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Country Doctor: “Sadly, humanity will fall by the wayside“
Doctor Jens Grothues; © beta-web
Rural exodus is not just a well-known German problem, but happens all over the world. In the foreseeable future, this development will have a negative impact on the rural infrastructure and with it also on medical care. The fact remains: Many physicians prefer the city and a country atmosphere doesn’t do much for them.
Many questions remain unanswered: How do you make up for this development, which concepts for medical care in the countryside have a future and how can young medical academics be lured to the country? During the Gesundheitskongress des Westens 2011 in Essen - “Health Congress of the West“ -, MEDICA.de spoke with Doctor Jens Grothues. He is a general medical practitioner and works in the countryside.
MEDICA.de: Doctor Grothues, there are considerable distribution disparities in health care. Why is that?
Grothues: Principally I am convinced that the generation has changed. Today sociocultural factors are very important: Diverse shopping facilities, a large cultural offering and much more. Fewer and fewer colleagues, who originally come from rural areas and then studied at desirable universities or teach there, return to the country. For today’s generation, cities are simply more attractive.
MEDICA.de: How many physicians are expected to be lacking in the country in the upcoming years?
If you extrapolate the numbers based on the development in the morbidity rate overall, until the year 2015 we need approximately 15,000 physicians. In the Westfalen-Lippe (Westphalia-Lippe) area alone, we need 5,000 general practitioners and medical specialists. This is due to the fact that many physicians will reach retirement age and quit. A doctor today stops practicing at age 60.4, and not at 68.
MEDICA.de: According to a study, physicians should be paid an additional 8,400 Euros per month to lure them to the country. How pivotal is the financial aspect?
Grothues: This study is interesting. If approximately 8,000 additional Euros per month are supposed to sweeten the life of a physician in the country, then I ask myself why a city slicker from Munich won’t move into the Bavarian Forest. Of course it’s not just about compensation. It is about quality of life, optimal care for the family, the partnerships, the children and education at schools. All soft location factors play an ever more important role today. If a physician has the chance to make a living with a part-time job in the city, why would he/she take the economic risk of a single practice in the country? This is simply too strenuous, country doctors oftentimes have to look after large areas with enormous personal commitment.
In the countryside incentives for doctors are missing; © panthermedia.net/Jan-Christer Neimöck
MEDICA.de: By now, several health care incentives have been created to improve the situation in rural areas. Are these measures noticeable?
Grothues: The incentives that have been created don’t have any effect, since there is no reliability and transparency for physicians. One popular argument is that private medical practitioners and hospitals have received about ten billion Euros since 2008. But where did the money go? Above all, we the “private practitioners“ need reliable general conditions, meaning planning dependability. How else is it otherwise possible to take over a practice, buy it up, to establish it and to prosper? Physicians have to provide 100,000 to 150,000 Euros upfront to be able to establish a practice. How is this supposed to happen if they don’t have a safe economic basis for the next few years? Banks will not support and finance this project any more. We need incubators and facilities that alleviate the start for innovative people setting up their own new business, by providing infrastructure and financial means comparable to a company start-up. This means that we need to establish a type of franchise system with other physicians, let young colleagues profit from our experience and collaborate.
Some things have already been implemented or will still change. For example, there was a change in emergency service structures, the burden of long shifts is in part omitted and the recourse situation will certainly change. Communities are trying to establish a pick-up and delivery service for patients. You need to make sure, that the significance of the medical profession is upheld in the population and that one black sheep doesn’t discredit all other physicians. The psychological extent that’s behind all this is enormous.
MEDICA.de: How is medical care in the old and newly-formed German states turning out?
Grothues: Due to established medical practices, health care in the old German states for the past 50 years is still significantly better than it is in the newly-formed states. The new German states have larger demographic difficulties and a higher morbidity rate. In the long run, this will exponentiate the lack of physicians and can already be seen in the examples of Thuringia and the Uckermark. Without a quota for medical students, which includes reserving some of the medical university admissions for those applicants that come from these regions, it won’t work. But you can also not obligate someone to move to the countryside. The rural offerings for physicians however can be designed in a more attractive way to where the training of a future doctor who is already in the countryside, takes places at a practice on location from the get-go. This way you can make sure that physicians from the region possibly also return to it.
MEDICA.de: At what point do you talk about underprovision of medical care?
Grothues: According to §29 of the German Requirements Planning Directive you don’t refer to underprovision of medical care until a care level of under 75 percent for general practitioners and under 50 percent for medical specialists is reached. Those are numbers that don’t match the reality.
MEDICA.de: Despite a low concentration of medical care in rural areas: Does competition of medical facilities present a problem?
Grothues: This depends on which areas physicians work in. One example from the city: For the past ten years an oncologist has his own practice one kilometer away from a hospital. In accordance with § 116 b SGB V (German legal requirements for ambulant medical services in hospitals) , the hospital now requests the supply of ambulant medical services and in this case for oncology services, which up to that point were primarily reserved for statutory health insurance physicians. A development such as this questions the financial future of the well-established oncologist and the value of his practice. Early decisions from Frankfurt, Leipzig and Dresden are now supposed to afford special protection of the practice. However, collaboration with hospitals is beyond all question in rural areas. But if I as an oncologist purchase an ultrasonic device for my practice, I pay for it with my own private means and I need to finance it. Due to the dual financing model, a hospital has other options. A medical specialist is not able to compete with that.
House calls are expensive and last a very long time. Many countries aren’t even familiar with them; © panthermedia.net/Wavebreakmedia ltd
MEDICA.de: A large part of medicine is becoming female. What ideas could you envision to balance family and job better?
Grothues: New opportunities for collaboration and employment need to be created for this purpose. A woman in a practice with two physicians will have the ability to pick up a large amount of work. However, you cannot expect the future to consist of ten-hour days at the doctor’s office. I think if anything, part-time models or 21-hour work week models will become widely accepted. These models just have to be sensibly integrated.
MEDICA.de: Are there best practice examples which could expedite a reverse trend of going to the country?
Grothues: Seven years ago we deliberated establishing a medical center and implemented this idea within six months on 3,000 square meters. This was preceded by the realization that the mobility of the rural population keeps decreasing more and more. More often than not, the next medical specialist in the countryside is far away or medical care by a specialist is not available at all. Nowadays, the grandchild does not drive grandma to the doctor. The physician colleagues also are almost at the point of closing their office due to their advancing age. You also cannot create as many branches as you like. Only physicians that decide in favor of new prospects early on are able to implement a concept such as the medical center through their contacts and enthusiasm. Our medical center in the countryside includes four private general practitioners, one orthopedic specialist and part-time tenants such as a diabetologist, a cardiologist, an oral surgeon, an oncologist and a hematologist. All in all we integrate seven areas of expertise. In addition, the hospital makes a cardiovascular surgeon available, who will offer consultation hours with us. In one and a half years, we will be joined by a gynecologist.
Admittedly these models cannot necessarily be transferred to other areas. In a similar situation at another location everything needs to be newly created. The long-term motto is: It’s not the patient that comes to the physician, but it’s the physician that comes to the patient. We try to establish humanity with this concept on location, to be able to provide adequate medical care to people in rural areas. This way, we save the rural population from having to undertake mile long journeys, for example to receive a blood bottle.
MEDICA.de: Would such a medical center be armed in case of aging of rural patients?
Grothues: Yes. The concept of private practice physicians works for us. In principle, this concept can also be offered and implemented by a hospital. A hospital could assign a physician colleague once a week who then establishes his consultation hours in the country and thus presents a specific professional identity. This way, older patients would no longer have to travel long distances to the nearest medical specialist. Admittedly, this model cannot make up for the lack of physicians, but in times of lacking physicians it can help improve the medical care of the population. If the idea is attractive enough, it attracts young, new physicians that might possibly also take over a practice in the countryside.
MEDICA.de: Can new technologies help older or severely ill patients?
Grothues: Telemedicine is already fully functional in specific rural areas. These technologies will increasingly play a role in diabetes management and cardiology, since they come from the case management area. In the long term, high risk patients have to be monitored, but at the moment the number of emergency patients is still low. Health insurance companies only support these projects, if they can save money through them. Oftentimes, telemedical technologies create even more work for physicians. Not until telemedical connection has been perfected, does it become interesting, for example through so-called control mechanisms, which for instance read back cardiac insufficiency- and blood pressure values of the patient. Unfortunately, this is not yet implemented nationwide.
MEDICA.de: How do European neighboring countries solve the issue of rural medical care and the general lack of physicians?
Grothues: Many countries have the same problems, for instance Austria and Germany. At first you don’t believe this, because Austria has a surplus in physicians at the moment. In 2016 at the latest, this will turn the opposite way. Until then, the health care system there is being ramped down and the physician admission numbers are being decreased. The health care issues are the same in all European countries. In Sweden or Finland, affected by the vast distances in these countries, only two patient contacts per year take place. Here Telemedicine and other ideas are needed. France has a union approach, which also applies to the funding of physicians. The average German physician on average has 55 to 65 patient contacts. In France that’s only 30, but there you make the same amount of money as you do in Germany. Germany’s compensation system is therefore also responsible for the problems.
MEDICA.de: Which European models could be interesting for rectifying the lack of physicians?
Grothues: One person favors the primary care physician model with enrollment options like in the Netherlands, where you are tied to a general practitioner for one year. Generally I think that health care systems should be created differently, since we need to increasingly work for the regional demand. Today we should get patients out of the habit of getting house calls after the office is closed at 6 pm. House calls are expensive and last a very long time and other countries aren’t even familiar with them. It is almost impossible to ask an American physician to make a house call, because it costs a lot of money.
MEDICA.de: Which predictions do you make for the future?
Grothues: A new health care law will also not be able to effectively solve the problems, because people are free to choose. If a physician decides to put up his practice in the countryside, it is not a health care law that convinces him to do so. Either you are excited about this job or you are not. To prohibit a physician from moving to the city has an adverse effect. He then goes abroad or engages in other options. The health care law should use a more drastic approach and include politics and communities in decisions.
In the future, it will be a large health care advantage for communities to have medical care. If there is no medical care, it will have an impact on other areas. New housing developments will not work, because people won’t find a doctor there. If this trend continues, in the future physicians in the country will have less and less time for the individual patient. They reach their limits, because a doctor’s office cannot take on an endless number of patients, no matter how perfectly it is organized. Sadly, humanity will fall by the wayside, since we increasingly have to work based on compensation. This dehumanization worries many of my colleagues. We stepped up to see people through their illnesses and politics needs to give us reliable general conditions to also be able to make this possible.
This interview was conducted by Diana Posth and translated by Elena O'Meara.