(Archive piece, first published in April, 2017)
As he enters the monumental building, headphones in his ears, and heads for the green elevators at the end of the hall, Felix Wiesner is unruffled by the scenes of haste, pain and ennui unfolding around him.
After a long wait, he steps through the doors, casually noticing an old man bleeding heavily out of his nose into a paper tray. The elevator chimes at every floor, spilling out staffers rushing to their stations, navigating the labyrinthine orange-tiled and grey-floored halls. Arriving on his floor, Felix passes bedbound people in blue gowns reaching for attention from white smocks brushing past. Finally, he reaches the back, dons his white coat, straps on his sneakers and steps out into the hall. Another work shift at the AKH, Vienna’s General Hospital, has begun for the young surgical resident.
Healthy does it
“Initially, I wanted to study law,” says Felix, 25. “But then I was among the 100 best performers of 9,000 candidates for the medicine entrance test. So I tried it.” After six months in a U.S. hospital in his second year, he was hooked. “I realized that I was really good at it and can accomplish great things, and at the same time actually help people.”
Now Felix is doing his surgical residency at the AKH. With more than 9,000 employees and 1,500 doctors, the hospital is one of the biggest in Europe.
As health care systems go, the Austrian one is a little bit like your grandmother: Sometimes eccentric, a bit all over the place, but always fervently committed to your well-being and ready to put in time, effort and money to patch you up, whatever your real (or imagined) ailments. In 2016, Austria spent 10.6 percent of its GDP on health care, amounting to about €4,000 per capita, four-fifths of which is covered by the state and public health insurance, according to the annual study by the Organisation for Economic Co-operation and Development (OECD) “Health at a Glance.” Coverage is nearly universal, thanks to the general statutory health insurance law of 1956 (ASVG) stipulating health care as a “right.” The Austrian state lives up to this claim, earning an excellent 9th place ranking from the World Health Organization (WHO).
With the population aging and chronic conditions like diabetes, obesity or long-term pain becoming more widespread, the Austrian system, like national health services across Europe, is coming increasingly under pressure. Spending in the sector has doubled since the 1970s and while this is far better than the U.S., where it has tripled, it is a challenge for a society that does not want to compromise on the principle of universal health care.
Doctors and patients alike have grievances – from the controversial new working hours law to the elusive specter of the dreaded Zweiklassenmedizin (two-tiered medical system). The Austrian debate, as elsewhere, has its very own special features.
What is similar, however, is the politicians’ dilemma: How to satisfy citizens who want excellent care at affordable prices, without touching structures they have grown fond of – lest voters punish them at the ballot box.
The health care system is a formidable enigma. And even if President Trump didn’t realize it (“Nobody knew health care could be so complicated!” February 28, 2017), one man surely does: Prof. Wolfgang Schütz, former rector of Vienna’s Medical University (MedUni) and a harsh critic of current health care policy.
Make it till you break it
“The health care system in Austria, as across Europe, is on the verge of collapse, because we are simply lacking doctors. But the gravity of the situation has apparently not yet fully dawned on the people in power,” Schütz says. He deplores short-sighted policies aimed at fixing the symptoms with a quick plaster instead of treating the causes.
Twenty to thirty years ago, it took young doctors up to eight or nine years to become a medical specialist, Schütz explains. The system forced them to become both a general practitioners and specialists in their respective field, while piling on care and administrative work. “Poorly paid as they were, they were a cheap way of keeping the sy
stem running without hiring more nurses or secretaries,” he says. In the 2000s, though, that began to change and young graduates started to look abroad to complete their education. “Now, we face a shortage of general practitioners in the countryside and of specialists in hospitals, where the botched implementation of the new working hours complicated matters further.”
The new law, based on a EU directive from 2003, limited weekly work shifts to 48 hours on average, allowing for some exceptions when calculated over half a year. Passed ostensibly to improve both working conditions for young doctors (among other professionals) and the quality of care – who wants to have surgery performed by an exhausted doctor at the end of an excruciatingly long shift, the argument goes – the new rules have shaken the Austrian health care system.
After putting off the changes for years, Austria was jolted into action in 2014 when the transition period expired, and it hastily passed the “Arbeitszeitgesetz” (work time law) of 2015, which cut the maximum weekly working hours from 60 to 48. Doctors, used to working well-paid long hours to keep the system running smoothly, suddenly faced significant losses of pay while hospitals struggled to fill their shifts, all leading to the widely covered Ärzteproteste (doctors’ protests) throughout 2015. The impasse ended with a pay raise of 20–30 percent across the board for many doctors and temporary opt-outs to the new rules for certain groups. Hiring up to a third more doctors to fill some shifts is still very much a work in progress.
Practice, practice, practice
Surgeon in residency Felix understands the protests. “Young surgeons want to get the best training, to be able to treat our patients well and to advance in our careers. But to get there you need exactly one thing: practice, practice, practice. You can have two left hands and become a good surgeon – if you do it 2,000 times.” That morning, Felix had a chance to perform a routine surgery under the watchful eyes of the chief resident, on a patient he had met and prepped the previous day. At the afternoon conference, the whole team debriefed the day’s surgeries, reviewing each patient’s results and progress. Being a surgeon is not just about being an ace in the emergency room – analytical skills, empathy and the self-confidence to inspire trust are just as important.
But it’s never enough. “We can’t get the hours, now even less than before. After six years of training here I can easily do routine surgery on my own, but the more advanced ones I may have performed a hundred times, rare ones only a couple of times. Then a surgeon from the U.S. sweeps in, and has probably done the procedure 500 times – of course he’ll be better.”
Sitting down after the actual end of his shift at 17:30 (the official end was 15:30), Felix tries to get on top of all the documentation, discharge letters and reports he was supposed to write during the day but could not if he wanted to actively engage with patients.
“It would already be much better if we didn’t have these huge amounts of paper work,” he grumbled.
He spends about 50 percent of his time on this Papierkram and one to two hours on the phone, arranging CAT scans, consulting with colleagues, organizing appointments. “When I come back from my rounds, I need 40 minutes just to document.” The solution? “More qualified secretaries and nurses would already help a lot!”
In the meantime, catching up on work in his off hours has to suffice. “All of us have signed the opt-outs, but we are also here in our free time,” Felix confesses. “We want to get stuff done and we want the practice, so we are here.” But unpaid overtime is uninsured, of course, which he considers “ridiculous.”
Does he feel overworked? Not at all. “I love my job.”
Emergency room reloaded
An alternative way to solve the vexing problems of hospitals like the AKH is to convince more patients to consult general practitioners before going to the emergency room. But since these are open around the clock and are free to any insured person – that is, nearly everyone – many Austrians acquired the habit to go there first. As a consequence, the country has 7.7 hospital beds per 1,000 inhabitants, an astonishing 60 percent above the OECD average, fewer only than Japan, South Korea, Russia and Germany. Waiting times can be long, but Austrians seem to roll with it.
“When I go to the emergency room of a university clinic, I know I get the best treatment,” says Thomas Horvath, a 35-year old physical education teacher in Vienna and father of two. “When children hurt themselves at school, I may first ask the school physician for his opinion. But we’ll always also end up at the hospital clinic. Who knows if something may be broken?”
Experts proposed an emergency room fee in an attempt to change this pattern, but encountered fierce resistance. In many places alternative infrastructure does not exist – and some aren’t even sure it’s a good idea.
Set the doctors free?
“The politicians want to set up Primary Health Care (PHC) centers, come hell or high water,” explains Dr. Thomas Szekeres, human geneticist, specialist of clinical chemistry, laboratory diagnostics, board member of the Austrian Ärztekammer (Medical Association), as well as former head of the AKH workers’ council, he is a leader of the doctors’ protests.
“We all agree that local care is essential for a smoothly-running system. But the proposals on the table want to open up PHC to private investors and even non-medical personnel, and establish separate contracts with doctors. This would weaken solidarity and pave the way for a Zweiklassenmedizin.” Some private insurers already offer their own emergency rooms, he notes.
“But with the current levels of pay for general practitioners, we cannot even keep our own doctors in the country, much less attract more for ill-conceived regional care centers.”
The idea of a Zweiklassenmedizin is the perpetual nightmare of the Austrian health care debate, decried by doctors and patients and spurned by politicians eager not to upset their constituents. The reality, though, is more complex, as civil servant Karin Steiner, 61, knows from experience.
After years of chronic knee pain, she finally acceded to her GP’s advice to get surgery. With a non-critical condition, she had a choice of waiting a couple of months, or paying something on top to do it right away in a private clinic. “Luckily, my private insurance covered it and all went well. I even got one room all for myself,” she reports. Still, “the service was not any better than in public hospitals, I must say.”
The choice between Kassenärzte (the vast majority, whose fees are fully covered by the public health insurance), Wahlärzte (to whom you have to pay a top-up) and Privatärzte (where you pay everything yourself) also reflects this layered system. In Austria, thus, additional private insurance mainly helps you get more comfort, more choice of doctor (often those with non-traditional expertise like Chinese medicine) and quicker appointments, but not better treatment, per se.
Both critics and defendants agree on this point and insist fervently that no one needing urgent care will be ever denied.
Caring is sharing
Many existing problems in the system could be alleviated by hiring more paramedics, caregivers and professional nurses, Szekeres points out. Currently, however, jobs in the care sector are so badly paid that most are done by foreigners, many from the new EU member states. The new government scheme proposed by Foreign Minister and ÖVP prodigy Sebastian Kurz, to limit payments of the Austrian family allowance for EU citizens working here whose children are living abroad, amounts to a further cut in compensation for employees in these sectors and could worsen the squeeze, warns Szekeres.
“A real ‘New Deal’,” says Szekeres, alluding to the promised reforms of SPÖ chancellor Christian Kern, “would be a decisive move towards an integrated system where health care, social support, care for the elderly and counselling for the young are all interconnected.” This would allow the different services “to pool resources, information and responsibility and work together towards common goals” – certainly a vision in a country where health care spending is split 40/60 between taxes and social contributions. Under the current system, each is beholden to the federal government and the regions, and reformers are often caught in the web of 18 independent public Krankenkassen (statutory health insurance). These range from the Gebietskrankenkassen (GKK) for the salaried employees in each Bundesland (state), to special funds for public servants, the self-employed, farmers or curiosities like the (publicly mandated) company health insurance of once state-owned industries like the steel group Voestalpine, the Austrian branch of the British-South African paper giant Mondi and the City of Vienna’s very own Wiener Linien.
While most commentators seem to suggest that more money is needed, one way or another they are in fact calling for a smart but daring overhaul of the whole structure.
Bring them home
“We had ten years to set up this new infrastructure, it just didn’t happen,” Felix complains. During his night shift of 12 hours on call, he likes to stop by the nurses’ station for a chat. Understaffing and low pay are concerns they voice, as well as the patients’ increasing confusion with the frequent shift changes. “People often do not feel sufficiently appreciated,” he says. “Especially if you officially are not even allowed to ‘work’ but are still here, since, of course, you want to help your patients.” The doctor shortage is a homemade problem, Felix thinks. “We’ve got 1,600 medical students starting every year at the universities in Vienna, Graz, Linz and Innsbruck. That alone would be enough for a country of our size – but you’ve got to convince them to stay, particularly the ambitious ones. That’s simply not happening. If you want to become a top surgeon, you got to go to Switzerland where they don’t limit your working – and training – time.”
Former MedUni Director Schütz agrees. “You can rearrange doctoral shifts as they do in Germany, so surgeons get more training. You can relieve doctors of bureaucracy and you can set up sensible PHC’s complete with caregivers, pharmacists, psychologists, social workers, occupational therapists and young, better paid general practitioners … None of that costs more money, it just needs brains and guts to do it.” Thomas Szekeres agrees: “Health does cost money. But more importantly, it needs imagination and the courage to call things by name.”
At 9:00, exactly the time he arrived at the AKH the day before, Felix Wiesner is unwinding from his on-call night shift and prepares the handover of his patients to the next surgeon in residency. He takes off his white coat, catches one of the incessantly moving green elevators and reaches the big entrance hall, where the bustle of doctors having a quick snack, patients in blue hospital gowns ambulating about and new arrivals finding their way to the right office is once again in full swing.
Plugging in his earphones, Felix steps out of the big glass doors into the sun of the plaza and takes a deep breath of fresh air. “There really is no job in the whole world I’d rather do,” he says again with a smile and heads off towards the U-Bahn.