Education and training for all health professionals is regarded as key in the development of palliative care services in Israel, and has been an important aspect of service development from the early 1980s, with the opening of the first hospice. Since the late 1990s there has been an increase in organising and developing training with more courses available.⁸¹ Although palliative medicine is still not recognised as a specialty in the health care service, it is part of all general nurse training and also part of postgraduate oncology nurse training. Some medical schools include short units for fifth year medical students. There are currently also training opportunities in Israel for physicians at postgraduate level with a two year diploma course at Tel Aviv University for physicians co-ordinated by Alexander Waller, Medical Director and Michaela Bercovitch, hospice physician. Tel Hashomer Hospice (Table 4).

Table 4: Palliative care education and training available in Israel - 2005

Nathan Cherny, Director of the Cancer Pain and Palliative Medicine Service, Sha’are Zedek Medical Centre, Jerusalem explains the current situation:

‘Palliative care is part of core training for nurses and it is an integral part of the training for oncology nurses.  Palliative care training for oncologists is weak and relatively ad hoc, despite the fact that at least on paper they have adopted the curricular guidelines of the European Society of Medical Oncology (ESMO) which are fairly stringent guidelines as to what has to be incorporated in training, it’s between the policy and practice that there continues to be a gulf.  Outside of the oncology framework palliative care is very under developed; when the AIDS crisis was at its peak there was an in patient hospice but the whole picture has changed.  But for people with degenerative neurological diseases or whatever they fall into the rubric of whatever of the home care services but in a very ad hoc manner and not necessarily with a lot of skilled care.

In terms of physician training there is a diploma programme in palliative care that has been running for a number of years and I think has put through probably close to about 90 or 100 graduates.  It’s a 2 year part time programme through Tel Aviv University, which has been primarily co-ordinated by Alex [Alexander Waller, Medical Director, Tel Hashomer Hospice] and has been a very successful programme, and people come to do that from a broad variety of disciplines and from very diverse parts of the country.  The specialty accreditation is all co-ordinated through the Israel Medical Association.  At present they are resistant to the development of palliative medicine as a sub specialty but there are moves afoot to have a fellowship recognised.  In the presentation that was made the recommendations have gone to the Ministry of Health, this issue is being addressed but these decisions are not in the hands of the ministry alone.’⁸²

In addition to formal education courses there are a variety of training programmes for health professionals (physicians, nurses, social workers, psycho-oncologists, spiritual counsellors and creative therapists) that are organised by individual palliative care services and also as part of the work of national associations (see IAPC, ICA, IPMS). These programmes include study days, seminars, conferences, Continuing Medical Education (CME) courses and specialist training units.

Israel Cancer Association (ICA) has a strong commitment to professional and public education. Since 1978, Head Nurse Aliza Yaffe and her colleagues at ICA have pioneered a specialist community oncology nurse training, which includes stoma care, breast care and palliative care. One of the current goals is to create a palliative care nursing specialty. ICA funds short specialist programmes, for example training radiographers in mammography. Regular public education programmes are organised to raise awareness about cancer, early detection treatment, and support. ⁸³ ICA also funds research into cancer, including initiating and evaluating new developments in medical and nursing services.

Israel Association for Palliative Care (IAPC) in collaboration with the Israel Cancer Association and Ben Gurion University of the Negev is currently organising short ‘train the trainer’ courses in different centres around Israel. Three courses ran in 2004, and 5 in 2005. These are run as a 40-hour course with the hours divided equally between psychosocial issues, physiology, symptom control and pharmacology. Nurses can get CME (Continuing Medical Education) points for attending. IAPC board member Dr Amitai Oberman describes the future direction for palliative care education:

‘I believe that geriatric and oncology postgraduate nurses should know something about [palliative care]. On the whole the feeling is that positive things are happening, and the last two years have been very fulfilling and we see change, and there’s money and there’s more people, and people are coming to the conferences, which have been very, very successful. We are able to attract more professionals and more public figures and health professionals, key leaders in medicine. Tons of work to do, especially within the hospital system, but the fact is that we have this committee which also Pesach headed, from the Health Ministry, is a major, is a major change. It will take time ’til it will be implemented and there will be money and funding for palliative care, but it’s a change, it’s a move.’

Many services also train volunteers as part of their ongoing work. There are other specialist programmes including spiritual counselling, and international opportunities: such as fellowships and Masters courses.

At Ben-Gurion University of the Negev there is a programme of palliative care residencies for trainee family medicine doctors run through the Negev Palliative Care Service. Through the university’s Faculty of Health Sciences the palliative care service runs a variety of post graduate and undergraduate courses. These include short training units for medical and nursing students as part of their professional development; postgraduate courses; seminars; and specialist training for oncology nurses. Medical Director, Dr Yoram Singer explains current developments in palliative medicine education and research, including more details about the collaborative ‘train the trainer’ courses:

‘We are more and more involved in education, to get [palliative medicine] into [the] undergraduate curricula. At the moment we are more involved in Continuing Medical Education (CME) courses for medical professionals - nurses and doctors mostly - and, because of the success of the mobile unit, we got an extra funding for this from the New York Federation. [NYF funded the Negev desert mobile unit]. They are enthusiastic at how things work. We had a six-day get-together for a ‘train the trainer’ course, and there we [developed] the curriculum. Now we’re in the middle of running [courses], ’til the end of June we will run three national courses on palliative care (40 hours each). It’s very interesting; the enrolment is from social workers, nurses and doctors: multi/interdisciplinary experience. Now we have requests from many other places and we’re slowly building it up. And, of course, [we have] the family medicine medical students. We do a little bit of research, more kind of audit kind of research at this stage.’^84,85

Middle East Cancer Consortium (MECC) as part of its ongoing educational and research workorganises regular seminars in cancer registry and in oncology.⁸⁶ Since 2004 MECC has also started to address the need for information and education in palliative care for all health professionals working in the field. The consortium has funded members to attend courses with the American Society of Clinical Oncology (ASCO) and has set up a collaborative ‘training the trainers’ palliative care course between Calvary Hospital, VA, USA and the oncology unit in the Italian Hospital, Haifa. In February 2004 and November 2005 palliative care seminars were run for health professionals from MECC member countries. ⁸⁷

With the growth in education and training in Israel there have also been more opportunities for research in the field. There is currently a well established clinical and academic research base in palliative care, with a strong record of extensive national and international publications and dissemination at international conferences. Key research in palliative care is undertaken by clinical and academic researchers from all disciplines involved in palliative care provision, many in collaboration with major universities in the country.⁸⁸ Major areas of research include pain and symptom management; ^89,90,91,92pain assessment and needs;^93,94cultural aspects of palliative care.^95,96 Palliative care research publications are also internationally disseminated from nursing and related clinical health professionals including social work, psychologists,⁹⁷ therapists, and academic health researchers.