A break from Brexit: scenes from general practice in Germany

BACKGROUND

Last year I organised my personal riposte to Brexit by signing up for the Hippokrates Programme — a system of international exchanges for registrars and First5s supported by the World Organization of Family Doctors (WONCA).¹ I chose Germany as the destination and before long I was accepted as the guest of a GP in the northern region of Ostfriesland. This wouldn’t be my first experience of German medicine — I had spent my elective in Dresden in 2007 — but on that occasion I spent 4 unhappy weeks in orthopaedics. I have a reasonable level of spoken language (my mother is from Westphalia) but this had done nothing to temper the fierce hierarchy of the hospital. Coming from a relatively collegiate graduate medical degree, this was a shock. Returning now, as a qualified GP, I hoped things would be better. Thankfully, the reality far exceeded my hopes — not only did I feel more welcome but also in my host I met a kindred spirit and made a great friend.

‘SPRECHSTUNDE’

The Hippokrates exchanges are non-clinical so I was essentially an observer during my visit. As a student I found observation tedious but on this occasion it was nice to be a ‘fly on the wall’. Much of my time was spent on ‘Sprechstunde’ — literally ‘consultation hour’ — watching the ebb and flow of patients and sitting in on consultations. My host surgery was in a rural village and clearly integral to the community. Each patient announced their arrival with a general ‘Moin!’ (Hello!) and departure by ‘Tschüss’ (Bye!) as if acknowledging the entire building, staff, and attendees. It was interesting to see their system of ‘turn up and wait’ (no booked appointments), although it filled me with dread of long waiting times. In reality, they coped with the demand because a typical day saw 60 consultations shared between two or three doctors and several auxiliary staff.

Sitting in on consultations with my host gave me an opportunity to consider how our jobs compared. Illness presentations were familiar, but a big difference was the style of consultation. It was striking how even newly qualified doctors did not use ‘ICE’ (checking for Ideas, Concerns, and Expectations). Consultations began with ‘How can we help?’ but rapidly narrowed to closed questions before arriving at a diagnosis, advice, or prescription.

I reflected how useful I had found the Cambridge–Calgary model of communication² and what my German colleagues might be missing. That said, consultation times were considerably longer, and through a more convoluted and random process concerns and expectations did frequently surface. My host explained that consultation skills are not an integral part of medical school teaching in Germany, although he sees this as likely to change. Perhaps it also reflects a society that can still feel relatively hierarchical and deferential to professionals of all kinds.

REFLECTIONS

I think I saw the best of German general practice while accompanying my host on home visits. Driven at speed in his convertible Mercedes to addresses he knew instinctively, we spoke to patients he had known for half a lifetime about problems that simple tablets could not solve. Often conducted in the local dialect, it was evident that the people entrusted him with their worries, emerging from discussions not just with a prescription but also guidance, reassurance, and friendship. At times the life of the German GP felt like a glimpse into a bygone age of British general practice — a doctor embedded in and part of the community, shepherding their flock at times of need. Sadly though, even my host described himself as a ‘dying breed’ — a life like his, shared with his patients as friends and neighbours, is no longer common there either.

FINAL THOUGHTS

My host and I spoke at length about the challenges, dilemmas, and rewards that are common to the job in both countries. As here, insufficient numbers of young German doctors want to become GPs, and, as here, the demands on the system are rising. I saw aspects of primary care that were better in Germany (less stressed doctors, more integration with the community), but also made me value positives back home like our structured GP training schemes and communication skills. I would encourage trainees and newly qualified GPs to take up the opportunity of a Hippokrates exchange. It was heartening to meet and feel so welcomed by foreign colleagues, particularly at this time of political change. Perhaps one day the scheme will be extended to GPs at all stages, helping us maintain the international bonds that our politicians seem so anxious to retreat from.