Saturday, November 1, 2008

HealthTrain Arriving from Germany

I participate in SERMO quite a bit (a physician only blog) and I came across an enlightening story about a german OB/GYN who immigrated to the U.S. after falling in love with a woman he met in N.Y. while visiting.  He tells this story on Sermo (ABC1530). Fragments are quoted here, and although his writing crosses much territory not directly related to medicine and health care, here are some of his observations and experience.....comparing, contrasting and teaching what is the difference about U.S. healthcare.................


"Flashback a few years, I am 18 and graduating from high school. I am considering architecture, because I would like to "produce something that I can touch, that I can show", but I end up choosing medicine. I trust my ability to study and memorize more than my artistic talent. And the promise of a good life and social standing help to change my mind. At the time admissions to medical school in Germany were strictly by grades and you needed something between A/B or A-. In Germany you have to decide on your career when you graduate from high school, typically at 18 or 19."

In the meantime the admission criteria for medical school have been expanded to include a lottery (based on the thought that performance in school may not be such a great criterion), a personal interview, a waiting list (the longer you wait and the older you are, the more likely are you to be admitted, and finally the good old grade average. They also reserve 2 % for foreigners - e.g Americans and 1-2% for "social cases" where you can be admitted after providing proof that your grades were unfairly diminished or you were impaired by circumstances beyond your control.
There is nothing comparable to the American "college" years where you look around and decide what you want to do in life. Medical school takes 6 years and The first two years are "preclinical", meaning you study medical terminology, chemistry, physics, biology, genetics, physiology, biochemistry and anatomy and histology. You take an exam after the first two years, passing is required for continuation. The following year is "introduction to clinical medicine" and includes pathophysiology, pathology, pharmacology, medical statistics, clinical examination and history taking and some introductory course in internal medicine and surgery. Again exam.
Then two years of clinical courses, which include "bedside teaching" and demonstration of actual live patients. course include all fields of medicine - internal medicine, surgery, obgyn, dermatology, neurology, urology, radiology etc. Another exam. The German exams pretty much resemble the USMLE 1, 2 and 3 in style and difficulty.
Courses usually have a "practical part", small group teaching, where attendance is checked and lectures in large lecture halls, where attendance is not controlled.
Overall there is much less control, supervision and guidance. You are free to do and not to do whatever you want. as long as you show up in the courses, pass the course exams and the USMLE equivalents, you are fine. There is no grading, ranking, no recommendation letters from faculty or from deans. You get out of medical school what you put in in terms of activity, participation, commitment and desire to learn.
You can start in fall and in spring. Medical school
Suvarov asked me about the expectations when you start?
Could you clarify the question? Expectations of the medical students, the parents, society?
I expected to learn a lot, have a challenging career, work quite a bit later in life and be rewarded with good social status and a stable income which is at least average, if not better.


The expectations when entering medical school are certainly not as high as here, at least not now. After a continuous decline in income and consequently status and power physicians are just another group of white collar workers. Much like physicians in America if the present trend continues (and, guys, here we go into the "conservative" issues you correctly expected).
Physicians in Germany were making excellent income with fee for service payments by the quasi government Allgemeine Ortskrankenkasse (General Local Sickness Fund), which was established almost immediately after the "Iron Chancellor" Bismarck Otto von Bismarck (1815-1898)

passed a law in 1883 to establish such funds and make health coverage mandatory for every German. Some speculate that it was a political move to ward off the socialistic tendencies at the time. The general health insurance worked very very well for almost one hundred years - and then the money ran out. The money ran out due to a combination of rapidly increasing health care costs across the board and the doubling of the number of physicians within a short time - thanks to our friends the lawyers. In the 70s it was one of the main ways to get into medical school. Peoples checked at the bottleneck places in medical school - usually the anatomy courses - and claimed that there were still unused spots. Meaning if there was a group around a cadaver of only 7 students, an additional student immediately sued and got in.

With those tricks the number of medical school students doubled within a few years - with disastrous consequences as you might expect. Within a few years there were unemployed physicians driving cabs and everybody was earning less - the pie, the pot of money available through the AOK obviously never increased, never changed. The pot of money is strictly limited by those 12% health taxes!
Consequently there was less money for everybody.....
The physicians representing the other physicians returned every year from the contract negotiations with a helpless shrug and the comment "we achieved to increase reimbursements for blablabla, in exchange for some cuts at blablabla. The cuts always were much bigger than the small pieces of candy the docs were thrown.

Pretty much the same as the negotiations with HMOs and Medicare (if there are any negotiations with Medicare!).
Those representing physicians were the same breed as the AMA people:

politicos who do not care about those whom they represent, and just enjoying their feeling of "importance", the travel, the cocktails etc.


Residents are picked by personal connections. Medical students that are interested in one particular specialty volunteer in that specialty, get to know the attendings, the chief etc.(PANDERING) They might help out on the floor, volunteer for overnight shifts etc. Then they might do a research project in that field, preferably in the hospital they would like to work and train in. (that works very well in university hospitals). Having good grades in the final test, the USMLE equivalent helps as well. Adn the rest is just timing, meaning you apply at the right time and you get in.
There is a significant difference to the US: While here all residents start on July 1st, in Germany you may enter medical school in Spring and fall and therefore people graduate in Spring and Fall and may apply all around the year. There is no such time as the July 1st. People start and graduate the whole year. So you never know when a position is going to be available.
Residences are not as scheduled, they are not as predictable as here. A residency may take you more time than the minimum. Your Department chief pretty much has the power to keep you and to delay your graduation for quite some time.
You can graduate when you have fulfilled your "numbers". For example in ObGyn you have to document 100 deliveries, 35 cesareans, 30 hysterectomies, 20 laparoscopies etc. Yes, these nunmbers are a guess, but they are about right. I do not remember them exactly, but they are VERY LOW compared to American standards.


AZdrydoc  Family Medicine

Posted Oct 25, 2008 at 4:28 PM

<The pot of money is strictly limited by those 12% health taxes! > 12% of what? Income? Sales? When you said "medical school is --free" I immediately thought, well, yeah, but who is paying for the "free"?


AZdrydoc, it actually is (now in 2008) between 13 and 15% of your income - of the gross (!) income! The employer and employee each pay about half of this. Yet,

this is total coverage, eyes and dental included. You have complete choice of doctors and hospitals.

I obviously have thought quite a bit about the differences between my German and my American residency. Conclusion: you guys are very lucky to have trained here. While Germans tour "academic freedom" - nowadays or at least for me just another label for "laissez faire", the Americans are much more regimented in their training, it is more scheduled, more supervised, more controlled, more defined.
Just one very important point: In Germany you have to fight for your desirable times in residency - in obgyn it is the operative floor. You try to cut your time short in places where you do not learn much, e.g "postpartum". In Germany I actually had a few months where I was responsible only for the postpartum floor. This seems utterly ridiculous for an American obgyn resident, who is used to taking care of the postpartum floor between 5 AM and 7 AM before going to labor and delivery - where, by the way, he or she also takes care of the "emergent Ob Clinic" or triage etc.
German physicians have to draw blood and start iv s in the morning! I can hardly believe it now that I am used to iv teams and respiratory that comes and draws blood gases etc. What a waste of physician time in Germany.
But then, my German Department chief said he did not want to upset the nurse by having them draw blood, because "you can get a doctor any time, but good nurses are hard to find"
The nurses really got on my nerve in Germany. I heard by far too often "You have to do that yourself Mr. (!) Abc1530,

I do not have time". Brought my blood to a boil every time. They would draw blood for the attending though....
When I left in 95, they were just introducing the ordering in the chart.....
Here in the US I write the order and bam, it get's done. If it does not get done, I am not blamed, but the nurse. If I really want, I can write her up. I have never done that though. Nurses are very good here.
Much better system here


Level of talent entering the door in medical school.
I am not sure if it differs. There is a study that medical students have an average IQ of 125 in Germany. I am not aware of a similar study here.

But I am absolutely sure there is a gigantic difference in ambition. American physicians are DRIVEN. Holy cow! I could not believe the push, the umpf, the stamina, the energy Americans put into their training.
Sorry, my liberal colleagues, but I believe that this is the result of two things: you have to pay for medical school! It is expensive, so it is dear to you, it is hard to get in, so you have to and you want to make the very best of it.
And, there is the promise of the big reward at the end, a reward to big that it is worth staying up late, going the extra mile, doing the whole 9 yards....
No such thing in Germany. Hey , medical school is free, yes, you heard it, free. So, it can't be worth THAT much, right? At least that's how you feel. And you do not earn that much afterwards, so why struggle! Let's live now, let's go out tonight, let's have a party..residency takes so long anyway, and hours are controlled, so youa re never exhausted, so why work your behind off?
I have seen so many slackers in my German residency, it was disgusting. I was very satisfied (sorry to say that, I aoplogize) to see that a resident who exhibited the typical slacker behavior of too many of my German colleagues in one of the American residency programs - was fired.

You either want good doctors or you don;t.


Yes, German physicians are more relaxed and pretty trusting, especially when they hear that someone has trained in the US. American medicine has a great great reputation almost all over the world. Americans and Sermoans may not fully realize the extent of this. You guys are the top, the best, the cream of the crop, welcome and admired all over the world. Not surprising at all that the anesthesiologist handed over the patient to you!
You grew up here, you trained here, you take the American efficiency, quality for granted!
You are the best! Become aware of it!
If I would return to Germany, my future would be secured just by spreading the word that I am board certified in the US and have actually trained and worked there.
Don't underestimate how good American medicine is! How respected it is...

In Germany we say "the prophet is ignored at home".....OUr colleagues are so used to the high quality of medicine here that they take it for granted and consider it "normal". Yes, thank God it is normal, but..... only for the US.
And , thank you for pointing out the probloem with "fixing" health care just to make it resemble the system in those countries that admire us.


Hi Mohican! Guten Tag!
I am using General Electric's "Centricity", formerly know as "Logician". Was programmed 20 years ago, and you feel it. I started using it 1.5 years ago. The part that is most useful is the ability to fax prescriptions directly to the pharmacy

Click-e-ti-clack and the Rx is on it's way, pt does not have to carry a piece of paper around, drop it off, wait, come back, pick it up. Now they drive by the pharmacy on the way home and it is ready.
Besides that it is a big drain on productivity. Everything takes longer, many things are hard to accomplish, such as sending a letter to the PCP that referred the patient to me.
The good side is that all docs in our health care "system" are using it and this actually saves duplicate entries and less things fall through the cracks. I can see the lab reports, the path, the radiology, the ER visit notes on my computer - and - nice too - in the office, at the hospital or at home, with equal ease. Just click and ...wonder...

But the damn thing does not even have a spell-checker! )(&!@^(%#()!

So, it has good and bad sides, overall it takes more time to work with it, but it wil surely get better over the years. When I retire the system will be just as I imagined it to be the first day when they told me about it---- ;-)


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