Essay

DECEMBER 2022

Attracting tomorrow’s doctors

The workforce shortage in Luxembourg hasn’t spared the healthcare sector. As doctors are leaving hospitals or retiring, the grand duchy will have to find ways to bring in more doctors to keep up with a growing demand.

In 2022, Luxembourg had more than 645,000 inhabitants, a year-on-year growth of 1.7%. The country between 2001 and 2020 saw its population increase by more than 20%, and by 2050, it should reach close to 1m. But who will take care of these residents?

A shrinking medical pool According to a government publication from 2020, which analysed Luxembourg’s healthcare system, Luxembourg has about three doctors per 1,000 inhabitants, and future prospects for Luxembourg’s healthcare system seem less than promising if nothing changes.

Indeed, a 2019 OECD study revealed that 55% of the grand duchy’s doctors were older than 54. The median age, according to the government, stands at 52 years for GPs. While statistics are similar in neighbouring countries, only 5% of Luxembourg doctors are under the age of 35, in comparison to Belgium (10%), France (15%), Germany (20%) and the Netherlands (30%).

Fewer doctors means more work for the rest if new recruits don’t join. The ones who stay--especially those working in hospitals--struggle to keep their heads up and, in turn, might reconsider their options. In October 2022, for instance, six cardiologists handed in their resignation notices to the Ettelbruck hospital complex, citing working conditions.

While the health ministry tells Delano that doctors aren’t fleeing the country, the shortage is clear. Exacerbated by tensions between the Luxembourg medical association AMMD and the ministry, it leads to a stalemate that makes it difficult to attract new or foreign talent [PB1] to Luxembourg. “Action is needed now,” says the national medical student union Alem. “There needs to be sustainable measures so that we don’t stay stuck.”

A tale of two systems For one, the grand duchy needs to accelerate its move towards a digitalised healthcare system. “Given the shortages and the size of the country, we should be focusing on digitalisation,” says regular Delano guest contributor and trained ophthalmologist, Dr Lilani Abeywickrama, who also has experience in the field of health and medical management in the grand duchy. Yet by the first quarter of 2022, only 39 doctors signed up to a

HOW LUXEMBOURG STACKS UP TO NEIGHBOURING COUNTRIES

Doctors per 1,000 residents (2014-2018).

Source OECD.Stat, IGSS

France 3.2

Luxembourg 3

Belgium 3.1

Germany 4.3

digital reimbursement tool that speeds up procedures for patients. According to the health ministry, there are around 4,000 authorised doctors in Luxembourg, 1,800 of which are GPs.

At the heart of the issue is a disagreement between the doctors’ lobby and the government agency eSanté. “During the pandemic, we developed a programme [called DHN] to facilitate reimbursements and make information exchanges between doctors more dynamic,” recounts AMMD lobby group president Alain Schmit. For him, eSanté’s electronic healthcare record project (DSP) isn’t placing the patient at the centre, among other issues.

“Our project is complementary to what the agency developed, but the latter sadly isn’t taking us into account,” he says. On its end, eSanté told Delano’s sister publication Paperjam at the start of November that it was still waiting for the technical specifications of the doctor-led programme.

Saving time through digitalisation The slow resolution of this conflict “is a big issue because political actors don’t agree on it,” explains Alem president Anne Eyschen. The union represents the interests of Luxembourg medicine students at home and abroad. Aiming to encourage the latter to work in Luxembourg, Alem considers the lack of digitalisation as one of the deterrents for potential doctors.

Having witnessed its implementation in the UK’s national health service NHS, Abeywickrama explains that there needs to be a mentality shift about digitalising healthcare. “Digitalisation is not here to replace doctors. It’s an adjunct--you can’t replace a human being.”

A well-implemented system--made uniform across the entire country--could save doctors time on paperwork and communications, avoiding unnecessary administrative work. “I think that what people fear is that it overplays the doctor, but we’re really not at that stage where we follow AI blindly,” reassures Abeywickrama.

Secure digital health records that are accessible to various specialists have many advantages. “As a patient, you get to have your records in your hands, you get to understand a condition better--it’s not fragmented,” explains Abeywickrama. For the doctors, “digitalisation keeps things in one place, it keeps things safe, it allows better communication between different specialists. It gives access to your blood tests, patient records, or even one day maybe prescriptions.” Something eSanté promises for 2023.

Investing in the future Aside from an approach to health records that doesn’t keep up with the times, Luxembourg’s educational offer may also deter potential talent. While the University of Luxembourg has offered a full bachelor’s degree in medicine since September 2020, the possibility of a master’s degree is still under discussion. At the earliest, a master’s degree could be offered in 2023, which Alem’s vice president for external affairs and communications Katrin Frisch considers “too late”.

“Without a master’s degree, the bachelor’s degree just isn’t interesting,” says Eyschen. Unlike other degrees, a bachelor’s in medicine doesn’t lead to concrete opportunities. A 2020 Alem study found that 30% of Luxembourg students didn’t plan on returning to the grand duchy after their studies, having become accommodated to their university’s system and opportunities.

The majority would only consider returning to Luxembourg for personal reasons. As students tend to settle down during and after earning their master’s degrees, it’s “crucial to attract and retrieve people in the 27-32 age bracket.” After this, it might be more difficult to bring them to Luxembourg.

liberal system in hospitals, “career-wise, what’s interesting and advantageous in Luxembourg is that it has a very flat hierarchy compared to neighbouring countries,” says Eyschen.

But more career-driven students might not find their luck. “For us, a university hospital would be a major plus because there are more career opportunities in a university clinic, which again attracts more people,” says Frisch.

Luxembourg, aside from general practitioners, also has a small proportion of specialists, with, for example, 16.4 children’s doctors and 16.9 obstetricians/gynaecologists per 100,000 residents. Currently, the University of Luxembourg offers specialised courses in general medicine, oncology and neurology, and “further consideration is being given to introducing additional specialisations,” per the health ministry.

A university hospital could offer a wider variety of specialisations, attracting more foreign specialists but also allowing local students to complete their training in the grand duchy.

For now, it isn’t on the cards. Until it is, Abeywickrama suggests an alternative: “Maybe we should team up with other universities in the Greater Region.”

Streamlined medical guidelines and paid internships for medical students in their sixth year--a common practice in neighbouring countries that has yet to be adopted in Luxembourg--could also raise the country’s appeal.

A generational need to consider The structure of Luxembourg’s healthcare system has another challenge: the evolution of science and medical practices over time. Young specialists “aren’t trained like before,” says AMMD’s president Schmit. “They’re much more specialised in specific topics, whereas old doctors have a more general knowledge.”

The issue is that by hiring young staff that is too specialised for general roles--in hospitals, for example--these might see their interest and development wane. For the AMMD, the solution to this would be to restructure Luxembourg’s medical system.

“We need congregations where doctors with different specialities within a branch can collaborate,” Schmit says. In theory, these communities would decide by themselves the profiles needed to complete their offer in a given field.

PHYSICIANS BY TYPE

Per 100,000 habitants in Luxembourg, 2020.

Source Eurostat

68.1

Total 298.5

86

21.5 89.6

16.4

16.9

General practitioners General paediatricians OB-GYN

Psychiatrists Medical group of specialists Surgical group of specialists

“Given the shortages and the size of the country, we should be focusing on digitalisation”

Hospitals would not be left aside, as these communities would have to cover hospital shifts, says Schmit. In certain domains, not all hospitals need an on-duty specialist, so instead of seeing some doctors being underemployed, “these communities would look at the grand duchy’s needs on a national level and not [at] each hospital [level].

These communities would also allow for a more developed ambulatory care system, and thus more efficiently distribute the workload between hospitals and external centres.

For Schmit, “we’ve never developed our hospital infrastructures in a way that allows external ambulatory care,” so that if Luxembourg recruited the doctors it needs, it wouldn’t be able to accommodate them. Current government efforts for an ambulatory service centred around hospitals are not sustainable for the long term, says Schmit.

Finding a common ground In the end, “we have to figure out how to attract the good doctors and not just the ones that nobody else wants,” says Schmit. Offering talent a clear, enriching and understandable concept that won’t collapse under the growing demand of Luxembourg’s population might help. More potential to evolve within one’s career and a swift adoption of digitalisation are also crucial for this goal.

While the ministry of health continues to develop its strategy--it, for instance, created a bill allowing young doctors to create doctor companies to be able to get started--the issue seems to lie in the communication.

“I think the doctors should have more of a say because they’re in a better position to create what would be the future healthcare system,” says Abeywickrama.

Schmit concurs: “If you don’t allow young, competent doctors who are ready for modern medicine to be creative, we will end up in situations like the one we’re in now.”

Alem’s Eyschen shares this sentiment: “[Students] have access to experiences abroad and see what works and what doesn’t. We will be the ones who have to work in this system, so please listen to us.”