Dr. Friedman with medical center colleague PA Yehuda Naiman. Every medical encounter is something to learn from and move forward with

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fter two years at Baragwanath, Dr. Friedman left to focus on primary care medicine. “I wanted to connect and understand the families, and get to know them and not just their ailments,” he says. He worked at a clinic in Alexendra, a poor, black-only township near Johannesburg. Dr. Friedman took full advantage of the fact that the South African system of health care ensured that his financial reimbursement was not directly tied to any particular quota or volume he produced. “Otherwise, I surely would have gone broke,” he says. “I would sometimes see a patient and tell him to come back in the afternoon before prescribing medicine, just to see if perhaps the ailment changed since the morning and to confirm that antibiotics were appropriate treatment.”

After a year of working in this family practice clinic, the young doctor and his wife, Batya, decided to relocate with their growing family to Eretz Yisrael. But the year was 1990, and his initial aliyah didn’t last long. After just nine months, the Gulf War broke out when Saddam Hussein ordered his soldiers to invade neighboring Kuwait, setting off an international conflict and drawing Israel into the center of the battle with a six-week long barrage of SCUD missiles. Knowing that many Arab states would be unwilling to fight alongside Israel, the Iraqi dictator made a calculated, strategic move: If he could provoke the Jewish State into retaliating militarily and attacking Iraq, it would cause many Arab countries to abandon the US-led coalition that was leading the offensive against Iraq, as they wouldn’t fight on the same side as Israel.

“Our families were pressuring us to leave Israel, and so I went to Rav Shlomo Zalman Auerbach to ask him what we should do,” recalls Dr. Friedman. As they hadn’t really settled yet, Rav Shlomo Zalman told them to leave, but not to return to South Africa. They chose the UK.

Unlike the apartheid system he’d recently left, in which white citizens received first rate medical treatment while blacks were relegated to under-resourced, poorly staffed, and overcrowded clinics and hospitals, the United Kingdom’s socialized health care system gave free care to all its subjects through the publicly funded National Health Service (NHS).

During his time in the UK, Dr. Friedman, unsure of how long his stopover would last, took a break from his medical career, instead enrolling in a Manchester kollel to learn full-time. Just two seats away was a fellow doctor who had taken a planned sabbatical year and joined the kollel as well. Over their pre-seder coffees, the doctors-turned-avreichim would discuss the differences in medical systems, with the South African trained Dr. Friedman and the English educated doctor trading notes.

“In the UK, the government controls how many doctors are in which areas, so you can’t just open a practice — you have to be allocated a practice by the government,” Dr. Friedman explains. “That happens in two situations: when a practicing doctor passes on, or when a doctor’s workload necessitates that he look for a partner. They apply to the NHS who find the doctor to fill that post.”

While the ironclad control of the government is advantageous because it ensures health care to all Brits at no cost, because there is no competition, it’s often a struggle to get cutting-edge, effective, proactive health care to the public.

“Preventative care is always cost effective, so the UK system rewards that by incentivizing doctors to have their patients take preventative measures,” he explains. “If you hit 80 percent of patients taking certain measures that the government sees as preventative, your reimbursement rate for those services will be very high.” That’s obviously a boon for the masses, but there is some serious fallout along the way. “To get into any sort of specialist, there is a rigorous referral process in place,” he says. “A doctor must be able to make an explanation satisfactory to the bureaucrats at the NHS justifying why they can’t treat this particular condition.”

The family doctor appreciated the low barrier of entry to coverage, but balked at the difficulty in obtaining specialists. He was still going strong in kollel though, and he had no immediate plans to resume his medical career. In fact, he was getting so comfortable in this new life that he even contemplated moving to Gateshead to join the yeshivah and kollel there.

Dr. Friedman asked the Manchester rosh yeshivah, Rav Yehuda Zev Segal, if he should continue his learning, and if so, where. The response was eerie. “The Rosh Yeshivah responded that I should stay in Manchester, but then added somewhat cryptically that if I’d like, I can go back to Eretz Yisrael… on Purim,” recalls Dr. Friedman. That second part was somewhat mysterious and unsolicited, but Dr. Friedman marveled when the Gulf War officially ended on February 28, 1991. The Hebrew date was 14 Adar, 5751.

Dr. Friedman returned to Israel and resumed his practice, landing a job as a doctor in Kiyrat Sefer for the local Kupat Cholim health fund, a sort of managed Medicare/Medicaid practice in which all the primary care and specialty care is managed through that one entity. Being a physician in Kiryat Sefer also meant being “the” physician, as the chareidi stronghold did not have any doctors in its proximity until Dr. Friedman arrived.

The knowledgeable, genial physician moved up the ranks of the Israeli system, eventually becoming head doctor of the entire Modi’in region for Meuhedet. The post included tasks that were more administrative in nature, and it gave Dr. Friedman the ability to bring different specialties and outpatient services to the clinics that he was overseeing. Dr. Friedman had stipulated with Meuhedet that he’d take the position as long as he would be able to still see patients, and the combined administrator/doctor role turned out to be a good fit: The new position allowed Dr. Friedman great leeway in molding the medical apparatus to his vision. “These health funds were entities like the insurance conglomerates — they had huge infrastructures in place, so if I would make a case for a service to be added, they would approve it, and they had the system and infrastructure to implement it.” 

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ecause of the socialized structure of the system (today, three decades later, the system has seen many changes), Dr. Friedman wielded the “power of the pen.” He implemented a philosophy that a patient should never be issued a flat-out denial for a request for services.

“Not that we approved everything that came our way, but when we had a patient come to us who was recommended to undergo certain tests, we looked at his entire file and based on that, either gave the approval for the test that the primary care doctor had recommended or we’d recommend a different test,” he says.

The new system was popular with its patients and the administration. “I didn’t look at the finances, but the folks in the administrative offices at Meuhedet were excited — we were making more money than any other region while maintaining the best clinical outcomes, and there was more demand for people to join,” he says.

Dr. Friedman’s clinic achieved the coveted award for having the highest satisfaction level of any clinic in the country. It was no doubt partly due to Dr. Friedman’s insistence that no patient ever be denied appropriate testing or treatment, but there was something else, too: the value of communication he picked up in South Africa.

“I never recommended a patient to a specialist without calling the physician first and relating my thought process in referring them,” he recalls, “and when I would call, the specialist would say to me, ‘Why are you calling ahead? No one else calls me, but you know something? I really appreciate it.’”

And so a synergy was formed. “There was a connection between me as the primary care provider and the specialist. We were able to collaborate and the patient was getting a consistent message. If a primary care provider doesn’t understand what the specialist is doing, and the specialist isn’t privy to what the primary care provider is telling the patient, it creates a level of anxiety. By creating a connection and getting one unified message across to the patient, it gave us a much higher patient satisfaction, better outcomes, and though this wasn’t our intention, Meuhedet was telling me that we were doing superb from a financial perspective as well, because our methodology allowed us to prevent unnecessary run-around, while at the same time getting people the help they needed.

And even though the Israeli system, like the UK, was socialized medicine, Dr. Friedman found that the issues he found wanting in the latter were not present in Israel. “Generally, you could get good specialists, even elective surgery, without much waiting, whereas in the UK, you’d sometimes have to wait years for such a surgery. We never felt like we were fighting the system.” Dr. Friedman posits that this may be due to the influx of American-trained physicians coming from United States to Israel and sharing their knowledge and training with a younger generation of Israeli medical students.

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hile Dr. Friedman integrated well into the Israeli system, a personal medical situation forced him to continue his medical odyssey on yet another continent.

“My son was born with a certain health condition, and the system wasn’t able to provide us with the level of specialty care that we needed for him,” Dr. Friedman says. He consulted two gedolim on how to proceed: Rav Elyashiv and Rav Moshe Shapira. They both agreed that the family should emigrate to America. When Dr. Friedman expressed his hesitancy to Rav Shapira, the Rav responded that, “you South Africans are too soft! Go tell the Americans that whoever helps you will see tremendous brachah.”

The Friedmans settled in Lakewood’s Forest Park development, because, “we wanted a place as similar as possible to Eretz Yisrael.” His foreign medical degree and license weren’t fully recognized by the medical establishment in the United States, so he joined what he jokingly calls, “a small company specializing in tax and business services” — American Express, or “AmEx.” The goliath financial corporation had recently acquired a huge health care portfolio, with “FQHCs” (Federally Qualified Health Centers) — federally funded nonprofit health centers or clinics in all 50 states that serve medically underserved areas and populations regardless of one’s ability to pay — and Dr. Friedman worked as a consultant for the recent acquisition.

He was tasked with training the staff at the various facilities on how to improve workflow, patient safety, and to design, establish and improve the implementation of electronic medical records. He flew around the country consulting for community health care centers on the three aforementioned points, and as he was being jetted from one facility to another, noticed something interesting about the American health care system.

“The United States is the top of the line if you’re looking for subspecialties, but there is an emphasis on treating the pathology more than the patients. There is more emphasis on curative than preventative services, and physicians as a whole are encouraged to go into subspecialties, which produces superb quality health care, but doesn’t produce good overall outcomes for patients. Medical students aren’t encouraged to become general practitioners anymore.”

But Dr. Friedman saw it differently. “I believed we shouldn’t only help people heal, we should help people prevent illnesses in the first place — it’s cost-effective to the patient and cost-effective to the system overall. This is done chiefly through a strong primary care provider system, which can have the longest-term impact on patients, especially if it’s implemented well.

“Specialty is extraordinarily important if someone needs it,” he clarifies, “but it needs to be a coordinated approach dealing with the patient and not just with pathology. Whatever illness there may be, there is always a patient behind it. The patient will be compliant or not, the patient may understand or not — the pathology is just one aspect of it — and in addition, the patient is surrounded by a family and they, too, can be affected by what is going on in medicine.”

It would still be some time before Dr. Friedman would be able to implement his vision. After being with AmEx, Dr. Friedman accepted a job with Henry Schein, one of the biggest medical companies in the world and employer of tens of thousands of people in over 35 countries, as Physician Executive. Shortly thereafter, the company invited him into their C-Suite as Chief Medical Officer, a position that included generous compensation in addition to shares in the billion-dollar company.

But there was another offer on the table. “There was some talk about building a federally qualified health care clinic here in Lakewood, and they heard I had experience,” he says simply, “so they reached out.” Initially, he dismissed the idea. But then he mulled it over a bit more, and decided it was for him.

But why would he opt to run a health center in Lakewood over enjoying one of the most prominent — and lucrative — positions in the administrative health care world?

“First of all,” he explains, “I had accrued plenty insight into the challenges of starting a community health care center. Everyone in the frum community wants high-quality care — it’s a discerning clientele and no one wants to go to a general clinic.” There was another concern. “How are you going to bring mental health services to a community that by its very nature is traditional and cautious about anything new?” he asks. “If this was going to be successful, it was going to take time and patience.

“But,” he continues, “I’d seen so many health care centers at this point: Many were very well run, and some were extremely poor — but I wanted this to be different. I wanted to build an integrated health care system where we can create a vision and move the organization in line with that vision to serve the fastest-growing community in the entire country, but shrinking in terms of medical professionals.”

He points to the fact that a local hospital shut its labor and delivery ward, this, “despite us having the second highest birth rate in the world, only slightly behind Niger.” And so the offer was enticing.

“I learned in that overcrowded South African hospital that the care would work if it was explained in a way that made sense to them,” Dr. Friedman tells Mishpacha’s reporter. In hospitals around the world, perhaps the most valuable skill he picked up was the art of communication

DR. Friedman knew he wanted to build on the key concepts he’d learned along his journey around the world: culturally sensitive, primary care based on an integrated, holistic approach to medicine.

The result is one of the most admired health care centers in the region. “We went from the State Health Department looking at us as the Jewish place in Lakewood to being the model health care center in the state,” a Lakewood askan told me. That admiration was on display when New Jersey governor Phil Murphy and his health care team — in one of their first public appearances since the onset of the pandemic — made a highly publicized visit to CHEMED to express his appreciation for the center.

“Dr. Friedman encourages us to think huge,” said Mr. Menachem Berkowitz, COO of CHEMED. “He gave us his vision of integrating our entire operation. That means that if a patient walks in to our urgent care, we have his entire medical record pulled up, so the physician may have a different perspective of what he is looking at. If a young man walks in complaining of strep-like symptoms, a traditional urgent care may be able to check for a specific diagnosis, but they don’t know about the patient. Here, we can see what his history is — did he come in recently for anything similar? Maybe we should approach it from a different angle.”

The center has also set up a case management unit in which a team of nurses, therapists and pharmacists follow up with patients on any referral-based matter — getting test results, getting access to other doctors if necessary, helping the patient navigate appointments and keeping in touch with the specialist team to be able to relay the information back to the primary care provider, so everyone involved with the patient is on the same page, and the patient is getting a consistent message.

Dr. Friedman is clearly in his element as he provides a tour of the facility. In the pediatrics department, a specialty team was brought in from Rutgers in order to build a better system, and they’re doing the same with adult specialty.

“We believe very strongly in an integrated system,” Dr. Friedman says. “For example, if one of our providers picks up that a patient may be having anxiety, a social worker will come in on the spot and talk to the patient for 15 minutes. Similarly with dental — it isn’t a separate, freestanding department, but is part of our team, which means that one of the staff can come into any of the other exam rooms if we see that a patient also needs dental work.”

While Dr. Friedman is clearly satisfied, he’s not slowing down.

“These are programs that we created, and we continue to look for other ways. My plan is to create a medical village and bring in partners to create outpatient and image services and a high level of academics. I don’t want to outsource all the specialties. I do believe that when we need expertise, we should push to get into the best medical facilities, but I don’t believe in sending out for every patient — I want to bring the highest level of quality care to Lakewood.”

And not just Lakewood. That’s one reason he initiated the annual Jewish Medical Ethics Conference four years ago, as a platform for Orthodox medical professionals from all over to join together and explore the most relevant issues facing the frum community, and to harness cumulative knowledge, talent and connections.

Dr. Laurence Cohen, a radiologist from Brooklyn who has attended the conference since its inception, agrees. “Since the first conference in 2019, many patients around the world have been helped and lives have been saved due to connections made,” says Dr. Cohen, noting that it’s an opportunity to meet and interact with medical colleagues in many different specialties. “Those relationships are invaluable, whether to consult on a case or to assist with treatment.”

If Dr. Friedman took all the medical experiences culled from around the world and brought the best of them to Lakewood, he now envisions bringing Lakewood to the rest of the world — or at least to other frum communities and beyond.

“If we do this right, we can create a model for all over the country. If we improve the process of how a patient goes through this system, we can save money for the patient and the system,” he says. “Most solutions are not complex. The complexity is implementation. People are resistant to change, but it can be as simple as looking at workflow, making sure services are implemented at the right time, providing them early, and improving outcomes. It’s so easy to create your daled amos, to build boundaries around yourself, but real success is to work together so your daled amos are no longer four, but eight, twelve, however far they can stretch. One person alone can only accomplish so much, but when we integrate together, the expansion is exponential. And that, ultimately, is the best outcome.”

(Originally featured in Mishpacha, Issue 966)