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Problems Have Delayed Germany’s Medical Studies Reform

The German government’s long-awaited Master Plan for Medical Studies 2020 remains incomplete. By arranging for this plan to be drafted, the federal coalition government of 2013 to 2017 sought to strengthen primary care and increase practical relevance. Its scheduled completion date was the year 2020. Now, the new regulation for licensing physicians is to come into effect in 2025, but the corresponding draft bill has still not been released. What is going wrong with the medical studies reform?

In May 2015, the German Federal Ministry of Health and the Federal Ministry of Education and Research, along with representatives of the Standing Conference of the Ministers of Education and Cultural Affairs and representatives from the coalition factions of the German Bundestag, fulfilled the political mandate of the old coalition treaty. A federal–state working group was established. The master plan was agreed upon in a circulation procedure, and it was released to the press on March 31, 2017. Its 37 measures aim to reform medical studies.

From the start, the initiative was subject to questions about financing. In December 2018, the German Council of Science and Humanities, headed by Manfred Prenzel, PhD, finally submitted its expert opinion. The council generally regarded the suggested measures as sensible and appropriate. However, implementation is expensive and requires urgent stabilization of the financial framework of university medicine, according to the council, which has estimated the cost to be €300 million. The reform project ground to a halt, and the pandemic compounded the delay.

Financing a Problem

“Since the master plan was adopted, we believe that its implementation has primarily floundered on the financing,” Ina Reiber, head of the Department for Medical Studies and Continuing Education at the Hartmannbund association, told Medscape Medical News. “Neither at a federal nor a state level can a financing model be agreed upon that meets the requirements of a new regulation for licensing physicians. Unfortunately, this means a schedule delay, and the deletion of important and new features should also be expected.”

In the past few months, students have frequently commented on the slow process. “It worries me that the federal government and states have still not managed to develop a functioning financing model,” said Peter Schreiber, chair of the student council at Hartmannbund. “But it doesn’t just worry me. It worries the whole student council. I think that this is the case for most students focused on this topic, even outside of Hartmannbund.”

The Master Plan

The amendments proposed to strengthen primary care involve the following points:

  • Admission: In addition to final examination grades and attendance records, motivation and social or communicative skills should be considered in the medical school admission process.

  • Design and content of the studies: Primary care and practical knowledge should play a greater role in medical studies. The physician–patient consultation should become a part of the study content, and the first contact with a patient should take place during the studies. Conducting scientific research should become mandatory.

  • The exam: The medical history and physical examination at the patient’s bedside for the third state exam shall be evaluated in the future. Primary care knowledge should be reviewed in the state exam at the end of medical studies. Physician–patient communication should be adopted as an additional exam topic in the third state exam.

  • The practical year: The practical year used to be divided into thirds, but 12-week quarters are planned. Surgery and internal medicine remain mandatory rotations and must be completed in at least two quarters. At least one quarter must be completed in outpatient practice (eg, with a primary care physician, pediatrician, or gynecologist). The choice of one rotation is completely open.

In addition, it has been proposed that states be released from the rural physician quota. The states could then allocate as much as 10% of the medical studies places in advance to applicants who commit to working in primary care in underresourced rural regions for as long as 10 years once they finish their studies and specialist training. Otherwise, students should be better informed of the option to complete whole periods of their training in rural areas.

In 2017, Hermann Gröhe, then federal minister of health, called the Master Plan for Medical Studies 2020 an “important step toward a modern study of medicine” that prepares physicians for future challenges and ensures quality patient care into the future. “Greater practical relevance during medical studies and an increased focus on primary care are already extremely important, especially with regard to quality care in rural areas,” said Gröhe.

Practical Year Debate

Through its 2014 survey, Medical Studies 2020 Plus, the Hartmannbund discovered how students envisage the future of their field of study. Few of the 7500 students surveyed were enamored with the mandatory section of the practical year in primary care. The medical students also rejected the introduction of mandatory scientific research.

The students’ preferred model (desired by 75% of those surveyed) consisted of two mandatory quarters and two elective quarters, which would mean that students would have the chance to gain an in-depth understanding of multiple fields.

In a July 2015 position paper, the Hartmannbund, on the basis of results of the survey, proposed dividing the practical year into quarters (two mandatory quarters in internal medicine and surgery and two elective quarters). The Hartmannbund also called for an elective quarter in outpatient practice with primary care physicians or specialists. It rejected the rural physician quota.

In February 2016, the Federal Representation of Medical Students in Germany (BVMD) and the medical students of the Hartmannbund campaigned for their positions in two open letters and approached multiple members of the Bundestag.

In November 2016, the junior physicians and medical students of the Hartmannbund, the Alliance of Junior Physicians, the BVMD, and the Marburger Bund appealed to the government to decide upon practical measures oriented to training requirements. The four associations feared that medical study would be unilaterally aligned to symbolic and medical care policy considerations. In their opinion, the current process needed to modernize study content and teaching conditions from scratch and to improve their quality.

New Licensing Regulation

Reiber is not optimistic. “We are afraid that the original schedule can no longer be fulfilled. A revised draft bill for the new regulation for licensing physicians has still not been released, even though the minister for health promised this for spring of this year.”

She added, “Even if this bill is released shortly, it still has to pass through the legislative process. Subsequently, the universities need time to modify the study course. The teaching would have to be restructured and go through appeal proceedings, et cetera…. As a result and in the meantime, we unfortunately consider the date of inception for the new regulation for licensing physicians of October 2025 to be extremely unlikely, although its necessity is undisputed.”

This article was translated from the Medscape German edition.

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