level, and an additional year of rotating internship. Two 4-year, graduate-level entry programs exist, one in The Sackler Faculty of Medicine of Tel Aviv University and one in the Faculty of Medicine in the Galilee of Bar Ilan University. Bar Ilan also offers a 3-year clinical program for 40–50 Israelis returning after 3 years of medical school abroad.
The curricula at three of the four veteran schools, The Hebrew University-Hadassah School of Medicine in Jerusalem, Sackler Faculty of Medicine of Tel Aviv University, and the Rappaport Faculty of Medicine of the Technion in Haifa, have historically been very traditional, while the medical school of Ben Gurion University in Beer Sheba, now known as the Goldman School of Medicine, introduced an innovative community-oriented, integrative, student centered program with early clinical exposure from the start . However, all four veteran medical schools have reviewed their curricula in the past two decades, in an attempt to integrate selected modern educational paradigms .
BME in Israel is regulated by the Council for Higher Education (CHE), an agency of the Ministry of Education, which allocates budgets, determines national academic policies, and is charged with quality assurance of higher education in general, including medical education. This agency is also the body that authorized the establishment of a fifth medical school and commissioned an International Review Committee (IRC) as part of a review process . A formal periodic review of medical schools was introduced by the CHE in 2000 and repeated in 2007. In June 2014, an IRC submitted a new report following visits to all Israeli medical schools .
There is no statutory medical licensing examination in Israel for Israelis who are graduates of any of the five Israeli medical schools. Uniform exit examinations in five disciplines were introduced by the deans of Israeli medical schools about 20 years ago , and all medical schools participate. A license to practice medicine is granted by the Ministry of Health to graduates of Israeli medical schools after completion of a 1-year internship. In general, Israeli graduates have an excellent reputation internationally [1, 16]. IMGs are required to take a licensing examination before they can seek employment or apply for residency training . The number of IMGs who took the licensing examinations from 2010–2014 varied from 489 to 608 candidates annually .
Present State of the five Medical Schools
Key features of medical education in the five Israeli medical schools
Types of programs
6 year with 4 patterns (regular, Military Medicine, research oriented, community oriented)
MMI (in house)
MMI (in house under MSR supervision)
Computerized screening and interview
Type of curriculumb
Traditional until Oct-2016, when a reform was launched
Originally traditional, later reformed
Originally traditional, later reformed
Originally innovative, further reformed in a number of cycles
Innovative from the school’s establishment
- Number of small group/self-directed courses
- Lecture-based courses
- Team-based learning
At least 1
At least 1
At least 1
At least 2
At least 3
Adequate (but more small group space needed)
Adequate (but more small group space needed)
Methods for student assessment
Traditional – predominantly MCQ
Mixed – MCQ+ OSCE + other
Mixed – MCQ along with innovative modalities
Mixed, with extensive use of OSCE
Weight of teaching performance in promotion decisions
Minimal,except in a teacher track (5 % of promotions)
Recently added courses
Professionalism emphasis, longitudinal strands
Literature and medicine, genomics and medicine, entrepreneurship and medical technologies
Interprofessional education (IPE) and some of the humanities courses.
The school is new, so full curriculum is new. ETGAR course – transition between hospital and community \care.
Prizes & awards for teaching
Medical education unit
Adding tracts, Significant community exposure increase
Physician self-care, gender medicine, and enhanced assessment of professionalism
Increase in the staff of the medical education unit
Simulation center, strategic plan to redesign the curriculum
Expand interprofessional education and increase the use of simulation.
As indicated in Table 3, all five schools have recently undertaken significant steps to update and upgrade medical education. The medical school in Jerusalem is embarking on its first comprehensive, integrative curricular reform, and each of the other older three medical schools has moved ahead in several key areas in recent years. The medical school in Safed, which was established in 2011, adopted an innovative curriculum from the start.
While there are differences among the medical schools in their admissions processes, teaching methods and student assessment models, there is also a common trend toward considering non-cognitive attributes in admissions, moving towards more interactive and small group teaching, and adding performance and computer based testing to the prevalent MCQ based examinations. Three of the five schools consider their teaching spaces wanting. Sackler enjoys access to two simulation centers in its affiliated hospitals, while the four other schools are in various stages of incorporating simulation as part of their infrastructure. Where the consideration of teaching excellence, scholarship and leadership in promotion and tenure is concerned, Beer Sheva is the most progressive in including it as a significant promotion criterion, and Jerusalem has recently added a modest teacher promotion tract. All five schools include humanities in their curricula, and all are moving in the direction of more inter-professional education, a clearer focus on professionalism, and strengthening of their medical education teams.
How appropriate is Israeli BME?
During the past 5 years, as described above and in Table 3, the trend of modernizing, humanizing, and professionalizing Israeli medical education in general, and BME in particular, has materialized independently in each of the medical schools. Israeli medical graduates’ grades on international examinations (i.e. USMLE part 2) are comparable to those for graduates of American medical schools (the same average), and markedly higher than graduates from other OECD member countries such as the UK . This may support the assertion that BME in Israel is effective, in the sense that medical schools are producing academically competitive graduates. However, since only a self-selected (albeit large) group of Israeli graduates takes the USMLE, it is unclear to what extent scores for this subset of students are representative of the graduating classes as a whole. The IRC, recently commissioned to evaluate Israeli BME, reported that there is still room for improvement. The main domains deemed to be in need of further reform are discussed in the next section.
Thoughts for the future
Admissions: Two schools (Sackler-Tel Aviv University and Bar Ilan-Safed) collaborate on an admissions procedure that incorporates evaluation of non-cognitive attributes based on an MMI process. Interviews are conducted at the national simulation center (MSR) . The Hebrew University have adopted a modified Multiple Mini Interviews (MMI) system, which they presently run in-house, Rappaort runs an i d entical to MSR procedure in-house, While Goldman-Ben Gurion continues to rely on a more elaborate interview system. An investigation of the predictive validity of the various admissions procedures appears to be warranted. Evaluations are underway at the Hebrew University-Hadassah Medical School  and in advanced planning at Bar Ilan.
Exit Examinations: As already mentioned, about 20 years ago the deans of the medical faculties decided to hold an integrative joint exit multiple choice questions examination for all five schools . Recently, a task force selected by the deans visited the US-based National Board of Medical Examiners (NBME), which led to proposals to adopt a version of the USMLE; however, the plan was rejected. The IRC has recommended introduction of additional assessment methods, e.g., an Objective Structured Clinical Examination (OSCE), to ensure that the desired threshold of clinical competence has been achieved by students .
Collaboration Between Medical Educators and Health-Care Providers: In 2007, and again in 2014, the IRC recommended that “the Council for Higher Education (CHE) or another national agency play a major role in designing and implementing a coordinated plan for all the resources needed for effective “medical and other health professions education” based on “comprehensive health care and physician workforce planning” . We fully endorse this recommendation.
Medical Education: There is an apparent lack of expertise in the science of education as applied to medical education in Israel. Only a handful of academic professionals have formal credentials in medical education. The IRC recommends building medical education centers to provide the needed expertise . The authors share this sentiment, and most medical schools include strengthening their medical education operation in their future plans. One recent positive development, recommended also by the IRC and supported by the deans of medicine, has been the establishment of the Israeli Society for Medical Education (HEALER).
Faculty Development: The IRC recommends that the CHE should encourage each faculty of medicine or health sciences to create a portfolio of faculty development and remediation activities and demonstrate that faculty performance is improving in all domains of medical education . HEALER has already made this issue a priority and is initiating nationwide faculty development activities.
Teaching and Assessment Methods: Current medical education paradigms, as the IRC, recommend a reduction in dependence on frontal lectures, providing more opportunities for interactive learner-centered small group and discussion formats (problem-based and team-based learning methods, for example), and for learning in clinical settings, even early in the medical curriculum. Students should be provided with opportunities for more active involvement in patient care activities, in both inpatient and ambulatory settings . In the same vein, reduced dependence on multiple choice examination formats for student assessment is deemed desirable. Increased use of performance-based assessments using faculty observation, patient instructors, or other clinical simulation methods as appropriate, is recommended. Finally, wherever individual students or small groups have contact with a faculty member over a period of a few weeks or more, the student should receive formal, written formative performance feedback, which should become a part of the student’s educational record .
Simulation: The IRC found that each of the schools is underutilizing clinical simulation methods for both teaching and performance assessment. Further resource development, from small-task trainers to whole-body simulators, and including patient-instructor/standardized patient methods, is needed. This is another area in which nationwide collaboration, utilizing resources such as the Israel Medical Simulation Center (MSR) , may be helpful .
HEALER: The IRC calls for nurturing, supporting and sustaining HEALER, the new organization dedicated to scholarship in medical education, so that it can help in in developing a national infrastructure for medical education . The Israeli Society for Medical Education (HEALER) aims to fill this role, and to foster collaboration among the five faculties of medicine as well as the educational bodies of other providers of health profession education, to establish a resource center, and to promote several specific interest groups.
Interprofessional Education (IPE): In the absence of a significant amount of team-based learning and interprofessional education (which are now much more available in other developed countries), there is little educational infrastructure to prepare graduates for working in teams. IPE needs to become prevalent beyond the Goldman Medical School .
Funding for Medical Education: The IRC states that Israel should specifically reconsider the funding model for medical education, including all the funding of those involved in physician education at all levels, and not only at the undergraduate level. This should involve the Ministry of Education through its higher education finance bodies (BME & some residency positions), the Ministry of Health (for the internship year & residency positions), healthcare providers and institutions (mostly for residency positions), the Ministry of Absorption (for new immigrants training) and additional bodies. Failure to do this could lead to ineffective or inefficient programs for the education of the physician workforce needed for the 21st century .
Shortage of physicians, International Medical Graduates: If the trend s reported above, about the changing numbers and composition of newly licensed physicians in Israel continue, then up to two thirds of newly qualified physicians in Israel will be trained in countries where some of what the Israeli programs (and the IRC) see as basic may be absent (i.e. communication skills training, ethics, EBM, to name a few). It behooves the relevant stakeholders to further study the implications and consider realigning policies such as the licensing requirements (i.e. addressing missing domains as above), and the educational imperatives (i.e. educational oversight of the internship year, linking needs with their acquisition evaluation), as well as manpower planning and its consequences (i.e. growing lack of residency positions).
This paper has presented an up-to-date description and evaluation of the Israeli medical education system and highlighted several important developments and challenges. First, a change is noted in the numbers of both Israeli graduates and IMGs, which may, on one hand, eventually address the present physician shortage, and on the other hand, adds to the concerns mentioned above. The quality of Israeli medical school graduates appears to be internationally competitive, as judged by graduates’ performance on standardized international examinations . At the same time, the recent IRC report, as well as the authors’ reports and analysis, outline a roadmap for further improvement . The salient features that require strengthening, according to the IRC, include “enhancing the coordination and efficiency of medical education across the continuum of education and training, and re-examination of the financing of medical education” .
For the authors, the importance of development of policies, teaching, and assessment methods, as well as an expertise in the science of medical education, are additional building blocks for future positive change. However, the possibility that 60 % of newly licensed physicians in Israel will not benefit from this hoped-for improvement is a cause for concern.
Inspired by the IRC report  and this analysis, we hope for expansion and deepening of the collaboration between the five Israeli medical schools. The existing collaboration is focused on exit examinations, the deans’ forum, and support for the establishment of HEALER. Further collaboration is embodied in the writing of this paper. We hope for future enhancement of this collaboration where each of the schools as well as HEALER contributes. As each school has its unique strengths and particular innovations, amply described in the Appendix and Table 3, these can be shared and serve as a common asset to others as needed. In addition, we hope that better integration of all stakeholders and other institutions relating to education in the health professions will materialize in the near future.
With this cooperation, we hope that continuing improvement in the quality and effectiveness of Israeli medical education will be fostered, resulting in better health for all within the country and hopefully the region beyond our national borders.
The recent addition of a fifth medical school in Israel and an international audit of Israeli medical education provide a rare opportunity for a detailed review of Israeli basic medical education.
While the quality of Israeli medical graduates as measured by the performance of a sample taking the USMLE is competitive, room for improvement exists and is analyzed in detail.
Enhancing the coordination and efficiency of medical education across the continuum of education and training, and re-examination of financing mechanisms for medical education, as well as increased collaboration in development of policies, teaching, and faculty assessment methods, and building national expertise in the science of medical education, are building blocks for future positive change.
The present shortage of physicians may be corrected if present levels of student recruitment and returning IMGs persist. However, this will also mean that it is not clear whether two thirds of newly licensed physicians in Israel will benefit from improvements in Basic Medical Education recommended in this paper.
The three above cited committees came up with the range of 1000–1200 and not a specific fixed number, as needed to maintain the required level of physician to population ratio. We will use either this range or 1100 across the paper
Basic Medical Education
[Israeli] Council for Higher Education
Comprehensive Integrative Puzzle
[U.S.] Education Commission for Foreign Medical Graduates
Faculty of Health Sciences
Israeli Society for Medical Education
International Medical Graduate
International Review Committee
Multiple choice questions
Multi Clinical Station Examination
Hebrew acronym for ‘selection for Medicine’
National Simulation Center
[U.S.] National Board of Medical Examiners
Organization for Economic Cooperation and Development
Objective structured clinical examination
U.S. Medical Licensing Examination
World Federation for Medical Education
Availability of data and materials
Not applicable as this is an integrative article.
SR conceived the report, initiated its design, was in charge of its coordination, drafted the manuscript, and edited the different iterations. JU, DN, DM, OKM, RB, RN, PG, and AZ described their respective institutions in the paper. All authors participated in the different editing phases, and all have read and approved the final manuscript.
Shmuel Reis MD MHPE is both Head of the Faculty Development Unit, Bar Ilan University Faculty of Medicine in the Galilee, Safed, Israel, and Academic Head, Medical Education Center, Hadassah-Hebrew University School of Medicine, Jerusalem, Israel. He is also Chairperson of HEALER, the Israeli Association for Medical Education. He is a practicing Family Physician in the Misgav Heath Center, Misgav, Clalit Health Services, Israel.
Jacob Urkin MD MPH, is Chair of the Moshe Prywes Center for Medical Education, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. His major tasks and activities are faculty development, advising the various faculty and University committees, promoting research in medical education, and building the next generation of faculty members in medical education.
Rachel Nave PhD is Head of the Medical Education, Examination & Assessment Unit and Head of the Faculty Development Program at the Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa.
Rosalie Ber MD DSc is an Associate Professor of Medicine, Emeritus, and former Head of the Department of Medical Education, Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa.
Amitai Ziv MD is a Clinical Associate Professor for Medical Education and Associate Dean, Sackler School of Medicine, Tel Aviv University. He is also Deputy Director of the Sheba Medical Center Head at Tel Hashomer for Patient Safety and Risk Management, and Founder and Head of the Israel Center for Medical Simulation (MSR), Chaim Sheba Medical Center, Tel Hashomer, Israel.
Orit Karnieli-Miller PhD is Senior Lecturer and Social Worker, Department of Medical Education, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. She specializes in research focusing on communication in healthcare.
Dafna Meitar MD is Senior Teacher and Coordinator, Department of Medical Education, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. She is a Children’s Palliative Care physician and an expert in teaching communication skills.
Peter Gilbey MD is Head of the ENT, Head and Neck Surgery Unit, Ziv Medical Center, and Head of the Teaching Committee, Bar Ilan Faculty of Medicine in the Galilee, Safed, Israel.
Dror Mevorach MD, is Vice Dean for Teaching Affairs and Chair, Global Medical Curriculum Studies, Faculty of Medicine, Hebrew University-Hadassah School of Medicine, and Department Chair, Internal Medicine D, Hadassah-Hebrew University Medical School, Jerusalem, Israel. He is also a Founder and Scientific Advisor for Enlivex Therapeutics, Ltd.
The authors declare that they have no competing interests.
Consent for publication
All authors have reviewed and approved the final manuscript.
Ethics approval and consent to participate
Not applicable; this is an integrative article and did not involve any primary data collection regarding human subjects.
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