gms | German Medical Science

The discussion surrounding medical care in Germany, against the backdrop of demographic changes, has been intense and public recently focussing on buzzwords such as shortage of doctors, care shortages and emigration. In contrast, the statistics of the Federal Medical Council [1] show that both the number of people employed in healthcare and the number of physicians not active in medical work increased in 2009, as it had in previous years, with a growth rate of 2%. The number of emigrants (in total 2,486), for the most part was to German-speaking countries (701 to Switzerland, 262 to Austria), has declined and has returned to the level of 2007 [2].

However, the continued increase in the average age of SHI physicians under the age of 69 increased to 51.9 years in 2009, which is seen as problematic [3]. Medical psychotherapists form the group with the highest average age (53.6 years), followed by GPs (53.1 years). A shortage of physicians through the continually aging population and consequently the threat of shortage of supply in Germany can be noted mainly for rural areas. Possible reasons for the declining attractiveness of the medical profession are seen in the increased workload and inadequate income level [4]. As a solution, Health Minister Rösler (FDP) proposed to favour candidates in the allocation of university places in medicine who are willing to commit to working in rural areas for several years [5]. Using a rural doctor quota, new selection criteria and increasing the number of places better medical care in rural areas could be achieved. The question remains whether such a decision by young people at the start of their studies will in fact result in the required specialist training and subsequent practice in the country [6].

So what is the reaction of those who are just starting on their career path and apart from individual leanings and preferences in their choice of a future field of study might also consider the debates and developments in Germany outlined here? This question was investigated in the online survey project ‘Medical Studies and the Future’. The latest results on the job expectations and concerns of medical students at the University of Witten/Herdecke (UWH) during their studies are presented here and compared with the data collected nationwide up until 2008.

The online survey project is being carried out on the initiative of the Department of General Medicine at the Ruhr-University Bochum (RUB) since the winter semester 2006/2007 under the direction of Dr. Osenberg. After initially restricting it to the Bochum medical students, in subsequent survey phases it was extended to all German medical schools. By late 2008 it involved a total of 4398 medical students (of which less than 0.1% were UWF students), so the results form a basis for comparison with the results from Witten [7].

At the beginning of the summer term 2010 in cooperation between the RUB and UWH, the anonymous online survey was released as a late data gathering survey for medical students at UWH, with a running time of 6 weeks (12 April - 30 May 2010). The email sent by the Dean's office with the request for participation in the survey included a link to the semi-standardised questionnaire with 25 questions. In addition to socio-demographic information, the topics career planning, fields or practice considered, the expected impact of the health system on professional and personal life plans, possible concerns for the future and planning practice were investigated.

In total, 105 students participated in the online survey. With a total of 317 enrolled medical students in the summer term 2009 at the UWH, this represents a response rate of about one third (33.1%). Six participants could not be included due to defined exclusion criteria (questionnaire answered incompletely or not medical students). The responses of 99 medical students (52 female, 47 male) with an average age of 24.9±2.9 years (min. 21 years, max. 42 years) were included in the calculations. Half of these (50.5%, N=50) were in the first four semesters, 39.1% (N=39) in the 5th to 10th semester and 10.1% (N=10) were in their internship year (PJ). About one third (33.3%) of the sample has already started or completed vocational training, for the most part in the area of health services, e.g. as a paramedic or carer in intensive care. Compared to the national sample [7], the average age is comparable but the proportion of female students is lower by about 10% and the proportion of students in the PJ by about 4%. The sample is therefore not wholly representative of medical students in Germany [8]. It explicitly describes expectations and concerns for the future from the perspective of students at the UWH whose professional expectations were also compared with the actual job situation and chosen medical specialisms of 264 former medical students from the UWH who participated in an alumni survey in 2005 [9].

Taking into account the levels of measurement of the variables and their distribution, the most appropriate statistical methods (chi-square test, variance analysis) were selected and carried out using SPSS 17.0 [10]. With a significance level of 5%, the results of the analysis are taken as statistically significant.

The results of the UWH sample are differentiated according to the length of study, grouped according to “Pre-clinical” (1^st to 4^th semester) vs. “Clinical” (5^th to 10^th semester and PJ). This allows the illustration of possible changes to the evaluation of future careers while at university. The two groups of UWH students, Pre-clinical (N=50) and Clinical (N=49) differ significantly in terms of the independent personal variables of age (Variance analysis: F=28.7, p=.000) and gender (Chi-square test: χ²=4.5, p=.027), with a higher proportion of younger and male students in the preclinical group.

In term of motivation for degree selection, no significant differences between the two groups at the UWH could be seen. Most students state that the main motivation was an interest in medical issues (see Table 1 [Tab. 1]), followed by the motivation to help in (pre-clinical), and enjoying contact with people (clinical). Only a few students of the clinical UWH group stated their own personal medical history as being the main motivator.

When asked about their intended degree specialism in their future working life, it was possible to state several alternatives. 39.4% of students took advantage of this opportunity and on average named two disciplines. The results for the entire UWH sample are shown as percentage frequencies (see Figure 1 [Fig. 1]).

Paediatrics (23.3%) and internal medicine lead the table of desired specialisms, followed by surgery (18.4%) and general practice (17.5%). In mid-field, we find gynaecology, anaesthesiology, neurology and psychiatry (all > 10%). At the bottom of the league of desired specialisms are occupational health, ENT and pathology (all 1%). Significant differences (Chi-square tests) between the UWH groups were found for general practitioners (χ²=6.5, p=.011), surgery (χ²=7.6, p=.006) and gynaecology (χ²=6.6, p=.010). In the pre-clinical group, interest in general medicine (28% vs. 8.2% of each group) and surgery (30% vs. 8.2%) is more pronounced, in the clinical group, the interest in gynaecology (6% vs. 24.5%).

About half of medical students at the UWH at the time of the survey were still undecided in terms of plans for practice. In response to the question “Can you imagine setting up your own practice in the long term?”, 21.2% of students answered “yes, definitely”, 55.6% “yes, possibly”, 19.2% answered “probably not” and 4% “no, not at all”. 27.3% can imagine working at a medical clinic, 16.2% could not and over half (56.6%) is think this is possible but weren’t sure. Two thirds (65%) of students reject the idea of not working directly with patients, while 26.2% could imagine doing so and 3.9% intend to do so. In Figure 2 [Fig. 2], the percentage frequencies of the unique preferences (yes/no) are shown.

When repeating the question regarding future forms of practice in a forced-choice format (“If you were to consider setting up practice, what location would you prefer for your practice?”), 65.7% opt for the city and 34.3% for a rural location, independent of group affiliation.

The appraisal of the impact of the health system on professional and personal life planning is similar in both UWH groups. 58% of pre-clinical students suggest a significant impact, 38% little and only 4% no effects. In the clinical group, 50% expect a significant impact, 37.5% some and 12.5% no negative impact through current developments in the German health system. The ranking of anticipated negative impacts is listed in Table 2 [Tab. 2] according to the pre-clinical frequencies.

In both groups, for about two-thirds the option to set up medical practice abroad is in first place. The clinical group sees less impact on planning family life and their choice of medical specialism. The fact that none of the UWH students are considering quitting their studies is noteworthy.

The problems areas of future everyday working life, which is so far known the students only from their practical modules, is assessed similarly by the two UWH groups. Given the option of multiple answers, in first place we find working hours (71.7%), followed by quality of patient care (70.7%), remuneration of services (62.6%), occupational stress levels (55.6%) and expected communication styles (52.5%). Technical requirements are only identified by 5.1% of the students as a future area of problems (see Figure 3 [Fig. 3]).

In a final question on whether they would choose to study medicine again, 76.8% of UWH students answered “yes, always”, 21.2% said “maybe, not necessarily” and only 2% “probably not”. There was no significant difference between the pre-clinical and the clinical groups at the UWH (chi-square test: χ²=5.6, p=.060). At the start of studies in the first four semesters, 86% would again choose medical studies, in the UWH clinical group this figure is 67.3%.

The development and, if applicable, realisation of the desired medical specialisation of medical students at Witten can only be verified in prospective longitudinal studies. But the description of the job situation by UWH alumni gives a possible indication of the possible preferences in specialisation. In 2005, in cooperation with the Centre for Higher Education Development (CHE), a survey of UWH alumni was conducted, which in addition to basic data and a comprehensive evaluation of their university studies collected data on the job situation [9]. The results of 264 alumni (49.8% female, 50.2% male) aged 36.6±5.7 years, who passed their final medical examinations 7.3±5.1 years earlier, are available. Their current occupation is described by 37.5% as being in non-university hospitals, 26.5% in university hospitals, 17.4% in a medical practice and 18.6% in other areas, e.g. in public health services, the private sector or in non-medical activities. 40% had already completed specialisation, 50% were still in training in their chosen fields. UWH alumni frequently state the following as their working areas: internal medicine (20.2%), psychiatry (15.3%), general practice (13.2%) and paediatrics (11.5%). Less frequent are neurology (6.2%), anaesthesiology (5.4%), gynaecology (3.7%) and surgery (3.6%).

The results of the UWH sample presented here to a large extent reflect the results of the nationwide online survey ‘Medical Education and the Future’ [7] but also show specific desires and attitudes by the medical students at UWH. At UWH, which offers Germany’s smallest and only medical degree which is predominantly privately funded, which in the pre-clinical part of the course (1^st to 4^th semester) has a consistent problem-oriented structure and in the clinical part has a strong practical orientation. This results in graduates judging their professional skill levels as being high [11]. But at the start of the degree course (pre-clinical part UWH, see Table 1 [Tab. 1]), a strong interest in medical issues predominates with a frequency that is comparable to the nationwide sample (>40%).

The ranking of the most common specialisms of working physicians in Germany [12] also appears reflect the desired disciplines of medical students. Thus, the top grouping of specialisms aspired to by medical students at UWH of internal medicine, surgery and general practice (see Figure 1 [Fig. 1]) don’t come as a surprise, as they enjoy great popularity nationally, especially at the beginning of the degree course (internal medicine 31.2%, surgery 24.6%, 22.5% general practice). In the nationwide online survey [7] surgery suffers from a significant loss (-52%) of interested students through the course but this also applies to paediatrics (-26%). In a comparison of the desired specialisms of medical students at the UWH with the historical results of the UWH alumni survey [9], the percentage of medical graduates in specialisation in psychiatry, including child and adolescent psychiatry (15.3%) seems confirm the current indications of medical students (12.6%, see Figure 1 [Fig. 1]). However, the pronounced interest in paediatrics (23.3%) is not reflected in the percentage of graduates in specialisation in this field by the alumni (15.3%).

There are clear similarities between the UWH sample and the results of the nationwide survey as regards the feared negative impact of the health system on their own professional and personal life planning. More than two-thirds expect to move abroad to practice medicine and more than a third expects that their plans for setting up a practice may be adversely affected or prevented by external conditions (see Table 2 [Tab. 2]). In the national survey, a comparable 70.3% also consider moving abroad and 37.4% making changes to their plans for setting up practice [7]. Nationally, 2.1% are considering quitting their studies but none of the medical students at the UWH. One collected free text answer sums up the concerns succinctly: “I really want to live as a GP in the countryside but currently under no circumstances in Germany!” But perhaps this shows a direct response to the political demand for a rural doctor quota starting from early April 2010, with about a third of students at UWH indicated that they planned to set up in a rural area in the online survey which began in mid-April 2010.

The future problem areas of working in Germany with supposedly long working hours, increased stress levels and non-performance-related remuneration of medical services are sufficiently well known to all medical students, as is reflected in the similarity of evaluations. Among the six prominent problem areas in the Witten sample (see Figure 3 [Fig. 3]), five were also at the top of the nationwide survey [7], albeit in a different order apart from the top-rated working hours (79.4%). For the medical students at the UWH, the quality of patient care (70.7%) is in second place of anticipated problem areas, nationwide, however this only ranks in sixth place (55.9%).

In conclusion, it can be noted that in spite of the discussions about medical care in Germany which are often emotional and the conflicting information regarding impoverishment or top-level incomes of established GP [13], doctors retain their interest and joy in their profession. Contrary to the basic attitude of resignation which was found nationwide in the online survey over the course of the degree course [7], the vast majority of respondents would choose again to take a medical degree. This is true nationally (61%) but especially for medical students at the UWH (77%) and UWH alumni (80%).

The authors declare that they have no competing interests.