Medicine

Working as a doctor in Germany: things to know before you start

Despite little activity on my blog these days, I’ve noticed that one old text has been getting an increasing amount of attention since I published it some 3 years ago: Surprising things about being a doctor in Germany.

In addition, I’ve been getting a number of personal e-mails from medical students and junior doctors from around the world asking for more information and advice on the subject of potentially starting out as a doctor here in Germany.

So, here are a few of my personal experiences and tips from the perspective of a British-trained doctor who moved over to Germany in 2009. I have a fair bit of information to share, so I plan to write about it over a series of texts. I hope this helps some of you.

Before you start

1. Have I got a good chance of getting a job as a doctor in Germany?

Short answer is yes. Germany does need doctors at the moment. It of course depends on your speciality of interest and your place of interest. The chances of getting a job in smaller or less attractive cities is obviously higher than for example a renowned university teaching hospital. But it’s a big country and there is a lot of choice at the moment.

2. Is my medical training recognized in Germany? What documents do I need?

Before you start actively looking for a job, it would be best to check with the regulating body here what the requirements are for having your medical degree recognised and subsequently obtaining a license to practice.

Each ‚Bundesland‘ has its own governing body (for example ‚Ärztekammer Nordrhein, Bayerische Ärztekammer etc). I suggest you pick your place of interest in Germany and enquire at the local Ärztekammer there, but bear in mind that there may be differences between the states.

Applying from a member state of the EU

In general, applying from within the EU is more straightforward than from outside and incorporates getting high school/university certificates translated, references from bosses, security checks from your home country and assurances from your governing body that your medical degree is in line with the standards set by the EU. The usual occupation health issues such as HIV status, immune status against hepatitis as well as a medical certificate from a doctor assuring a good bill of health is also required. The Ärztekammer I applied to refused to look at any documents until they were officially translated from English into German to tell me if they were the correct ones (despite the fact that they could clearly read and understand English). This is therefore a costly and time-consuming process (both in terms of money and your nerves). In the end I got my registration one day before I was due to start work.

Applying from outside the EU

For those outside of the EU, things can get a little trickier. Depending on the structure of your medical training, it can require extra (un-paid) placements and a medical viva to check your knowledge and skills, in addition to the above paperwork. I would check all of this out before your decision to move here so that you can plan your finances and expectations appropriately. From what I gather, things seem to be decided on a very individual basis.

3. How good does my German have to be to work here?

Germans institutions often ask for the Goethe-certificate level B2. This is a requirement for university entrance and acquiring citizenship for example and is a good rule of thumb before you start work here, regardless of whether it is an official requirement or not. For your own sake. It is a level which just about gets you by in conversation and in reading and writing although far from ensuring an easy start. I found that whilst doctor colleagues and allied healthcare professionals spoke and understood english at varying levels, patients (especially the older ones) generally did not and furthermore expect, quite naturally, to be communicated with in their native language.

Tips for improving your German language skills

Like all languages, your German will only get better through use. If like me at the time, you are starting from scratch, there is nothing like living in the country, reading local newspaper, watching Germany films and making friends to improve your fluency.

I did a one month intensive language course (level B2) before I started work. It was a brilliant way to start my life in Germany and is a September I look back on with immense fondness. I made some great friends from this course from all over the world and went to some great parties. It was the ERASMUS year I never had. Aside from the social side though, it was a good foundation for my language skills.

Throughout the year, I met weekly with a friend from Argentina who had been living in Germany for a few years and wanted to improve her English. We would talk for 30 minutes in English and then 30 minutes in German. Over the years, this turned into wonderful evenings of drinking red wine over bowls of delicious pasta in favorite local restaurants and a lasting friendship. And of course we improved our language. It’s quite easy to find a so-called ‚Stammtisch‘ through Facebook groups days to achieve something similar.

That’s it for today. I will write about the medical training system in Germany and some practical tips about looking for and applying for jobs in further posts!

On Immunity

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A colleague and I have noticed how paediatricians here appear to be ever so latently and subtly anti-vaccinators. They don’t tell you this outright, but it’s the feeling you are left with when the topic of vaccination is brought up.

Sure, doctors are no longer paternalistic, and that’s a good thing. And parents are increasingly well-informed. But an expert opinion and clear illustration of the main facts are always invaluable. I don’t know if it’s time constraints, but my perception was that the approach was heavy on parental choice with a distinct impression of lack of concern if parents decide not to bring their child along for certain jabs. Disappointingly without really spending the time to explain the benefits of vaccination for that disease, both to your child and the community of children it lives in. Or to mention that we are speaking about standard vaccinations that are recommended by paediatric societies in many parts of the world.

On my reading list this week was therefore ‚On Immunity – An Inoculation‘ by Eula Biss. A book tackling the history of inoculation, the scientific world of immunisation and the ethical and social side to vaccination. What I wasn’t expecting was that these hard issues would be told in a creative journey of stories relating to mythology, metaphors and motherhood. And what a beautifully written journey it is – a journey through hard facts, conflicting opinions, the fascinating history of medicine, a personal narrative of the neurosis and anxieties of new motherhood and with just a little bit of philosophizing along the way.

A highly recommended read for anyone really. And certainly for all mothers. All parents.

Music therapy: singing as a medicine

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Music is something which accompanies all of us through life: a way of expressing happiness, indispensable at times of sadness when words alone seem too feeble or simply too difficult to bear, for melancholic evenings at home so we are never alone or empty, a source of fun to be shared with friends, to mark all festive occasions.

Music can also accompany illness. I’ve always been vaguely aware of the existence of music therapy. But despite my interest in all things musical, it’s not something which I have encountered in my medical life so far, so that I conclude that it is far from a routine offer in conventional adult medical practice.

The weekly medical magazine in Germany – Deutsches Ärzteblatt – reports this week about the healing power of song. Studies have shown that singers in a choir not only feel better and more relaxed subjectively, but that they have a measurably increased production of the feel-good hormone oxytocin and of immunoglobulin A as well as a reduction in the level of the stress hormone cortisol.

The positive effect of a choir practice at the end of a long day at work is something I have never failed to feel.

But singing can be used to help the sick. It has been shown that the anxiousness, fear and pain in patients suffering from cancer can be reduced through singing.  In Germany, there is even an ‚Association of singing hospitals‘, where musical therapy specialists lead singing groups for patients and where research in the field takes place. Some 23 hospitals in Germany claim the title. That’s not very many, given the size of the country, and probably explains why I have never come across something like it in my everyday life. But something which appears to be growing.

The article reminded me of a member of my old choir who was diagnosed with a metastatic recurrence of her breast cancer many years after her initial therapy. On the week I telephoned to enquire how she was feeling before the results (waiting for results is often the worst time of all), which I knew from the scans looked bad, she told me above all about the choir practice she had attended and about the next choir project she was looking forward to. Perhaps she had her priorities right.

Living a life with an illness can be a difficult thing. But if music is indeed in some small way a healer, then let it play on.

How to feed babies at risk of nut allergies

Those suffering with an allergy are never truly understood by people without them, with their allergies often being taken less seriously than they should. My sister-in-law has a nut allergy.  On one occasion, her post-nights husband breakfasted unthinkingly on crunchy nut cornflakes before driving home to kiss his wife. The traces of nuts were enough to set off an impressive facial swelling. And it was finally clear to the nut-loving family that she had married into, just what having a nut allergy means.

The recent editorial in the New England Journal of Medicine reported what can be viewed as breaking news in the world of allergy. To date, parents with multiple allergies were told to avoid feeding their children – particularly in the first year of life – with highly allergenic foods (such as peanuts, milk, egg, tree nuts) in order to reduce the likelihood of them developing allergies. Following observations to the contrary, a controlled trial was started to test this hypothesis. Specifically, peanut allergy – being one of the commonest food allergies and also potential one of the most life-threatening –  was studied. The results were published this week.

Over 500 children at high of a peanut allergy (for example those with eczema or milk allergy) were randomly assigned to either receive peanuts in their diet on a regular basis or to receive a peanut-free diet. Before enrollment, the infant were checked with skin pick tests, to rule out a severe sensitization against peanuts. At 5 years of age, the children were given a peanut challenge to determine the prevalence of peanut allergy. The prevalence of peanut allergy in the group avoiding peanuts was 17.2% as compared with 3.2% in those who consumed peanuts 3 times a week over a period of 5 years.

The clarity of the results suggests that guidelines are likely to be changed in the future and will hopefully lead to a fall in the currently rising levels of peanut allergy. And it will be interesting to see what the implications are for other food allergies.

The less than aesthetically pleasing world of the medical congress

When I was little in India, I had a relative who was a dentist and used to fly around the world to medical meetings. It seemed like the most glamourous thing to do.

But as a grown-up, glamour is the last word I would attach to medical conferences attended by doctors. Other words I would also not use are cool, creative or innovative.

I look on enviously at the internet/media conferences that my husband attends (where Alicia Keys has sung a set at the closing ceremony) and at the colour-themed and styled conferences of my arty Instagram friends. Where attention is payed to design, stage sets, food and entertainment as well as the factual information that is being presented.

Over the past 5 days, about 22,000 lung doctors from all over the world descended upon Munich for the yearly European Respiratory Society (ERS) meeting. The huge numbers meant it pretty much had to be held at the Munich fair. As far as fairs go, the one in Munich is airy, well-lit and being Munich, even has a designated area for a beer garden. And with the sudden unexpected bursts of sunshine after a dreary summer, this piece of green space was a treasure.

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The congress in Munich as a whole was a betterment in many ways compared to the last few years. The usual inelegant, plastic congress bag with gaudy lettering – which you could normally not even reuse as a child’s gym bag for fear of complete social exclusion and eternal bullying of said child – was pleasantly upgraded. The jute bag has arrived at the ERS. While it doesn’t get 10 out of 10 for style, it equally doesn’t have to be deposited at the neared Gift Box or charity shop asap.

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And the usual 100 unwanted flyers advertising the evening drug-company sponsored symposiums did not make their way into the newly spruced up congress bag, but retained their place soley on the congress app. The contents of the bag were thus one fat congress programme (for detailed reading additional to the app) and one block of writing paper. So far so good. Although a pen and a little bag of sweets would have been ok too.

The app was user-friendly and useful. I’ve blogged about the lack of doctors on Twitter before. The app this year surprising had an in-built Twitter stream. Progress! Except it was a Twitter stream purely to display the tweets of the organising committee. Last year, the hash tag #ERS2013 was thin on the ground. This year Twitter took off – but mostly lead by the pharmaceutical companies.

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22,000 doctors in one exciting congress and a maximum peak of 1874 tweets in one day according to the stats provided by Symplur. Took off is relative.

The top tweeters, were a Columbian, 2 Dutch, one Turkish and a couple of Brits, alongside the organisers and the drug companies. No Germans in sight.

Thanks all in all for a great congress ERS. Yes, we are here to come together, to share research and to learn, but next time take on a media expert and a graphic designer onto your organising committee.  I hope one day for sessions chaired not predominantly by men, more interaction, just a little bit of style, a bit of live music perhaps and less of a stiffened atmosphere.

Hope and herbal remedies

ApothecaryI’ve mentioned already that Germans in my view have a much greater interest in herbal remedies and alternative medicine than the Brits. You will find a traditional apothecary (as opposed to a Boots pharmacy)  in every corner – in many cases places which appear to hail directly from the renaissance, lined with tiny wooden drawers and brown and green glass bottles filled with potions and powders. Buy a simple body lotion from your local chemist and you will be swamped with free supplies of magnesium and zinc as goodies to take home.

Despite being a creature of conventional medicine, in my time here, I have learnt that teas with thyme are good for coughs and colds (bronchial tea), the rootstock of the herbal plant Valeriana (Baldrianis used commonly to help against insomnia (we even supply it for hospital in-patients) and zinc is a must when you have a cold (although I’m not convinced it helps you recover any quicker from a cold than the eggs with pepper and spoonfuls of honey that my dad is quick to recommend). How much of it is placebo and how much helps, I really don’t know. But they definitely can’t do you any harm. I see that companies such as Orthamol market their strong vitamin cocktails to expecting mothers, athletes and immunosuppressed patients at fancy prices (40-50 Euros a month) and question their need. Although admittedly, whilst not exactly eating junk food everyday, the thought and effort I put into securing a nutritiously balanced diet every day is nominal.

My knowledge of alternative medicine is shamefully limited to one special study module many years ago at university. I am the sceptic that scoffs quietly when someone tells me of an acupuncture course to reduce the duration of labour. But when patients quiz me on alternative treatments for their newly diagnosed lung cancer, I regret that I can’t offer them a more expert opinion. Other than to tell them there is no clear evidence for their use in this field and an offer to check that there are no drug interactions with any conventional therapy they take.

Recently we treated a Chinese patient who relied on Chinese herbal medicine to treat her advanced lung cancer. Several discussions with the patient and her family made clear that the aversion to chemotherapy was not just due to cultural differences and a rejection of conventional medicine, but due to the underlying hope that a remedy exits somewhere which could offer a cure. A cure which is out of reach with the chemotherapy we had to offer. This is the side of alternative medicine which I find the hardest to come to terms with.

Love, Hope and Cancer

Just after Christmas last year, Elana Miller, a young American pyschiatrist wrote a blog post which went viral. Her text ‚Love is…(holy shit, I have cancer)‘ about her truthful and acute response to the sudden and life-changing diagnosis of a rare T-cell Lymphoma was liked, shared, translated into several languages and spread across the world. Her response was one of shock, anxiousness, sadness but overwhelmingly of hope and fighting spirit.

Half a year later, I wondered how Elana was getting on under her treatment and peeped into her blog Zen Psychiatry . And you know what? She’s having a hard time of it. She writes: ‚I thought having cancer would be the worst part about having cancer, but it’s not.‘ Because life doesn’t stop throwing its challenges along the way, just because you have cancer. There are still nasty landlords and break-ups to deal with. And it simply doesn’t seem fair. I’m wishing Elana lots of strength, a bit of luck again in life and renewed hope. 

Hope can certainly be found in the story and work of Kate Granger, a young British doctor suffering from a terminal cancer. Kate has written books, pieces for the Guardian and campaigns heavily for better care of the terminally ill. Starting with the doctors who look after them. Her campaign ‚Hello my name is…‘ is on the surface one which remind doctors to always introduce themselves to patients by name (as Kate went from being a doctor to suddenly having to be a patient, she noticed that this was not always a given), but represents a call for a more holistic and compassionate provision of medical care. I’m looking forward to reading her book ‚The Other Side‘ – her story as a patient through a doctor’s eyes. I have a feeling I will learn a lot from it.

Polio once again a risk

Watching a friend’s 11-month old baby crawling swiftly across the floor recently left me amused, as it reminded me of an army soldier crawling (I’ve since learned that this is in fact a legitimate crawling technique, and is known as ‚the army crawl‘). I must have put a similar crawling technique to use as a baby – but instead of my parents looking on with wonder, they were worried for a few days that I may have been infected with the poliovirus. Poliovirus is a highly infectious virus which begins as a typical virus infection but invades the nervous system leading in some cases  to paralysis and even death. The infection mainly occurs in young children under the age of 5.

This is hard to imagine for us in the modern world. But polio (poliomyelitis) epidemics occurred up until the first half of the 20th century in America and remained endemic in many low-income countries much later on into the 20th century. There is no treatment for the infection, but the production of a vaccine in the mid-50s and its slow distribution throughout the world, together with better sanitation, has led to an eradication of the disease in 80% of the world. India was declared free of polio just in March this year. Polio is still endemic in Pakistan, Afghanistan and Nigeria. The World Health Organisation targets the complete eradication of polio in 2018.

This week, 2 bits of worrying news have been reported. Firstly, that cases of polio have been reported in 10 developing countries around the world this year. Secondly, that there is a shortage of the quadruple virus (diphtheria, tetanus, pertussis, polio) in some countries in Europe, meaning that the booster vaccine has not been available for some school-aged children and adults. The vaccination of babies has not been affected.

In my medical life, I see a case of so-called post-polio syndrome – the disability seen in the aftermath of the infection in sufferers of polio – every so often. A gentle reminder of how things used to be. While polio is not a threat to those living in most parts of the world now, having an awareness of the severity of this terrible childhood disease should hopefully remind us to appreciate the vital role of vaccinations in our modern life.

Freediving: an extreme sport that needs a good pair of lungs

One medical recommendation is applicable to almost every patients with lung disease: physical training. (standing side by side with don’t smoke!) When diagnosed with mild asthma years ago, Herbert Nitsch could be said to have taken the advice a little too seriously. Nowadays, the Austrian former airline pilot calls himself ‚the deepest man in the world‘, after breaking record after record over the last decade in the (rather terrifying) field of freediving.

Freediving is basically diving purely relying in breath-holding, without the use of additional breathing apparatus. Why are you not able to hold your breath very long before panicking and gasping for breath? Because breath-holding leads to a fall in blood oxygen levels as well as a steady rise in carbon dioxide. The fall in oxygen, when severe enough, can eventually lead to a blackout. The rise in carbon dioxide however normally  stimulates the breathing centre and triggers the urge to breathe before this occurs. But as with all sports, it’s a question of training.

In his keynote speech at a respiratory conference on Saturday, Nitsch explained how his average sized pair of lungs, with less than average function (due to his asthma) could be trained in order for him to hold his breath for more than 9 minutes in a static position as well as to eventually dive down to a breathtaking distance of 214m. Videos of deep blue seas, the excited nervousness of his safety team upon descent, encounters with sharks and one near fatal episode of decompression sickness (also known as ‚the bends‘) kept an audience of a couple of 100 chest physicians enthralled.

As well as techniques to increase lung capacity and to control the breathing reflex, divers have to deal with the pressure changes under water. Upon descent, the body is subjected to increasing pressures and the lungs are pretty much squeezed. Changes in the behaviour of gas according to pressure laws leads to an increased tissue absorption of nitrogen. When a diver ascends too quickly, the absorbed nitrogen is released back into the blood in the form of bubbles which can block up blood vessels causing everything from muscle pain and skin itching to damage to the nervous system, breathing failure and death.

The path into the world of extreme sports is fascinating. A world of risk, discipline, mental strength and seemingly insatiable ambition: after Nitsch spent 1 week in a coma, 1 month in a recompression chamber and months at a rehabilitation clinic learning to write again after a severe case of decompression sickness.

High cholesterol and blood pressure: should you be worried?

The German word for supper is ‚Abendbrot‘. It’s a fitting word because the literal translation is ‚evening bread‘ and actually, most Germans do eat a cold supper of bread accompanied most often by cold meats and cheese. Watching the way many of my friends here smear their bread with a 2cm layer of butter followed by a generous slice of cheese or two on a daily basis, does make me cringe and worry a bit about their cholesterol.

Growing up, I was always told to eat everything I like while I am still young.  As a 30-something, I am starting to wonder if this adage still actually applies to 30-somthing year-olds. At some point, it’s going to be time to start thinking about cholesterol levels, blood pressure and start doing some risk stratefication. But the question is when?

Well, national guidelines recommend the following for those at low risk:

Blood pressure checks starting from the age of 20 every 2 years.

Lipid screening blood tests  for men  starting from the age of 35  and for women from the age of 45 every 5 years.

Hmm. Apparently 30-something cannot be considered as young. And as for eating everything you like, perhaps it’s time to think again on the way to your doctor’s appointment…

 

 

 

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