Background
The international context of physician migration
The German situation
Methods
Study design
Sampling and recruitment
Internal medicine | Psychiatry | Surgery | |
---|---|---|---|
Romania | ≥1 | ≥1 | ≥1 |
Poland | ≥1 | ≥1 | ≥1 |
Russian Fed. | ≥1 | ≥1 | ≥1 |
Greece | ≥1 | ≥1 | ≥1 |
Iran | ≥1 | ≥1 | ≥1 |
Country of birth and training/specialty
| |||
Internal medicine | Psychiatry | Surgery | |
Romania | 3 | 2 | 1 |
Poland | 2 | 2 | 1 |
Russian Fed. | 2 | 1 | 1 |
Greece | 1 | 1 | 0 |
Libya | 1 | 0 | 0 |
Iran | 0 | 1 | 0 |
Syria | 0 | 0 | 1 |
Gender
| |||
Female | 12 | ||
Male | 8 | ||
Years practised in Germany (at time of interview)
| |||
>10 years | 7 | ||
5–10 years | 7 | ||
1–5 years | 3 | ||
<1 year | 3 |
Data collection
Data analysis
Results
Experienced difficulties with the organization of the healthcare system
In Germany, doctors take blood and insert IV cannulas. In [country of origin] it is different. In [country of origin] nurses take blood. […] You need 1.5 hours of your working day for this. […] And I was always a little frustrated (laughs) because my colleagues working in France or Belgium tell me that over there nurses are still attending to those tasks. (Interview 3)
Inadequate norms regulating medical practice | Rules for treatment of psychiatric patients useless, harmful, coercive, and ambiguous |
Allocation of tasks between professional groups inefficient and unsatisfactory | |
Excessive patient education and documentation of decisions | |
Ineffective and too comprehensive specialty training | |
Working/changing jobs burdensome with temporary licensure | |
Inadequate organization of routes for getting and preparing for a job as hospital physician | Licensure process slow and cumbersome |
Licensure requirements ineffective in securing competency | |
Licensure requirements for non-EU applicants unfair and overburdening | |
Future employer does not truthfully inform about working environment | |
Inappropriate support to prepare for clinical work | |
Inadequate organization of hospital work and learning environment | No financial support, job prospects, and interesting tasks for interns |
Insufficient support for reaching postgraduate (specialist) training objectives | |
Tasks assigned do not match level of expertise | |
Inappropriate support to deal with difficulties experienced | |
Staff shortages and excessive workload | |
Further hospital-/person-specific inadequacies in organization | |
Further institutional difficulties | Career advancement difficult for women |
Important information not shared between different institutions | |
Unfair differences in treatment of migrant doctors across time |
In our country, physicians were regarded differently. When a doctor says something, one has to listen. […] People listened; there was no need to have hour-long discussions with them. […] You could take the time for patients, for their clinical picture, for procedures, you see? And that was, as said, not so, stressful is not the right word, but you didn’t have to protect yourself so much. (Interview 11)
I: “Where is the bottleneck with your temporary licensure?” P: “With the job center. Well, I registered there five weeks ago, but always needed to wait, have eight new documents, further documents. That isn’t easy. […] Waiting for a month costs too much of my money and time.” (Interview 17)
You need help. That is just the way it is. […] And they promise all those things and then such a situation arises. And then most of us still have to manage on their own. And life is like that. I guess that is okay, but they should not make all those promises. That is a little disappointing. (Interview 20)
In my country […] I was head physician, I had my own office. And it was a bit difficult for me to work again as resident physician (Assistenzarzt). And I had to ask questions as if I did not know. My senior physician (Oberarzt) said, I had to ask him everything. (Interview 12)Then after a month they said I had to take care of patients by myself. And we are speaking of 16 patients. At the beginning, I found it difficult to do that alone. (Interview 3)
Experienced difficulties with own competencies
Insufficient language competencies | Knowledge of everyday language |
Knowledge of medical jargon and nomenclature | |
Knowledge of colloquial terms for medical issues | |
Written expression and use of grammar | |
Understanding dialects | |
Insufficient knowledge of the German healthcare system | The scope of own and co-worker’s responsibilities |
Organization of healthcare outside of hospital setting | |
Legal requirements regarding treatment of patients and patient data | |
Care processes and technical equipment used within hospital | |
Insufficient clinical competencies | Clinical knowledge exceeding own specialist field |
Experience with certain diagnostic/therapeutic techniques | |
Experience with treating certain medical conditions | |
Further necessary practical skills like taking blood | |
Insufficient cultural knowledge | Cultural and historical context as basis for psychotherapy |
Cultural (implicit) rules of conduct like how to show emotions | |
Further competencies lacking | Knowledge of machines causing accidents as basis for surgical interventions |
Handling own deficiencies/insecurities well | |
Adjusting to and accepting the new environment |
For example: If a relative calls the ward and wants to talk to a doctor. In [country of origin] you talk to them. It’s family. Here the patient needs to first sign a release from confidentiality and then you can talk to them. I did not know that at the beginning. I did talk to the partner. God bless, […] they did not want to sue me. (Interview 20)
Because compared to [country of origin] where you do a narrow, where I predominantly did cardiology and that was it, in Germany I had to care for all of internal medicine, also during night shifts. That was professionally challenging. And that is the same everywhere in Germany, I realized, also during night shifts. Although you are a cardiologist, you are responsible for the whole of internal medicine. That was difficult at the beginning. (Interview 3)
Yeah, when I have an idea, an advice, I cannot really put it across to my patient. I am myself enthusiastic about the idea, but the patient looks at me… I get the feeling, this is all about, he either did not really understand me or it does not fit the nationality – could one say – or the culture. (Interview 9)
Experienced difficulties in interpersonal interactions
Concerning acceptance from colleagues, how do you say, rejection. Well, in fact, they wanted to prove at all costs that it (note CK: working in psychiatry) cannot be accomplished by a foreigner. [....] And well, constantly some insulting or, how can one say, remarks or jokes about [country of origin].[…] I resigned after three months. (Interview 9)
Inadequately treated by patients or co-workers | Rejected or discriminated as foreigner |
Rejected or discriminated because of other attributes | |
One’s professional competencies are misjudged/mistrusted | |
Annoyed, impatient, or unsupportive reactions to (language) deficiencies and questions | |
Not appreciated for effort and achievements | |
Certain characteristics of patients or co-workers complicate teamwork/patient care | Co-worker of different opinion regarding adequate patient care |
Co-workers lack necessary competencies or motivation | |
Hearing impaired/old patients’ inability of proper expression | |
Further difficulties in professional interactions/relations | Burdened by history of military conflict between countries of origin |
Family issues impair professional performance | |
Diverse behaviour patterns and attitudes of people found irritating to infuriating |
I realized that I have to prove myself more. If I make a mistake, everybody thinks that I made it because I do not understand. A German doctor can make the same mistake, but then it is just a mistake. […] For example, I wanted to write 1.5, but the comma wasn’t well printed, it read 15. […] And they were thinking: She does not understand, she wanted to give 15 instead of 1.5. Small things, but frustrating. (Interview 20)
Back then I was working with a head physician, he well, how shall one say, was a narcissist. He screamed at all of us, we were all stupid – German or foreign – all were equally (laughs) bad. (Interview 19)
A nice grandpa, 90 years old who came with three…, well, who ended up with me. I was the physician responsible for his ward. For three days he did not want to talk one word with me. On the third day, he started crying and then I asked him, why, what the issue was. And he said that he was at the Eastern front and he shot [citizens of country of origin]. He never thought that someone from [country of origin] would ever treat him. That was very pleasant (ironic). (Interview 7)