IDAR-OBERSTEIN, Germany — At Ivana Stankovic's anesthesiology ward in the German countryside an hour and a half west of Frankfurt, there's not a single native German among the youngest rank of doctors.
The 29-year-old resident works alongside other assistant doctors from India, Hungary, Egypt, Ukraine and Slovakia. They're all part of a wave of young doctors from eastern and southern Europe that are pouring into Germany.
Germany's doctors are aging: 44 percent of them are older than 50. And there are fewer young doctors to take their place. That's because the population as a whole is aging even as many of Germany's young physicians leave the country, eager to earn higher wages in Switzerland or enjoy shorter working hours in Scandinavia.
That in turn creates a big opportunity for immigrant doctors from the south and the east, drawn by higher pay and greater career opportunities. It's a trend occurring across continental Europe. The number of doctors in France who got their medical degrees outside the country climbed 43 percent between 2008 and 2013 to 17,835, according to the French medical board. In the U.K., which has long welcomed doctors from India and Pakistan, 37 percent of physicians got their initial degrees abroad.
While the opportunities are plentiful for immigrant doctors, the decision to uproot is never easy.
"It's not just the language; it's whether you're accepted as a person or a doctor," said Mladen Stankovic, Ivana's husband, who is also 29. "When we were in Serbia, we were confident that we would never leave Serbia. But then there was so much pressure. We were 27 years old without any future. So we sat down, and I said, 'We must do something. We can't wait until we're 40 years old.' "
Fresh from medical school in Nis, Serbia, the couple, both from families of doctors, hired a tutor for a year to learn German before moving to the hillside town of Idar-Oberstein on New Year's Eve. A year before they left, they began scouring the Internet for jobs.
They first planned to go to Heidelberg, a picturesque city with a 628-year-old university that was a stop on Mark Twain's European grand tour and today hosts more than 5,000 international students. Heidelberg's state government has tough rules for foreign doctors from outside the European Union. The Stankovics would have had to pass an exam, in German, to prove the equivalency of their Serbian qualifications.
So the couple moved on to the neighboring state of Rhineland-Palatinate, where non-EU doctors with degrees from foreign universities can work for two years before they have to take the test, and then have three tries to pass. The 588-bed Idar-Oberstein hospital there was looking for an anesthesiologist and Ivana got the job. Mladen joined her as an unpaid intern while applying for his own position.
"The farther you go to the periphery, the more foreigners you'll find," said Juergen Hoffart, head of the medical association in Rhineland-Palatinate. State officials aren't explicitly recruiting foreign doctors, he said, but they're coming anyway, lured by better salaries and working conditions.
An entry-level doctor in Serbia earns about 350 euros ($477) a month, while an apartment in Nis can cost about 120 euros a month, Mladen said. An assistant doctor in Germany might earn 10 times as much.
The rural hospitals are often in places where German doctors don't especially want to work, Hoffart explained. They also are looking higher pay and more flexible hours, a quest that is taking many across the border to Switzerland and beyond. Last year, about 3,000 doctors left Germany for countries including Switzerland, Austria and the United States.
This revolving door of departing German doctors and arriving immigrants is fraught with potential pitfalls. Language is a critical hurdle. German, with its split verbs and genders (the word for a heart attack is male while the heart is neuter), isn't the easiest tongue to master. Rhineland-Palatinate has checked about 360 would-be doctors since testing began in August 2012, with about a third of those failing the test.
Hoffart met Mladen during a round of language tests on Fat Thursday, the beginning of the annual weekend of Carnival parties in Rhineland-Palatinate's state capital, Mainz. Brass bands were already collecting crowds of costumed revelers outside the train station. Nearby, Mladen and other would-be doctors were translating 25 Latin names for body parts and ailments into German, conducting a mock examination and writing a patient report. Hoffart's office put out a plate of traditional carnival doughnuts as candidates from Mumbai and Ekaterinburg filed into the exam rooms.
Mladen's only slip-up was translating the Latin "collum" into English as "neck" instead of writing down the German word, "Hals."
"We're bleeding out the other countries," Hoffart said after passing him with flying colors. "He's not going back to Serbia. He's staying in Germany. I'm totally sure."
After months of volunteering at the hospital, Mladen had realized he wouldn't land an urology residency in Idar-Oberstein. His three-month tourist visa was up, and lacking a job, his only remaining option was return to Serbia and apply for residency based on his marital status.
For Ivana, leaving before the end of her one-year contract was out of the question. She had thrown herself into the hospital schedule, assisting at surgeries during the day and studying at night. And she'd been working with technologies, including robot-assisted surgery, that she said she'd never have encountered in Serbia.
"Here you can really learn a lot," she said in serviceable German. "It goes quickly — fast, fast, fast."
Later that week, her husband boarded a plane back home for what turned out to be a six-week separation.
Mladen Stankovic returned to Germany in early May after obtaining a general surgery residency at a small hospital about a half-hour's drive from Idar-Oberstein. On the first weekend in June, the couple moved from their small studio to a large apartment with a balcony and a bit of garden.
"We keep forgetting the words for things in Serbian," Mladen said. "We'll see. We're planning for the next two to three years. At least."