The first doctor or physician ever recorded was called I-em-Hetep, who lived in Egypt around 4500 B.C. His name meant the “bringer of peace” and he also possessed two other titles, “The Master of Secrets” and “The Scribe of Numbers”. Ancient Egyptians are known for their miraculous cures for a variety of diseases. I-em-Hetep had been held “in high honor by his generation and to have received ample rewards for his professional work, for the well-known “step pyramid” at Sakkara, the old cemetery near Memphis, is attributed to him, showing that he was only next to the king in honor and also very probably in revenue.”(THE FIRST PHYSICIAN | JAMA:). However, as the world modernized, and the art of medicine and healing spread around the globe, most famously in the Renaissance with Leonardo da Vinci dissecting corpses to combine his anatomical and physiological research, the value of doctors in Germany decreased.
Doctors went from healing and helping their patients, to mostly focusing on paperwork, according to the Guardian (German health warning: don’t burden doctors with a costly paperchase). How did it get to this in the first place?
I interviewed the Managing Physician and owner of the Sina Ärztezentrum in Obertshausen, Privat Dozent Dr. med Dr. med Habil Mehran Baghi. He has worked as an ENT surgeon and Plastic surgeon for over 25 years, first in a hospital and then for a doctor’s office. In 2007, he started owning his own doctor’s office, making him a self-employed doctor. According to him, the German ‘Krankenkassen’, or health insurance companies, are to blame.
I asked him, how the working conditions were for doctors when Dr. Baghi started studying medicine, versus now and how it has changed. He answered that for the newcomers, the students studying medicine, the conditions were horrible. He described it as: “really long working hours without payment […] it was voluntary work, for experience […] sometimes I would have to work for 3 days straight with little-to-no food or sleep and get 750 euros at the end.” Now, he mentions, it is much better for newcomers, because the students advocated for themselves, because no one dared to back then, and: “political influence changed that, because the working conditions were optimized, so that young and inexperienced doctors doing shifts get 8-9 times more money than I would have.” He also mentioned something interesting that “older and more experienced doctors working in a hospital or are self-employed and have their own doctor’s office, have a lower salary than someone who owns a restaurant, for example.”
“Can you please elaborate that in more detail?”
Dr Baghi: In medicine, there are 2 main sectors. Someone who is self-employed and someone who works for a hospital or a medical institute. People who are self-employed will have the health insurance companies pushing them further, but they don’t pay enough anyways. They don’t pay enough for our effort and services, rather, they dismiss them completely, and they say ‘you aren’t getting this, you didn’t pay for it’, even though we don’t even get paid enough. When you do your job in too much detail, you can get into trouble. Why? Because you need to cash up your time, and if you do your work in too much detail or too thoroughly, you can’t cash up more. They don’t care how much you’ve worked – for them, it is important that you work from an economic standpoint. If your patient is healthy or not, it doesn’t matter. However, if you work in a hospital, it’s slightly different, because your salary is not assigned to the health insurance companies to organize, like with self-employed doctors. The hospital controls your salary, not the health insurance company. However, the structure of a hospital system is inefficient and ineffective. These institutions are created to control and observe you while you are working.
“Why are doctors striking in Germany? How is it personal to you?”
Dr Baghi: I did strike, because of the horrible working conditions for doctors like me; we work for too long for too little money. Why do you think that? Because doctors also need to make copies of stuff that aren’t as critical as helping your patients. There also aren’t any assistants that could help make those copies. We didn’t study medicine for 6–7 years to run around making copies and reports. Doctors need to both pay for the reports and also make the reports, as the health insurance company doesn’t pay for them at all. Also, mentorships are hard to get because of the vast lack of doctors in my and the next generation. And if there were doctors, they would be significantly overwhelmed with their work.
“So have the working conditions ultimately changed?”
Dr. Baghi: In the long run, no, not from when I started practicing medicine to now. Let me tell you this. In Germany, the average doctor, for example me, would see 80–90 patients a day, versus in Switzerland, the average doctor would see 8–9 a day. This is also a reason why most doctors don’t practice medicine in Germany. People who studied medicine for free run away after they are finished studying, simply because they don’t want to work in Germany with these working conditions. German doctors are running away from Germany, and Germany lets them run away. Instead, Germany gets doctors from foreign countries to work here. The foreigners are happy to work and are generally happy to get out from wherever they were and get paid, so they agree with everything, and that is how the system works.”
(Fact check: are there really more foreign doctors in Germany than German doctors? According to Schengen News, “About 1 in 8 doctors are foreigners, meaning, they do not have German citizenship. However, the same source adds how in the coming generations in the future, “Germany will mainly rely on foreign doctors”. This is because nearly one third of doctors are 55 or above in Germany.)
When asking about what specific laws are counter-productive for the doctors, Dr. Baghi mentions how the laws in place are “‘health insurance company’-friendly”, meaning, that the laws focus first on the health insurance companies, then the patients, which means that the doctors need to pay for the things the health insurance company doesn’t pay. The example he used was the ‘Leistungsbudgetierung’ Law, or the ‘Performance budgeting’ example he used before.
Dr. Baghi: “The health insurance companies only allow you to see a specific number of patients. If you see more, you get in trouble. You also need to pay for the patients that went above that specific amount, because the health insurance companies have a budget of how much they can spend on each patient, and if that limit exceeds, the doctors are held responsible. But as a doctor, I cannot just say to a patient that I cannot see them because the health insurance says so. My job is to help patients and to do no harm. Many doctors go over the limit of patients the health insurance puts on us. Some doctors don’t tell the health insurance companies, or they tell them and have to pay the fees – and the doctor is guilty.”
“If you could change one thing about the German healthcare system, what would it be and why?”
Dr. Baghi: I would give doctors more autonomy and freedom. I would make it a free system, where the doctor works independently of the health insurance. The system would be that the patient has health insurance, the doctor treats the patient accordingly, then the doctor needs to calculate how much money they need to get the money from the health insurance. Right now, doctors get their money 6–7 months after treating a patient. For example, if I treated a patient today in October, I would get the money in April next year. Currently, the health insurance companies pay for so-called installment payments, so I can pay my employees – and those are fixed costs. In Germany alone, there are about 220 different health insurance companies. In my opinion, they should all make it one.
This concludes the Interview with Dr. Baghi.
Based on this interview with Dr. Baghi, the laws for granting the health insurance companies such autonomy are to blame. He highlights how the main reason for doctors leaving Germany or them striking, are because of the controlling ways of the health insurance companies, which restrict most doctors from doing their jobs, which is to help their patients. Every doctor goes by Primum non nocere which means ‘do no harm’ (Primum non nocere Definition & Meaning – Merriam-Webster).
Is the statement about the disputes between doctors and health insurance companies true? Yes. The National Association of Statutory Health Insurance Physicians (NASHIP, or the Kassenärztliche Bundesvereinigung), is an organization that has the doctor’s interests at heart and represent their needs (KBV – The National Association of Statutory Health Insurance Physicians and the regional Associations of Statutory Health Insurance Physicians). They are responsible for ensuring that doctors are receiving fair reimbursement rates for their services and that, simultaneously, patients have access to high-quality medical care. These disputes were tried to be stopped by the NASHIP, but have been unsuccessful, since patients often experience delays and/or disruptions in their care. In some extreme cases, doctors won’t treat patients with certain insurance, because the insurance gives them too much trouble, however, this is rare. All the institutions in play for doctors are actually under the law, which is counterproductive, because the law supports the health insurance companies and patients and other institutions more than the doctors themselves. An example of a law would be the Leistungsbudgetierung law, mentioned by Dr. Baghi. Zeit Online, wrote how The Federal Minister of Health, Karl Lauterbach, announced an ‘end of budgeting for medical services’, where it’s described that budgeting is “[…] that the money that doctors receive for treating people with statutory insurance is capped by the health insurance companies.” However, most medical practitioners see this as too good to be true, and if it were to happen, the current plans are “incomplete and far too vague”. “It is therefore “clear to the association that the protests must continue”.”
So, how much ARE doctors worth?
According to themselves, much more than they get paid and recognized for. According to their patients, they are priceless. According to the law, they are 8,960 Euros (How much money can Doctors make in Germany?). But how much are doctors worth, in your opinion?
