25 July, 2014

Doctor's Visits and Medical Stuff

For various unfortunate but non-life threatening reasons, I've been to the doctor more often during my time in Germany than during any other time in my life. I've now been to three different doctors and have been to each of these three offices multiple times, so I have a fairly good idea by now of how German doctor's offices typically work. One may not expect medical care to vary that much between two developed countries with advanced health care systems, but there are some slight differences that I simply could not have anticipated. The odd thing is, I didn't even notice some of these differences until I consciously thought back to what my American doctor's appointments have been like.


**Disclaimer: this post is based just on my own personal experiences. Other people may have quite different experiences, and I encourage others to add your stories in the comments if you feel I've missed or mischaracterized something.**


At the First Appointment

At the first visit to an American doctor, one of the things you can expect to do while you sit in the waiting room is to fill out some forms. They include name and other basic identifying information as well as a long and often tedious medical history.

At two of the three doctor's offices I've visited in Germany, I was asked to fill out a form with my name and contact and insurance information, but I was never at any of the three asked for a medical history. Not on paper, not verbally as part of the first appointment, not even later at subsequent appointments. Is this something that German doctors are just not trained to do? There may be things that your doctor needs to know before he/she prescribes you a medication or treatment plan, such as what other medical conditions you have or even what vitamins you take, and I find it a little concerning that German doctors don't seem to realize this.


Before Seeing the Doctor

Any time I visited the doctor in America, I was called into the exam room by a nurse's aide or medical assistant who took my blood pressure, height, weight, and (I think) temperature and then asked me a few questions. These things were noted down on my chart before the doctor even entered the room.

Again, this practice is simply not done in Germany. After approximately 9 or 10 doctors appointments in Germany, I have never once had my blood pressure, height, weight or temperature taken, either by a doctor or a medical assistant. The staff usually asks on the phone, and sometimes again when you check in for your appointment, the reason for the visit and marks it on your chart, but there seems to be no general assessment of basic health signs at the beginning of the visit that is customary at US doctor's offices.


During the Appointment

Logistics

After having vital signs taken by the medical assistant, in most American doctors offices you are given a hospital gown and asked to change out of your clothes and into the gown once the assistant leaves the room. The assistant leaves enough time for you to change before sending the doctor in, so when the doctor enters the room you can be in the gown and sitting on the exam table ready to go. The doctor then comes in, sits facing you in a chair with your chart in hand, and the questions and physical exam proceed from there. After the appointment is over and the doctor has left the room again, you then change back into your normal clothes.

The set-up is a little different in German doctors offices. When you are first shown to the exam room by the assistant, you sit down in a chair on one side of a large desk, still fully clothed. The doctor comes in and sits on the other side of the desk, you discuss the reason for the visit, and, with the doctor still in the room, you undress (behind a curtain) and then sit on the exam table. The exam is usually quick, and when it's over you dress again and then sit back down at the desk across from the doctor to discuss the results.

Contents of the Discussion

With any America doctor I've been to, I explain the problem I need addressed in as much detail as I can manage and then I expect almost a barrage of questions from the doctor to clarify where the trouble really is. "Where exactly does it hurt?" "Can you describe the pain?" "How long ago did the pain start?" "Are you on any medications?" Things like that. It gives the reassuring sense that the doctor is trying to fully understand the issue and come to the most accurate diagnosis and treatment possible.

Maybe it's just the doctors I've visited, but only one out of the three I've been to so far in Germany has even asked a single clarifying question. With the first two doctors I explained as well as I could the problems that I was having, and the very next thing the doctor said was, "OK, time to do an exam. Please undress." I ended up leaving many of those appointments feeling not entirely satisfied with the visit, and the lack of inquiry into the details of my complaints is one of the main reasons. I didn't feel like there was enough communication and clarification of what the issue actually was. Again, this may be the individual doctors I went to and not a clear reflection of all medical professionals in Germany. The third doctor I visited, by far my favorite out of the three, asked a bunch of questions and made me feel very reassured that she actually understood exactly what I was experiencing.


Bonus Round: Medical Charts

This is a tiny thing, but medical charts in Germany and the US are different sizes. In the US most medical charts are the size of a manila folder (a bit bigger than a letter-sized sheet of paper) and contain regular size papers clipped to the chart. The papers may be clipped to an actual manila folder or a clipboard.

In Germany, medical charts are made up of a single sheet of paper similar to the thicker manila folder material which is folded twice to make what looks vaguely like a large envelope. Notes are written directly on the inside of the "envelope" and other papers are folded and stuck inside. Not that this is a consequential difference, but it's one of the little things I noticed.


Related Topic: Pharmacies and Medication

Maybe it's just been the nature of the appointments I've had here or the individual doctors I've seen, but it seems to me that German doctors are often more problem-focused than American ones, meaning they focus the appointment only on the problem or issue that brought about the visit and don't focus so much on achieving overall health or talking about preventive strategies for avoiding a return visit. With this in mind, it is not surprising that after a good number of visits, I found myself traipsing to the pharmacy to fill a prescription.

The differences regarding prescriptions start before even leaving the doctor's office. When American doctors write prescriptions, they are responsible for deciding the type of drug, the dose, the number of pills to be taken and the number of days over which they are to be taken. All of these factors are typically explained to the patient before the patient leaves the office, and are also provided in writing.

After leaving the office, the patient then takes the written prescription to the pharmacy (or sometimes the doctor's office calls it in to the pharmacy instead) and may have to wait anywhere from a few minutes to a few hours for the proper pills to be assembled in the proper arrangement. This wait is due to the fact that the pharmacist has to individually separate out the right number of pills containing the right amount of medication and place them in a generic-looking, orange plastic bottle with the patient's information and the dosing instructions printed on a sticker on the outside. If the pharmacy is busy, this wait time can become long. (One exception I can think of is when the prescription is for birth control pills. These come pre-packaged and do not need to be sorted out by hand or placed in a new bottle.)

In Germany, however, the doctor decides the medication and often the strength but has little to no control over how many pills. Every drug that I've gotten here has come pre-packed, with one or more blister packs of pills in a small box.

These are blister packs.

The box states the name and manufacturer of the drug but does not include any added labels that are specific to the patient, as the prescription bottles in the US do. There are standard, unchangeable numbers of pills in each box, and although the doctor can specify that you take a different (i.e., smaller) number of pills than is in the box, they rarely do this. The pills come with comprehensive drug information and dosing instructions and the patient simply follows those. This also means that there is often very little discussion with the doctor of how the medication should be taken. He or she may say how many days you should take it for, but often does not; rarely does the doctor specify things such as how many times per day, common side effects, when to stop if you have complications, etc. That's what the in-box instructions are for.

This blister-packs-in-a-box system applies even to things such as Aspirin and ibuprofen which are available on the shelf in bottles in the United States. The boxes of non-prescription strength pain killers also contain way fewer pills than bottles of the same medicine do in the US. For example, I have a bottle of Aspirin that I brought from home, which originally contained 100 tablets and probably cost around $4 (according to my quick Google search). When I went to a pharmacy in Berlin and asked for Aspirin, I was given a box containing 20 tablets, albeit at a higher dose than what I would normally find in the US, for a little less than 5 euros (around $6.75). I have the feeling that this is because Americans are more likely to simply throw large numbers of pain killers at a problem in hopes that it will go away, and so larger quantities of these medicines are in demand.

Also interesting to note: a pharmacy is the only place you can buy things like Aspirin and Tylenol, as well as most other medicines that can simply be grabbed off the shelf in any pharmacy or supermarket in the United States. In this regard Germany prefers to have different things in different stores, rather than having huge box stores that sell everything imaginable.

American

American pharmacies are often huge, almost like supermarkets. Some of them are open 24 hours, although not all of them, and some of them have a drive-thru. They always have a wide variety of goods for sale, and the pharmacy counter is usually all the way at the back, almost as an afterthought. (Clearly it's arranged this way so that you are forced to walk through all the other stuff they sell on your way to get your medicine, leading you to buy more stuff.) The counter where the pharmacy is and the counter where you pay for non-pharmacy items are separate.

German

Most German pharmacies are small storefronts. They have regular store hours (meaning weekends from morning to late afternoon), but I think there is a regulation that says there should always be one open within a certain distance. If this regulation is the same as it was in Spain, the pharmacies in a certain area rotate staying open overnight/longer hours, and the ones that are closed post the name and address of the nearest open pharmacy on the window.

What Can Be Purchased At American Pharmacies
  • medicine (prescription and over-the-counter)
  • food 
  • soft drinks
  • beer and wine
  • school supplies
  • pregnancy tests
  • toothpaste
  • toothbrushes
  • shampoo, conditioner, hairspray, etc
  • hair brushes, hair clips, etc
  • body wash
  • skin care products
  • makeup
  • toys
  • candy
  • vitamin supplements
  • batteries
  • cheap phone chargers
  • cigarettes
  • lottery tickets (I think?)
  • sunscreen
  • gift cards
  • blank CDs
  • magazines
  • newspapers
...and the list goes on.

What Can Be Purchased At German Pharmacies
  • medicine
  • pregnancy tests
  • skin care products (sometimes)
There are, of course, places in Germany where you can buy all of that other stuff that American pharmacies sell, but, as I mentioned above, the concept of the big box store-type pharmacy just doesn't exist here. Pharmacies are for medicine, and that's it.

Medical care is one area of modern-day life that I was certainly not expecting to have such extensive knowledge of here in Germany, and I was also not expecting any differences between the medical establishment in Germany and the US. But, as life would have it, I ended up being proven wrong twice. But hey, at least I got a blog post out of it! (For those of you wondering why I didn't talk about health insurance, that will come in a later post.)

4 comments :

  1. Martin and I discussed the size difference in medication and he said that pill packs never come with so many that you can overdose. So, if taking 20 aspirin at once will cause liver damage, you can only buy them in 10 packs. It doesn't prevent suicide (if you REALLY want to take enough to die, you just buy more) but it helps prevent accidental overdosing of children and the elderly. Also, whereas in America you might want to stockpile medication just like you stockpile toilet paper and Doritos, in Germany they generally sell the amount you would need for a short period of time, or a small incident. If you need to take like 8 aspirin a day you probably need better, prescription strength meds. You can't get that in the US without a hefty fee, so you take the 8 aspirin instead. Here you go to the doctor and they give you the script for free.

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  2. Very good point. Maxim also pointed out that the reason for packing the pills in blister packs rather than bottles is so that each pill stays sterile until you need to take it. When you have pills in a bottle and accidentally dump more than you need into your hand, the ones you put back may still have germs from your hands on them the next time you open the bottle.

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  3. I was also really shocked to go to the doctor and not get asked anything about my medical history or even the medical I was on. I went to the doctor for a throat/ear infection which I wrote about here http://consumingcate.blogspot.de/2014/07/greetings-from-leipzig.html and had to tell them I get asthma. I was told by other Australian expats that German doctors are really reluctant to prescribe medications and as I have been on a number of medications for a long time (some over 20 years with good effect) I decided to bring 6 months worth of meds with me. In Australia you can buy pain killers at the supermarket and many other meds over the counter at the chemist. No booze though!

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  4. I've also found this reluctance to prescribe medications, but only when it comes to antibiotics and painkillers stronger than aspirin. Unfortunately, that's what I need at the moment. I think the doctor I went to prescribed me too low a dose of antibiotics because my symptoms didn't get better after the full course of meds he prescribed :( He also prescribed a very low dose painkiller, which also didn't really work. Back to the doctor I go! I wish he had just prescribed me the stronger meds to begin with, then I wouldn't be running back to the doctor after less than a week.

    Or, I wish German doctors were more into the prophylactic antibiotics (aka, antibiotics before the procedure as a precaution) like American doctors are, then I probably wouldn't be having these problems in the first place.

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