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May 6, 1998

Physician Surplus: The Czech Story

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Copyright 1998 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1998American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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JAMA. 1998;279(17):1402. doi:10.1001/jama.279.17.1402-JMS0506-6-0

Not long ago physicians in the Czech Republic could be found working in factories at manufacturing occupations. After being forced out of health care by the communist regime, these doctors accepted practically any paying job. Although the communists are no longer in power, a similar situation may arise for a different reason: the Czech Republic has an excess of physicians.

In the 1970s, elementary school students in the Czech Republic were taught that the health care systems of their country and of the Soviet Union were the most developed in the world. While statistics showed a high number of physicians, this did not always translate into a high level of development. Probably the major factor that contributed to the current situation was the organization of health care. As with similar other branches of the national economy, the work productivity in health care grew extensively, not as the result of increased efficiency but of a greater number of physicians and staff being hired.

This surplus was not apparent in the communist system, but became clear in the new Czech market economy after the so-called Velvet Revolution. In 1995, there was 1 physician per 295 citizens. This was much higher than other countries, such as Great Britain where there was 1 physician per 715 citizens, or Italy which had 1 physician for every 667 inhabitants.1 Insufficient control over expenses and inefficient management caused waste of labor and supplies. The widespread shortage of health care resources motivated a group of physicians to call a strike in the fall of 1995. This in turn led the health care minister to convene a group of experts to analyze the efficiency of hospitals, with the intention of closing the least productive health care facilities. The theory is that the management of the remaining hospitals will have to improve so as to handle a greater workload.

Because a rapid downsizing of the health care system would likely cause a high rate of unemployment, officials decided to reduce the number of students accepted to medical schools. This has already been reflected in the total number of medical graduates. In 1994 and again in 1995 more than 1500 students graduated from all Czech medical schools; in 1996, the number dropped to 1293.2

Even with these changes, however, unemployment is expected to grow. There were 289 registered unemployed physicians by December 31, 1995.2 This number represented less than 1% of the total 36348 physicians at that time. Significantly, however, 202 of these unemployed physicians were 1995 medical graduates, representing almost a 14% unemployment rate for that class.

Medical graduates are clearly in a difficult situation. Hospitals are hesitant to sign contracts for longer than 1 year because even the near future is unstable. The general viewpoint of the medical graduates was reflected in a recent questionnaire released by Chamber of Physicians.3 Approximately 40% of the medical school graduates questioned would not have applied to medical school again. Even though the majority of them still obtained jobs, more than 25% had to accept a specialty that was not their first choice. A small percentage of graduates set their sights on practicing abroad.

Although the percentage of graduates who do not practice medicine remains undetermined, it seems that those who leave the field can usually find work in pharmaceutical companies or others in the medical field. Many graduates choose this option intentionally, lured by higher salaries and a more attractive lifestyle. For example, in 1996 the average monthly income of a medical graduate was approximately Kc 6310 (US $185),3 while the national average was Kc 9676 (US $285).4 Starting salaries in pharmaceutical companies are generally well above the national average. In an effort to continue postgraduate education and to become eligible for national board examinations, some medical graduates work for a much lower monthly salary (Kc 3000, or US $88), or even for free.3 While pharmaceutical and biotechnology companies offer more than satisfactory salaries and benefits, there are still other attractive options including a combination of research and clinical work. Career tracks of this type have traditionally not been supported in the Czech Republic, but several universities have recently opened programs offering positions for those interested in research.

The process of Czech health care transformation continues. In the meantime, the Czech model of downsizing and redeployment will continue to serve as a valuable teacher, and its successes and failures may guide other countries that face similar problems.

Ministry of Health Care, Czech Health Statistics Yearbook 1995.  Prague, Czech Republic Ustav Zdravotnickych informaci a statistiky Ceske Republiky [Institute for Health Care Information and Statistics of the Czech Republic]1996;9118- 123
Ministry of Health Care, Lekari evidovani na uradech prace v Ceske republice jako uchazeci o zamestnani ke konic letosniho dubna. [Physicians registered at unemployment offices by the end of April of this year]. Zdravotnicke Noviny (Health Care Newspaper). 1997;3511
Not Available, Casopis lekarske komory. [Journal of the Health Care Chamber]. 1997;611
Not Available, Tyden. [The Week]. 1997;1224