After Russian otorhinolaryngology (ENT) specialist Karina Volkova contacted Düsseldorf physician Rainer Frerich about a position in his practice, everything moved quickly. With a €1500 monthly subsidy from KV Nordrhein (the Association of Statutory Health Insurance Physicians for the North Rhine area) and a temporary professional permit issued by the Münster District Government in January, she has been working as an assistant physician in Frerich’s practice since the start of the year.
The special permit expires at the end of 2027. By then, she must obtain a full German medical license, ie, an approbation, or she will no longer be allowed to practice medicine in Germany.
But the road to full licensure has proven long and difficult. Volkova’s career progression has stalled, mainly due to administrative barriers.
Volkova moved from Russia to Germany in 2019 to join her husband, who has lived in Germany for 30 years. “He grew up here,” she said. The couple now has a 6-year-old son. She studied medicine in Moscow, Russia, where she also completed 2 years of specialty training in ENT. She worked as a physician in Moscow for 5 years before relocating in 2019. “I always dreamed of becoming a doctor,” she said. “My grandmother was a psychiatric nurse. She inspired me to study medicine.”
Germany’s Medical Language Exam: The Highest Hurdle
Germany’s medical language proficiency exam, required in addition to all professional credentials, is often the biggest challenge for foreign-trained doctors. Volkova passed it on her first attempt, she said proudly.
For 6 months, she commuted daily by train from Düsseldorf to Cologne, both in Germany, for a language course. “I don’t have a driver’s license or a car. On weekends I studied, and I took online courses too,” she said.
She had taken basic German in Moscow, roughly at the A1 level. “I needed it for our wedding. But in Germany I had to reach C1 for medical terminology,” she explained, now speaking fluent German.
Foreign physicians who want to work in North Rhine-Westphalia must show at least B2-level general proficiency and an additional C1-level exam focused on medical language. B2 is often required just to apply for licensure.
Equivalency Review: 19 Months and €1600
Next came the formal equivalency assessment comparing her Russian medical education with German standards. The Münster District Government reviewed her application for 19 months. Volkova had to pay €1600 out of pocket, Frerich said. “That’s a lot of money to put on the table.”
The result: Her Russian training was deemed not fully equivalent. She must complete 4 months of internal medicine and 4 months of surgery in German hospitals before being eligible for full licensure.
On the positive side, KV Nordrhein approved the subsidy for her placement quickly — “in just 2 weeks,” Frerich said.
No Internship Without a License, No License Without an Internship
Then came another obstacle. The state medical association does not consider Volkova a medical student and therefore will not arrange clinical internship placements (similar to final-year clerkships, or practical year [PJ] rotations in Germany).
“They say, ‘As far as we’re concerned, she’s a doctor. And we only arrange internships for students,’” Frerich explained.
In other words, she is considered a doctor, so she cannot receive a student internship. But without the internship, she cannot become a licensed doctor. A bureaucratic paradox.
Volkova applied directly to several hospitals to complete the required rotations. “I sent my documents everywhere. But all I get are rejections because I don’t have a license,” she said.
Hospital administrators are often reluctant to pay €5000 per month for a physician who will stay only 4 months, Frerich noted.
Frerich has now approached the local employment agency. “It would be easy if the employment agency paid Volkova the same net salary she earns in my practice during her 8-month hospital internship,” he said. “Then the hospital director would have no objections.”
It remains unclear whether the proposal will succeed. “Germany would benefit far more if Volkova could become fully licensed quickly,” he argued. “She would help address the physician shortage — and she would pay taxes.”
“If Dr Volkova doesn’t secure an internship, she’s out,” Frerich warned. “It’s absurd: KV provides funding to integrate a foreign doctor into the German health system, and the district government says, ‘Without the internship, you’re out.’ It’s wasted money. There needs to be better coordination among all the agencies involved.”
‘My Life Is Full of Hope’
There is one remaining alternative, Frerich said. “She could take an oral exam before a physicians’ commission appointed by the district government instead of completing the internship. It would be like taking another state exam. But she doesn’t feel able to prepare for such a demanding exam again, especially with a family.”
In his practice, Volkova has already proven herself. “She does an excellent job and supports me exceptionally well,” he said.
She can continue working in his practice until the end of next year. And after that, does she still hope to secure the internship she needs?
“My life is full of hope,” she said.
This story was translated from Medscape’s German edition.
