Out-migration and attrition of physicians and dentists before and after EU accession (2003 and 2011): the case of Hungary

This paper employs a large-scale, individual-level, panel dataset to analyse the effect of EU accession on the probability of out-migration on the part of Hungarian physicians and dentists between 2003 and 2011. The study uses event history modelling and competing risk models. The results show that EU accession did not at the time affect the probability of out-migration while after the end of the transitional period of restrictions on the free movement of labour from the new EU member states to Austria and Germany, the probability of doctors’ migration increased considerably. Relative wages and peer pressure also exercise a significant role in the out-migration decisions of young medical doctors. We also find that more than half of those medical doctors who left the country during the observation period returned some time later. The data furthermore suggest a massive flow of doctors to domestic jobs outside the health care system.     

The reform of hospital financing in Germany: an international solution?

From 2003, each inpatient's stay at a German hospital will be reimbursed according to diagnosis related groups. The former German hospital financing system, which consisted partly of per diem rates and partly of per-case rates, was abolished in an attempt to increase efficiency in hospitals. This can be seen as the government's attempt to act on the principles of evidence-based policy. Since there is no strict global budget for inpatient treatment, it is not certain that those diagnosis related groups will actually decrease overall expenditures on hospitals. Also, it is argued that the introduction of diagnosis related groups in Germany may not be the last step in rebuilding the German health care system. The manner, scope and timing of this reform suggests that it will not succeed. Reforms lead to yet more reforms.     

德国医学PhD培养对我国医学研究生教育的启示

与德国医学博士研究生培养模式相比较,我国医学博士研究生培养起步较晚,尚处于探索阶段,亟待完善和发展。本研究从德国现代高等医学人才培养模式的历史发展脉络人手,分析了德国医学PhD教育的特点,从培养目标、入学资格、导师制度等方面,对中德医学博士研究生培养模式进行比较研究,为改革我国医学研究生培养模式提供借鉴和参考。     

山东省3所医院医生收入和业余医疗服务收入的分析

为了了解医生目前的收入水平和业余医疗服务收入方面的情况，我们对山东省一、二、三级公立医院各1所的所有临床医生进行了有关收入和收入结构的问卷调查、结果表明：公立医院的医生在医院获得的正式劳务报酬不高；从事业余医疗服务收入能够提高医生收入水平；业余医疗服务对医生的职称、工作年限等要求较高。在今后的卫生改革中，必须重视医疗服务定价中医生的技术劳务价值，提高医院总支出中人员经费、工资总额所占的比例，制定医生兼职政策，规范、管理医生业余医疗服务活动。     

Ausbildung zum Arzt: Was ist erreicht, was bleibt zu tun?

The reform of the education of doctors with the regulation for licensing of doctors (Approbationsordnung) of 27 June 2002 was a fundamental one. The results of the reform are a better practical training, a better link between theoretical and practical education, a better training in general medicine and a reform of the examinations. As a further result of the reform the additional practical training of 18 months could be abolished with the law from 26 July 2004. Now the universities must transform the regulation into practice and evaluate it. The universities must implement the federal regulation in their university educational regulations and in their day-to-day practice. The further changes in Europe, in the German regulations of specialisation and in the German health security system will create new needs for forthcoming reforms.     

西安市乡镇基层疾病预防控制现状与对策

目的了解西安市乡镇基层疾病预防控制工作情况。方法由经过培训的调查人员按统一标准要求对3个有代表性的农村区县的9个乡镇卫生院、8个村卫生室进行调查。结果乡镇卫生院普遍基础设施较差,缺少常用的医疗设备和业务精通的专业人才;1／3以上的乡医是70年代的赤脚医生,1／3～1／2的乡医是各区县卫校毕业生;乡医工资未能完全落实,防保人员1人身兼数职。结论乡镇基层卫生院基础设施较差,防疫人员不足,整体素质低,建议政府应加强财政支持和人员培训。     

医护人员健康教育专业知识水平的调查与分析

目的通过对医院医护人员健康教育专业知识的调查,了解医护人员学习与掌握健康教育专业知识的情况与水平。方法查阅医院健康教育工作档案相关资料,现场对医护人员进行询问,利用A、B两种健康教育专业知识试卷对医护人员进行测试。结果对医护人员进行健康教育专业知识培训的医院为69.2%,未培训的医院为30.8%;医护人员健康教育专业知识知测试及格的医院为53.8%,不及格医院为46.2%;健康教育专业知识晓率达标医院为15.4%,不达标医院为84.6%;医护人员健康教育专业知识及格率为66.7%,知晓率为64.1%;健康教育专业知识错题率最高的为基础知识。结论医院领导对开展医护人员健康教育专业知识培训的认识不足;负责健康教育的专、兼职人员责任心不强;医护人员自觉学习健康教育专业知识的很少;健康教育的业务指导、检查不到位等,是医护人员健康教育专业知识缺乏的主要原因。     

The migration of doctors to and from Germany

Aim  To analyse the role of Germany in the context of the strong international migration of doctors. In doing so, the migration of German doctors abroad and foreign doctors to Germany is qualitatively and quantitatively presented. Subjects and methods  The annual statistical reports from the country's medical associations given to the Federal Medical Association were investigated on migratory movements. Furthermore, a survey on how many German doctors are working in these countries was done within relevant organisations in some European countries and the US. Results  Germany is affected by an international migration of doctors in two directions. German doctors are emigrating and as well foreign doctors are immigrating. The exchange is not balanced, Germany loses more doctors every year to foreign countries than it gains through immigration. Discussion and conclusions  The increasing emigration of German doctors reinforces the shortage of doctors in Germany. In addition, the functioning of the German health system increasingly depends on the immigration of foreign doctors.     

Do more health insurance options lead to higher wages? Evidence from states extending dependent coverage

Little is known about how health insurance affects labor market decisions for young adults. This is despite the fact that expanding coverage for people in their early 20s is an important component of the Affordable Care Act. This paper studies how having an outside source of health insurance affects wages by using variation in health insurance access that comes from states extending dependent coverage to young adults. Using American Community Survey and Census data, I find evidence that extending health insurance to young adults raises their wages. The increases in wages can be explained by increases in human capital and the increased flexibility in the labor market that comes from people no longer having to rely on their own employers for health insurance. The estimates from this paper suggest the Affordable Care Act will lead to wage increases for young adults.     

Medicine as social science: Rudolf Virchow on the typhus epidemic in Upper Silesia

Rudolf Virchow's Report on the 1848 typhus epidemic is one of the neglected classics of "social medicine"--a term he did much to popularize. His analysis of the epidemic emphasized the economic, social, and cultural factors involved in its etiology, and clearly identified the contradictory social forces that prevented any simple solution. Instead of recommending medical changes (i.e., more doctors or hospitals), he outlined a revolutionary program of social reconstruction; including full employment, higher wages, the establishment of agricultural cooperatives, universal education, and the disestablishment of the Catholic Church. This article includes the first English translation of these long-term recommendations. It also locates Virchow's Report within the context of the Medical Reform Movement of 1848 and traces his influence on the subsequent development of social medicine. Parallels are drawn between Virchow's attempts to reform health care and current developments in the political economy of health.     

Variations in general practitioners' views of asthma management in four European countries.

The aim was to identify differences and similarities in views regarding asthma management among general practitioners in four European countries (Germany, Netherlands, Norway and Sweden), and to explore reasons for suboptimal performance. The results are to be used for the development and tailoring of educational interventions. Semistructured interviews with 20 GPs in each country were conducted and analysed using a phenomenographic approach. The domains of (i) general view of asthma, (ii) the doctor-patient relationship in managing asthma, and (iii) overall management of asthma (treatment goals and evaluation of results) were approached during the interviews. There were different ways of experiencing phenomena related to asthma management both within and between the four countries. Three general views on asthma were found where different perspectives were emphasised: a medical, a 'global' (including community health, social and environmental aspects) and a patient's perspective. Within the medical perspective, only a few German doctors emphasised a psychological aetiology of asthma. The views on the doctor-patient relationship described as 'authoritarian', 'teaching' or 'empowering' occurred similarly in all countries. The majority of the doctors showed confidence in the effectiveness of the pharmaceutical treatment of asthma, some doctors were concerned about limitations, but only in Germany a few doctors were explicitly critical of the values of conventional pharmaceutical treatment. The main treatment goals were either conceived as getting the patient symptom-free (Netherlands, Norway, and Germany) or to control the inflammatory process (Sweden). Several German and some Norwegian doctors expressed the view that patients had to accept the disease and learn how to manage it, while a few German doctors aimed at alternative treatments of asthma. The existence of qualitatively different ways of experiencing asthma management, both in and between countries, calls for consideration when trying to implement general evidence-based treatment guidelines. A variation of approaches in continuing medical education for GPs is needed to address such existing beliefs and conceptions that could sometimes be opposed to the content of educational messages.     

Die Gesundheit von Kindern und Jugendlichen in Deutschland

The deficits in our knowledge of the health status of infants, children, and adolescents in Germany are large and significant. To close the gaps, the concept for a national, representative health interview and examination survey of the young generation has been developed by the Robert Koch Institute supported by the expertise of German and international specialists. The development of the concept, study design and methodology took several years. After a pilot study, which took place over a period of 12 months and involved 1,630 young people aged between 0 and 17 years, the concept, design and materials were thoroughly revised. The survey will start in 2003, and include about 20,000 individuals in this age range. It will be the most comprehensive health study of young people ever undertaken in Germany. The funding comes from the German Federal Ministries of Health and of Research and Education, as well as from the Robert Koch Institute. Over a period of 3 years, participants, randomly selected from the registries of inhabitants, will be medically examined and their parents interviewed. From the age of 11, the youngsters themselves will also fill in a questionnaire serving as an additional source of information. The data obtained will form the basis for a National Health Report on children and adolescents, open new fields of prevention and intervention, and support the research of the scientific community as a Public Use File which will be available 1 year after the end of data collection.     

Nurses’ labour supply with an endogenous choice of care level and shift type

It is argued that increasing wages will not only attract more nurses to the health sector, but also increase the number of hours worked for those already there. This article focuses on the response of registered nurses employed in the public sector when they are allowed to endogenously choose between jobs in hospitals and primary care and between day and shift work. A structural labour supply model is estimated on Norwegian micro-data with job-specific wages and hours. The simulation of an overall public wage increase indicates a reduction in total hours. Thus, in contrast to the claim, the income effect seems to dominate in the labour supply of health sector employees.     

Förderung der Versorgungsforschung durch die Bundesärztekammer

The 108th German Medical Assembly adopted a 6-year support initiative for health care research in order to contribute to the further development of this young scientific discipline which has not yet been sufficiently established in Germany. The program is focussed on the following subjects: (1) influence of economic changes on outpatient and inpatient medical care, (2) implementation of medical guidelines in medical routine and (3) the physician factor. Setting methodical standards in this new field and opening up access to medical data should provide a relevant impulse to health care research in Germany. The promoting strategy of the German Medical Association will be completed by initiating a network of scientists, research promoters and health care players.     

上海市病人反应性的分析

通过对上海市三级综合医院、三级专科医院、二级区（县）中心医院、街道医院和乡镇卫生院的典型调查，考察了门诊和住院病人对卫生系统反应性的认识，大部分病人反映可得到及时的关注，能方便地从社区或新闻媒体获得就医信息。超过半数的门诊和众议院病人认为有治疗自主权，选择医生或护士的比例也在增加。多数病人会把个人稳私无保留的向医生陈述，并能得到医务人员对病情的合理解释。说明上海市卫生系统改革注重病人的反应性，取得了较好的效果。     

On the effect of prospective payment on local hospital competition in Germany

The introduction of prospective hospital reimbursement based on diagnosis related groups (DRG) in 2004 has been a conspicuous attempt to increase hospital efficiency in the German health sector. As a consequence of the reform a rise of competition for (low cost) patients could be expected. In this paper the competition between hospitals, quantified as spatial spillover estimates of hospital efficiency, is analyzed for periods before and after the reform. We implement a two-stage efficiency model that allows for spatial interdependence among hospitals. Hospital efficiency is determined by means of non-parametric and parametric econometric frontier models. We diagnose a significant increase of negative spatial spillovers characterizing hospital performance in Germany, and thus, confirm the expected rise of competition.     

深圳市第二人民医院医护人员健康教育服务状况调查分析

目的了解市级综合性医院医护人员健康教育服务状况。方法采用随机抽样方法运用自编问卷对医院的医护人员进行调查。结果医护人员对健康教育理论知识掌握程度尚不够(知晓率为89.7%),90%左右的医护人员能为病人提供健康教育服务。在对门诊病人进行口头健康教育、对住院病人进行病因与康复健康教育、饮食指导健康教育以及出院健康教育等四个方面,医生与护士的参与比例存在统计学差异(P<0.05),医生高于护士。在运用图画或模型等辅助工具对病人及其家属进行健康教育方面医生与护士之间存在显著的统计学意义(P<0.05)。结论医务人员在健康教育工作方面的力度尚不够,应转变传统的医疗为主的观念。     

Rudolf Virchow on the typhus epidemic in Upper Silesia: an introduction and translation

Rudolf Virchow's Report on the 1848 typhus epidemic is one of the neglected classics of ‘social medicine’— a term he did much to popularise. His analysis of the epidemic emphasised the economic, social and cultural factors involved in its aetiology and clearly identified the contradictory social forces that prevented any simple solution. Instead of recommending medical changes like more doctors or hospitals, he outlined a revolutionary programme of social reconstruction; including full employment, higher wages, the establishment of agricultural co-operatives, universal education and the disestablishment of the Catholic church. The present paper includes the first English translation of these long-term recommendations. It also locates Virchow's Report within the context of the Medical Reform Movement of 1848 and traces his influence on the subsequent development of social medicine. Parallels are drawn between Virchow's attempts to reform health care and current developments in the political economy of health.     

Stand, Möglichkeiten und Grenzen der Telemedizin in Deutschland

In Germany there are many successful special applications of telemedicine. However, these projects are generally not extendable to the whole nation because of the highly complex German health care system, limited funding, heterogeneous IT standards in ambulatory and hospital care, insufficient official electronic health card use, the different data protection and privacy regulations of the federal and state governments, doubts of physicians and patients as well as unequal costs and benefits for the various persons involved in telemedicine. These problems can be overcome by better legal regulations for a seamless interaction of ambulatory and hospital care, improved IT standards and support of the interoperability of telemedical and other health care IT, adaption of the health care organization, work flow and reimbursement of telemedicine services, better information and education of all persons involved about the necessity and limits of telemedicine. There are no doubts about the benefits of telemedicine but to achieve these advantages for the whole healthcare system in Germany requires much work, time and good will.