Dr. Nicholas Kamerichs is a general practitioner in the small town of Lütjenburg, 30 kilometers east of Kiel in northern Germany. On a typical day, he often makes it home for lunch with his wife and daughter, and is back in the office by 3 p.m. After studying in larger cities, he was happy to land his practice in a small town with a view of the Baltic Sea.
Dr. Kamerichs has seen first-hand the dwindling interest in what appealed to him as an ideal career. When he took over the practice nine years ago there were 13 GPs in Lütjenburg. Now, there are no more than ten. Throughout Germany, doctors in rural areas wanting to retire increasingly complain they cannot find a replacement.
Even in regions that currently have enough doctors, officials are getting worried. Every third GP in Germany is older than 60. A recent study by the AOK, one of Germany’s public health insurers, has shown there is not a general shortage of doctors in Germany. But attracting them to rural areas is a growing problem.
The shortage isn’t just because towns like Lütjenburg can’t compete with the cultural attractions of metropolitan centers. The model of owning your own practice, perhaps jointly with another doctor, no longer appeals to many young doctors.
Part-time and permanent employment is more popular than ever. In 2009, one in 20 practicing physicians worked part-time. Six years later, it was close to one in seven. The number of doctors with their own practice sank by 0.7 percent in 2015, even as the number of salaried physicians rose by nearly 12 percent.
“Understandably, they are no longer willing to fill a supply gap at the cost of their personal lives.”
Two-thirds of graduates in the field are now women. For them, and increasingly for their male colleagues, it’s important to strike a balance between career and family.
“A very confident generation of doctors is developing,” says Frank Ulrich Montgomery, President of the German Medical Association. “Understandably, they are no longer willing to fill a supply gap at the cost of their personal lives.” The career of a freelance doctor, long held up the ideal by regional Associations of Statutory Health Insurance Physicians (KV), is falling out of favor.
Dr. Kamerichs believes politicians and officials have painted a picture of country doctors working around the clock, boxed in by bureaucracy, scraping by at the bottom of the medical hierarchy. But that doesn’t reflect his experience.
The practice opens at 7:30 a.m., with a few house calls beforehand. “I’m really an early morning person,” Dr. Kamerichs admits. The practice is closed on Wednesday afternoons and he and his colleague, a pediatrician and GP, take turns handling Friday afternoons.
Dr. Kamerichs works more than 40 hours a week, sometimes closer to 60, and occasionally more like 80. But he has one of the most secure jobs imaginable, with six weeks paid vacation a year. The 43-year-old says he can live “more than well” from what the practice brings in. He wouldn’t get out of bed in the morning for the approximately €7,000 gross income that a senior doctor in a public hospital makes.
Yet such praise for the life of a country doctor isn’t being heard in some corners of the country.
Faced with the prospect of residents being unable to reach a doctor in time, the rural municipality of Sögel in Lower Saxony sought approval from its KV to run its own practice and hire doctors, which towns and cities have been permitted to do since 2012. The Lower Saxony KV decided to instead handle the matter itself. In 2014, it brought in the first doctor in Germany to be hired by a so-called “secured practice,” managed by a KV service provider.
So, a happy ending? Not quite. Though doctors associations are responsible by law for making sure there are enough physicians practicing across the country, they do not view it as their task to ensure that private practices are distributed throughout the land. At least not in the long run.
The eastern region of Thuringia is a trailblazer in the field, having opened five general practices run by a foundation of the KV and state. But health expert Jürgen Wasem from the University of Duisburg-Essen warns of a conflict of interest. “When a KV runs its own practice it becomes party to the invoicing of fees, when it should be a neutral party.”
The German National Association of Statutory Health Insurance Physicians (KBV) views this problem as a short-lived and hypothetical one. The hope is that after a few years, GPs in these arrangements will want to take over the practices themselves. This has worked out twice thus far.
But the regional KVs’ interventions haven’t always been timely. In the seaside town of Büsum in Schleswig-Holstein, the municipality felt compelled to act when three out of five doctors in a practice were ready to retire, with no successors in sight. For the last year, a municipally owned company has operated the medical practice with management transferred to a physician’s cooperative. Its six doctors are now all salaried employees.
Dr. Volker Staats did not give up his autonomy as a freelancer without careful consideration. Still, he can understand that young doctors do not want to take on the perceived business risk of their own practice. And he says it is “quite refreshing” to have younger colleagues around. One of them, Ole Lorenzen, is currently studying to become a GP and occasionally refers to his more experienced colleagues for a second opinion.
Dr. Lorenzen is in his mid-thirties and previously lived in Hamburg. He says quality of life in Büsum is better, prices more affordable, and the workload lighter. In the summer tourist season Dr. Lorenzen and his colleagues work a little more – in winter, a little less. Dr. Lorenzen wasn’t prepared to take the leap into owning his own practice, but this model allows him to gain experience.
Dr. Kamerichs in Lütjenburg has been looking to hire someone like Dr. Lorenzen for the past two years. Despite €5,000 gross income per month, six weeks of annual paid vacation plus two weeks education leave, flexible work hours, off-call evenings and weekends, Dr. Kamerichs struggled to find anyone willing to join his practice.
But he has finally struck gold. Starting next June, the practice will take on a new doctor for an initial 18 months. “A real stroke of luck!” he said. Dr. Kamerichs’ new colleague will not be coming straight from medical school. Rather, after twenty years of surgery, a fellow doctor is ready to trade in his scrubs to become a GP.
Stefani Hergert reports on education for Handelsblatt. To contact the author: firstname.lastname@example.org