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Workforce ethnic diversity and culturally competent health care: the case of Arab physicians in Israel a
b
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Ariela Popper-Giveon , Ido Liberman & Yael Keshet a
Department of Adult Education, David Yellin Academic College, Jerusalem, Israel b
Department of Sociology & Anthropology, Western Galilee Academic College, Akko, Israel Published online: 07 Mar 2014.
Click for updates To cite this article: Ariela Popper-Giveon, Ido Liberman & Yael Keshet (2014) Workforce ethnic diversity and culturally competent health care: the case of Arab physicians in Israel, Ethnicity & Health, 19:6, 645-658, DOI: 10.1080/13557858.2014.893563 To link to this article: http://dx.doi.org/10.1080/13557858.2014.893563
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Ethnicity & Health, 2014 Vol. 19, No. 6, 645–658, http://dx.doi.org/10.1080/13557858.2014.893563
Workforce ethnic diversity and culturally competent health care: the case of Arab physicians in Israel Ariela Popper-Giveona*, Ido Libermanb and Yael Keshetb
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a Department of Adult Education, David Yellin Academic College, Jerusalem, Israel; bDepartment of Sociology & Anthropology, Western Galilee Academic College, Akko, Israel
(Received 3 September 2013; accepted 28 December 2013) Objectives. In recent years, a growing body of literature has been calling for ethnic diversity in health systems, especially in multicultural contexts. Ethnic diversity within the health care workforce is considered to play an important role in reducing health disparities among different ethnic groups. Methods. The present study explores the topic using quantitative data on participation of Arab employees in the Israeli health system and qualitative data collected through semi-structured interviews with Arab physicians working in the predominantly Jewish Israeli health system. Results. We show that despite the underrepresentation of Arabs in the Israeli health system, Arab physicians who hold positions in Israeli hospitals do not perceive themselves as representatives of the Arab sector; moreover, they consider themselves as having broken through the ‘glass ceiling’ and reject stereotyping as Arab ‘niche doctors.’ Conclusions. We conclude that minority physicians may prefer to promote culturally competent health care through integration and advocacy of interaction with the different cultures represented in the population, rather than serving as representatives of their own ethnic minority population. These findings may concern various medical contexts in which issues of ethnic underrepresentation in the health system are relevant, as well as sociological contexts, especially those regarding minority populations and professions. Keywords: Israel; Arabs; physicians; workforce diversity; ethnic diversity; cultural competence
Introduction In Western/globalized urban centers, health care is provided within contexts of increasing ethnic diversity (Kai et al. 2007). Concerns about ethnic disparities in health care have long preoccupied researchers, policy-makers, and health care providers. Increasing the ethnic diversity of the health care workforce is commonly accepted as a promising means of providing culturally and linguistically competent care to improve the health of minority populations and reduce health disparities (Cohen, Gabriel, and Terrell 2002; McGee and Fraher 2012; Smedley et al. 2001). As health care is a cultural construct originating in beliefs about the nature of disease and the human body (Kleinman 1980), cultural issues are of key significance in medical treatment delivery. Culturally competent health care may increase ethnic concordance between patient and practitioner, thereby increasing the use of health care services and *Corresponding author. Email:
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enhancing patient trust and satisfaction (Laveist and Nuru-Jeter 2002; Saha, Arbelaez, and Cooper 2003). Such care may be provided by a health care workforce prepared to interact with the variety of cultures represented in the population or by a health care workforce that is representative of the population that it serves (McGee and Fraher 2012). Consequently, minority recruitment into the health professions is used as a strategy to address ethnic disparities in health care (Betancourt et al. 2003; McGee and Fraher 2012). Nevertheless, ethnic minorities are often ‘underrepresented in the medical profession relative to their numbers in the general population’ (Association of American Medical Colleges 2012). Not much is known about how practicing health professionals themselves experience and perceive their work with patients in ethnically diverse contexts. Some may experience considerable uncertainty causing hesitancy and inertia in their clinical practice (Kai et al. 2007). Klein et al. (2008) found that although physicians concerned with minority health issues agree that commonly suggested strategies for elimination of racial and ethnic disparities in health care could be useful, they have difficulty in implementing such approaches. These studies assessed the views and experiences of practicing physicians who usually belong to majority groups. Few have investigated whether practitioners from minority backgrounds are more likely than nonminority practitioners to serve the underserved. Studies focusing on the minority physicians’ point of view found that minority primary care physicians are more likely than their majority counterparts to care for minority, poor, and uninsured patients (Grumbach et al. 2008; Ko et al. 2007). There is a lack of relevant qualitative data on how specialist physicians from ethnic groups underrepresented in medicine experience and perceive their work. Their attitude may indeed shed light on ethnic diversity in the health care workforce and on cultural competence in health care. We conducted our study in Israel, assessing the views of specialist physicians in the Arab minority population who work in Israeli hospitals. The Israeli health system provides a sound case study for exploration of the dynamics of an ethnically diverse health system and the minority physicians’ perspective.
The Arab minority population and health disparities in Israel The terms ‘Jewish’ and ‘Arab’ used in the present article follow the distinctions used by Israel’s Central Bureau of Statistics to denote these two distinct groups of population that widely differ in their historical, national, religious, linguistic, and cultural contexts. According to the Central Bureau of Statistics (2013b), Arabs constitute the largest minority group in Israel comprising 20.6% of the country’s total population while the Jewish majority comprises 75.1%. Despite some degree of modernization, the Arab way of life is still semi-traditional and certainly far less modern and secular than that of the dominant Jewish culture (Smooha 2010). Most of the Arab population reside in peripheral areas of the country and in small localities, in which they account the majority of local residents (Ali 2006), as well as in several urban centers with mixed Arab-Jewish populations. The Arabs in Israel are a low-status minority (Herzog 2004). Many of the poor households and localities are Arab. Despite the sharp rise in the level of education among the Arab population, it is still lower (except among Christians) than that of the Jewish population (Abraham Fund 2013). Furthermore, Arab children in Israel are placed in a separate educational system in the Arabic language, constituting a further obstacle,
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besides the conflictual political context, to their successful integration into Israeli society, in the academic world and the job market alike. Besides their poorer socioeconomic status, their psychological and physical health situations are inferior to those of the Jewish population. As of the end of 2010, their mortality, morbidity, and infant mortality rates were higher (6.8 per 1000 live births vs. 2.7 for Jews) and life expectancy lower (75.9 and 79.7 years for Arab men and women vs. 79.6 and 83.4 years, respectively, for Jews; Abraham Fund 2013). Among those who speak Arabic as a mother tongue, 29% encounter difficulties in obtaining required health care services because of language barriers (Averbuch 2010). Despite Israel’s National Health Insurance Law that provides coverage to all citizens, Arabs in Israel face barriers in accessing health care such as inadequate allocation of health-related resources, clinics and manpower in the periphery (where most Arabs in Israel live), and personnel not sufficiently culturally sensitive to the Arab’s population special needs (Borkan, Morad, and Shvarts 2000). In addition, Arabs are less likely than Jews to seek specialist care (Baron-Epel, Garty, and Green 2007) because many Arab communities are distant from the major cities in which high-quality medical care and specialist services are located (Lubetzky et al. 2011). We assessed the underrepresentation of Arab workforce in the Israeli health system, relative to their percentage of the general population, and sought to find out how Arab Israeli physicians view their role within this system. Do they consider themselves to be culturally competent physicians for an underserved minority ethnic population, as mediators between the dominant and minority ethnic group, or simply as physicians?
Methodology We integrated both quantitative and qualitative methodologies in planning this study. The mixed methods approach is not new to public health researchers and social scientists (Abusabha and Woelfel 2003): Although the manner in which the elements of quantitative and qualitative methodologies are combined is liable to be fragmented and inconsistent, mixed methods may be used to produce a more complete picture by combining information from complementary sources. We used both quantitative and qualitative methodologies to obtain two diverse but related types of data. To determine whether the Arab minority is underrepresented in health professions in Israel, we analyzed data from a survey of households conducted by the Central Bureau of Statistics (2013a) addressing the permanent population of the State of Israel aged 21 and above in face-to-face interviews of about an hour duration in Hebrew, Russian, and Arabic. All in all, the sample comprised 9533 persons, with the goal of obtaining about 7500 respondents. The actual number of respondents was 7064 of whom 1104 were Arabs. The survey assessed the percentages of Jews and Arabs in various professions, including those in the health and welfare fields. The quantitative data refer to Arab minority physicians in Israel as a societal phenomenon. To deepen our knowledge of the attitudes and perceptions of individual Arab physicians working in Israeli hospitals, we conducted complementary qualitative research. The qualitative data were obtained in 10 semi-structured, in-depth interviews with Arab physicians working in Israeli hospitals, carried out during 2013. We focused on hospitals located in two large Israeli cities – Haifa and Jerusalem – that have mixed Jewish and Arab populations. The hospitals in Haifa provide health care to the population of the
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Haifa and Galilee Districts, 43% of which is Arab, whereas those in Jerusalem serve a population that includes 31.4% Arabs (Central Bureau of Statistics 2013c). We applied the snowball sampling method reaching one physician through another. Except two who refused to participate in the research, all physicians we turned to agreed to take part. Interviews lasted between half an hour and an hour and took place either at the hospitals or – in two cases – at the physicians’ homes. As both the researchers and the interviewees speak fluent Hebrew, the interviews were conducted in Hebrew. The interview questions aimed at exploring the manner in which Arab physicians perceive their personal and professional identities, as well as their experience as minority physicians integrated in the Israeli health system that is dominated by Jews (e.g., which was founded as part of the Jewish Zionist project, Jews occupy the prominent positions Hebrew is the dominant language, and Arab doctors are an ethnic/culturally minority). Although ‘Palestinian Arab’ is the term commonly used in research in Israel (Mizrachi and Herzog 2012), we chose in this article to use ‘Arab’ instead, since the interviewees themselves opt it as their self-definition, maybe as part of their ongoing effort to integrate in the Israeli society. We interviewed nine men and one woman, a ratio that reflects the small number of female physicians in the Arab population of Israel (Keshet, Liberman, and Popper-Giveon 2014). The physicians’ ages range from 25.5 to 57 (e. 42). Participating physicians enjoy seniority at their places of employment, as most studied at relatively young age (Arabs in Israel do not serve in the army and may thus begin their higher education immediately after high school). Seven of them were specialists in endocrinology, anesthetization, internal medicine, pediatrics (2), trauma (2), and three were at various stages of specialization in pediatrics and internal medicine (2). Seven of the 10 interviewees studied abroad (in Italy, Turkey, Egypt, Romania, and Slovakia). This interesting situation results primarily from the inability of many Arab applicants to achieve the high grades required for admission to Israeli medical schools. Many of the Arab physicians interviewed grew in small villages in the northern periphery where educational infrastructures are underdeveloped. Consequently, they had to apply for higher education outside Israel. All interviews were recorded and transcribed verbatim. Qualitative conventional content analysis (Hsieh and Shannon 2005) of the transcribed interviews was performed to identify key themes. In this article, qualitative content analysis is defined as a research method for the subjective interpretation of the content of text (transcribed interviews) data through the systematic classification process of coding and identifying themes or patterns. We chose to use qualitative conventional content analysis that rejects preconceived categories, instead allowing the categories to flow inductively from the data. Conventional content analysis is generally accomplished according to a study plan aimed at describing a phenomenon for which existing research literature is limited. Data are gathered primarily through interviews and open-ended questions and probes tend to be either open-ended or specific to the participant’s comments rather than adhering to a preexisting theory (Hsieh and Shannon 2005). First, the data were read word by word and codes were derived by highlighting words in the text that appear to capture key concepts. Next, notes of our first impressions and thoughts were taken; labels for codes emerged and were used as the initial coding scheme. Codes were then sorted into categories based on relations and links among them and the emerging categories used to organize and group codes into meaningful clusters.
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As we employed qualitative content analysis, that is a subjective interpretation of the content, analysis was carried out by two authors (A.P.G. and Y.K.). They analyzed interviews independently and then met several times to discuss the emerging themes and codes. Following these clarifications, further analysis was conducted independently.
Quantitative findings: underrepresentation of Arabs in health professions We found that the Arab minority is underrepresented in health professions in Israel. Analysis of data from a survey conducted by Israel’s Central Bureau of Statistics (2013a) that provides up-to-date information on the living conditions and well-being of the population indicated that Arab participation in medical and health professions, especially at senior educational levels, is low relative to that of the Jewish majority. The percentage of persons from the minority Arab population of Israel employed in health and welfare professions is lower than that of the Jewish majority population sample. Only 5.53% of the Arab population work in health and welfare professions versus 7.53% of the Jewish population (P < 0.001). There is also marked significant underrepresentation in the percentage of academically trained Arab persons in these professions. Only 1.90% of the Arab population are academics who work in health and welfare professions versus 3.39% of the Jewish population (P < 0.001). The higher the educational and professional demands, the more underrepresented the Arab population. In the context of underrepresentation of the Arab minority in health care professions, and especially of academics, we asked what is the attitude of Arab specialist physicians working at Israeli hospitals toward underrepresentation of Arabs in the health professions and health disparities between Jews and Arabs? In particular, how do they perceive their role in reducing these disparities? The qualitative findings presented in the following section articulate the individual Arab physicians’ point of view as minority physicians, thus completing the statistical data presented here. They express two points of view: That of Arab patients who use the Israeli health system (as derived from the content of our interviews with Arab physicians) and that of the physicians working in this system. The findings show that the two points of view complement one another. Moreover, they shed a unique light on the manner in which Arab physicians at Israeli hospitals perceive their role and position in this context.
Qualitative findings As indicated, the Arab minority population is underrepresented in the health and welfare professions, especially among academically trained professionals such as physicians. Two chief findings emerged in our qualitative assessment of the reactions of Arab specialist physicians working in Israeli hospitals – who are close to the pinnacle of the professional medical hierarchy – to the aforementioned underrepresentation of the Arab population in medicine and especially to their own role in reducing health disparities. First, the participants felt they could provide Arab patients with better treatment because they know their language and are familiar with the special values of Arab society in Israel. Second, even though the Arab population is underrepresented among health professionals and the participants recognize their potential contribution in providing culturally competent care to Arab patients, they are not interested in treating Arab patients in particular but rather aspire to integrate into Israeli society by participating in its health system – that is
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perceived in many respects as more egalitarian and enabling than other public systems – and exerting an influence from their position therein.
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Culturally competent care – Arab patients seeking treatment by Arab physicians Participants indicate that treatment by Arab physicians can benefit Arab patients, especially considering the Arab population’s underrepresentation in the Israeli health system. The participants feel that they can provide Arab patients with better care because they are familiar with the language and values of Arab society in Israel. In other words, the Arab physicians are aware of their role in reducing the health disparities that adversely affect the Arab minority in the medical establishment: Many times, I sit with families to explain treatment to them and to make major decisions – such as [those concerning] an infant who has no chance [of survival] … We had such a case yesterday, a child with no hope, with cranial defects … but if you speak simply … you’ll say to the family: ‘Come, I want you to decide whether or not you want to continue treatment,’ they’ll tell you that it’s forbidden [to terminate treatment] from a religious point of view. So you approach them in a different manner. ‘Listen, your child has defects. Go and consult with your religious leaders. Tell them what the situation is and what I think.’ Truly, they will accept this far more easily if they hear it in a different language and a different manner. [Samir, pediatrician]
Note that the participants themselves do not aspire to treat Arab patients in particular, but rather ascribe such aspirations to the patients and their families who ask specifically for Arab physicians despite the discomfort it causes in the purportedly unbiased Israeli health system: In my opinion, an Arab patient who sees an Arab doctor feels more comfortable, as if to say ‘Aha! There’s someone who understands me.’ It sometimes leads to awkward situations. Once I was with a Jewish doctor and he was supposed to be the one providing care, but the Arab [patient] only paid attention to me. He only wanted me to answer him. The Jewish doctor understood this, so he’d say to me: ‘Tell him this or that.’ I do not think they feel that I would treat them better, but communication becomes more convenient: It’s easier to talk, easier because I understand them. It may be that there are special features of the [Arab] sector – in behavior, in everyday life – that I can understand better than the Jewish physician. [Musa, anesthesiologist]
The participants thus note their contribution to reduction of the health disparities. They claim that they can communicate more easily with Arab patients and thus also provide more precise diagnoses and treatment. Along with this observation, however, they also express entirely different sentiments: While their efforts at reducing health disparities tag them as ‘niche doctors’ who respond chiefly to the Arab population, their true desire is to free themselves of the Arab sector’s constraints and integrate into Israeli society, that is demographically, religiously, culturally, and linguistically predominantly Jewish. Arab patients, as described by the physicians, perceive themselves as part of the Arab sector, as part of the minority, seeking support from those who resemble them. Arab physicians, by contrast, are interested in breaking through the walls of Arab society. While the Arab patients are portrayed as a collective with a special language and unique cultural features, the Arab physicians describe themselves as individuals who seek to integrate, assimilate, contribute to, and derive benefits from Israeli society.
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Arab physicians at Israeli hospitals: aspiration toward integration rather than positioning as niche doctors Despite the Arab population’s underrepresentation among health professionals and the participants’ capability of providing culturally competent care to the Arab minority, the physicians interviewed express no interest in treating Arab patients specifically. They do not perceive themselves as representatives of the Arab minority within the predominantly Jewish Israeli health system, but rather as individuals who succeeded in breaking through the glass ceiling of the Israeli employment market and liberating themselves from sectorial constraints. In the interviews, the Arab physicians express their aspiration to join Israeli society by integrating into the health system: I’m in favor of integrating everyone in the same society. There should be Arabs in the parliament and at universities and also at hospitals … It’s both integration and cooperation, in which each one learns from, lives with and understands the other, an Arab doctor understanding what a Jewish doctor says … That’s what we have to do in order to progress and live together like human beings. [Musa, anesthesiologist]
The aspiration to integrate into the majority Jewish society is reflected in repeated use of the word ‘integration’ in the interviewees’ remarks, as in this example: I think that I’m doing a good job that helps a large share of the patients, whether they are Arabs or Jews. I think that integration of Arab physicians is beneficial to society … Arab physicians integrate well at hospitals and contribute much … Some of these physicians are good and successful and I think that integration of Arab physicians is good for society in Israel and good for medicine in Israel. [Naim, internist]
The integration to which Naim refers to does not take place in villages in the Arab community, but in mixed-population cities or Jewish population centers. In localities such as Haifa or Jerusalem, Arab physicians may fulfill themselves and develop personally, professionally, and economically. In mixed cities, there may be opportunities to progress to higher specialist grades and to increase income by engaging in private health care activities in addition to holding publicly funded positions. In this context, one may distinguish clearly between two groups of Arab physicians in Israel. The first group, most of whose members did not opt for specialization, serves primarily at community clinics in the Arab sector, while the second, from which the participants in this study were selected, is employed at hospitals outside Arab population concentrations. Its members intentionally chose to break through sectorial boundaries, advance personally and professionally, and specialize and develop, as Naim stresses: I do not think that my job is to treat the Arab population only. Treating Arab patients is fine as far as I’m concerned, but it’s also very important to treat Jewish patients … Under certain circumstances, there may be Arab physicians who treat Arabs only. They acquire a kind of stigma for treating patients from their own ethnic group exclusively. If they are local clinic doctors, that’s fine. But if they’re in major public hospitals, I think they have to learn to treat [everyone]. I treat Russian patients [Jewish patients who immigrated to Israel from the former Soviet Union] even though there are language problems. [Naim, internist]
Arab specialist physicians, some of whom, like Musa, attained senior management positions in the Israeli health establishment, consider their role to be different from that of
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Arab community physicians – both specialists and general practitioners – who work within sectorial boundaries. An Israel Ministry of Health report (Shemesh et al. 2007) indicates that Arabs account for 12% of all community physicians and 16% of all primary care physicians in Israel. The percentage of certified medical specialists is smaller among Arab physicians, both primary care and others, relative to their Jewish colleagues amounting to only 8% of the population of community specialist physicians. In contrast to the community physicians surveyed, most Arab specialists succeeded in breaking through sectorial boundaries, advancing professionally, and integrating into the Israeli health system. Musa, who heads a department at a major public hospital in a mixed city, explains his reasons for advancing up the career ladder and not remaining a community doctor, even though he would help many Arab patients by doing so: If a physician does not stay in the community, he will not be able to influence anything. If he stays in the community, he can exert an influence. The likelihood that he will remain in the community is not great, because it does not have the infrastructure, laboratories, X-ray facilities or pharmacies … He can’t make much money there. To make money, he has to go out into the wide world. The money is in Haifa, in Tel Aviv, not in Arab localities. [Musa, anesthesiologist]
Musa says that he decided to study medicine because when he was young, he witnessed the inferior health situation among the Arab population – the lack of physicians, poor access, and low professional level. Nevertheless, when he grew up, he chose to fulfill himself outside his community: I am a person who loves to develop and learn things and I can advance professionally in Haifa more than in the village … In the village you have to deal with social matters – and this, of course, comes at the expense of career advancement … It’s a problem. When you live in rural society, your time is not your own at all. But living in Haifa, in the big city, I can develop … Had I stayed in the village, I would not have accomplished all that I did. I’m nearly certain of that … with all the family events. Here, I don’t have such obligations. [Musa, anesthesiologist]
Some of the Arab physicians state explicitly that they would prefer treating Jewish patients and not Arab patients, as Elias explains: I do not say ‘I don’t want to treat you’ to anyone, but I would prefer not [treating Arabs] … I’ll take the Arab patient because it’s for the patient’s good, because he will certainly be able to communicate with me and explain his problems more than he can with a Jew. But if you were to tell me: ‘You have two workplaces to choose between, an Arab locality or a Jewish one,’ I would prefer working in the Jewish locality. [Elias, endocrinologist]
The participants described their difficulties working with the Arab population, claiming that it is precisely their familiarity with the culture, social connection, and receptivity to community that hinder true concentration on medicine: There are physicians who actually prefer working in the Jewish sector … At times, it is very difficult to take a medical history from the Arab population. They do not explain things well. They don’t keep to the point. You don’t just ask and get an answer; you ask and get a whole story … How’s your son and how’s your daughter and this one got married and this one got divorced, this one has a son and this one does not, this one had a miscarriage and this one did not … So instead of concentrating on medicine, we get sidetracked … In Jewish localities,
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where there is no such kinship and camaraderie and candor, the physician truly concentrates on medicine. I think that the patient gets better, higher quality and safer treatment that way. [Musa, anesthesiologist]
The participants also described their apprehension about being labeled as ‘doctor for the Arabs’:
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Diversity is important. When I accept only Arab patients and I am stuck with Arabs only and don’t get to know anyone else, I will not become familiar with the norms of other groups, say, religious Jews … You cannot work just with one group. That’s not good. You are a doctor for all. [Basma, internist]
The participants thus seek to integrate and not isolate themselves. The distance, paternalism, and alienation that they display toward the Arab population may be the price they pay for integration into the predominantly Jewish Israeli public medical system. From their position within the medical system, they strive to create opportunities for positive encounters between the two peoples. They perceive the medical sphere that is assumed to manifest a neutral, apolitical, and humanistic character to be an appropriate venue for dispelling hostility between Jewish and Arab society in Israel. In this arena, they seek to entrench a reversal of images: Instead of the murderous ‘bad Arab’ stereotype, they embody the image of the ‘good Arab’ who benefits and heals others. Their remarks indicate that Jewish society can accept Arabs as physicians. In the transition from the personal to the political, treating both Jews and Arabs can engender a shift away from hostile patterns of thinking and behavior. They describe the hospital as the appropriate venue for dissipating reciprocal demonization and for building trust. As a distinct location with its own special rules, the hospital enables an encounter between social extremes and thus renders it possible to effect a significant change: When Jewish parents see Arab doctors tending to their children, they change the way they think. The Arab does the same when he is examining that Jew and sees that the entire staff is speaking the same language … At times, when you send a Jew to examine an Arab, he [the patient] calms down and says: ‘Apparently everything is good and there’s none of the discrimination I thought there would be … He tends to me and an Arab is tending to a Jew and everyone is satisfied. They speak like people who are concerned for one another.’ This really solves problems, many problems. [Muhammad, pediatrician]
Ahmad describes a case in which his treatment of a Jewish child sparked a change in the atmosphere, reducing the suspicion and hostility that had prevailed in the department previously. Metaphorically, this case introduced the word shalom (Hebrew: literally ‘peace,’ also a greeting) into departmental discourse, underscoring transition from the personal sphere (the physician treating the patient) to the political one (relations between two peoples in Israel) that was enabled in the hospital context: There was a boy who was ill. His father actually said, right in front of me, that he hates Arabs. He behaved really badly towards me … He really did not want to speak to me. When I asked him questions about his son, he simply did not answer me. He was always shouting and people started telling him: ‘Listen. He’s a good doctor.’ … That didn’t really concern me and I continued treating his son. The boy’s condition worsened, but I managed to save him. Suddenly, the father started saying ‘shalom’ and began to speak with me more often. We sense a change in the atmosphere. [Ahmad, pediatrician]
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The participants feel that they are succeeding in using medical ethics as a path toward integration in the majority Jewish population and as a means of reducing hostility, bias, and stereotyping between Jews and Arabs in Israel. An Arab trauma specialist, whose patients include Jews injured in terror attacks, described the complexity of the situation: Some people have that kind of mentality: They see an Arab and start screaming and do not want to talk … What do they think? According to what they show on television, Arabs are terrorists and thieves … But I speak nicely to them. I say to myself that I have a mission. I have to help the sick. I never said, not even to myself or in my head, that a Jew gave me a dirty look. I am a forgiving person, a person who loves others, who helps others. It doesn’t matter how he behaved towards me, what he said to me, because my intention is to help the patient … I never look at people as Jews and Arabs. No, they’re patients. What is the physician’s oath? That every patient who comes to you is a human being and you have to help him with everything – body, mind and soul. Gender, race and religion make no difference. [Ibrahim, trauma specialist]
The participants seek to intensify their own integration in the system and dispel the hostility, fear, and sense of deprivation that characterize relations between Jews and Arabs, as conflicting ethnic groups in Israel. The number of Arab physicians working at Jewish hospitals is still small. Perhaps the percentage should be raised to shatter all the nonsense that remains … There are still people who cannot tolerate an Arab physician and there are still people who cannot tolerate a Jewish physician. If you have Jewish physicians who speak Arabic and Arab physicians who speak Hebrew and they all are involved in one another’s professional spheres and all provide the same treatment at the same level, I believe that all those thoughts will dissipate. [Muhammad, pediatrician]
The participants thus perceive their representation as Arabs in the Israeli health system as significant. Nevertheless, they do not relate to the Arab patients’ desire to be treated by Arab physicians familiar with their culture. Rather, they strive for their own integration – as individuals, not as representatives of the Arab minority – in the Israeli health system. Instead of confirming our initial assumption that Arab physicians provide culturally competent care to Arab patients, the interviews show that they aspire to integrate in the predominantly Jewish Israeli health system.
Discussion This study can contribute to both medicine and sociology. In one respect, it may prove beneficial in addressing ethnic underrepresentation in the health system and increasing cultural competence in provision of medical care. McGee and Fraher (2012) suggested that culturally competent care may be achieved in two ways: Training medical staff to interact with people from the various cultures represented in the population and creating a health care workforce that represents the minority population. The present findings show a case in which physicians in minority group effectively manifest the combined effect of these approaches. Having integrated at relatively high levels of the public health system, their everyday work helps dispel stigmas and fosters improvement in the medical staff’s interaction with patients from different population groups. In this context, representation does not imply that a minority group patient will be treated by a physician from the same
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group, but rather that minority group physicians will exert an influence on overall system performance. Another potential contribution benefits research in the sociology of minorities. Our quantitative findings show that Arab participation in medical and health professions, especially at higher educational levels, is low relative to that of the Jewish majority. This finding is consistent with previous studies. While Arabs account for 12% of all community physicians, they comprise 16% of primary care physicians, and only 8% of community specialists (Shemesh et al. 2007). Also in Israel’s civil service, for example, 12.46% of all physicians and 22.52% of all residents are Arabs, but at the higher echelons the percentage of Arabs is only 3.76% (Reznik 2011). These statistics show that the higher the educational requirements and expertise required for a position, the more severe the underrepresentation of the Arab minority population in the Israeli medical establishment. The Israeli case study presents the point of view of members of an Arab minority group that succeeded in ascending and reaching positions at relatively senior levels in the public medical system. The findings raise the question of whether the field of medicine that is perceived as humanistic and apolitical can serve as a venue enabling integration of minorities. Does the human and egalitarian platform that this field purports to represent – along with its focus on matters of life and death, of sickness and health – provide a basis for integration of the minority into the majority, even when the two sides are engaged in a national conflict? The participants in this study are physicians at the pinnacle of the professional medical hierarchy, as well as those who aspire toward reaching it: specialists or residents at hospitals and not community physicians. They are aware that Arab physicians can provide Arab patients with better care than their Jewish colleagues can because of their fluency in the language and familiarity with special customs. Nevertheless, they do not wish to work with Arab patients exclusively but rather to integrate as individuals in the majority Jewish population in terms of lifestyle, workplace, and the patients they treat, even at the cost of alienation from their own people. They recognize the disparities in health between Jews and Arabs in Israel and know which steps to take to benefit the latter, but they do not perceive themselves as representatives of their sector or as niche doctors, but as physicians who succeeded in breaking through sectorial boundaries. They attempt to influence the complex fabric of life in Israeli society and – through their practice of medicine – to demonstrate that it is possible to integrate Jews and Arabs, that an Arab physician, just like a Jewish one, can treat both Arab and Jewish patients. Interviews with Arab physicians who hold positions at public hospitals depict their workplaces as venues for integration rather than representation. The physicians perceive themselves as individuals, each of whom separately made his way upward. From their position within the system, they see themselves as professionals only. By contrast, Arab patients, on the outside, wish to be defined in cultural and political terms. They expect the Arab physicians to act on their behalf because of the ethnic affinity between them, while the physicians ignore such expectations in their quest to be perceived as treating patients in a professional manner. We initiated this study because we perceived Arab physicians in the system as trailblazers, as pioneers, at times the first of their villages to aspire for high medical education and prominent positions in prestigious hospitals. Ultimately, they were shown to be highly conformist in nature. In other words, the interviews depict them not as
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standard bearers for their own ethnic group but as trying hard to integrate and assimilate in Jewish-Israeli society conforming to their Jewish colleagues’ lifestyle. Most strive to adapt themselves to the Jewish job market, residential environment, and family pattern. They integrate in Jewish health organizations, live in mixed neighborhoods or even Jewish ones, and have relatively fewer children (many have three children – a number close to the average for the Jewish population of Israel), exerting mighty efforts to integrate into Jewish society as individuals and to advance professionally to senior levels in the medical profession. They are depicted as a vanguard in their efforts to dispel hostility between ethnic groups in Israel within the confines of the hospital – a venue in which ethnic differences are ignored, medicine is structured as the objective space of ‘the clinical gaze’ (Foucault, 1973) where the physical body and life and death situations are encountered. Other researchers have also argued that new groupings within the profession frequently face difficulties in gaining access to the most prestigious – and hence often the most economically rewarding – positions (Hoff 1998; Weeden 2002). They describe examples of how formal and informal strategies create internal stratification, wherein candidates most similar to the dominant group – white, middle-class males – are better positioned (Tomaskovic-Devey 1993). Similarly, Arabs in Israel who wish to be integrated in the prestigious medical establishment often describe themselves in hues similar to those of the Jewish dominant group. From their place as insiders in the state medical system, the Arab physicians interviewed aspire toward creating opportunities for encounters between peoples. They perceive the neutral, apolitical, and humanistic medical environment as fertile soil for dispelling hostility between Jewish and Arab society in Israel. In this spirit, they also underscore the egalitarian attitude they accord to all who seek their assistance, Jews and Arabs alike. Equality in treatment is emphasized primarily by physicians working in critical environments, such as emergency rooms, intensive care wards, or neonatal departments, where ethnic differences fade and disappear, overshadowed by issues of life and death. Participants depict the Israeli health system as a venue for blurring differences and schisms. Hospitals in particular are perceived as sites at which differences among the various ethnic groups in Israel are obscured. Hospitals deal with matters of sickness and health, of life and death that are considered universal. The universal message of the medical profession, as embodied in the Hippocratic Oath, ostensibly transcends ethnic differentiation and classification. Hospitals are said to practice objective professionalism that rises above emotions, traditions, and prejudices. Furthermore, the National Health Law in Israel mandates equal treatment for all patients, irrespective of origin, consolidating the health system as relatively egalitarian when compared with other systems, such as education, for example. The present research, local in nature, based on a relatively small convenience sample and therefore does not provide a representative view of all Israeli Arab physicians, did not provide responses to certain important questions that future studies may address, in Israel and in other national contexts that entail majority/minority relations: Does integration help patients? Is it beneficial for the physicians and their families, who pay the price of living between two worlds, blurring their values and identities and exposing them to discrimination in the establishment and to criticism at home? Is the hospital indeed a venue for reconciliation and the shattering of prejudices? These questions remain open
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and may be addressed using both quantitative and qualitative methods, thereby supplementing the present article and forming an extensive body of knowledge regarding physician’s role in multicultural contexts.
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Key messages (1) Ethnic diversity plays an important role in reducing health disparities among different ethnic groups. (2) Arab physicians in Israeli hospitals do not perceive themselves as representatives of the Arab sector and reject stereotyping as Arab ‘niche doctors.’ (3) Minority physicians may prefer to promote culturally competent health care through integration in the population, rather than serving as representatives of their own ethnic minority population. References Abraham Fund. 2013. “Information File – Arab Society in Israel.” [In Hebrew.] Accessed November 1. http://www.abrahamfund.org/55441. Abusabha, R., and M. L. Woelfel. 2003. “Qualitative vs. Quantitative Methods: Two Opposites that Make a Perfect Match.” Journal of the American Dietetic Association 103 (5): 566–569. doi:10.1053/jada.2003.50129. Ali, N. 2006. “The Unpredictable Status of Palestinian Woman in Israel: Actual Versus Desirable.” Paper presented at Religion, Gender and Politics: An International Dialogue, Van Leer Institute, Jerusalem, September 11. Association of American Medical Colleges. 2012. “Underrepresented in Medicine – Definition.” Accessed July 8. https://www.aamc.org/initiatives/urm/. Averbuch, E., ed. 2010. Inequality in Health and How to Cope with it. [In Hebrew.] Jerusalem: Ministry of Health, Economics and Health Insurance Division. Baron-Epel, O., N. Garty, and M. S. Green., 2007. “Inequalities in Use of Health Services among Jews and Arabs in Israel.” Health Services Research 42 (3): 1008–1019. doi:10.1111/j.1475-6 773.2006.00645.x. Betancourt, R. J., G. R. Alexander, E. J. Carrillo, and O. Ananeh-Firempong. 2003. “Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care.” Public Health 118 (4): 293–302. Borkan, J. M., M. Morad, and S. Shvarts. 2000. “Universal Health Care? The Views of Negev Bedouin Arabs on Health Services.” Health Policy and Planning 15 (2): 207–216. doi:10.1093/ heapol/15.2.207. Central Bureau of Statistics. 2013a. “Social Survey.” [In Hebrew.] Accessed June 27. http://www. cbs.gov.il/reader/?MIval = cw_usr_view_SHTML&ID = 569. Central Bureau of Statistics. 2013b. “Selected Data from the Statistical Abstract of Israel No. 64, 2013.” Accessed December 12. http://www.cbs.gov.il/reader/newhodaot/hodaa_template.html? hodaa = 201311255. Central Bureau of Statistics. 2013c. “Population by Population Group, Religion, Age, Sex, District and Sub-District.” [In Hebrew.] Accessed November 1. http://www.cbs.gov.il/reader/shnaton/templ_ shnaton.html?num_tab = st02_19x&CYear = 2013. Cohen, J. J., B. A. Gabriel, and C. Terrell. 2002. “The Case for Diversity in the Health Care Workforce.” Health Affairs 21 (5): 90–102. Foucault, M. 1973. The Birth of the Clinic: An Archaeology of Medical Perception. New York: Pantheon Books. Grumbach, K., K. O. Walker, G. Moreno, E. Chen, C. Vercammen-Grandjean, and E. Mertz. 2008. California Physician Diversity: New Findings from the California Medical Board Survey. San Francisco: UCSF Center for California Health Workforce Studies.
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