Abstract
We know that the number of foreign physicians in Germany has at least tripled since the early 1990s from 10,275 in 1993 to 34,706 in 2014. The published PhD of Juliane Klein deals with the contemporary shortage of medical professionals in Germany, as hospital administrations in predominantly deprived regions increasingly tend to recruit non-German physicians. This qualitative study analyzes highly-skilled migrants’ actual integration and focuses primarily on Central and Eastern European (CEE) migrant physicians in German hospitals.
Migrant physicians account for at least 10% of all physicians practicing medicine in Germany nowadays. The majority of foreign physicians in Germany come from Romania, Greece, Austria, and Poland, although the number of medical doctors from the European Union (EU), particularly post-accession (2004) CEE countries – like Latvia, Hungary, Poland, Romania, Bulgaria, Czech Republic or Lithuania – has increased dramatically in the 2010s. At the same time Germany observes a dramatic shortage of physicians, especially in the eastern (former GDR) regions, due to demographic aging, structural work time regulations, preference among physicians for urban work-life environments, and an increasing trend among younger physicians of both genders towards part-time work in order to ensure a better work–life balance.
Klein’s study presents several strengths and makes a most-needed contribution to the still relatively scant evidence of highly-skilled migration into the German public health context. As Klein notes correctly, integration of highly-skilled migrants is often perceived as an unproblematic issue in contrast to low-end work migration and discourses on deskilling of certain job fields by introducing ‘cheap’ labor from CEE countries to the European Union. However, Klein shows that the liberalization of access to the medical profession is lacking sustainability in terms of integration of highly-skilled physicians into the local workforce. Interaction with lay patients and colleagues does not only require medical expertise and language skills, but also familiarity with the local culture, implicit knowledge, and routine with informal procedures. Therefore, implementation of supportive structures by receiving employers needs to be ensured, but is so far often missing as migration is perceived as an individual and non-collective task.
By applying an exploratory-qualitative approach and interviewing human resource managers or medical directors (n = 9) and 21 CEE physicians from seven hospitals in rural and urban areas in eastern, western and northern Germany, Klein links two levels of analysis. First, she is interested in the organizational recruitment of foreign physicians by hospital administrations. Second, next to individual motivations to migrate Klein reconstructs subjective perceptions of CEE physicians’ working situation. The inductive-deductive analysis identifies that factors such as hands-on training and informal recognition play a central role in the workplace integration of CEE physicians. Even a group of highly-skilled migrants – such as highly-educated medical doctors – can be possibly unsupported in key aspects of developing and exercising new skills or competencies.
The migration of CEE physicians to Germany is clearly demand-driven and shares a lot of similarities with the EU post-accession (2004) East–West migration to the UK. In terms of hospital administration recruitment strategies, the findings reveal differences with regard to size and location, as well as tensions and attitudes of human resource managers towards CEE physicians. Especially rural hospitals declare that they would not be able to keep their hospital running without hiring foreign physicians, while city hospitals state they rely only partially on migrant doctors. Rural hospitals recruit physicians from abroad more actively and systematically and are better attuned to assist migrant physicians in terms of accommodation, language courses, and useful support in bureaucratic procedures. However, hospital managers are also dissatisfied with their dependence on a foreign workforce as they cannot be very selective in their recruitment, and ask for governmental solutions to address the shortage. The liberalization of access regulations to the medical license for highly-skilled foreign physicians in Germany is perceived as a rather problematic and unsustainable measure. However, the large majority of hospital administrations reveal quite high and unrealistic expectations of foreign physicians, such as expecting them to function immediately in order to fill the existing vacancy. At the same time, adequate induction into the local work routine is rarely provided and the fact that foreign physicians were trained in different medical systems is not systematically addressed and reflected in practice.
Migrant physicians from the CEE, for their part, intend to establish normality and stability in their professional life by moving to Germany. They have clear ambitions to advance their careers as physicians within a modern and attractive healthcare system, as is the German context perceived. Institutional regulations on recruitment strategies and already existing social networks among CEE physicians facilitate moving to Germany. Most CEE physicians intend to stay in Germany long-term, while they are mostly employed in remote, rural areas that German-trained medical students and doctors tend to avoid and perceive as unattractive for work and life. Foreign physicians also perceive barriers such as, to some extent, a devaluation of their cultural capital and a loss of status as medical doctors within the respective hierarchical structure of the hospital. This relates not only to conflicts and mistrust at work with colleagues such as nurses, but partly also to perceived discrimination, symbolic exclusion, and adverse stereotypes that devalue CEE physicians due to their origin. Implicit, and tacit knowledge, respectively, was found to be an important mediator to transfer professional knowledge and skills, and for the local work culture and situational components of language proficiency. Still, foreign physicians have trouble fulfilling their envisioned role as medical professionals because they are, especially at the beginning, not able to perform their tasks independently and are therefore afraid not to appear competent in contact with both colleagues and patients. This may result in discomfort and limited self-esteem. The majority of CEE physicians report insufficient or non-existent support on the part of the hospital administration, which limits quick adjustment to the local work culture. The reluctant and unsupportive attitude of the hospital administration is one of the most striking and interesting findings, which point to the need for systematic integration into the local work environment.
However, there are some weaknesses and serious limitations of Klein’s study that must be critically discussed. The qualitative analysis yields interesting empirical results, but sociological readers may miss substantial theories or models. Except for conceptual approaches to the transfer of skills, researchers may miss traditional organizational or implementation theories from social sciences. Having said this, we do know and acknowledge that medical sociology and public health research are predominantly empiric-driven. The study focuses exclusively on physicians from the CEE (Czech Republic, Bulgaria, Hungary, Latvia, Poland, Romania, and Slovakia), but a relevant and growing proportion of non-EU physicians in Germany are from Arab-Muslim (e.g., Syria, Egypt) or European non-EU countries (e.g., Russia, Ukraine, Western Balkans/ex-Yugoslavia). Foreign physicians with different skin color or Arabic appearance may experience the identified barriers in daily life differently or may even be exposed to a higher degree of discrimination, racism, and hostility (e.g., Orientalism, Islamophobia) than ‘white,’ ‘Christian’ physicians from post-socialist EU countries. The quantitative descriptive data on foreign physicians in Germany derive in part from the year 2012, but could have been at least updated to 2014/15 for the study that was published in 2016, as the number of Syrian and Western Balkan physicians for instance increased significantly in 2015. Issues of brain drain for the CEE and mechanisms of externalizing risks and adverse outcomes from European centers (like Germany) to peripheral healthcare systems (like CEE countries) are mentioned by Klein, but neither theoretically nor empirically sufficiently critically discussed as sociologists would expect. However, this intra-European imbalance and unequal distribution of skilled medical professionals is probably one of the most striking problems to solve in the future of EU health policies. The continuous reference to Germany as a country with a ‘liberal immigration policy’ throughout the book may appear problematic to some readers, as this may hold certainly for highly-skilled EU migrants from the CEE, but not necessarily for migrants with medium or lower educational levels from non-EU third countries like African or Middle Eastern regions. Structural barriers in gaining access to the German labor market still exist for lower-skilled migrant groups that are considered ‘unwanted’ migrants or discursively perceived as people who just want to migrate into the German social welfare system, such as discriminated minorities from the CEE (e.g., Sinti and Roma). Therefore, the permanent reference to Germany as a country with a ‘liberal immigration policy’ in relation to highly-skilled migrants raises some substantial concerns of partiality and conditionality.
Overall, this doctoral thesis is an important contribution to the field of medical sociology at the interplay of organizational and migration research. The finding that a transfer of professional knowledge and skills for highly-skilled migrants is far from a smooth and simple one-way road highlights the need for practical enhancement of existing supportive structures for foreign physicians within the healthcare system even beyond the German context. Klein’s book asks for an implementation of supportive structures by receiving employers and reminds us that migration/integration should not be understood as a simple individual, but rather collective task.