Actual Situation of Pediatrics in Germany

Academic pediatrics was founded at the end of the 19th century. 1894 Otto Heubner was called to the first chair of pediatrics at the Berlin Charité. In 1918 pediatrics was for the first time incorporated in the medical exam and in 1925 the title “pediatrician” was conferred for the first time. However in the mean time, about 100 years after its official establishment, pediatrics has become a discipline under threat. This is based on the following facts. 

Population development in Germany

In 2009 about 651 000 children were born in Germany, which is about 200 000 newborns less than 1990 and only half of those in 1964, when 1,36 million newborns had been registered. Actually every 5th young woman is childless. This leads to an actual figure of 1.38 children per woman in Germany and corresponds to one of the lowest positions on the scale of European countries. There is a difference between the western part of the republic and the area of the former German Democratic Republic (GDR). In western Germany, a family has in general 2 children, whereas in eastern Germany the standard is the one-child-family. Only every 5th mother has 3 or more children. Also foreign immigrants only have 1.6 children per family, compared to 1.3 children in those of german origin. In the middle of the 70ies immigrant families still had 2.7 children per mother. Until 2060 it is expected that the German population will decrease from 82 to 65 million.

During the last 50 years two causes for the decrease in birth rate can be observed. First, the influence of the birth control pill at the end of the 1960ies and second the German reunion. After 1990 a sharp decrease of the birth rate was observed almost exclusively on the territory of the former GDR. In the GDR the average age of a mother giving birth to her first child was ~21 years. After the reunion of the country this age has increased to now ~29 years.

Actual changes of the medical profession in Germany

Actually there are three changes which have a mayor impact on the medical profession in Germany.

• German physicians leaving the country.
• Increasing amount of foreign physicians in Germany.
• Increasing number of female physicians and its political implications.

During the last 10 years more than 20 000 physicians left Germany. From the year 2000 on there was a steady increase from ~1000 to now ~3000 physicians per year. The main countries of destination are Switzerland, Austria, USA, England and the Scandinavian countries. At the same time an increasing number of foreign physicians is registered in Germany. The number of foreign physicians increased from 12356 in 1994 to 14603 in 2000 to 21764 in 2008. The foreign physicians mainly came from Austria, Greece, Romania, Poland and Russia.

The actually increasing number of female physicians is expected to cause a mayor impact on the society. In 2010 we are approaching 70% female medical students. From 1991 to 2008 the percentage of working female physicians in Germany increased from 33.6 to 41.5%.

This has to be realised on the background that female physicians on the one hand whish to have children and on the other hand in Germany exists the right for part time employment. This will not remain without social-political implications. 

Pediatrics in Germany

At the end of 2008 there were officially 319 897 working physicians in Germany. 11973 of them were pediatricians (3.74%), of which 5233 were male and 5740 female. In the time between 1991 and 2008 the number of children per pediatrician decreased from ~1700 to ~1200.

After the 5 years of medical studies the pediatric speciality training lasts 5 years which concludes with an oral examination at the chamber of physicians. Afterwards it is possible to undertake a subspeciality program of next 2–3 years duration. The available subspecialities can be subdivided into 4 „main specialities” (neonatology, pediatric cardiology, pediatric hemato-/oncology, pediatric neurology) and an additional speciality training with emphasis on 5 subjects (pediatric endocrinology and diabetes, pediatric gastroenterology, pediatric nephrology, pediatric pneumology, pediatric rheumatology). The pediatric subspecialities represent medical progress on the one hand however may be problematic on the other hand with respect to the politicalunity of pediatrics. The latter occurs when subspecialities consider themselves as totally independent and subspecialists only attend their own meetings. This leads to an increasing disintegration. Organ related subspecialities are in danger of being absorbed by the corresponding subspeciality in Internal Medicine. This trend may be heavily supported for economic reasons by the managers of the institution. 

German Society of Pediatrics and Adolescent Medicine (DGKJ)

The DGKJ (www.dgkj.de) represents scientific pediatrics in Germany. In March 2010 the society had 14271 members with a constantly increasing number of females. Actually, in 2010, 68% of the members below 45 years of age and 77% of those below 35 years of age are female.

To characterise the activities of the society, the organisation of the annual congress, pediatric training courses and the production of problem oriented information material for parents should be especially mentioned. The publication organ of the society is: „Monatsschrift für Kinderheilkunde” which is published monthly. 

Pediatric Hospitals in Germany

Between 2000 and 2008 more than 1 200 000 children from 0 to 15 years had to be admitted to a hospital per year. There exists a big discrepancy of available pediatric hospital facilities among the different regions of the country. The availability of a pediatric hospital bed for inhabitants <18 years ranges between 360 in Sachsen-Anhalt (capital Magdeburg) and 1032 in Schleswig-Holstein (Capital Kiel). In many aspects there is still a noticeable difference between the area of the former GDR (“new states”) and the former Federal Republic of Germany (FRG). 23% of the pediatric Hospitals have less than 30 beds. Most of them are located in the area of the former GDR.  25% of the pediatric Hospitals are treating less than 1500 children per year. Again, most of them are located in the „new states”. In the hospitals with less than 30 pediatric beds ~200 children were treated per physician and year whereas in those with more than 100 beds the number of children decreased to ~150.

At the moment there is increasing economic pressure on all German hospitals, however this is especially so for pediatric facilities based on two main reasons:

1. high costs for medical personnel, which in pediatrics are generally 10% higher than in internal medicine and
2. the diversity of pediatric subspecialities and different age groups.

University hospitals in particular are under extreme pressure because besides patient care they have the obligation of medical student training and research. Funding of research is more and more based on impact factors of high quality international publications. This requires highly dedicated and professional personal, which means that molecular biologists, biochemists and biologists are needed. However their adequate funding is almost impossible in many places.

Pediatrics in Germany shows the following points of consideration which have serious and international implications:

• Decreasing number of available pediatricians.
• Increasing feminisation of medicine with all the possible social-political implications.
• Pediatric subspecialists, aiming at independence from general pediatrics, cause the threat that pediatric organ specialities will be integrated into the corresponding subspeciality of internal medicine. This trend is highly supported by hospital managers.
• German politicians, exclusively for economic reasons, are supporting the englisch system of patient care. Then, children would be seen primarily by general practitioners (GPs) and trained pediatricians would be concentrated in hospitals. As within the next few years almost an entire generation of pediatricians in primary care is going to retire, there has to be expected a sharp reduction in the availability of pediatric expertise in primary patient care.

Taking all points together classical pediatrics can be considered as a clinical subject whose survival is in acute danger. These considerations should be brought to political attention.

Prof. Dr. med. Dr. h. c. Hansjosef Böhles

Zentrum für Kinder- und Jugendmedizin

Theodor Stern Kai 7

60590 Frankfurt am Main

Germany