Specialist training in medicine in GermanyBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7100.2 (Published 12 July 1997) Cite this as: BMJ 1997;315:S2-7100
- David Maclachlan, specialist in internal medicine ()
David Maclachan completed vocational training for general practice in Britain before moving to Germany and training as a hospital physician. This article will help doctors who want to make the transition
The mutual recognition of primary medical qualifications and specialist training within the European Union and the countries of the European Economic Area (which includes Liechtenstein, Norway, and Iceland) theoretically allows specialist training undertaken in one member state to be recognised in another.1 Important differences still exist between the countries, however; this article describes the organisational context in which German doctors train and work and also some of the pitfalls that may arise when doctors attempt to transfer their skills across national boundaries.
Basic medical qualifications
The German medical student studies at university for a minimum of six years. The curriculum consists of basic medical sciences for the first three years and clinical studies for the final three years, but only the last year involves daily ward work. Te remainder of the clinical course consists of lectures, courses, seminars, and weekly teaching ward rounds. In university holidays the students are required to gain ward experience as a “Famulus.” The final year (Praktisches Jahr) involves clinical ward attachments for four months to a medical specialty, a surgical specialty, and a specialty of the student's choice.
To qualify the student must pass the Staatsexamen. Most students also undertake either a scientific or literature-based project and complete a short thesis and an oral examination. They are awarded the degree of Dr med, which is not required to practice medicine but is required for being titled “Doctor”. Thus a person with basic medical qualifications from the United Kingdom is referred to only as Arzt and not Doctor.
Practical points about working in Germany
If you want to return to Britain after specialist training in another EU country, get approval from the appropriate royal college in advance
Good German is essential except in some research posts
The accepted medical treatment of some conditions is different in Germany and Britain
German physicians tend to use drug brand names-these are generally different from those in Britain
SI units are not yet in common use in western Germany (though they are in the former GDR)
Around two-thirds of German specialists are office-based
Those who wish to practice medicine must work for 18 months as an Arzt im Praktikum, which is analogous to preregistration posts in the United Kingdom. Following this, the Approbation, which is the equivalent of full registration, is awarded. This can be undertaken in the chosen specialty or even in basic research and counts towards specialty training.
These doctors are given very little responsibility on account of their limited clinical experience, and the pay is very poor (about £600 per month), so I would advise that a British graduate complete preregistration posts in the United Kingdom. I was able to have my six month house officer post in the United Kingdom recognised for specialist training in general (internal) medicine in Germany.
Specialist training in general (internal) medicine (Innere Medizin) takes six years in approved posts and can include the time spent as an Arzt im Praktikum. There is no general professional training and no equivalent of college examinations. At the end of training, the title of Facharzt fÿr Innere Medizin is awarded provided that the training is satisfactorily completed and the oral examination (FachgesprŠch) is passed. This is equivalent to a CCST in general (internal) medicine according to the European Specialist Medical Qualifications Order. The training in medical specialties is for at least two years, of which one year must be completed after the award of Facharzt fÿr Innere Medizin, making a total of at least seven years. There is, however, no provision for the mutual recognition of individual subspecialties between the member states of the EU and EEA.
The following sub-specialties are recognised in Germany: angiology, cardiology, chest medicine, endocrinology, gastroenterology, haematology/medical oncology, nephrology, rheumatology. The specialties of dermatovenereology, neurology, human genetics, and transfusion medicine are completely separate, with their own curriculum separate from general (internal) medicine. The minimum period of training is five years in these specialties. Clinical geriatrics and intensive care medicine are not regarded as separate specialties but a certificate is awarded to internal physician, general practitioner, or neurologist who has satisfactorily completed two years in approved posts.
BundesŠrtzekammer, Herbert-Lewin-Str 1, D50931 Kšln This supraregional body publishes Deutsches Arzteblatt, a general medical weekly with job ads. Medical registration is handled by the regional LandesŠrztekammern: a full list is available from the BundesŠrtzekammer.
Marburger Bund, Riehler Str 6, D50668 Kšln. German junior doctors' trade union-a useful source of information
Medical Protection Society BmbH, Im Rosengarten 11, D61118 Bad Vilbel. Medical indemnity cover is usually provided by the hospital, many doctors do not belong to a medical defence organisation.
The curriculum for specialist training is set by the regional chamber of physicians (Landes- Šrztekammer), which is also responsible for the final examination and the awarding of the specialist status. There are some regional variations, but the curriculum is broadly similar throughout the country. Approved posts can be in university hospitals (UniveristŠts- kliniken), teaching hospitals (LandesŠrztekammern), district hospitals (KreiskrankenhŠuser), rehabilitation hospitals (Rehabilitationskliniken), or in the office-based practice of an internal physician.
Depending on the trainer, the post can be recognised for anything from six months (for example, practice of internal physician) to six years (university hospital). In general (internal) medicine, at least one year must be completed under a trainer recognised for the full six years training and at least four years in ward service, including six months in intensive care. The trainee must keep a catalogue of practical procedures and investigations, (such as central lines, lumbar punctures, pleural drainage, and liver biopsies, ECGs, exercise ECGs, Holter ECGs, and ultrasound, Doppler, and endoscopic examinations).
Prerequisites for working in Germany
To be able to practice in another member state of the EU or EEA without a work permit, you need to be a citizen of and have graduated from a university of a member state. A language qualification is not necessary, and it is up to the employer to ensure that the applicant has the necessary linguistic skills. Obtaining the German “Approbation” is a formality involving sending certified copies and German translations of the birth certificate, passport, medical degree, GMC certificate, and a certificate of good standing (which can be obtained from the GMC) to the regional chamber of physicians (LandesŠrztekammer) of the region in which you wish to work. If previous specialist training is to be recognised, detailed certificates and certified translations from the respective consultants are required.
Applying for hospital posts
Vacant posts are listed in the Deutsches €rzteblatt, which is a general medical weekly published by the Federal Chamber of Physicians (BundesŠrtzekammer; the supraregional equivalent of the LandesŠrztekammer). This can be accessed on the world wide web (http://www.aerzteblatt.de/dae/owa/suchestellen.%20home). However, most vacant posts are never advertised and filled by word of mouth. A good strategy is to write to the chief physician (Chefarzt) of a hospital in which you would like to work, including a detailed curriculum vitae, a passport sized photograph, and copies of relevant certificates and recent testimonials. Often the application is unsuccessful and the documents are returned, but occasionally this strategy can be successful. Despite the excess of German graduates, applications from British candidates often have a good chance of success because the quality of medical education in the United Kingdom is recognised to be high.
The medical establishment in Germany is more hierarchical than in the United Kingdom. The head of department (Chefarzt) has ultimate clinical responsibility and performs weekly ward rounds on all wards of the department. The senior physicians (OberŠrzte) are specialists who fulfil a similar function to consultants and supervise junior staff but do not have ultimate responsibility for clinical care. AssistenzŠrzte are the equivalent of specialist registrars. Each ward has a ward physician (Stationsarzt), who is an Assistenzarzt and is responsible for the day to day patient care on that ward. Transfers between different wards involve a transfer of care to the Stationsarzt of the new ward.
Salary and terms of service
The salary of an Assistenzarzt is higher than in the United Kingdom, and there are married persons' and child supplements. The average basic annual salary for a married physician with two children is about £30 000 at current exchange rates (£1 = DM2.80). Additional duty hours are paid at between 20% and 80% depending on how onerous the speciality is. Full shifts are paid at 100% of the full hourly rate. Details can be obtained from the Marburger Bund (see Useful addresses).
The rate of tax is more than in the United Kingdom for a single person but considerably less for married people with children. The employee's contribution to social and health insurance is approximately £240 each month. Superannuation contributions are compulsory and made to a state run pension fund for doctors, dentists, and veterinary surgeons. They cannot be transferred to the United Kingdom on return, but could be reserved until retirement age in Germany.
Contracts usually include a probationary period in which either party can terminate the contract at two weeks' notice. After this, contracts are given for one to three years. Paid holiday is about six weeks, depending on age. Public holidays are plentiful, and additional duty hours with a supplement are paid if you are rostered to work on a holiday. Study leave is only granted in exceptional circumstances, for example if you are making a presentation at a conference.
For those who intend to return to Britain at the end of specialist training in a medical specialty, it is essential to note that only the specialist qualification in general (internal) medicine is directly transferrable. Only training completed after the MRCP(UK) can be counted towards training in a medical sub-specialty, and prior approval should be obtained from the Royal College.