Health care systems serve a growing population that reflects an aging population in most developed nations. Each countries system requires many players in every setting to make it successful. However, doctors are often seen as the unofficial or official leaders, and while practitioners across the globe are referred to as doctor medical education for physicians differ widely. In this comparative paper, I look at the medical education in the United States and Germany and reflect on how each model impacts health care in their respective country.
Medical education in the United States is a large enterprise with 180 medical schools broken into allopathic and osteopathic programs. The allopathic, also known as the M.D. program, make up the majority of the schools with 147, while the osteopathic, or D.O. program, equates for 33 of the schools (Zavlin et al.). Each type of medical education has its own accrediting body ((Zavlin et al.; Weggemans et al.). However, both programs are similar, with the big distinction being that D.O. programs include bone and joint manipulation and a larger emphasis on the natural sciences. The United States sees approximately 53,000 applications for medical school every year and has an acceptance rate of 39.6% overall, with about 21,000 matriculating (Zavlin et al.).
There are two paths to admission to medical school in the United States. The primary route is completing a four-year bachelors with pre-medical requirements which vary by school and completing the Medical College Admission Test (Zavlin et al.). The MCAT is a computer-based standardized test which is also used in Australia, Canada, and Caribbean Islands (What to Expect in Medical School, 2018). While bachelors in pre-med are common, medical schools will also consider students who have complete alternative undergraduate degrees. The second route, which is less common, is a combined bachelor and M.D. program. This combined program waives the traditional application process and often allows entrance without the MCAT but does require the student to choose this route early on in their education (Zavlin et al.).
The medical school curriculum is broken up into two distinct phases. The first two years are generally a mix of classroom learning and lab work concentrated on basic sciences, which is either organized by block, semester, or in an interdisciplinary approach that focuses on a single system at a time (What to Expect in Medical School, 2018). Each school has leeway in curriculum design, and some schools like the University of New Mexico introduce clinical experiences in this phase to assist students in building their interviewing and examination skills. Traditionally, large group lectures are utilized, but new curriculum standards are transitioning teaching models towards problem-based learning and small group activities. Additionally, new technology is providing opportunities for students to develop their skills using mannequin-robots. At the end of the students first two years, and completion of this phase, they complete the United States Medical Licensing Examination (USLME) Step 1. This examination is the first of three steps to obtain a medical license in the United States (Zavlin et al.).
The second two years of the curriculum is focused on the practice of clinical sciences and patient interactions in a hospital and clinical settings. It provides students with a range of knowledge, but not enough to practice in any given specialty (What to Expect in Medical School, 2018). The first year of this phase is structured around exposure to core disciplines which are organized into specific clerkships. While each school is able to dedicate clerkship lengths and specialties, internal medicine, family medicine, obstetrics/gynecology, and surgery are standard. The third-year ends with USMLE Step 2, as well as with students being encouraged to pick a specialty. This leads to the fourth and final year of medical school which is more flexible and allows students to pick clinical rotations that will lead towards their residency (Zavlin et al.). Such clinical experiences require large time commitments from faculty, which have led schools to reach out into the local communities for volunteer faculty at affiliated sites.
In addition to medical school, some students opt to complete combined degree programs. The most common of these are incorporating a Master’s in Public Health or completing a Ph.D. in a selected field of research (What to Expect in Medical School, 2018). These extra programs will extend the students schooling by one to four years prior to starting residency, which is anywhere from three to seven years. To practice medicine in the United States, one has to have completed medical school, passed licensing examinations, and complete at least one year of graduate medical education. However, newly graduated students are able to begin utilizing a title of doctor directly after graduating from medical school (Weggemans et al.).
Residency programs are accredited by the Association Council for Graduate Medical Education and matching largely is done through the National Residency Matching Program. This matching program was created in 1952 to centralize the securing of residency positions across the country. It also makes it easier for international medical students to apply to. However, it is up to each student to apply to selective residency programs and complete individualized interviews (Zavlin et al.). All students who do not require early matching, learn of their residency placement at the same time all over the United States.
Approximately fifty-three percent of medical schools in the United States are public while the remaining are private institutions. Tuition, fees, and health insurance for public universities equal around $34,592 per year for residents and $58,668 for nonresidents with a $20,000 increase for private schools on average. Along with the high price tag, students also have to finance their housing and living expenses. Such costs have led to seventy-six percent of graduates incurring debt, which does not include undergraduate education loans (Zavlin et al.).
A striking difference between medical education in German and the United States is that in German it is largely free. Medical training is mostly tax-funded by each state, where students only pay administrative fees which range from 50 to 90 Euros per semester. While scholarships and loans are available they are used to cover housing and living expenses (Zavlin et al.). There was a structure reform of the curriculum that occurred in 2003 after reports indicated that German medical education did not meet requirements or stipulations from the European Union. As part of this reform, a controversial 500 Euro tuition was removed (Chenot). Now curriculum standards are set by the federal legislature and written into law (Zavlin et al.).
Today, the integrated medical curriculum in Germany consists of two years of pre-clinical basic sciences, followed by four years of clinical after which time graduated students go into residencies. Students are eligible to apply to medical school once they have completed their advanced high school work, which would be comparable to an Associate degree here in the United States. Germany has 36 different public universities that offer medical education with only a couple private ones. Approximately 10,000 new students start medical school each year, and 6,000 graduates. This means that entering classes have around 277 in each cohort and drop to 166 students by the time of graduation (Zavlin et al.; Chenot).
Everyone, even people from other countries, are eligible to apply to German medical schools free of cost. However, admissions are highly competitive with only students with grade point averages of 1.0 to 1.1 out of 4.0 being considered where 1.0 is the highest possible GPA. In Germany, GPA is calculated using grades from students last two years of advanced high school, a research paper, and final examinations. Additionally, students can obtain “bonus” points to aid their admission by participating and passing a standardized exam (similar to the MCAT), by prior military or civil service, completion of a nursing degree apprenticeship, or by illustrating superior performance in science classes during high school (Zavlin et al).
The application process starts with students ranking their top six universities and submitting their preferences to the University Admissions Foundation. This foundation coordinates the placement of all undergraduate students to ensure the best use of capacities of German higher education institutions while ensuring fair and equitable admissions (Stiftung fuer Hochschulzulassung). Twenty percent of the available spots are given to those applicants with the highest GPA including bonuses, sixty percent are awarded via internal process of medical universities which are based on GPA, bonuses, and personal interviews and the last twenty percent admitted are based on how long they have been waiting for admissions to an undergraduate program since completing high school. The 2016/17 admission year awarded spots to people who had been waiting seven years and saw 5 qualified applicants for every available spot (Zavlin et. al.). Currently, the average age of medical students at the start of the program is 21.9 years old, and as seen in the United States, Germany has witnessed a slightly higher female attendance than male (Chenot).
The first two years of medical school in Germany are focused on basic sciences taught in a didactic format, consisting of 16 credits to include chemistry, biology, physiology, physics, psychology, and anatomy. Plus, a 3-month unpaid nursing internship, which is equivalent to a nursing assistant in the United States. After completion of the first phase, students are eligible to apply for the first state board exam. The first board exam is broken up into two parts: part one is a 320-multiple choice exam, and part two is a small group oral exam. Once a student passes the first board exam they can move onto their clinical phase graduation (Zavlin et al.; Chenot).
The clinical phase is broken into two sections with the first encompassing the first three years. During this time students cover 21 two-week clerkships and four one-month selectives (Chenot). The selectives are to include two-months in-patient, one-month out-patient, and one-month with a board-certified family medicine physician. After each of the required clerkships, students complete either a multiple-choice exam, oral/practical evaluation, or essay. Once the student has completed the first section of the second phase they take the second state board exam which consists of 320 multiple-choice questions (Zavlin et al.).
The second section of phase two, and final year of medical school in Germany consists of three 16-week rotations. A sugary rotation and an Internal Medicine rotation are mandatory, while the third rotation is an elective. During this time students are also allowed to do away rotations including international ones (Zavlin et al.). This final year of clinical work is also aimed at providing experiences to aid students in deciding on a residency. While the student is officially done with the required curriculum at this point, some decide to complete additional research or clinic. The final state board exam is a four-hour oral exam, and after successful completion, students obtain a license to practice medicine and can be addressed as a doctor (Chenot). However, seventy percent of graduates eventually pursue an academic title of Dr. med. which required additional scientific activities, publications, and a dissertation, as it is seen as important for career promotion and to attract patients (Zavlin et al.).
Residency programs are anywhere from four to six years in Germany depending on the specialty, and the application process is highly individualized. Newly licensed physicians submit personal applications directly to residency programs, which start throughout the year. While there are government guidelines for hours and compensation, employment length and other minor details are negotiated individually. And often resident physicians have to complete different parts of their program at different sites as one site often does not encompass all of the requirements needed for completion (Zavlin et al.).
In Germany, there are strict standards for obtaining the highest rank of a medical teacher, but current trends in medical education tend towards teaching in small groups and practical settings rather than large lectures. Recent years have seen the inclusion of standardized patients (actors portraying certain symptoms), communication skills, and problem-based learning in multimedia settings as well. Since this type of education requires substantially more faculty, universities are turning to residents, fellows, and senior student participation to fill the gaps just like in the United States (Zavlin et al.).
Similarities and Differences
The United States and Germany have many similarities in their educational models, which include starting the curriculum with a foundation of basic sciences knowledge prior to introducing clinical experiences. While there is a difference in timing and length of each stage, both countries have identified that by setting a groundwork in biology, chemistry, anatomy, pharmacology, and systems sets students up for success when building direct patient skills. Another similarity is the evolving curriculum with the incorporation of practice-based learning and small group activates, as well as intensive faculty mentorship into the clinical rotations. This is in line with adult learning models which move away from didactic lecture and towards more interactive education. The final stage of a residency program also mirrors between Germany and the United States, with the expectation that students move into specialized work at that time.
Key differences in the medical education systems include the integrated education model in Germany which is in contrast with the traditional and disjointed bachelor’s degree followed by medical school in the United States. Additionally, the substantially larger class sizes in Germany is intimidating by United State school standards which cater much more to smaller ratios of faculty to students. However, the potentially the greatest difference between the two medical education systems is the price tag. While German graduates walk away with little to no debt, new graduates in the United States commonly accumulate $200,000 in student loans by the end (Zavlin et al.).
Today’s world is very globalized, and we can benefit from learning from other countries on best practices and things to avoid. Considering the high cost of medical school in the United States it is relevant that newly practicing physicians in the United States can expect to earn upwards of $140,000 straight out of residency, with an expected salary of between $217,000 and $489,000 per year throughout their career (Grisham, 2017). This is in sharp contrast to German students that assume little to no debt and only earn around 48,000 Euros annually straight out of residency, with head physicians earning between 125,000 to 400,000 Euros per year (Wang, 2015). Keeping in mind that Germany is able to see better health outcomes then the United States while the United States spends 6.4% more of its GDP on healthcare (Johnson, 2018), perhaps it is time to look at the impact the high price tag of education is having on our healthcare system.