Exodus
Two in three medical students consider leaving Germany after their final exam, reports Annette Tuffs
About 70% of German medical students consider going abroad after they have passed their exams, show the results of a study
from Bochum University, published in the press in November 2008. The most popular countries are Switzerland, the United Kingdom,
Austria, and Australia and those in Scandinavia. Only 22% of medical students plan to work in Germany. Preliminary data from
the ongoing study were presented at the General Medicine and Medical Schools symposium in Munich. The study will be published
in 2009 in the German medical journal Deutsches Ärzteblatt.
The author Dorothea Osenberg, from the department of general medicine at Bochum University calls this “alarming” and says
that patient care is in jeopardy. The results are in agreement with last year’s statistics from the German Medical Association,
which forecast a shortage of doctors for the next 10 years.
About 4000 medical students took part in the anonymous, internet based survey, and 1300 were enrolled at Bochum University.
The mean age was 25-26. About 25% of the students had another profession before they studied medicine, mainly in health. Almost
two thirds of the participants were women.
Negative expectations
Students in their last year, which is spent entirely in hospital, were especially negative and said that their attitude towards
practising medicine had been heavily influenced by their recent experience in hospital. For many this is the first time that
they are confronted with the reality of a hospital and are expected to carry out procedures that they have never been properly
taught.
Why is practising medicine in Germany not attractive any more? The main reason is worry about the state of the healthcare
system, the study says. About 77% of students expect that developments in the health system will have a negative effect on
their professional future. In particular, their private life will be affected by long and irregular working hours. The developments
started in the early ’90s, when doctors and hospitals got fixed budgets and hospitals were paid for each case rather than
for the days of hospital stay. Hospital doctors in other countries have better pay. A junior doctor is paid about €2000 (£1700;
$2600) less a year after tax, but might get extra payments for night duties, being on call, and extra hours. Furthermore,
working as a general practitioner or a specialist in your own practice is risky because budgets are fixed despite increasing
costs for drugs and more attending patients.
About 2500 participants in the study gave comments, including “The situation is so desperate that working as a doctor in Germany
is impossible” and “Studying medicine is masochistic.”
The exodus from clinical medicine contrasts sharply with the desire to get into medical school. University places for studying
medicine are still in demand. High exam grades are needed to win a place at one of the 35 medical schools in the country,
and there are three or four applicants for each place. However, during studies many medical students give up or after qualifying
go into other professions, such as healthcare management and consulting or the drug industry. Altogether, the study found
that about 40% of all medical students never practise clinical medicine. Only 62% say that they would study medicine again.
Continuing problem
In October 2007 the German Medical Association presented similar data. The president, Jörg-Dietrich Hoppe, said that politicians
should be ashamed that German doctors are going abroad because their work at home is not recognised, and they are overloaded
with bureaucracy.
This negative trend has already had consequences for health care in Germany. Since 2004 the number of advertisements for jobs
in the Deutsches Ärzteblatt has risen from 7250 in 2004 to 13 500 in 2006. However, Professor Hoppe thought that tight budgets might prevent hospitals
from employing necessary staff.
In 2007 about 16 000 German doctors left the country, the largest group (4200) to practise in the UK. Outpatient care is also
suffering. Several rural areas do not have enough general practitioners, gynaecologists, ophthalmologists, neurologists, and
dermatologists. Patients have to wait several months for an appointment or travel to the next town.
“In 2012 we expect a deficit of about 41 000 doctors,” said Andreas Köhler, head of the National Association of Statutory
Health Insurance Physicians, when he presented the data together with Professor Hoppe at a press conference in October 2007
in Berlin.
How can the exodus from clinical medicine be stopped? The health minister Ulla Schmidt recently said that the federal states
should sponsor medical students in return for their future services as qualified doctors. In addition, the German National
Association of Statutory Health Insurance Physicians is trying to improve the situation for women who want to practise part
time.
Germany is trying to offer students more intensive courses, where practical skills and patient communication is taught earlier.
In Bochum about 10% of students are participating in such a course. Their attitude towards the medical training and their
professional future was markedly better than that of their traditionally trained colleagues.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
See “Would you advise anyone to become a doctor?” (Views and Reviews).
Annette Tuffs journalist Heidelberg
ATuffs@web.de
Student BMJ 2009;17:001-036-ISSN 0966-6494 | January 2009
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Exodus
(Annette Tuffs, January 2009)
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Ruchi Gupta
(December 27th, 2008)
Medical Student (Final year), Postgraduate Institute of Medical Sciences, Rohtak, HARYANA ruchigupta.md@gmail.com
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Exodus is a nice article that summarises the problems faced by German medical students. In India too, that is a common problem faced by medical students. Most of the medical students like to go to USA, Australia or England for higher education or better opportunity.
We agree, that providing opportunity to have a medical degree is one of the important responsibility of the sate but assume that giving incentives to medical students to serve their country and people should also be a state responsibility
Importantly, Annette Tuffs1 has brought out a very important subject that has not been adequately addressed and we all quite agree and take it as a normal part of being medical student.
Here is what we feel The State can do:
- Increase number of postgraduate seats as we assume this is the main reason of exodus.
- Give good incentive in terms of salaries proportionate to services offered by doctors.
- Improve health care delivery systems, so that doctors like to stay back home.
- Improve work conditions and make them congenial so that they could take up challenge of working.
- Enhance training opportunities and so that training for speciality becomes less cumbersome.
We feel if these things are looked into, exodus could be limited.
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Exodus
(Annette Tuffs, January 2009)
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Benjamin K.
(January 6th, 2008)
Medical Student / Last year of med school, Germany / Medicine MD benboy@hotmail.de
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With great interests I have read your recently published article about the situation of German medical students (Exodus). I am a medical student in Germany myself and I thought an insider´s view would be interesting for you. At the moment I am in my last year of medical school, where all students have to fulfil one year of an internship in internal medicine, surgery and a chosen speciality (called Praktisches Jahr).
I think, the cause why so many medical students in Germany choose not to become medical doctors but to work in other fields as you wrote in your article, lies in the experiences they have during this final year. And so, in my opinion, the main cause isn´t to be found in wrong political decision or systemic mistakes, but in the behaviour of many of our older fellow colleagues and so under charge of many doctor´s organization which are not seeing that they are part of the problem and not the answer.
I can only speak for myself, but I know that many of my fellow students are encountering the same situation.
My workplace is a major university hospital in western Germany. On my first day of my practical year it all started with a chaotic mix-up. The practical year has existed in Germany almost since the foundation of the Federal Republic, and many universities don´t have curricula or people in charge for the internship students. Law recommends that the teaching hospitals have such things but they exists only on paper in many cases. Nobody is there to tell you how many work hours are required, who is responsible when you are ill or have a problem or what to do about holidays like
Christmas. In the last months there is a great discussion about paying the students. I think that´s not the real question. The first step would be to worthy the students. To give them something to work with, like a handbook, or a curriculum, some regulations. Today you are only in the control of the chief of the ward you are put into.
In my case I was put into one of the cardiology wards. The first day there (the second day of the internship) wasn´t about showing the ward or hospital or telling me what to do, when you have an emergency etc. during the work, no sir, the only thing was a tray full of needles for taking blood samples.
The first thing every student has to learn in Germany is that you are there to take the blood samples. Every morning, mostly alone on a whole ward with up to thirty patients. My second duty is to examine the new incoming patients, but without a supervising or attending doctor. You are there on your own. Nobody helps you, nobody tells you how to do it or gives you a feedback, if you are doing things right. But the worst thing is that you have to talk on your own with the patients about the procedures (like PTCA e.g.) to get their written consent. Not only that this is sometimes difficult when it is a procedure you never heard about or have seen in your courses, but that it is illegal in Germany. I think, when you do a study, most of German written consents are made by students and doctor´s only sign it afterwards with their names.
Besides this you are mostly only like a manservant. You write medical reports for the doctors, you bring them their x-rays or even make them coffee.
I know, in every profession you start on such a basis. But you have to remember we are not paid, we have studied five years and you have to do this year even if you don´t want become a doctor but maybe a researcher instead. If you learn something during this year is only pure luck: my university e.g. did not have an educative course for their internship students until this year, and even now it´s only an hour per week about fundamental things like doctor patient communication. That isn´t enough. Especially when you know that after the new law on medical education their is a new final exam after this year which consist of the three old exams that existed before this reform.
So you work a whole day (there are no regulation by law how many hours you have to work all between 4 and 10 is possible in my university) and have to learn afterwards at home for this exam.
I think, the first thing that has to change in Germany is that our old fashioned model where students are only menservants and where chiefs are god like and don´t do clinical teaching has to be repealed.
If students no longer experience hospitals as chaotic, hostile environments without any rules or responsible persons many of them would choose to work in them and not outside of them.
I myself was sure to become a clinical physician, but after my practical year and experiences in foreign countries and in searching, I would say: no way.
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Exodus
(Annette Tuffs, January 2009)
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Lukas A. Holzer
(January 18th, 2009)
Medical student, University of Bonn, Germany n0442687@students.meduniwien.ac.at
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I read Mrs. Tuffs article [1] with great interest, but with no big surprise. This situation in Germany's public hospitals, especially in the university hospitals is considered as a chaotic one as several articles have shown [2-4]. I'm a medical student from Vienna, Austria, but currently I'm doing the internship at the University of Bonn, Germany.
As my experience shows, it is quite easy to understand the data reported [1]. As a student in the internship in here you are not primarily positioned in the role of a student who should learn, but far more as some kind of working aide. It is not such a rare case that interns do the patient transport or deliver X-rays to wards. Furthermore if you see the role of residents in here the data is not just easy to understand - it is the only logic consequence. I have seen very well educated, hard working residents here doing secretary jobs. Their patient contact is probably less than 10% of an average work day. Generally they are chronically overworked. Many working unofficially after the official working time to get their work done. Seeing residents in the hospital at the weekend, during their free time, isn't such a rare case. It is very hard to understand why such systematic errors are happening.
It's time for a change in here for students and residents as well. It is a cry for help that has to be heard soon. Otherwise Germany will face massive problems in their future health care.
References:
- Tuffs A. Exodus. Student BMJ 2009;17:4-5
- Janus K, Amelung VE, Gaitanides M, Schwartz FW. German physicians "on strike"--shedding light on the roots of physician dissatisfaction. Health Policy. 2007 Aug;82(3):357-65
- Nowak D. Doctors on strike--the crisis in German health care delivery. N Engl J Med. 2006 Oct 12;355(15):1520-2
- Cooper-Mahkorn D. German doctors strike against health budget cuts. BMJ. 1999 Jan 9;318(7176):76
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