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Stephan Hofmeister


Background: The German ambulatory care sector is mainly sustained by more
than 177 000 statutory health insurance physicians and psychotherapists. They
provide approximately 650 million high quality treatments per year (versus around
20 million treatments in hospitals) including ambulatory emergency care around
the clock. The system is based on self-employment with doctors and psychotherapists
running their own practices. They are organized within a system of self-government
on a regional and a national level. Satisfaction with working conditions and income
is high.
Objectives: This article considers the difference between employed and selfemployed
doctors as the main key to understanding reasons by which employed
doctors are prone to a higher risk of suffering from burn-out than self-employed
doctors. It further describes how working conditions are changing and which
challenges arise for doctors both in the ambulatory sector and in hospitals.
Method: In addressing these objectives, this article considers databases and several
surveys performed by the Kassenärztliche Bundesvereinigung and German health
profession organizations.
Results and Discussion: Owing to several factors, the number of employed doctors
in the ambulatory care sector is rising. As for employed physicians in the hospital
sector, the employed doctors in the ambulatory care sector show significantly
lower satisfaction rates with their working conditions. This group is at higher risk
of experiencing burn-out or at least limited well-being within their professional
Conclusion: To prevent doctors in the ambulatory care sector from suffering
burn-out it is important to reinforce the principles of self-employment within
owner-run practice structures. It is also important to improve the efficiency of
doctoral working hours by reducing the currently expanding bureaucracy and by
cautiously considering the appointment of non-medical professionals that operate
under strict guidance of doctors in addressing aspects of ambulatory care that
would be suitable for this task-shifting. It is also essential to improve and
implement e-health technologies, and for instance facilitate remote treatment in
rural areas.

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