Life of a urologist in ….Austria
The Republic of Austria is a federation composed of nine provinces on the basis of a parliamentary democracy. In 1995, the country became a member of the European Union. The territory comprises approximately 86,000 square kilometres and is thus about one quarter the size of the Federal Republic of Germany.Austria is currently in a phase of rapid population growth. Since the mid-nineties, the population has grown by more than half a million inhabitants to the current 8.3 million, although the birth rate has continued to decline from 9.8 per 1,000 inhabitants (in 1999) to 9.1 (in 2009). The major reason for this development is an unexpectedly high immigration rate during the last decades.
As in virtually all European countries, the life expectancy of the Austrian population is increasing. From 1999 to 2009, the life expectancy at birth of an Austrian increased for men and women from 74.8 to 77.4 years and from 80.9 to 82.9 years, respectively. These data demonstrate that one of the biggest challenges to social and health policy in the coming years will be the greater-than-average increase in the number of elderly and very old people. Currently some 1.8 million people (22%) are older than 60 years. Based on current statistics, this figure will reach more than 2 million in 2015 and further grow to 2.7 million (32%) by the year 2030. Accordingly, the over-80 age group will greatly increase from 339,000 (2005) to 461,000 (2020) and 590,000 (2030), whereas the 15-60 age group will steadily decline.
HealthcareGiven this demographic development, it is quite obvious that urology is an important part of the national healthcare system. Urological disorders such as urolithiasis, BPH, or urinary incontinence are quite common, and the 2009 point prevalence of malignant diseases such as prostate cancer, bladder cancer and renal cell cancer was as high as 45,000, 16,000, and 13,000 cases, respectively.
Like every other speciality, urology is embedded in our healthcare system. In Austria, the safeguarding of health is a function of government. Although the public health services are a federal matter in terms of both legislation and execution, the necessary responsibilities do not exclusively lie in the hands of the Federal Ministry of Health. Some important responsibilities are also assumed by various ministries at the federal level, by provinces and municipalities, as well as social security institutions and self-administrated public corporations.
Access to individual services of the public health care system is governed by social insurance law based on the model of compulsory insurance. The hospital system – the largest and probably most important part of our healthcare system – is regulated by the Federal Constitution Act, meaning that the Federation is only responsible for legislating basic principles whereas the execution thereof is the responsibility of the provinces. This distribution of competence, however, as well as the variety of financers and the mixture of means of financing (tax revenues and social insurance contributions) requires a significant amount of coordination and arrangements among the various decision-making sectors and the financers.
During the last 20 years, the annual increase of healthcare expenditures was 5.5%. In 2008, Austria spent a total of 29.5 billion Euros for health care which is 10.5% of the gross domestic product (GDP). Although it is impossible to exactly quote the proportional allotment, the spending for specific urological hospital treatment and drug prescription only account for a small proportion of the integrated total.
UniversitiesThere are three public (Innsbruck, Graz, Vienna) and one private (Salzburg) medical universities in Austria. Due to the limited capacity of our academic centres, students have to successfully pass a qualifying examination to enter medical school and the medical degree is earned after six years. After graduating from medical school, a resident has to conclude a training period of six years comprising general surgery (15 months), gynaecology (3 months), internal medicine (6 months), as well as four years of urology. Unlike other countries, in Austria virtually every division or department of urology is acknowledged as a resident training centre. However, the number of residents mainly depends on the size of the institution based on their actual number of beds.At the end of their residency, young urologists have to pass both a theoretical and a practical examination in order to become a board-certified urologist. In recent years, most young urologists have taken the opportunity to become a Fellow of the European Board of Urology (FEBU), because this examination is equally recognised by the Austrian authority. In 2010, a total of 19 residents participated in the EBU examination and their score was fortunately 0.5% above the EBU average. In order to facilitate this examination, and according to the intention of the European School of Urology (ESU), the Austrian School of Urology (ASU) was launched a few years ago, providing both theoretical and practical instructions for residents according to a curriculum that covers all aspects of urology during a four-year period.
For board-certified urologists, continuous medical education (CME) is also strongly encouraged. CME credit points can be earned primarily by attending national or international congresses as well as qualified educational symposia. A substantial number of high-quality educational events is being offered every year to all Austrian urologists involving well-recognised national and international experts in their fields as lecturers. In addition, the Austrian Society of Urology and Andrology has two annual congresses, one of which is organised together with the Bavarian Society of Urology, and educational courses of the ESU are integrated in these events whenever possible.
Post-certificationUpon completion of training and successful certification, approximately 60% of the urologists will practise urology in single-physician offices. A very recent legislative reform also allows group-practising, however, their number is still low. The remaining 40% stay at the hospitals as senior staff members. There are three University Departments of Urology (Innsbruck, Graz, Vienna) and 35 Departments of Urology in the entire country. Together they have 1,362 urological beds and the number of admissions approached 102,000 patients (average stay 3.6 days) in the year 2009.
In total, roughly 39,000 medical doctors act in Austria, two thirds of whom are medical specialists including dentists, one third are general practioners. The number of board-certified urologists in 2008 was 499 and there are currently 88 doctors completing their urological residency – a sufficiently high number to allow nation wide urological care.
Almost all Austrian urologists are members of the Austrian Society of Urology and Andrology (Österreichische Gesellschaft für Urologie und Andrologie; ÖGU). In November 2010, the actual number of members was 560 including two corresponding and eight honorary members. The society is well-organised and comprises not only an executive committee but also several task groups for education, certification issues, as well as special task groups for virtually all aspects of modern urology. For the upcoming year, a new task group has been launched dealing with gender-specific aspects of urology.
In addition, most office-based urologists are also members of a special interest group (Berufsverband der Österreichischen Urologen, BVU). The major goals of the BVU are to ensure the ethical handling of our patients, continuing education, and contemporary office facilities. This unique effort was rewarded in 2007 when Austrian urologists were certified by the “Institut für Qualität in der Medizin” as the first group of specialists ever so in this country.
ChallengesAlthough, at the moment, the urological facilities are still excellent in Austria and office-based urologists manage to take care of a significant proportion of our daily urological services, there is also a flipside to the coin resulting in concerns and a variety of future challenges. In brief, the breakneck speed in the development of latest technology such as laser techniques, laparoscopic surgery, robotic surgery, and improved endoscopic devices limits their general availability not only for office-based urologists but for many departments too. Together with a distinct lack of training possibilities in such new techniques, this leads to an increasing shift of patients from outside into the hospitals. However, the high costs of investments also render the latter almost impossible to keep pace with every new achievement, which in turn could give rise to the emergence of centres being highly specialised – but only for a small spectrum of urological procedures. To what extent such a development will negatively impact both training quality and medical care can only vaguely be presumed. Beyond such reasonable doubts, it is also unlikely that, in the future and in contrast to current practice, our strained health care system will be able to pay the costs for every new technology irrespective of the fact whether it represents a real progress with well-documented benefits for our patients or a transient enthusiasm only shared by a minority of proponents. Therefore, separating the wheat from the chaff will become one of the paramount duties of our academic centres which by now already struggle with an increasing amount of bureaucracy but decreasing financial support.
However, apart from such presumable challenges of the future which I am sure will be accomplished by a collective endeavour of all our members, and in order to conclude, as a member of Austrian urology in general and as the incoming president of our society in particular, I need to take pride in the fact that, almost second to none, Austria is explicitly dedicated to the visions and intentions of European urology. A huge number of Austrian urologists attends the annual congress of the EAU at regular intervals, and many of them contribute actively either as scientific presenters, or invited speakers and session moderators. This dedication to European urology was impressively underscored only recently by the resolution taken at the occasion of the last general assembly, that the Austrian Society of Urology and Andrology will apply for the en-bloc membership of the EAU on behalf of all their members.