Canada's medical manpower problems pale in comparison with Germany's Nomi Morris
K rimhild Luft finished medical school in the fall of 1987 but did not find full-time work until February 1991, when she joined the Department of Surgery at Berlin's St. Marien Hospital. In between, she applied for nearly 150 jobs and was granted more than 20 interviews.
"I was waiting for the postman, waiting for a telephone call, waiting for the latest medical magazine," she recalled. "I went through all the emotions: depression, anger, disappointment, hope, doubt. I often felt worthless, wondering if it was my fault, if there was something wrong with me." There was nothing wrong with Luft or her qualifications she had received 6 years' training at the Free University of Berlin. Instead, the problem is a glut of physician manpower that leaves an average of 20 000 German doctors unemployed every year. (Canada has about 52 000 practising physicians.) Most of the out-ofwork MDs are in their first years of practice. In recent years western Germany has been enrolling first-year medical students at a per capita rate that is three times higher than the rate here. By 1987, this meant the physician-to-patient ratio in that part of the now united country was nearly twice as high as it was in the province of Alberta.' In 1990, western Germany's 26 medical schools graduated approximately 12 000 doctors to serve a population base of 61 million people. In the previous Nomi Morris is a Canadian freelance writer based in Berlin. 1618
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two decades the number of prac- school, substituted for sick or vatising physicians grew by about cationing general practitioners
3.2% a year; at the same time, the and assisted a doctor who specialpopulation was declining.2 ized in workers' compensation acAlthough the number of doc- cident claims. She worked on an tors was lower in the country that used to be called East Germany, the disruption in health care ser-
vices brought about by the November 1989 opening of the Berlin Wall has only made things worse for job seekers in both eastern and western Germany. The result is a serious underuse of qualified professionals: newly minted physicians take jobs as fill-in nurses, receptionists in doctors' offices and research subjects for pharmaceutical studies. They even work as baby-sitters and taxi drivers. "One colleague of mine was working in the field of telephone sex," said Luft, who spent more than 3 years caught in a revolving door of contract and part-time jobs. She taught in a nursing
Luft: often felt worthless
water-quality study, and
an entire summer as a chef and waitress in a neighbourhood restaurant. "Every job I took started and finished very suddenly, and in the meantime you'd sit and wait for the big one," Luft remembered. "I never knew if I could plan a little trip to see my parents, or whether I could afford to buy a pair of new shoes." In 1989 Luft's financial predicament forced her to get an abortion. "I had no security," she said. "There was no way out." One of the things that kept her going was a. support group started by the Berlin Chamber of Physicians. Nearly 50 of the city's 1500 unemployed doctors come to the biweekly meetings. Several chambers throughout Germany they are equivalent to Canada's academies of medicine - have set up employment offices. They spend much of their time trying to create new ABMs, a German acronym for a job-creation scheme in which the government funds temporary, salaried positions that are filled by students or unemployed professionals. Sometimes the situation is so bleak unemployment offices merely counsel physicians about ways to apply for welfare payments. But the main advice given to young doctors who can't find work is to return to school for specialized training, or go abroad for a few years. More than 1000 German physicians have left the country since 1987, with most of them ending up in Britain. even
"Still, there is no guarantee," sounded," said a recent report in said Sabine Rost, employment of- the daily newspaper Berliner Morficer with the Berlin Chamber of genpost. Physicians. "There are some who Part of the glaring gap in the have gone to England, come back supply and demand of hospital and didn't find anything. Many doctors is related to age. Hospitals give up medicine altogether for are often seeking experienced spejobs in related fields. Some go cialists for senior posts, not young back to professions they had be- doctors entering the field. fore entering medical school." The November 1989 fall of She said established doctors the Berlin Wall and the unificaare partly to blame for the job tion of Germany last October shortage. "There is little interest added new complications to a sysamong those who have jobs to tem already out of kilter. The change the system and to share much publicized flow of doctors their hours with those who don't," from east to west has levelled off Rost said. She cited a 1988 survey somewhat. However, the exodus that determined that the total that did take place involved mainnonpaid overtime hours worked ly highly qualified physicians and by German doctors is equal to thus failed to open the eastern 19 000 full-time positions. German market to the mass of Another issue affecting to- unemployed physicians from the day's job market is a change in the west who are seeking entry-level procedures medical students must posts. follow on the way to becoming "In the first year after the qualified to practise. Since 1988 wall opened we filled 90 East an 18-month praktikum - intern- Berlin positions with West Berlin ship - has been included in the doctors," Rost said. "Before unity formal phase of studies. Many many western doctors were prehospital positions that used to go pared to work in the eastern to first-year graduates were turned states. But now the number has into praktikum posts, which cost stabilized." the employer only half the salary Many western doctors hesiof a graduate physician. tate to take jobs in the east beIn Berlin, this means that the cause they fear the positions may 700 doctors who graduate each be phased out within the next few year are competing with a similar months. When the East German number of medical students in health care system was absorbed their last 2 years of training. The by West Germany last October, a trainees are known as "probation- major restructuring was set in motion. One part involved a reorganary doctors." There are 113 hospitals in the ization of the neighbourhood pogreater Berlin area, which is home lykliniks that served as walk-in to 20000 physicians. The over- clinics in East Germany. More than 350 Berlin doctors supply of doctors means it can take an average of 1 to 2 years to have already lost their jobs and up find permanent work. "In 1988 to 2500 more positions may be the average time it took to find a cut in the coming year, Rost said. job was a half year," said Rost. One 54-year-old specialist in in"Now the competition is tougher. ternal medicine, who used to hold a senior post at East Berlin's medIt's cheaper for the hospitals." At the same time, the Mar- ical school, is now lucky to have a burger Bund, the German union 2-month contract doing adminisof salaried physicians, says 30 000 trative work in the health departmore hospital positions are need- ment of the Berlin Senate (city ed in Germany, including 1000 in council). "The situation is very Berlin. "An alarm has been insecure," Rost observed. "It's
unsure whether certain jobs that are open now will remain." As well, the Berlin Senate's 1991 Hospital Reform Plan calls for the elimination of 7000 hospital beds over the next few years 5000 of them in East Berlin hospitals. As in Canada, there is a drive to cut budgets by relying more on ambulatory care. In time, the dismantling of the former East German polykliniks may prove to be another irony of German medical history - they are gradually being replaced by a similar system. But for now, as in many other professions, the aim is to bring services in eastern Germany in line with western standards and practices. The restructuring of hospitals and clinics has also provided the rationale for firing East German medical professors and department heads, many of whom held high positions in the ruling Communist Party. One top-ranked specialist fired recently was Dr. Peter Altaus, the head urologist at Berlin's Charite Hospital. He had treated the former head of the Communist Party in East Germany, Erich Honecker. The reorganization of health care in the eastern states means many mid- or late-career physicians now find themselves in the same boat as young doctors in western Germany: they are looking for work. "It's a big misuse of qualified people," said Luft. She knows of some doctors willing to work in small, private hospitals for the stunningly low rate of $12 an hour. "The doctors doing the jobs know it's crazy to work for so little," she said. "But they have no choice. It's a kind of prostitution."
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CAN MED ASSOC J 1991; 145 (12)
References 1. Becker WJ: Do West German medical schools provide a lesson for Canada? Can Med Assoc J 1990; 142: 987-989 2. Iglehart JK: Germany's health care system. N Engi J Med 1991; 324: 17501756 1619