German Medical Education has not been described in international journals since the new "Regulation of the Licensing of Doctors" [Approbationsordnung f?r ?rzte (AppO?)], which came into effect in 2003 [⁷], [⁸], [⁹]. This structural reform became necessary when reports from governmental and non-governmental institutions concluded that medical education in Germany did not meet actual requirements in medical care or stipulations from the European Union [¹⁰], [¹¹]. While interest in medical education in Germany was relatively low compared to e.g. The Netherlands or the United Kingdom, it has now gained momentum with the new AppO?, which required substantial changes in the curriculum. The main changes are [⁸]:

• Incorporation of the changed requirements in medical care
• Linkage of theoretical and clinical instruction
• Extension of interdisciplinary and topic-related instruction
• Improvement of bedside training, reduction of lectures
• Reform of examinations
• Strengthening of General Practice
• Evaluation of teaching
• Improving pain management and palliative care

Although of limited importance to medical faculties, for graduating medical students the most tangible change represented the abolishment of the lowly paid 18-month internship [Arzt im Praktikum (AiP)] before obtaining the full license to practise medicine [¹²].

In the following description of the medical curriculum and in the discussion, the main goals of the new AppO? will be referred to.

With few exceptions, the General Certificate of Aptitude for Higher Education [Abitur] is a prerequisite for admission to higher education in a university. It usually requires 12 or 13 years of schooling. Roughly 39% of all school children will obtain the Abitur [¹³]. The Abitur cannot be compared to a high school diploma in the United States; it is closer to the associate degree of US colleges. Secondary school diplomas obtained inside the European Union are mutually recognised; however students with diplomas obtained outside the European Union have to apply for a certificate of equivalence. Undergraduate education e.g. preparatory classes for medical school, prevalent in some countries, do not exist in Germany. Therefore, the term undergraduate or graduate education does not apply in the strict sense.

In Germany, the average age of medical students is 21.4 years when they start medical school [¹⁴]. There are several reasons for this. Germany still has mandatory service of nine months for men either in the military or an alternative civilian service [Zivildienst] for conscientious objectors. Additionally due to waiting time or professional training in other areas, a significant proportion of students are older. Although there is no formal regulation, an age of 40 years is considered the upper limit for entering medical school. Similar to many other countries, the number of women studying medicine has increased steadily and is now exceeding the proportion of male students [¹⁵]. This however is not yet reflected in higher academic ranks.

The number of applicants to medical schools largely exceeds the number of available places; therefore admission is subject to restrictions [numerus clausus]. On average four to five prospective students apply for each place, however there are large differences between the faculties. In Germany, application to medical schools is administered by a federal organisation, the Central Office for the Allocation of Places in Higher Education [Zentralstelle f?r die Vergabe von Studienpl?tzen (ZVS)] [¹⁶]. Criteria for admission are the overall Abitur grade, which is roughly comparable to the American Grade Point Average (GPA), and waiting time. The Abitur is considered the best predictor for successful completion of the curriculum [¹⁷]. Each student can rank and apply to 6 medical schools at once. The majority of medical students (80%) used to be admitted by this process and there is a quota for foreign medical students and the military.

The proportion of students who are selected by the medical schools themselves is supposed to increase to 60%. Usually students apply with a letter of motivation to medical schools. After screening the applications a few are invited for interview [¹⁸]. However the process is time consuming and sometimes the number of applicants is overwhelming. Therefore faculties find it difficult to motivate faculty members to participate in the selection process. There is also often no consensus on the criteria that should be used to select future doctors. Given this situation, the nationwide medical admission test [Test f?r Medizinische Studieng?nge (TMS)], which had been abandoned in 1997, has been reintroduced by some faculties [¹⁹]. The TMS is comparable to the American Medical college admission test (MCAT) [²⁰]. The TMS is not mandatory but allows students to improve their score and their chance of being selected to come for an interview.

In Germany, medical education is structured, not in years like many other countries, but in semesters or in a few instances, trimesters (Hamburg, Hannover). It takes six years (12 semesters) and three months to complete the curriculum, however on average, students require 6.8 years [³]. The curriculum is divided into three sections (Table 2 (Tab. 2)):

• Basic science (2 years)
• Clinical science (3 years)
• Clinical year (1 year)

The majority of medical students follow this track. Some medical faculties have chosen to offer an experimental curriculum [Modellstudiengang] which offers an alternative process to becoming a doctor (Table 1 (Tab. 1)) [²¹].

Until the new AppO?, the achievements of medical students in courses and clerkships were evaluated simply with a pass or fail. Only state licensing examinations were graded. From the faculties perspective the most radical changes with the new regulations for medical education were 1. the requirement to grade each course and clerkship and 2. the reduction of the number of licensing examinations from three to two. Grades are given on an ordinal scale ranging from 1 (excellent) to 5 (fail).

Strengthening the responsibility of faculties had mixed effects. Previously faculties invested only a minimal effort with respect to examinations. This was left to the centrally organised state licensing examination administered by state authorities [Landespr?fungsamt]. Students received certificates [Scheine] with little or no formal assessment in each of the subjects required in order to register for the licensing examinations. Most often physical attendance during the course was sufficient to obtain the course certificate. Only a few subjects such as anatomy required time consuming oral examinations. Previously, on the final licensing examination certificate only one summative grade of the written multiple choice exams and the final oral examination appeared on the diploma.

Now each subject must be graded and appears on the final diploma. On the one hand this has led to the introduction of modern assessment tools to evaluate practical skills like the objective structured clinical examination (OSCE) in several faculties [³³]. On the other hand time and staff consuming examinations turned out to be a burden especially for smaller departments. For example psychosocial sciences in the preclinical section had to stop administering oral exams exceeding their staff capacities.

The new licensing examination consists of a written test with multiple choice questions (MCQs) and an (unstructured) oral examination. The administration and development of MCQs continues to be organised by the Institute for medical and pharmaceutical examination questions [Institut f?r Medizinische und Pharmazeutische Pr?fungsfragen (IMPP)] [³⁴]. Although each medical faculty has its own curriculum, the IMMP has a catalogue of topics covered by the written exams [Gegenstandskatalog].

The first part of the medical licensing examination [Erster Abschnitt der ?rztlichen Pr?fung], traditionally called ?Physikum?, is the first hurdle students have to take. In order to proceed to the clinical section, this examination must be passed. The average initial failure rate is roughly 20%. The examination can be repeated twice; about 5% of all students never pass. This exam is not equivalent to the USMLE step 1 (United States Medical Licensing Examination).

The new second part of the medical licensing examination [Zweiter Abschnitt der ?rztlichen Pr?fung] of the clinical year has colloquially been termed ?Hammerexamen? which can roughly be translated as ?monster exam?. It has replaced three previously separate examinations and covers the entire spectrum of the clinical sciences. It consists of a written exam and a combined oral and practical exam. This exam lives up to its nickname since the previously low failure rate associated with the written part rocketed from 2% to 9%. Only a few students fail the oral and practical examination, which is only one of several reasons that this exam format has been criticised [³⁵]. It is also felt that final year students are less well prepared than previous generations who took the last written examination before entering the clinical year. It is suspected that students focus on preparing for the ?monster exam? and are distracted from clinical practical work and learning [³⁶]. It had been hoped that the tendency of the IMPP to create multiple choice questions around rare syndromes would be abandoned in favour of more interdisciplinary and clinically relevant topics. Although the new case-based format still consisting of multiple choice questions is considered a significant improvement, remembering medical oddities and irrelevant facts still remains important [³⁷].

Ranking of faculties is rather new in Germany and, as elsewhere, dependent on the selection criteria. The German Academic Exchange Service has ranked medical faculties in various topics including research, infrastructure and student evaluation [³⁸]. Ranking based on students? performance in state licensing examination is also available [³⁹]. Adjustment for differences in allocation of resources per capita or the proportion of foreign medical students has a significant impact on ranking.

A student who passes the final licensing examinations is awarded a license to practice medicine [Approbation als Arzt], but does not receive an academic degree with an academic title [⁴⁰]. Graduates are authorised to use the German professional title Arzt/?rztin (Physician), but are generally addressed informally with the honorary title "Dr." [Doktor]. As in other countries, writing a dissertation/thesis is an option required to obtain the academic degree ?Dr. med.?. It is estimated that 70% of all graduates will eventually complete a dissertation, which is perceived to be important for career promotion and to attract patients [⁴¹].

Excellent doctors are the result of an excellent medical education. The new "Regulation of the Licensing of Doctors (AppO?)" has certainly fostered important improvements in the education of medical students in Germany. The increased interest in medical education is documented by the dynamic development of the German Society for Medical Education [Gesellschaft f?r Medizinische Ausbildung] [⁴²] and the introduction of the first postgraduate Master of Medical Education (MME) programme in Germany in 2005 [⁴³]. Previously the only German-speaking MME-program was offered by the University of Bern in Switzerland.

It is uncertain if the goals of the new AppO? have been achieved as there are no official reports available. However, some professional organisations have conducted surveys.

Strengthening the role of General Practice in the face of an anticipated shortage of general practitioners was one of the multiple goals of the reform. Although some faculties have founded new Departments of General Practice, more than half of all faculties have no such department [⁴⁴]. Similarly the stipulated strengthening of palliative care and pain management has also not yet been achieved in all faculties [⁴⁵]. A national survey of teaching in Geriatrics, which had not previously been a component of the curriculum but is now covered by a mandatory interdisciplinary teaching module ?Medicine of aging and the elderly?, revealed that less than half of all medical faculties provide teaching in this topic [⁴⁶].

Mandatory evaluation of teaching was also among the aims of the AppO?. The main purpose of evaluation is quality control but also distribution of funds [⁴⁷]. The last national survey on the evaluation of medical teaching in Germany was performed in 2000 before the reform [⁴⁸]. Multiple evaluations of courses have been reported (selected examples [⁴⁹], [⁵⁰]) however there is no national standard and reporting bias is likely.

Unlike other university programmes awarding degrees to students, medical faculties in Germany are not subject to formal mandatory accreditation and reaccredidation procedures, since the final degree is a license awarded by the state. Although the German Council of Science and Humanities [Wissenschaftsrat] [⁵¹] has evaluated medical faculties, it is left to the discretion of the states as to how to ensure compliance with the stipulated requirements [⁵²]. So far only one faculty has been on probation in 2005. It is conceivable that the states, which are responsible for funding medical faculties, have a conflict of interest given that external accreditation might reveal deficiencies due to under-funding.

Enacting the new AppO? was a pure administrative act and unfortunately was not provided with a budget to ensure its implementation [⁵³]. Medical faculties are facing incredible difficulties to fulfil all the new requirements. The reduction in the number of lectures and rise in bedside teaching has increased the need dramatically for both clinical teachers and available patients. Although lip service is paid to the commitment for medical education, young academics are not rewarded for their efforts, and teaching, which must compete with research and patient care, is sometimes considered a lost cause [⁵⁴].

At the same time, virtually all university hospitals to which medical schools are attached are in serious financial crisis, partly due to a new invoicing system and budget cuts [⁵⁵]. Some of the previously state-owned university hospitals have been privatised (e.g. Giessen and Marburg) or transformed into foundations (e.g. G?ttingen). This has increased the already pressing need for separate accounting of patient care financed by hospital revenues and teaching, and research covered by state grants or third-party funds. This has turned out to be extremely difficult since a significant proportion of the faculty is actively involved in both [⁵⁶]. Only a few medical faculties (e.g. Kiel/L?beck, Dresden/Leipzig) are administered completely separately from university hospitals [⁵⁷]. The funding of medical education has been described in more detail elsewhere [⁵⁸].

In 1999, the Education Ministers from 29 European countries including Germany adopted the Bologna declaration [⁵⁹]. The principal goals of this were to permit easily readable and comparable university degrees within Europe and to introduce a system essentially based on two main cycles, undergraduate and graduate, thus increasing mobility within Europe. In fact the mobility of medical students is already hampered at a national level by the multitude of non-compatible curricula although the Bologna declaration should also theoretically apply to medical education. However, this idea is neither encouraged by the German Medical Association nor some other medical associations [⁶⁰]. The main reason to reject the implementation of the Bologna declaration for medical training is the fear of introducing a fast track ?barefoot doctor?.

I am a general practitioner working part-time in academia and part time in private practice which has influenced my review.

I would like to thank Wolfgang Himmel, Ilidk? Gagyor and Michael M. Kochen for helpful criticism.