You were one of those students, caring about the wellbeing of others, who happened to be somewhat good at science in school. Medicine seemed like a wholesome career. Now, you’re in med school or working as a clinician and just stumbled upon Greg Lewis’s posts calculating how little impact the marginal doctor in the developed world has.
Welcome everyone to our joint existential crisis!
A common advice you may hear is “have you considered biorisk?” and for some, this could be an excellent choice to specialize in. Arguments in favor of biorisk, resources to learn more, and arguments for a clinical career from an EA perspective have been discussed elsewhere. In this post, I want to present some considerations for German-speakers who do want to work as a clinician and optimize their Earning to Give potential.
Almost all linked sources are in German — sorry!
The famous tale of the rotation to Switzerland, the land where blood flows into the tube because the nurse draws it and not the intern; and the intern earns some money for fulltime work, has often been told among German med students. Although 80,000 Hours has an article on increasing your earnings as a doctor, Switzerland as the country with the 2nd highest GNI per capita in Europe is not mentioned among the options for migrating. To close this gap, here are my thoughts and calculations after 16 months of internship and residency in Bern.
Switzerland’s healthcare relies heavily on foreign doctors, especially from Germany. The medical schools’ supply of graduates is not sufficient for the need of doctors. Depending on the specialty, if you plan ahead and apply early, there’s a good chance you get into the specialty you want. More details in the paragraph on “How To Apply”.
You can look up the range for your gross income of doctors in Switzerland on the corresponding “VSAO”-webpage. It differs from canton to canton (keep this in mind since it applies to a lot of specifics in this post). For Zurich, you can calculate it with this nice tool, depending on specialty, clinic, and work experience. For Bern, where I work, you can look up the extremely wide range here. In my first year as a resident in psychiatry, I would earn around 92K for 100%. I once asked my attending whether applicants ever negotiate or have the opportunity to do so, and she said they don’t have that for junior roles at university hospitals. Take this with a teaspoon of iodized salt. Private clinics, I was told, pay a competitive salary. If you read this post and decide to Earn to Give in Switzerland, I’d be curious to read about someone systematically applying for different clinics and disclosing the gross salaries they were offered — most I know is hearsay.
I knew that I wanted to do psychiatry. This choice was not in quest of maximizing Giving Potential, but satisfying “I can stand this for at least a few years”, because I’m one of those huge wimps who couldn’t work 12h per day on a regular basis like orthopedic surgeons do around here. One could also make a case that psychiatry-skills are more on the transferable side among clinical specialties. Depending on your priorities and whether you plan to pursue this career path for the foreseeable future, your decision process may be very different. Keep in mind that residency salaries should be in the same ballpark across specialties, but vary greatly after you finish training and work in your own practice (data from 2014: 220k p.a. as a psychiatrist, 820k as a neurosurgeon).
How to Apply
Swiss medical students sign contracts for attractive residencies up to 24 months in advance. Note that they have barely any objective qualification to compare candidates at that point.
For specialties with a high supply of applicants, your prospects are best if you have worked in the clinic before during your internship year or even an earlier clinical rotation (Famulatur). Internships are often competitive, too — but on a “first come, first serve”-basis. For spots as desired as surgery or ophthalmology in the University Clinic of Zurich, apply shortly after the first state exam (32 to 36 months before your desired date) to be on the safe side. This is a horrible incentive structure, but doesn’t seem to upset anyone as much as me.
Hope is not lost if you have progressed further in your studies already. Sometimes, applicants cancel a few months before their starting date, so it makes sense to send out tons of applications consisting of your CV and a generic letter. PJ-Ranking is a great source for finding the contact person and gauging how long in advance the intern slots are booked if the clinic’s website is cryptic or doesn’t disclose it. For residency applications, an on-site visit with an interview and opportunities to informally chat with other residents is usually added to the process.
To start working as a doctor, accreditation by the MEBEKO is required. I had to wait six weeks for the bureaucracy and paid CHF 800 (which I hope to get back from my employer), but it was less paperwork than the equivalent in Germany.
I have met colleagues who switch countries from Germany or France to Switzerland during residency as well as after finishing training. It seems not too hard to get accreditation, but is probably easiest to complete residency in one country.
I studied in Bonn and completed a 6-week-internship in the psychiatric university clinic there, so I picked Bern and Bonn to compare.
Salary, Taxes and Living Costs
|Bonn (100% = 42h week)||Bern (100% = 50h week)|
|Gross annual salary 1st year||EUR 58,103 source||CHF 92,519.05 source: my work contract|
|Monthly salary (salaries p.a.)||EUR 4,841.95 (12 salaries)||CHF 7’116.85 (13 salaries)|
|Net monthly salary||EUR 2.957,02 (calculated with the defaults of this tool - assuming a 25yo single, no church tax)||CHF 5,196.81, calculated here, excl. Health insurance. With cheapest insurance (sanitas, family doctor model, highest deductible: CHF 180.7) CHF 5’016.11|
|Estimated monthly costs for a single person||EUR 853.85 source||CHF 1,430.45 source|
|Estimated rent, monthly (1 bedroom apartment, outside of centre)||EUR 603.85 source||CHF 1,043.75 source|
|Remaining||EUR 1,499.32||CHF 2,541.91|
|Currency switch (assuming 1 EUR = 1.07 CHF according to Morningstar on 2021/08/29)||CHF 1,611.76||EUR 2,364.57|
EUR 865.25/month 12*865.25 = EUR 10,383
13th salary = EUR 4,834.25
Total difference: EUR 15,217.25
Monthly remaining plus 13th salary: EUR 2,364.57 * 12 + EUR 4,834.25
Total annual donations: EUR 33,209.09
13 salaries are standard in Switzerland. 50-hour-work weeks are too, for doctors, but I'd be surprised if they actually work longer than in Germany, where extra hours are ignored a lot of the time.
Judging as someone who barely changed their standard of living after graduation, the estimated living costs and rent on the quoted site are pretty high, so interpret the total donations as a lower bound. Service work is especially expensive in Switzerland, so I limit restaurant visits to once a month and get a haircut no more than twice a year. Most months, I get by comfortably on CHF 1,500 including rent.
One big difference is the shifts. It is still common practice in Germany to be on call for 24 hours and be paid less in total. This is because you are getting paid less for the time you’re on call per hour, and you have to compensate the day after. In Switzerland, the night shift usually lasts 12 hours during which you are on call (you are allowed to sleep in the clinic if you’re not needed), you get a small bonus for working at night, and you get a day off. However, the attendings are on call for half a week at a time, 3-4 days in a row. They can go home after their regular work time and only come to the clinic if you need them.
Another difference I noticed is digitalization in healthcare. Shockingly, more often than not, an urgently needed report in Germany will be printed, sent by fax, and scanned. Secured e-mail communication and digital clinical records are the standard in Switzerland. Admitted, not everything is always running smoothly, and ORBIS makes me go crazy sometimes, but at least I’m in the 21st century and can copy-paste medication lists.
Thirdly, the tone in communication is different. Once, as an intern, I had to call a cardiologist. They took me seriously and answered my question with patience. After the phone call ended, I stared at the receiver for a few seconds in awe. What a rare specimen I just encountered! As it turned out, this is more the rule than the exception. Almost every single time someone was rude to me in 16 months of working here, it was a German consultant or attending.
The mandatory health insurance in Switzerland is cheaper. However, you get hardly anything for it, especially if you choose the highest deductible. It does not include dental, neither are screenings exempt from the deductible (which is horrifying from a public health POV).
Reconsider everything I wrote if kids are part of your life plans. It depends on the canton, but in general, paternity leave is extremely short (2 weeks) and kindergartens are expensive. The Swiss haven’t gone extinct yet, so it works somehow, and a lot of clinics have kindergartens on site. For what it’s worth, I know several attendings of both sexes with small children who do get to spend time with their offspring.
If you've conducted some cheap tests to rule out career options with more direct impact (research, policy) for you, optimizing your earning potential as a doctor could result in immense counterfactual donations. Moving from Germany to Switzerland might be the easiest way to do so, especially if you already work in a position of higher seniority with correspondingly higher costs of transitioning to non-clinical work. In general, moving to a different country can have substantial downsides depending on the individual. I probably underestimated how much the culture and especially the language in Switzerland are different to Germany, or at least the area where I’m from, and it shouldn’t be a rushed decision. However, there’s a lively EA community in the bigger cities, and a lot of other expats in medicine, which makes it easier to settle in.
Thanks to Jan Hohenheim, Jan Kirchner, Anemone Franz and Pauline Scheuber for proof-reading and feedback!
Edit (17.09.21): Thanks to the two Markuses for pointing out my calculation error!