My exchange hospital was in Korneuburg, a small market town north of Vienna. It is easily accessible from Vienna by a 30 minute journey with the Schnellbahn. The hospital is less than five minutes walk away from the picturesque town square. When I first arrived a dusting of snow completed the atmosphere created by the Christmas market and lighting around the Town Hall.
The Landesklinikum Weinviertel in Korneuburg is the result of a recent restructuring of the local hospitals. It is home to surgical specialties like surgery, urology, and anaesthesiology including an intensive care unit. There are 18 gynaecology and 12 obstetric beds catering for about 600 deliveries per year. There is no neonatal unit on site. High risk obstetric patients have to be transferred. A retrieval team will collect any baby who requires NNU admission unexpectedly. For a medical or other non-surgical opinion patients also need to be transferred.
The hospital is spacious, absolutely spotless, pleasantly furnished and well equipped. It also seems to be a very safe place. I do not remember seeing any devices on babies or cots to prevent abduction. I was met with surprise when I voiced concerns that my laptop would be left in an unlocked on-call room. I later saw laptops in use in the labour rooms and various offices – and they were still there three days later!
Differences in clinical practice
Despite being a low risk unit the Caesarean Section rate is 27%. No rotational vaginal deliveries are performed. Forceps are “banned to where they belong – the museum” (the words of an Austrian colleague). Only the Ventouse may be employed for a lift-out instrumental delivery.
On the other hand, breast-feeding is very popular. The midwives seemed surprised that this is an issue in the UK. They estimate that 95% of their mothers intend to breastfeed, and at least 75% do so when discharged from hospital. The support while in hospital seems excellent with relatively more midwives' time available per patient. Patients stay much longer in hospital post-partum than they do here. There is a new trend to book a “family room”, enabling fathers to stay overnight, too. However, the new mother may find herself without professional support once she leaves hospital. It is her responsibility to find a midwife for postpartum care. The cost for this will be refunded by the health insurance provided she has left hospital early enough.
There seems to be a happy and relaxed co-existence of conventional medicine with supplementary medicine. I saw notes advertising the services of acupuncturists etc. During a lull in their work midwives were busy making up home-made teabags of various herbal teas said to aid breastfeeding and other issues around childbirth.
I have been very impressed with the level and broad spectrum of gynaecological care available in Korneuburg. We witnessed a laparoscopic hysterectomy which was done very smoothly in one hour's time. There were also oncological patients on the ward who really appreciated the continuity of care. Having had their surgery locally, they were able to have their chemotherapy in the already familiar ward close to home. An oncologist comes to visit to decide on the regime etc.
The division of tasks amongst various doctors and other health professionals is different in Austria from the UK. In Austria breast surgery is often part of the hospital gynaecologist's brief. Doctors are more involved in low risk pregnancies than in the UK. There are many office gynaecologists who perform routine antenatal care, family planning, cervical smears etc. These are not part of a general practitioners' workload. In Korneuburg antenatal screening takes place in the hospital. An obstetrician/gynaecologist will counsel the pregnant woman and then perform the ultrasound scan. Ultrasonographers seem to be unknown. Ultrasound is performed by the obstetrician/gynaecologist and forms part of most clinical examinations. If a clinical room has a trolley with specula and gloves, it usually has an ultrasound machine, too. Another difference is that obstetricians take some responsibility for the care of the newborn, for example the first post-natal check-up before discharge from hospital.
Medical Training
In Austria undergraduate training takes at least 6 years. Until recently it was said that anybody with enough stamina (and financial resources) could become a doctor, because you could retake your exams as often as you liked. Allegedly, some doctors took up to 20 years to qualify… Whether or not this is an urban myth, the authorities are busy tidying up this anomaly. After graduation the young doctor has a choice of entering a three year rotation as a “Turnusarzt” or going straight into specialist training. The Turnusarzt rotation ends with an exam to become a general practitioner and gain the “ius practicante”, the right to treat patient independently, without direct or indirect supervision. It is very difficult to get into specialist training. I got the impression that the process is a little opaque and you are expected to “wait your turn”. The postgraduate training for obstetrics and gynaecology takes at least 6 years. Two of those years have to be worked in specialties other than obstetrics and gynaecology. For this reason most doctors do the Turnusarzt-rotation first. It gives them already one qualification and ticks the elective “box”. At the cost of only one extra year they have a “plan B” in place in case they never get into the specialist training programme.
Postgraduate training is less structured than in the UK. You can do all your training in one hospital, but are likely to benefit from different case mixes in different units.
After specialisation, you have the option of going into your own practice and become what is best described as an office gynaecologist. The “market” is at present well saturated with obstetrician/gynaecologists. Starting your own practice in the current climate may expose you to the risk of not attracting enough patients to make your business viable. This is only one of the reasons why most doctors prefer to stay in the hospital environment. However, they are entitled to work privately, too. Most of the specialists in the hospital in Korneuburg had one or two fixed sessions per week in a practice outside the hospital.
Staffing and working pattern in Korneuburg
The department consists of the Primararzt (head of department), 6 full-time and 2 part-time qualified obstetrician/gynaecologists (7 WTE), one O&G trainee and one Turnusarzt. The specialists are consultants in the UK sense in that they are entitled to practice independently and most practice privately for one or two sessions per week outside their hospital contract. However, within the hospital they do not have their own named patients. They are resident-on-call. The trainee is covered by a resident consultant when on-call. The only doctor not on the rota is the Primararzt. The Turnus doctors are on a hospital-wide on-call rota and cross-cover across the specialties at night. This makes their on-call very busy and means their on-call experience is often limited to siting venflons etc. rather than gaining meaningful specialty-specific expertise.
The working day begins at 8am, on operating days at 7.45 with the morning handover. This is compulsory for all doctors in the department and is also attended by the shift leaders on the gynaecological ward and the obstetric ward. The on-call doctor reports any admissions, deliveries and other notable events. Then they go through the list of inpatients. On operating days, the list is also discussed. In this way, everybody is up to speed with what is happening. Management of specific patients may be discussed and decided.
The division of labour for the day, i.e. who does which wardround, who goes to the walk-in service etc. seems very adhoc. There does not seem to be a long-term day rota. However, for the operating list, there is some long-term planning in that there may be visiting colleagues from Vienna to lend their expertise for specific cases. The working day officially finishes at 2pm, but in reality you saw more than just the on-call doctor working after 2pm! The obstetrician/gynaecologists are supposed to go home after their night on-call. Only the Turnusarzt has to battle on.
Of the different activities during the day the “Gyn Ambulanz”, effectively gynae outpatients, emergency and walk-in centre all rolled into one, offered the most variety. The fact that patients can effectively walk in with any complaint makes the service very accessible, but may lead to unnecessary duplication of investigations. A patient we saw on Monday had seen a urologist privately on Friday for a long-standing complaint of mixed urinary incontinence. He alleged prolapse as the cause and advised a gynaecological opinion. So she decided to pop in to see us without referral or any of her previous numerous investigations! The same morning we saw a woman who was referred by her gynaecologist for termination of pregnancy. This is available on demand up to the gestation of 14 weeks. Medical termination is managed on an outpatient basis, but can only be prescribed from a hospital. The patient is advised on how to take the medication and what to expect. She takes the Mifepristone under supervision and is sent home with the Misoprostol. She also receives a follow-up appointment to ensure completion of the termination.
The doctors seem to be happy with their lot. They appreciate the combination of some independence in their private practice and the support of and interaction with colleagues and opportunity for ongoing professional development at the hospital. Their hospital contract is for a 37 hour week. However, everybody is working overtime which is paid per hour worked.
Workforce planning
As in the UK it is very difficult to get the number of doctors right. As already indicated, the “market” for specialists in their own practice is very saturated. This means that colleagues currently completing their training are reluctant to leave the hospital setting. Wherever possible they stay in their contracts. This is currently leading to a reduction in available training posts.
The head of the department, Primar Peter Safar, is currently engaged in an interesting exercise run by the University of Krems and the public body which runs the hospitals in the region. They are trying to calculate the number of doctors needed by mapping the activities currently undertaken by doctors and calculating the time needed for that. This is welcomed by the doctors, because they expect that it will help the authorities to recognize the amount of work currently undertaken by them and support the case for the creation of more jobs.
Conclusion
Despite the short duration, the exchange visit and following meeting allowed insight into a number of differences in clinical practice and training. Although the systems are very different a lot of the issues, e.g. workforce planning, financial constraints, etc., are the same. ENTOG and EBCOG provide a good forum to learn from and with European colleagues. We should make good use of these networks to help improve the care for our patients in the long term.
Charlotte Smith
December 2007