Aims & Objectives
- To develop an understanding of healthcare in Israel and appreciate differences in their health and welfare system.
- To gain an overview of the care of people with intellectual disabilities, including psychological aspects, physical aspects and social care.
- To enhance my experience of psychiatry, with particular emphasis on the impact of culture on mental health diagnoses.
- To work on an audit or research project during my time in Tel Aviv.
- To learn some basic Hebrew and discover the culture of Israel.
Why this elective?
Throughout my time at medical school and previously, I have had an interest in the care of people with Intellectual and Developmental Disabilities. I have been able to explore this through an SSC with the paediatric neurodisability service at Ryegate Children’s Centre, Sheffield, through volunteering with Sense and Teddy Bear Hospital and through my part-time employment at Step Up Support currently. However, I wanted to use my elective period to fill a gap in my experience in the medical care of adults with Intellectual Disabilities (ID). Through contacts at the medical school and beyond, I was able to arrange an elective with the Intellectual Disability Psychiatry team at the Chaim Sheba Medical Center, Tel Aviv in Israel.
Meeting my aims & objectives
To develop an understanding of healthcare in Israel and appreciate differences in their health and welfare system.
Israel’s National Health Insurance Law requires all citizens to register with one of the four Health Maintenance Organisations (HMOs), the largest of which is Clalit (כללית). I was able to see during my placement that Clalit serves a significant proportion of the underprivileged, including people with disabilities (Balicer, et al., 2011). As far as I witnessed, health funds seemed to fulfil the principles of “justice, equality and mutual assistance” (State of Israel: Ministry of Health, n.d.) upon which they were based. While they have their differences, both Israel and the UK have universal health coverage.
To gain an overview of the care of people with intellectual disabilities, including psychological aspects, physical aspects and social care.
While describing in depth the health policy and welfare systems in place for people with ID in Israel may be instructive for the reader, I have the advantage of being able to refer to authors I met in the country for this information (Halperin, et al., 2005). I have gained a good understanding of health service commissioning in Israel for people with ID through discussions with two of the authors of the above, as well as with professionals I met on placement and during the interview stage of my research project.
I have been able to see many aspects of care for people with ID. I have met doctors, nurses, psychologists, behavioural therapists, speech and language therapists, teachers and researchers. However, time constraints did not allow me to visit other specialist services, such as a dental service specifically for people with ID. More planning of activities before my arrival to Israel would have allowed me to organise this more effectively, although my time was more than filled adequately.
Enhance experience of psychiatry, with particular emphasis on the impact of culture on mental health diagnoses.
The Bnei Brak clinic is specifically for the Jewish Orthodox population. However, in all of the clinics I was in I was able to see how culture influenced the relationship between doctor and patient, the acceptance of treatment and the role of the family in the process. In terms of differences in psychiatric care in Israel, there is one issue which stood out for me. I saw that challenging behaviour was not an uncommon indication for prescribing antipsychotic medication. This is not an indication I have seen here in the UK, and I need to do further research to find if it is common practice. As a result of my hands-on experience, I am inclined to promote non-medical management for challenging behaviours, and I am not convinced of the ethics of this method of ‘chemical restraint’ when experience has shown me how behaviours are usually a response to the environment.
To work on an audit or research project during my time in Tel Aviv.
The title of my research project was: ‘Stakeholder perceptions of guardianship and supported decision making for people with intellectual disabilities in Israel.’
Recent research has promoted the use of supported decision making, in contrast to historical methods of substitute decision making when working with people with intellectual disabilities. In Israel, people with disabilities are protected by the Legal Capacity and Guardianship Law of 1962, which was amended in 2016. This research considers how these recent changes are perceived by professionals in Israel.
Professionals with experience in policy making, law, social work and with direct experience working with people with intellectual disabilities (ID) were interviewed using semi-structured interviews and one focus group. Interviews were recorded and subsequently coded and analysed qualitatively.
Two major themes were identified. These were: The Law and its Phrasing, and Changing Culture. Findings highlight the process of change within guardianship law and practice and the challenges in implementation encountered so far and anticipated in the future.
Results from this study support those that have been found in previous studies from other parts of the world. More evidence is required to identify the most effective way to manage capacity and guardianship issues for people with ID.
My project is now complete, and we are in the process of submitting the final report for publication.
Learn some basic Hebrew and discover the culture of Israel.
I had hoped to find a class (Ulpan) to be learn some Hebrew while in Israel, but this was not possible. However, after some time in the country I was able to understand much more of the language.
During consultations I was surprised how much I could understand from expression and the little I had picked up of the language. I was also able to assess the majority of a mental state examination through only observation, and I certainly feel more competent with this.
Reflections on my experiences
My choice of Israel was a surprise to many of the people I met there, as I am not particularly religious. I was raised Catholic, and Israel is predominantly a Jewish state. However, the country held an interest for me as a place steeped in history and political controversy. Security threats were a minor concern: I reasoned that in light of recent attacks throughout the rest of the world, the danger for me in Israel was not much more than my colleagues in other parts of the world if I followed government advice. Whilst in Tel Aviv, I was surprised and comforted by the level of security displayed. My bag was searched at hospitals, bus stations, supermarkets and train stations and on some occasions I was asked to show my passport. On further reflection, I can see that while this increased security was a new phenomenon for me, the experience may have been less unpleasant as suspicion towards me as a white British female is relatively low.
On my first day at Sheba Medical Centre, I met with Joav Merrick who explained much of the information contained in the referenced article on health policy (Halperin, et al., 2005), as well as directing me to spend time with many of his colleagues. One of these was Mohammed Morad, another of the authors, who welcomed me with true Middle Eastern generosity into his town of Beer Sheva a few weeks later.
In one morning at his clinic, I encountered a traditional Jewish Israeli man, an orthodox Jewish lady, a Russian lady and an Ethiopian man. I understood that the clinic and its branches also serve the Bedouin community in the area. It is an incredible example of Jewish and Muslim living harmoniously: the doctor I met with was Muslim, his partner at the centre was Jewish. They talked to me for a long time about how they formed a group years ago to highlight the importance of doctors acting ethically and not be influenced by race, religion, politics or any other factor. In my position as a privileged and open-minded person, I have never considered allowing those things to alter the care I provide. However, it was clear that driven by propaganda, fear sets communities in this continent apart. As educated professionals, I hope, as they do, that we can set an example around the world of how to transcend these differences.
Looking to the future
My interest in the care of adults and children with Intellectual and Developmental Disabilities has not changed as a result of this trip. I am still passionate about this population. However, what I have found is that my career interests lie primarily in the diagnosis of children with developmental disability, and the behaviours they present with. As I am approaching foundation programme applications, I will be considering training pathways in more detail.
I am also finalising my research report and I am in constant contact with my supervisors to continue progress towards publication. I hope to do more research in this area.
I have been able to network abroad and attend conferences. I plan to attend the next conference at Beit Issie Shapiro and I am looking at further conferences closer to home.
Balicer, R. et al., 2011. Reducing Health Disparities: Strategy Planning and Implementation in Israel’s Largest Health Care Organization. Health Services Research, 46(4), pp. 1281-1299.
Halperin, I., Shupac, A., Morad, M. & Merrick, J., 2005. Health Policy for Persons with Intellectual Disability : Experiences from Israel. The Scientific World, Volume 5, pp. 71-92.
State of Israel: Ministry of Health, n.d. Rights of the Insured under the National Health Insurance Law. [Online]
Available at: http://www.health.gov.il/English/Topics/RightsInsured/RightsUnderLaw/Pages/default.aspx
[Accessed 02 08 2016].