The minimum duration of continuing medical education in Anesthesiology is 3 years, according to the EU Directive (EU-Directive 2005, Annex V, point 5.1.3). In Germany and Romania, the training period is 5 years, while in Poland it is 6 years. In all 3 countries the training is significantly longer than the minimum standard according to European law (The German Medical Association, BÄK 2013; Polish Centre for Postgraduate Medical Education, CMKP 2014; The Romanian National Centre of Perfecting the Skills of the Medical Personnel, CNPDS 2007). A comparison between the studied subfields within the anesthesiology specialisation and the time allocated to their study is shown in Tables 1-4.

In order to quantitatively compare the requirements for trainees, Table 2 compares the time required to study different subfields in the above-mentioned countries. In Germany, this assessment is difficult to make, as the training program may vary throughout the country and some subfields are studied alongside others.

In all 3 countries, the training is divided between the study of anesthesia and intensive care. In Romania, as shown in the last subfield, the training takes 2 years and is divided between multivariate intensive therapy with its surgical and medical branches (diabetes, acute intoxication, neurological coma, cardiac diseases, nephrology, paediatric care), traumatic intensive therapy and emergency receiving unit (Table 3). In Germany, the intensive care education is divided into 2 modules of 6 months each, while in Poland, because of the skills training modules it is difficult to identify how much time is allocated to each subspecialty.

As the curriculum is slightly different in the three countries, only a small number of skills were chosen for comparison. The comparison of the minimum number of procedures, which can be seen in Table 4, reveals a large difference between the compared countries.

The training referred to in the EU Directive as “General (internal) medicine” has a minimum duration of 5 years. In order to receive the specialist diploma for internal medicine in Germany, a training period of 5 years is required (BÄK, 2013). The training is divided into 2 parts: “basic advanced training in the area of internal” and “further training in internal medicine”.

In Poland, the basic training module has a 3-year duration and the main module a 2-year duration, which corresponds to the German training period (CMKP, 2014). Similarly, the 5 years training period in Romania is divided between the study of internal medicine (25.5 months) and complementary studies (34.5 months) (CNPDS, 2007).

Table 5 shows that although the length of these 2 modules may vary between Germany, Romania and Poland, the total specialisation time is the same: 5 years.

The explicit training periods in modules I and II and the comparison between countries can be seen in Table 6 and Table 7.

In Table 8, a comparison is made between the minimum numbers of treatment procedures in the medical training of the specialists. In Germany, around 2400 procedures must be demonstrated throughout the training period. In Romania, the number of independent procedures stipulated by The Romanian National Centre of Perfecting the Skills of the Medical Personnel (CNPDS, 2007) is

1585. Each training center can add its own procedures to this number. According to the Polish training regulations, only 270 procedures must be carried out independently. Kolodziej also made a comparison between the number of procedures in Germany and Poland (Kolodziej et al., 2016). She assumed that newly trained Polish internal medicine specialists would complete further training in Germany.

Directive 2005/36/EC of the European Parliament and of the Council of 7^th September 2005 regarding the recognition of professional qualifications was amended with Decision 790 on 13 January 2016. According to these decisions, the German language professional title of general practitioner is “Facharzt/Fachärztin für Allgemeinmedizin”, in Polish “Specjalista w dziedzinie medycyny rodzinnej” and in Romanian “Medic specialist medicină de familie”.

The general European tendency to prolong the length of residency can also be observed in Romania, Germany and Poland. According to the EU Directive of 2006, the general medicine study program requires a minimum training period of at least 3 years for future general practitioners. In Romania, this training took 3 years for those who commenced their training in 2007 (CNPDS, 2007); In 2016, according to the Ministry of Public Health (MS) order number 1109/2016, it was prolonged to 4 years.

For the training of family physicians, there is also a type of “part-time residency” that takes 5 years. In Poland, the residency program takes 4 years (CMKP, 2014) and in Germany 5 years (BÄK, 2013). In Germany, there are small differences between the training in the general medicine field in different regions of the country, but all of them require 5 years. For the purpose of comparison, the data for Germany will be taken from the guidelines on the content of continuing education from Bavaria (BLÄK, The Bavarian Chamber of Physicians, 2016). Table 9 lists the similarities and differences between the 3 training programs in the above-mentioned countries. The EU time requirements are clearly met in all 3 countries.

The Polish advanced training system lists the practical abilities required by the trainee to successfully complete further training, but without specifying a minimum number of treatments (CMKP 2014). Comparing the number of completed procedures in Romania (3386) with the number of mandatory procedures in Germany (2335), it can be concluded that the 2 years difference between the specialisation processes in these countries does not make an important difference. As an example of some of the studied fields, the data concerning the minimum number of examinations and procedures can be seen in Table 10.

Following the Romanian latest law regarding the time requirements for specialisation, starting with 2016 some changes were made regarding the allocated

time and number of procedures. A concise comparison of the 3 programs can be seen in Table 11.

An interesting fact regarding the place of birth of the participants on the study is that 4 out of 129 participants were born in Germany. The great majority of the doctors participating in the survey migrated from Romania in the period 2011-2012 and more than 30% of the Romanian physicians who migrated to Germany did so by their own initiative. Most of them were young physicians (around 32 years old) who graduated between 2007 and 2011 and were working in a hospital. More than half of the respondents were females (59.7%) and most of them studied in Cluj. In second place were those who studied in Bucharest and in the third place are those who studied in Constanța. Almost half of the interviewed physicians (47.6%) completed their residency training in Romania, and the remainder trained in Germany. There were also some (29%) who studied in both countries. At the time of the survey, 10% of the physicians were doing their residency in Germany, and about 52% were working under supervision (Assistenzarzt) and 30% were specialists. Despite the fact that 76% of the respondents stated that they had problems with German language and that level B2 was the recommended language level when they left Romania, all of them found that it was necessary to have language level C1 in order to be able to effectively work. This is why 66.7% struggled learning alone or with the help of language classes; only 21.7% of respondents learned it in school. In Figure 3, one can observe that the vast majority of the physicians were working in Nordrhein-Westfalen.

The main reasons of departure stated by the doctors interviewed were the working conditions (85.27%), and 99.2% of the respondents found the German working conditions better than in Romania. On the second place in the list of reasons for migration were the possibilities for professional development, which 79% found to be better in Germany. In third place was the fact that it was easier access to specialist training. Only 68.21% of respondents stated that a better salary was one of the reasons for moving to Germany. Even though this was not their priority, 97.7% wrote that they are able to earn more money per month in Germany, even after deducting the monthly costs. Opportunities for recreation and free time were not high on the list of rationalizations for their relocation. Only 24.03% found the recreation possibilities interesting.

Two very important preconditions for a good working environment and high confidence in one’s worth or abilities, which in turn promote better results in the workplace, are the level of professional recognition and the level of work-related integration. Almost all physicians (93%) found integration courses or language lessons helpful in the integration process.

Two strong indicators that the Romanian physicians who were interviewed have grown accustomed to the working conditions in Germany are that 93% of them see their future career in Germany and that 97.7% of them recommend Germany as a work destination for their colleagues in Romania.

A concerning aspect of the migration of physicians is that this phenomenon sometimes has its roots even before the doctors start their basic training. In order to confirm the data that is already available in the media and to better understand more of about it, a survey was performed. Among the 59 survey participants, 78% were females. It is worth mentioning that the respondents were relatively young, between 20 and 30 years of age (20.3% of them were 24 years old).

Out of the interviewed students/physicians, only 57.6% saw themselves later successfully being able to work in Romania. The ability to work in the desired field is one of the factors influencing their success.

Working conditions were of utmost importance for 93.22% of the people interviewed, and 74.57% considered that continuous skills improvement possibilities of high priority. Approximately 60% would take into consideration higher salary when looking for a job, while the rest of consider the salary to be of moderate importance. The considerations taken into account while searching for a job are presented in Figure 4(a) and Figure 4(b).

Various channels are used by students and physicians in order to inform themselves about job opportunities in Germany. Through the questionnaire it became evident that information from family and friends played a similar role to self-initiative in informing the respondents of job possibilities in Germany.

When asked about their future plans, the respondents shared opinions about the time period in which they would like to start working in Germany (Figure 5).

In order to facilitate the comparison of the results obtained in Poland by Kolodziej, Gresser and Richartz (2016) regarding the migration of physicians to Germany, the Romanian study used the same design. As the number of respondents differed from country to country, comparison will be made using only percentages.

According to the surveys, graduates from medical universities in both Poland and Romania could imagine themselves (in percentages higher than 90%) working in Germany. In Figure 6, it can be seen that there is a correspondence between the percentages found in both countries, while differences can be observed when looking at perceptions of work-related conditions and the possibilities of free time.

Even though they stated that a better salary was not one of their priorities, 97.7% of Romanian physicians who had emigrated and 87.5% of those from Poland believed that they were receiving more money than their colleagues in their home countries.

When asked about their personal monthly earnings, the great majority from both countries revealed that they were earning more than 3 times the salary that they would have in their country of origin (Figure 7).

A concerning issue for both Romania and Poland is that a large percentage of the medicine students in these countries were considering leaving (Figure 8) and a significant percentage of them were planning a long or undetermined stay in Germany. Both studied groups expressed little interest in only staying in Germany for their period of their residency.

In order to make the transition towards their goal smoother, many of them had taken specific measures. A comparison of the measures taken by students and physicians from Romania and Poland can be seen in Figure 9.

Recognising that language presents itself as a big challenge for foreign physicians aspiring to work in Germany, special attention was paid to this subject. Very close similarities can be noticed when looking at the results of the question that addresses the German language knowledge of the students and physicians from Romania and Poland (Figure 10).

Figure 11 examines the methods employed for learning the German language. The comparison is made between Romanian students and physicians aspiring to work in Germany, the doctors that already do so and the Polish doctors who had moved to Germany.

The degree to which work colleagues offer support and help foreign doctors feel integrated is of great importance for their feeling of belonging to the work

environment. Figure 12 compares how the Romanian and Polish doctors perceived their recognition level among patients and workmates.

Out of the Romanian physicians who participated in the survey, 93% saw their future in Germany, whereas 78.12% of the Polish doctors did so. The explanation for this small discrepancy could be found in the statistical results which show that 99.2% of the Romanian doctors stated that they found a better working environment in Germany, while 87.5% of the Polish doctors agreed.

Another small difference that can be observed when comparing the results obtained by Kolodziej, Gresser and Richartz (2016) for Poland and the current survey of Romanians is the stated main reason for remaining in Germany. For the Polish physicians the remuneration was the main reason for staying, with 81.23% declaring that they had not returned to Poland because of the stability that their salary brings. For the Romanians, the main motivation for remaining in Germany (93.8%) was their perceptions of a better working environment there.

Another element that illustrates the high level of integration of foreign physicians is that 84.37% of the Polish and 97.7% of the Romanian doctors recommended working in Germany to young physicians.