MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

An article has just been published announcing the reform of the German Heilpraktiker, the profession of alternative practitioners that has been discussed repeatedly on this blog and criticised recently by the ‘Muensteraner Kreis’. As the new article is in German, I will try to summarise the essence of it here:

The health ministers of all German counties have decided yesterday that they will start reforming the profession of the Heilpraktiker that has attracted much criticism in recent months. The current laws are no longer fit for purpose. There is neither a mandatory agreement for the education of the Heilpraktiker, nor a uniform regulation of the profession.

The senator for health from Hamburg stated: “We feel that the Heilpraktiker should not be allowed to do certain thing, but be permitted to do plenty of activities that remain legal.” At present, the Heilpraktiker is allowed to treat fractures, malignancies, give injections, and even manufacture certain medicines. “We believe there is a need for regulation to protect patients.”

Now a working group will be formed to investigate and produce a report within a year. Remarkably, the German health secretary avoided commenting. In a statement, it was said that patients must be empowered to make decisions on the basis of quality-assured information.

The full German text is below.

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Nach mehreren deutschlandweit Aufsehen erregenden Todesfällen beispielsweise von Krebspatienten, die kurz nach der Therapie durch einen Heilpraktiker in Brüggen-Bracht starben, will die Politik sich nun diesen Berufszweig vornehmen. Die Gesundheitsminister aller Bundesländer haben am Donnerstag beschlossen, eine Reform anzugehen. „Das unzureichend regulierte Heilpraktikerwesen mit seiner umfassenden Heilkundebefugnis steht unverändert in der Kritik“, heißt es in einer Erklärung. Das Heilpraktikergesetz könne dem heutigen Anspruch an den Gesundheitsschutz der Patienten nicht mehr gerecht werden. Für Heilpraktiker gebe es weder verbindliche Regeln zur Ausbildung noch eine einheitliche Berufsordnung. Andere Gesundheitsberufe müssten hingegen strenge Qualifikationskriterien erfüllen.

„Wir sehen es als kritisch an, dass einige Tätigkeiten zwar den Heilpraktikern untersagt sind, aber es noch eine Fülle von Tätigkeiten gibt, die zugelassen sind“, sagte die Hamburger Senatorin für Gesundheit, Cornelia Prüfer-Storcks, auf einer Pressekonferenz – sie hatte die Initiative maßgeblich  vorangetrieben.  So dürfen Heilpraktiker Knochenbrüche therapieren, schwere und bösartige Erkrankungen behandeln und Injektionen geben. Selbst die Herstellung von Arzneimitteln für bestimmte Patienten sei Heilpraktikern erlaubt. „Ohne die Prüfmechanismen, die wir normalerweise haben, wenn wir Arzneimittel zulassen und produzieren“, kritisierte Prüfer-Storcks. „Wir glauben, dass es hier Regelungsbedarf gibt aus Sicht des Patientenschutzes.“

„Die Ministerinnen und Minister, Senatorinnen und Senatoren für Gesundheit sehen eine zwingende Reformbedürftigkeit des Heilpraktikerwesens“, heißt es in dem kurzen, MedWatch vorliegenden Beschluss. „Der Bund wird gebeten, eine Bund-Länder-Arbeitsgruppe einzurichten, die eine grundlegende Reform des Heilpraktikerwesens prüft.“ Das Ergebnis der Prüfung solle bis zur Gesundheitsministerkonferenz in einem Jahr vorgelegt werden.

Bundesgesundheitsminister Jens Spahn erklärte auf der Pressekonferenz das Patientenwohl zwar zum entscheidenden Maßstab für die Gesundheitspolitik. „Deshalb finde ich es richtig, dass die Gesundheitsministerkonferenz bei der Patientenorientierung ihren Schwerpunkt setzt“, sagte er. Auf mögliche Reformen des Heilpraktikerberufes ging der Minister bei der Pressekonferenz jedoch nicht ein. Inwiefern sein Haus die von den Landesministern geforderte Reform des Heilpraktikerwesens mit unterstützen wird, bleibt offen. Auf Nachfrage, ob das Ministerium eine Bund-Länder-Arbeitsgruppe unterstützen würde, versteckte sich eine Sprecherin bereits im Mai hinter der Mini-Reform von Gröhe. Mit Blick auf die kurze Zeit seit Inkrafttreten dieser Änderungen sei es angemessen, zunächst zu prüfen, ob und inwieweit diese zum Schutz des Patientenwohles beiträgt, erklärte sie – „ehe weitere gesetzliche Maßnahmen in Betracht gezogen werden sollten“.

In einem Grundsatzbeschluss sprach sich die Gesundheitsministerkonferenz außerdem für „Patientenorientierung als Element einer zukunftsweisenden Gesundheitspolitik“ aus. „Das heißt, dass der Patient natürlich das Heft in der Hand haben muss, dass er versteht, was mit ihm gemacht wird, warum es mit ihm gemacht wird, mit welchen Chancen die Behandlung verbunden ist“, sagte NRW-Gesundheitsminister Karl Laumann. Auch in der Ausbildung des Gesundheitspersonals sollten diese Aspekte einen großen Stellenwert bekommen, betonte Laumann – und erwähnte zwar Ärzte als Berufsgruppe explizit, nicht aber Heilpraktiker. Der frühere Bundespatientenbeauftragte forderte außerdem mehr Transparenz ein. In Teilen des Gesundheitssystems gebe es wegen mangelnder Transparenz „eine gewisse Misstrauenskultur“, sagte er.

Die Minister wollen laut dem Beschluss die Patientensouveränität und der Orientierung im Gesundheitswesen verbessern, die Gesundheitskompetenz und gesundheitliche Eigenverantwortung beispielsweise durch die Einrichtung eines nationalen Gesundheitsportals deutlich stärken und Kommunikation und Wissenstransfer zwischen Patienten und allen Beteiligten im Gesundheitswesen fördern. „Patienten sollen so in die Lage versetzt werden, ihre Interessen besser zu vertreten und ihre Entscheidungen auf der Basis qualitätsgesicherter Informationen zu treffen“, heißt es.

Kommunikationskompetenz und wertschätzende Beziehungsgestaltung sei im Gesundheitswesen von wesentlicher Bedeutung für die Partizipation, Qualität, Sicherheit und den Erfolg der gesundheitlichen Prävention und der medizinischen Behandlung, betonen die Minister. Allgemeinverständliche „Patientenbriefe“ sollen als erster Schritt die Informiertheit von Patienten nach Krankenhausbehandlungen erhöhen. Außerdem soll das Bundesgesundheitsminister eine Pflicht schaffen, dass niedergelassene Ärzte ihren Patienten neutrale und evidenzbasierte schriftliche Informationen zu Zusatzangeboten – sogenannten „Individuellen Gesundheitsleistungen“ – zur Verfügung stellen müssen.

Bei Behandlungsfehlern sollen nach Ansicht der Landesminister auf Bundesebene weitere Erleichterungen umgesetzt werden: Die Beweislast und das Beweismaß soll zu Gunsten von Patienten überarbeitet werden. Außerdem sollten Krankenkassen gesetzlich verpflichtet werden, Patienten beim Nachweis eines Behandlungsfehlers besser zu unterstützen.

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I have been banging on about the German Heilpraktiker, its infamous history and its utter inadequacy since many years. This is what I published in 1996, for instance:

Complementary medicine is increasing in popularity. In most countries its practice is in the hands of non-medically trained practitioners, professions which are often not properly regulated. When discussing solutions to this problem the German “Heilpraktiker” is often mentioned. The history and present situation of this profession are briefly outlined. The reasons why the “Heilpraktiker concept” is not an optimal solution are discussed. It is concluded that the best way forward consists of regulation and filling the considerable gaps in knowledge relating to complementary medicine.

It goes without saying that, after so many tears of warning about the risks involved in allowing poorly trained practitioners, who are all too often unable to see the limits of their competency (and after many unnecessary fatalities), I am delighted that progress seems finally to be on the horizon.

29 Responses to Finally!!! The German ‘HEILPRAKTIKER’ is going to be reformed

  • Nur der stete Tropfen höhlt den Stein.

  • the article is from a site worth looking up:
    @medwatch_de.

    • only the continuous drop holloes the stone
      or as my hepatologist teacher used to say
      only the continuous drop kills the liver!

  • „Der Bund wird gebeten, eine Bund-Länder-Arbeitsgruppe einzurichten, die eine grundlegende Reform des Heilpraktikerwesens prüft.“
    (Translation: The German government is aked to install a Bund-Länder-working group that investigates a general reform of the Heilpraktiker profession).

    Prof. Ernst, i am certain that many people in Germany would benefit from your expertise for this working group. I´m sure that I would very much appreciate your input, if possible.

  • It’s going to be a tedious business. Last year, the “Münsteraner Memorandum Heilpraktiker” demanded either a fundamental reform or an abolition of these grotesque representatives of parallel medicine. The waves rose, the representatives of non-medical practitioners foamed – but did not present a paper with counter theses, but went into insults and whataboutism. To my blog posts I received mails with wild threats.
    Let’s hope for the best – and not again for a paper tiger like the “Guidelines for a uniform alternative practitioner examination” of the former Minister of Health Gröhe. This new activity is clearly more than that. I am sure that the debate on the paper of the Münsteraner Kreis is one of the triggers for the debate that is now emerging – let us hope that it will now develop the necessary momentum of its own – on a technically sound basis.

    • Sorry to say but the legislative proposal is ready already since the late 1960ties and there are other social forces behind to prohibit or to modify the regulations for the Heilpraktiker profession. The same ministers of health of German Bundeslander who want to reform the Heiloraktiker they want to regulate the “profession” of an “osteopath” at the same time too. It’s all about spin doctors and gathering majorities because “osteopathy” is en vogue as it is homeopsthy and most of the normal health insurances started to pay for “osteopathy” ad they do for homeopathy to attract clients to change and they spend a lot of money for that. The politics are just following such huge social movements. The small Münsteraner Kreis therefore is honirable but indeed meaningless.

  • As a German Heilpraktiker working for 19 years by now in a German hospital centre I must say that the departments of health in Hamburg who are quoted here are know as having one of the lowest standards of exam regarding this profession and they have been criticized a lot for that circumstances. It is interesting that they now are acting as spokesmen for reformation. 🙂

    Why not Bavaria? The Bavarian exam has the highest standard for this profession and as I was qualified in Wuerzburg only 2 out of 200 passed the exam.

    From my experience there must be a practical of one year minium in a hospital and only persons having a profession as nurse or pharmaceutical assistant (PTA) or having other already regulated health care professions first should be allowed to become a Heilpraktiker.

    The problem is much bigger as the profession of Heilpraktiker itself. The problem is the fight who will gain the huge market for alternative bogus therapies.

    As long as the medical societies are not willing to forbid physicians to pracice quackery the attempt to stop the German Heilpraktiker is an easily comorehensible play to gain billions of Euros of bogus therapies for their own profession and income.

    It would also be easy to make regulations that ALL health care professions have to follow the evidence based standards first and are not allowed to work against or without it neither in surgery nor in medication and that the patients must be informed first about such standards.

    • only 2 out of 200 passed the exam

      This is not so much proof of high standards, but of an educational system failing miserably, and of a profession attracting people who apparently think that they can play doctor without actual skills or knowledge in the field of medicine. This is in other words one more symptom that a reform is badly needed.

      It would also be easy to make regulations that ALL health care professions have to follow the evidence based standards first

      Unfortunately, the trend of the last few decades is quite the reverse, also here in the Netherlands: ever more alternative practitioners pop up in large numbers(*), offering treatments that have been proven ineffective, in effect scamming patients with impunity. All is is made possible because our law states that “anyone is allowed to provide healthcare” – but our lawmaker neglected to provide a definition of ‘healthcare’. So anything can (and is) be offered as healthcare.

      *: According to a rough estimate, we now have some 30,000 quacks here. Considering that we have some 60,000 real doctors, I think that this is a rather worrying development.

    • THERE IS NO “EXAM” FOR GERMAN HEILPRAKTIKER!
      The “examination” before the health authority does not serve the examination of healing knowledge and – ability. It is only intended to ensure that the prospective alternative practitioner “poses no danger to public health”. You should know that very well. Whoever compares the “Heilpraktikerprüfung” with a medical examination plays with dovetailed cards. And a diarrhea rate – I know it is constantly brought into play by the non-medical practitioners’ associations as an “argument” – at the stated level can have many causes. These causes should not be determined solely by an alleged “difficulty of the test”.

      The German “Heilpraktiker” is a system problem. Skills or achievements of one or other individual alternative practitioner are not the topic. The topic is the imagining of parallel medicine alongside scientifically based medicine, whose representatives – in contrast to academically trained physicians – have so far been able to more or less freely and rule. All of them are far removed from evidence-based medicine. And this is apparently becoming increasingly well known even in German politics.

      To repeat myself: There were no reasonably substantiated counter theses to the theses of the “Münsteraner Kreis”, but only wailing and whataboutism.

  • STOP the use of ANY BOGUS THERAPY FOR ANY health care professional NOW.

    Smallpox vaccination remained compulsory for everybody without exception and it is compulsory too that any person undergoing medical interventions has to join an elaborate explanatory meeting and must be informed about the risks and this has to be signed by the patient or by the subject’s legally acceptable representative and by the person who conducted the informed consent discussion before it is done.

    Therefore I said “It would also be easy to make regulations that ALL health care professions have to follow the evidence based standards first and are not allowed to work against or without it neither in surgery nor in medication and that the patients must be informed compulsory about such standards in the beginning of an consultation.”

    Why?

    It was possible to compel ANYBODY to be vaccinated against smallpox. Therefore the same legislative force must be behind evidence based medicine too. ANY health care professional must be forced to inform themselves about the evidence based standard AT ANY TIME (in Germany the AWMF guidelines) AND TO INFORM ANY PATIENT ABOUT THIS STANDARD (e.g. STIKO RECOMMENDED VACCINATION) in an elaborate explanatory meeting and about the risks not following such standards and this has to be signed by the patient or by the subject’s legally acceptable representative and by the person who conducted the informed consent discussion before it is done as soon as a patient is coming with a disease or illness related to such standards!

    ONLY AN WELL INFORMED PATIENT HAS A CHOICE. Parents must be compelled to accept the evidence based standards for their children whitout any choice as it was smallpox vaccination too. That is much easier to control than to forbid therapies or doctor games or stupidity.

    But there is no social movement behind such a proposal by now!

  • There are quite a lot of problems refarding Heilpraktiker no doubt … But the situation in Germany is not the same everywhere…

    in the 1990ties the German counties Bavaria Baden-Wuerttemberg and Thueringen agreed to join a common catalogue of medical exam questions that must be used in the written Heilpraktiker exam. This exam is lasting 2 hours with a fixed number of multiple choice questions selected from a catalogue.. This catalogue is made by a committee of physicians anf is orietentef on the GK I standard of the physicians medical exam. If one has passed this exam you must join a practical exam of one hour. The examiners are the head of the regional department if health a ohysician and a Heilpraktiker and a secretary to make a protocol continuously. In Wuerzburg were I passed my exam “Ueberpruefung” I had to show a whole body examination following the medical standard including palpating of all pulses correctly and a neurologic level diagnostic and I had to explain it. Then they continued to ask me about the medical standards of diagnosis AND TREATMENT of different heart diseases kidney and ophtalmologic diseases and a lot of other medical standards. I told all of this afterwards to the physicisn who trained me and he said that this totally changed his view on Heilpraktikers as his exam in the 1960 in Heudekber University was less difficult thsn mine as a Heiloraktiker in the 1990tirs. So far my answer to all the prejudices here …

    • I meant “Heidelberg University” sorry but there is a problem with your new program here on this webpage because as soon as I am posting a comment the post is vanishing and the option to correct faults and spelling errors is not shown on iPhone 7 any more and the sentence that you have received the post is not shown either.

      The worst problem of the profession of Heilpraktikers is that most of them are starting with the INTENTION not to follow evidence based medical standards at all and that there is no regulation about a practical in a medical institution at all and NO EFFECTIVE CONTROL about what they are doing later on. It`s just a free market as it is with physician`s quackery too.

      In contrast to heilpraktikers physicians have no choice to follow such medical standards as long as they are in training for specializing after having received their professional degree. But tey can stop practising such standards later at any time and to mix it up with quackery and a lot of them do so.

      As R said and I said it too very often … more and more quackery is spreading and more and more PHYSICIANS are selling quackery (in Germany called IGeL and alternative quackery) NOT INFORMING the patients about the evidence based medical standards and the reasons why it is made AND THE RISKS OF NOT FOLLOWING SUCH EVIDENCE BASED MEDICAL STANDARDS.

      Don`t forget. Physicians are trained to function under conditions of a brutal social hierarchy since they entered High School. As physician you have the feeling that you are joining a social elite per se having passed a high school exam with best results of your year of graduation and you have passed all the stress of a medical training and all the years of work overtime and you are conditioned to function under the circumstances of a cruel institutional hierarchy. So to me it is really comprehensible that you won`t accept a competitor for your income with such a minimal training and mostly very poor exam standards as it is done in most of the German countries/counties/Bundeslaender for Heilpraktiker and you want to prohibit and terminate the profession in general.

      But as a physician you won`t accept either that natural scientists are smirking about your minimal effort in how easy you can achieve a medical Dr./Ph.D in comparison to the effort a natural scienttist Dr./Ph.D. has to do because you feel yourself to be at top of the social elites already.

      But why are more and more physicians practising quackery? The problem with quackery is much bigger than just to focus on the regulation of the profession of German Heilpraktikers. No social movement can stop quackery but to say it optimistically there is an option to compel all health care professionals to inform about the evidence based medical standard and about the risks if a patient makes a decision not to follow it and this has to be documented in detail and signed by all persons involved.

    • … and in my exam for Heilpraktiker there was not a single question about alternative quackery not even from the Heilpraktiker who asked me to show the standard of mefical neurological examination. As Edzard said “the regulation of nonsense will still lead to nonsense” there was nit a sngle question about “alternative medicine”. The whole exam was about medical standards only.

      But from my own 19 years of experience working in a hospital centre as a Heilpraktiker I would say that Heilpraktikers should not be allowed to treat medical named diseases at all. That’s right. But they should be allowed to treat functional disorders and complaints and to follow the evidence based standards of examintion. They must send the patients to a physician as soon as they have a sudpicion that there is a medical named disease. I am doing it as a Heilpraktiker.

      AND you should recognize that in Bavaria they have always the best quality standards not only in brewing beer and in teachers training and teaching in schools 🙂

      • it’s not an ‘exam’!
        it’s a suitability test (“Eignungspruefung”) where candidates are asked to show that they know the regulations/law etc. no medical knowledge is supposed to be tested, as far as I know.

        • Edzard how would you call a total of medical 60 GK I related multiple choice questions without a single question about laws? Must be done in 2 hours!
          How would you call a ongoing questioning for one hour about medical standards of diagnosis and difeerential diagnosis and medical treatment standards for one hour without any alternative quackery?
          This was the standard in Bavaria Baden Württemberg and Thueringen in the 1990ties already. If you fail more than 10 % you have to come another time in 1/2 a year later only 3 times allowed)

          • I would call it a pseudo-exam; Heilpraktiker like to think of it as an exam; medics have problems with tis concept because it is such a far cry from a true medical exam. My finals consisted of 32 separate examinations many of them lasting half a day. The Heilpraktiker-Pruefung is a Mikey Mouse exam by comparison and does not test their proficiency in what they will do after they passed it.

          • 1) The law says “Überprüfung”. and doesn’t specify how the intention to protect people should be implemented. There are so called “Durchführungsverordnung” but every Bundesland has a choice how the “Überprüfung” is organized. So this varies from Bundesland to Bundesland. As I said in the 1990ties Bavaria Baden-Württemberg and Thüringen started to create a standard for exam oriented on the GK I exam for physicians. It’s a k.o. system. If you make any fault in the practical test you fail. The time how long the exam “Überprüfung” must last and the questions and the amount of questions is fixed in this 3 Bundesländer. I don’t know how many other Bundesländer are joining now. Because there is no standard for schools so most or many of the candidats fail the “Überprüfung” in this three Budesländer.

            As you can see it’s no problem to impair the “Überprüfung” and to raise the standard. I think that’s not the problem.

            2) The most severe problem is that there is not a single practical experience is necessary begore ir after the Überprüfung and no need to follow medical standards ( as physician’s are also allowed to leave the mefical standard too)

            3) The problem is not so much the “Überprüfung”. This can be changed very easily. The main problem is that there is a profession with the INTENTION not to follow medical standards in therapy from ther very beginning.

            As such intentions are raising in the physician’s profession too nowadays very fast I am hoping that they will stop Heilpraktikers from being allowed to treat medical named diseases and that they will implement a compulsory system that physicians must tell the patients the evidence based medical standard and that the patient has the option to sue the physician if he is not offering the medical standard and anything goes wrong in thetpy not following this mefical standard. The patient has to receive a written document in ehic the AWMF guidlines are orinted, related to his case and he has to sign this. The not well informed patient has no choice.

            As far as I can see the article quoted above is considering such intentions.

          • Sorry for my spelling errors – here is the corrected version – (please activate the option to correct spelling errors again after having posted a comment for a certain time. Its no longer activated on iPhone 7)

            I wanted to write: … and that the patient MUST be INFORMED comprehensibly that he has a choice to choose evidence based therapies at any time and the option to sue the physician if anything goes wrong in therapy if the physician is not following the evidence based medical standard. The patient has to receive a written document in which the AWMF guidlines are printed related to his case and he has to sign this and that he was well informed by the physician about such circumstances. Why? Because the not well informed patient has no choice. The physicians must be prohibited to tell the patients that not evidence based IGeL therapies are a MUST. This must be changed as soon as possible to do something effective against IGeL and quackery.

          • I am not your secretary

          • I’m not sure why the feature that allowed editing a comment after submitting it is not working but I’ll look into it.

          • There is an interaction between the comment editing plugin and the new tickbox that was introduced by WordPress on the last update. If you want to be able to edit your comment, you have to tick the box “Save my name, email, and website in this browser for the next time I comment.”

            I have put a banner at the top of the website to remind everyone of this and have informed the plugin author so this might be fixed sometime.

          • admin – thank you very much for your fast reaction to my hint. Your information is very adjuvant.

            Yes! It’s working again if I am following your advice Thank you so much.

  • I doubt that this intentioned reform will change anything at all. The “Heilpraktiker” is deeply embedded in the german health system. There was already a chance to finish it once and for all. After Second World War II the Heilpraktiker was not renewed in the GDR (German Democratic Republic), so the profession became extinguished until 1990. There were only 7 Heilpraktiker left when the GDR got bankrupted. And remember that the medical system in the GDR was a top player in medicine with the Charité. There was no need for a Heilpraktiker at all.

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