There is increasing interest and activity, nationally and internationally, in the further development of the healthcare workforce. This is, in part, motivated by changing patterns of disease and illness, which, alongside technological advances and new approaches to practice, are altering the way healthcare is delivered. At the same time, a number of countries are also facing impending shortages of certain health professions suited to adequately meet these changing needs.
In Germany, there are concerns about a maldistribution of the medical workforce in particular, with an oversupply of physicians in and around metropolitan areas and shortages in less-densely populated rural and economic-structurally weak areas. Yet, while there has been a steady increase in the number of physicians practising in the statutory health insurance system, there are challenges in securing the provision of new physicians in certain specialties in primary care that are required to address the changing healthcare needs of the population, such as general practice. A number of reform efforts have been put in place that seek to address these challenges. These mostly target the distribution of qualified doctors. However, there is recognition that efforts to ensure an appropriate balance in the healthcare workforce need to extend into the way physicians are being trained.
In this study, we seek to help inform the further development of medical education and training for primary care in Germany. We explore approaches to medical education and training in a small number of high-income countries and how these seek to address shortages of doctors practising in primary or ambulatory care through reforming their education and training systems. We do so by means of an exploratory analysis of the experiences of three countries: England, France and the Netherlands, with Germany included for comparison. Data collection involved a review of the published and grey literature, using a structured template, complemented by information provided by key informants in the selected countries. We set out the general context within which the medical education and training systems in the four countries operate, and describe the education and training pathways for general practice for each. We highlight options for medical education and training in Germany that arise from this study by placing our observations in the context of ongoing reform activity.
Several Components of the Medical Education and Training System Where Germany Appears to Diverge Most from Systems in Other European Countries Are Currently Being Considered as Part of a Number of Proposals and Recommendations in Germany
We observe that the medical education and training system in Germany appears to diverge from systems in place in England, France and the Netherlands in three broad areas: (i) the framework for determining the number of students to be admitted to medical school and the number of places for and entry into postgraduate medical training; (ii) the involvement of medical schools along the entire under- and postgraduate education and training pathway; and (iii) the financing of postgraduate training in ambulatory care settings. Observed differences do not necessarily imply that one approach is superior to another; indeed such a judgement would not be possible given the lack of empirical evidence on the relative advantages and disadvantages of different medical education and training systems and associated impacts on the quality of care and population health outcomes. Importantly, many of the areas which we identified to be different are already being considered by a number of proposals and recommendations put forward by various stakeholders in Germany and we discuss these in turn.
Germany Appears to Be the Only Among the Four Countries Studied Where the Annual Number of Students to Be Admitted to Medical School Is Determined at the State Rather Than the National Level, and Without Input from the Health Service
In Germany, higher education is the responsibility of the 16 states, as set out in the constitution, while responsibility for the healthcare system is shared among the federal government, the corporatist actors and the states. The respective state ministries of science and technology or of education define the number of medical students, and they do so in consultation with the medical schools. Views on whether the process of admission to medical school in Germany should be amended vary among stakeholders, including those interviewed for this study. The current debate focuses mainly on criteria for admission rather than the annual number of students to be admitted, with some stakeholders highlighting the possibility of placing more weight on aptitude and commitment to (future) practice in primary care among students applying to medical school, while others point to the lack of evidence about the degree to which different approaches to student selection impact on subsequent career choice in primary or specialist care.
England, France and the Netherlands Each Operate a National-Level Planning Process That Regulates Entry into Individual Medical Specialties
In France and the Netherlands, national planning regulating entry into individual medical specialties is undertaken by the respective ministries of health, informed by regional (France) or national workforce planning (the Netherlands), while in England, the number of places is determined at the regional level, but is based on national workforce planning by the Department of Health. In all three countries, trainee selection is also coordinated nationally, and entry into (any) specialist training is on a competitive basis. Conversely, in Germany, there is no planning for the number of specialist training places; regarding specialist training in general practice, a national agreement among the key actors foresees financial support for a minimum of 5,000 training places annually. Specialist training is not coordinated at the national level. Those pursuing specialisation have to organise the different rotations required for a given specialist qualification themselves, although postgraduate training networks are increasingly being established in general practice to facilitate rotation.
A national strategy or coordinating mechanism that defines the number of doctors entering training programmes for a given medical specialty may be an effective way to plan and regulate the entry of young doctors into different specialties. Based on medium- to long-term projections, such an approach would allow for the balancing of the number of required specialists in different medical disciplines and could reduce the impact of projected shortfalls in specific areas. This was demonstrated by the experience of health workforce planning in the Netherlands, which is seen to have contributed to mitigating an estimated shortage of general practitioners over a period of 10 years.
In Germany, a national strategy that explicitly plans for the number of doctors entering specialty training as a means to direct the future balance of specialties in the medical workforce does not appear to be discussed explicitly. However, commentators have highlighted a need for the better coordination of postgraduate training in general practice in particular. A number of activities are underway to strengthen coordination, with recommended approaches foreseeing the creation of a nationally coordinated approach with guaranteed posts for each trainee in general practice over the entire training period. Such an approach, it is argued, would allow for a more predictable pathway in general practice training and enhance its status as a career option.
Medical Schools in England, France and the Netherlands Are Involved in the Delivery of the Curriculum of Postgraduate Medical Training
Postgraduate medical training in Germany consists almost entirely of training on the job, with no formal taught course element. This is in contrast to the three comparator countries, where medical schools are involved (to different degrees) in the delivery of the curriculum of postgraduate medical training. Furthermore, England and the Netherlands have also set up “training institutes” that are linked to medical schools (“foundation schools” in England; general practitioner training institutes in the Netherlands). It is difficult, on the basis of the available evidence, to be certain whether the capabilities and competencies of physicians undergoing specialist training with medical school involvement are different from those doing so without medical school involvement, or whether these different training systems result in differences in the quality of care provided. However, medical graduates pursuing general practitioner (GP) specialty training in Germany have voiced concern about the lack of regular advanced training courses or seminars during training, which, they argue, are common for those training in hospital settings, and which would help ensure a minimum standardised knowledge base among GPs in training. Regional “competence centres” that are currently established by a small number of medical schools in Germany seek to provide training and mentorship opportunities for GP trainees and their trainers and to coordinate the training of GPs. It has been recommended that such centres be further strengthened at the regional level. Such approaches, alongside coordinating points that have been established at the state chambers of physicians, might address perceived concerns among GP trainees about professional isolation and might also address requests for a structured mentoring programme.
England, France and the Netherlands Have Set Aside a Specific Budget to Finance Postgraduate Training in General Practice
We found that all three comparator countries have set aside a specific budget to pay or finance trainees; in the Netherlands a dedicated organisation, the foundation for vocational training of GPs (Stichting Beroeps Opleiding Huisartsen [SBOH]) acts as single employer of all GP trainees. In addition, all three countries have mechanisms in place that, at the national level, ensure reimbursement of trainers (both at the undergraduate and the postgraduate level). In Germany, there is commitment to the support of specialist training in general practice, as set out in legislation and subsequent agreements among the key stakeholders, but there are challenges in the implementation of the relevant stipulations in practice. This can lead to interruptions in training and to phases of unemployment, which in turn prolongs the time required to complete the training. The advisory council on the assessment of developments in the healthcare system (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, SVR) recommended introducing a nationally coordinated financing mechanism that includes guaranteed GP training posts throughout the entire training period, as noted above. It proposed different ways in which such a mechanism could be funded, but stressed that it should be directed through an organisation—or, similar to the Dutch model, a dedicated foundation at the national level—and be independently financed through tax income rather than linked to the statutory health insurance system.
A Multifaceted Approach Is Needed to Strengthen the Status of General Practice and Primary Care as a Career Choice Among Medical Graduates and to Thereby Secure Adequate Supply in the Light of Changing Population Healthcare Needs
At the core of many proposals put forward by different stakeholders to reform the medical education and training system in Germany is a strengthening of general practice and of the general ambulatory care sector more broadly, in response to the changing burden of disease and the health needs generated by these changes. In addition to approaches listed above, recommendations include measures within undergraduate education and training seeking to enhance the recognition of general practice as a core subject in medical practice. Examples of such measures are the introduction of a mandatory placement in general practice in the final practical year or the introduction of academic departments or institutes of general practice at all medical schools. These measures regain urgency in the light of the most recent national survey of medical students in Germany of 2014, which illustrates that general practice as a career pathway has a relatively low status among medical students and practising doctors alike. Given that medical students' most trusted source of information about medical career is practising doctors, there is a need for a multifaceted approach in order to create an environment that is conducive to medical students gaining a positive experience of general practice during medical school early on that will likely influence their future career choice.
The research described in this article was prepared for for Kassenärztliche Bundesvereinigung (KBV) and conducted by RAND Europe.