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Desperately seeking surgeons

One of the most important medical disciplines, surgery, is suffering from a shortage of new blood. What are the reasons for this and what can be done to help? Questions to the founder of the Deutsche Chirurgie Stiftung (German Surgery Foundation).

Desperately seeking surgeonsProfessor Dr. Dr. Ulrich Joos is Director of the Department of Cranio-Maxillofacial Surgery of the University Hospital of Münster
Forschung & Lehre: Surgery is still an attractive profession, yet in Germany it suffers persistent problems with attracting new members. Why is this?

Ulrich Joos: A career in surgery is still a highly contemporary and attractive choice for young medics. It represents an ideal symbiosis of manual skills and extensive medical knowledge. The word "surgery" comes from the Greek meaning "working by hand" in the sense of highly skilled craftsmanship. To achieve such skilled artistry requires a long apprenticeship with all the highs and lows that this entails. In particular, the required manual skills must be learnt successively and continuously practised and improved like a high-level sportsman. This means that those who want to join this profession need to be highly motivated.

F&L: And are there young medics who want this?

Ulrich Joos: Young medics are highly disposed to become surgeons, as demonstrated by the fact that around 45 percent of first-year medical students want to work in a surgical field later. However, this figure drops to around 30 percent after the young medics have passed the second state examination, and to just five percent after they have completed the Practical Year.

F&L: A dramatic drop ...

Ulrich Joos: The fact that, statistically, surgery falls so far out of favour with prospective doctors is certainly due to many causes. One of the main ones, though, is that prospective doctors get to know the day-to-day work of a surgeon during their Practical Year and this is apparently so daunting that they stop wanting to join the profession. In this context, the current restructuring of the healthcare system is definitely highly significant. Doctors' workloads have risen dramatically due to clerical tasks (approx. three hours per day in a surgical field, Deutsche Krankenhausgesellschaft (German Hospital Association), reduced personnel, shift work etc. The hierarchical structures in hospitals have been dismantled to the disadvantage of doctors and replaced by so-called "healthcare managers". Doctors have become little more than accessories to the management in order to achieve economic goals. It is now practically impossible for doctors to have freedom and independence in hospitals. There is also hardly any provision for structured further training for young doctors since the dramatic reduction in personnel means the care needed can no longer be provided, and especially as the new accounting system for hospitals does not allow for this either. Due to the resulting lack of prospects, overwork and dependence, the surgical profession is becoming ever more unattractive.

F&L: How can young people be motivated to join the surgical profession?

Ulrich Joos: The impressive figure of approx. 30 percent of medical students interested in surgery before the Practical Year shows that young people can still be motivated to take up a career in surgery. To stop the dramatic drop in this figure during the Practical Year, targeted action must be taken. In order to promote further training, structured further training catalogues must be developed for individual surgical fields. These must also include practical content so that a young doctor can determine early on whether he is suited to the surgical profession. The further training content could be made available to all hospitals in Germany online and supplemented by corresponding practical courses to provide a blended learning framework. Since hospitals do not as a rule have training experts, this part of the practical training could be provided centrally by emeriti and the relevant chief physicians. The further-training hospitals could then connect to this system and be certified as a qualified further-training hospital. Doctors also urgently need to be freed up from bureaucratic tasks so that they can devote their energy to their actual profession again. A rethink is needed, so that top doctors can be offered the freedom and prospects they deserve. Another factor that must be taken into account is that the proportion of young women in medicine has now risen to around 70 percent. This means that flexible models are needed for working hours so that young women also have the opportunity to work in a surgical field.

F&L: What concrete measures can be taken to address all these problems?

Ulrich Joos: This is where the newly founded Deutsche Chirurgie Stiftung (German Surgery Foundation) comes in. With appropriate support, we aim to establish structured further-training programmes for all surgical fields as blended learning. Because we have already been doing this successfully for seven years in the field of oral surgery, a suitable IT platform already exists. We want to win over highly qualified surgeons and industrial partners to this project through the foundation's board of trustees. The Deutsche Gesellschaft für Chirurgie (German Society of Surgery) has agreed to support us in this. We will also strive to restructure conditions in the surgical fields so that the surgical profession becomes attractive again, in order to maintain the excellent reputation of German surgeons both at home and internationally.

F&L: Are there any concrete plans yet for initial projects, supportive measures, scholarships or prizes?

Ulrich Joos: As a concrete project, we would like to hold an event in Münster in June of next year for medical students and young doctors undergoing further training, possibly in collaboration with the Deutsche Universitätsstiftung (DUS - German University Foundation), aimed at demonstrating the attractiveness of surgery in research and patient care. The preparations for this are already underway: we are drafting concrete plans with our departmental student organisation. We also wish to offer a Ruth Erwig Innovation Prize to promote the recognition of innovative teaching methods, operating procedures or clinical surgical research.

F&L: Can you describe the journey from the initial idea to the establishment of the foundation?

Ulrich Joos: A key trigger was the unsatisfactory situation whereby not enough young medics are willing to begin further training in a surgical field. Other factors were the bequest of Dr. Dr. Ruth Erwig, who was intensively involved all her life in training oral and maxillofacial surgeons, the founding of the German University Foundation of the Hochschulverband (German Association of University Professors and Lecturers), and the positive experiences of the International Medical College Münster with blended learning. In addition, Prof. Dr. Hermann Bünte, emeritus surgeon from Münster and author at the International Medical College, has always supported our idea wholeheartedly and established a link with the German Society of Surgery.

F&L: How great are the foundation's assets currently and are they set to increase in future?

Ulrich Joos: The foundation was set up with the help of several benefactors including the Deutsche Hochschulverband (German Association of University Professors and Lecturers), the Arbeitsgemeinschaft für Elektronenmikroskopie (Electron Microscopy Working Group) (represented by Prof. Dr. H. P. Wiesmann, Chair of Biomaterials, Dresden), Senator h.c. RA A. Maccari (Chairman of the Foundation Board and Supervisory Board of the Augustinum group of companies, Munich), the International Medical College (MIB GmbH Münster), and myself. The foundation's capital is still small, but we envisage that we will be able to increase it rapidly in order to achieve our intended goals. We have already secured some pledges. Notwithstanding this, we are grateful for every amount donated.

F&L: Is the establishment of the foundation also about continuing your scientific life's work?

Ulrich Joos: As a young surgeon, I had the good fortune to meet a number of committed and exceptional personalities in the field who encouraged me to take up this exciting career. The basic surgical concepts were taught to me in a small district hospital by a very talented Iranian surgeon. My subsequent posts included, in particular, with Professor Wilfried Schilli at Freiburg University Hospital and Professor Jean Delaire at Nantes University Hospital in France. This was where I learned the significance of surgical schools and how important role models are, especially in surgery. I also benefited from an exceptional willingness to pass on experience and knowledge to young colleagues and received a huge amount of encouragement both at home and abroad. My wish now is to pass on my own positive experiences to today's younger generation, maintain the high standard of German surgery and motivate young doctors to join this hard-working but highly satisfying profession.

From Forschung und Lehre : January 2011