Medical School in Denmark

Today we have a wonderful guest blogger, Andy Skovsen, with us to talk about medical education in Denmark! Andy lives in Copenhagen, but seems to have been a bit of a nomad having lived in the US a while and just returned from working in South Africa! He has also spent some time in the Danish Military and still works part-time with them. I must say, I’m a little jealous of all the great culture and scenery he seems to have experienced. Andy graduated from medical school in 2008 and has been pursuing a career in Surgery, with a particular interest in trauma and emergency medicine. He has a great blog called Doctor’s Without Filter, which is co-authored by himself and two others in Danish (Go-Go Google Translate). Andy got married last summer (Congrats!!) to a doctor who is currently pursuing a career in Cardiology and in his free time (which sounds like it might be severely limited!) he enjoys sports like skiing, mountain biking, diving, and surfing! I have to admit, I want to be friends with Andy – he sounds like tons of fun!

 

Getting In:

How old is one when they begin medical school?

Usually around 18-20. Some gain entrance through a separate set of university specific merits and tests, and are usually a couple of years older.

What exams does one have to take to get in?

Entrance is granted through application. You take finals from “gymnasium” (roughly equivalent to last year of high school and first two years of college in the US). Entrance is based on your GPA after this. Approximately 10% gain entrance through a separate quota system, which is defined by each of the 4 universities in Denmark offering a medical education and usually involves testing as wells as merits.

Is there any required pre-requisite coursework?

Certain levels of Maths, Danish, English, Physics and Chemistry are required to apply. These can be supplemented post-gymnasium graduation.

Is it a competitive occupation?

Very competitive. The number of applications far exceed the number of places. At the moment, it’s the most sought after university degree in the country.

What are you called at this stage of training?

Medical student.

 

Being In:

How long is it?

6 years. After 3 years, you are given a Bachelors diploma, which is pretty much useless unless you want to transfer to a different Masters degree.

How are the years broken down?

This varies from university to university, but generally broken into 12 semesters with the first 6 being pre-clinical, and the last 6 being clinical.

Describe your typical day.

Varies immensely for each semester/rotation. The common denominator seems to be end-of-semester exams, which increases workload and hours hitting the books to all waking hours and eliminating partying to zero.

If you choose a specialty, when do you have to decide by?

After graduation you do one year of internship, then you apply for positions in your specialty.

What are you called at this stage of training?

Medical Student

 

Getting Out:

What exams do you have to take?

Once you take your final exams from medical school, you’re pretty much done with exams.

Do most people graduate?

Students drop out of medical school mostly to switch to other degrees. I remember starting medical school, during the first lecture, we were told to “look to your right and look to your left, those two people will not be here when you graduate.” A rough estimate tells me that about 1/4 to 1/3 of starters do not finish.

When are you finally considered a “doctor?”

After passing the final year of medical school you get your diploma, then you sign the Hippocratic Oath and become a doctor.

Do you have additional training after MS or do you start working immediately?

One year of internship is mandatory. The internship is split into two 6-month positions, the first usually being in a hospital, and the second often (80%) being in primary care/family medicine. Each year is a lottery, where all graduates are assigned a random number correlating with the amount of graduates is a number internships. The graduate that received number 1 in the lottery gets first pick and so fourth. Positions are all across the (small) country. The system is perceived as unfair by many, but is not looking to be changed any time soon.

What’s the average debt for attendance?

None! Medical school is paid by the state. When attending university, you also get a small allowance (about $750/month) to live on, but books you must pay for. Living expenses are rather high, especially in Copenhagen, so many students work and may also take loans.

What are you called at this stage of training?

Doctor, Intern or Resident.

 

Being Out:

What’s the average salary?

Salary is fixed. Currently base salary is around $4,500/month on top of this you get a small remuneration for being on call, etc. Usually comes to around $5,000/month. On top of this comes taxes (50%+). Through your career your salary increases in increments.

Is the job security good?

It’s good. 100% of graduates are employed in internships. In the long run, some specialties are very difficult to get into and others you can walk right into after internship.

Can you switch specialties?

Yes, you can switch, but you start back from the first year after internship.

What are you called at this stage of training?

Doctor or Resident

 Image By Andy Skovsen | Available on Flickr

Very interesting! Thanks so much for sharing, Andy – I really enjoyed reading about medical education in your country and I know these posts are some of the most popular on Mind On Medicine, so I’m sure others enjoyed the information as well.

Other Medical Education Monday posts can be viewed here!

Medical School in Indonesia

Today I’m excited to introduce to you Anna, a 22 year old medical student from Bogor, West Java province in India. She is in her last year of clinical clerkships at Universitas Pelita Harapan medical school, a bilingual (Indonesian and English) open to both local and foreign students.

Currently, Anna is undecided on a specialty, but is interested in both Neurology and Emergency Medicine. She has five more rotations before she finishes, so it will be interesting to see what she decides on! She blogs at Surreal Hours and you can catch her on Twitter @a_elissa.

She contacted me a few weeks ago asking if I was still open to having more posts in the Medical Education Monday series. I’m so thrilled that y’all find medical education in various countries as interesting as I do…it’s certainly been great to hear about all the different systems.

If you are (or someone you know is) a medical student or physician in a country not yet covered, please have them contact me! Here’s what Anna had to say about Medical School in Indonesia:

Getting In:

How old is one when they begin medical school?

We begin medical school directly after high school. However, some schools are open for students who already have an undergraduate degree, this is usually the case for foreign graduates.

What exams does one have to take to get in?

  • Public Schools: National exam called SPMB that is designed for a specific major, but is valid for any universities. This exam is not the actual entrance exam, it’s only for filtering out students who are academically eligible for a certain major, in this case for medical school. A prospective student sitting the medical school SPMB also needs to fill out a list of schools of their choice. The result of the exam is then sent out to those schools, and he will receive a notification about his acceptance. There is then another exam and an interview from each school that he has to complete and pass before being formally enrolled.
  • Private Schools: Each school has its own entrance exam, usually consisting of basic science focusing on human biology and chemistry, and an interview. Students applying for scholarship may be required to sit an additional exam.

Is there any required pre-requisite coursework?

The national high school system divides the curriculum into two major programs: Ilmu Pengetahuan Alam or IPA (Natural Sciences), and Ilmu Pengetahuan Sosial or IPS (Social Sciences). One has to do the IPA / Natural Sciences program to be eligible for medical school. If a student graduates from a foreign curriculum, like Cambridge or the International Baccalaureate (as in my case), then he must have taken at least biology, chemistry, and maths.

Is it a competitive occupation?

Very.

What are you called at this stage of training?

A high school graduate.

Being In:

How long is it?

5 years.

How are the years broken down?

  • The first 3 – 3.5 years are pre-clinical years. Using the new block system, we learn basic anatomy, physiology, biochemistry, and immunology for the first year, then system-based approach for the remaining pre-clinical years. The actual division of the organ systems depends on each school. In my school, it is musculoskeletal, cardiology, pulmonology, gastroenterology, genitourinary, endocrinology, neurology, obstetrics and gynecology, dermatology and venereology, tropical medicine, hemato-oncology, and emergency medicine.
  • Students who have completed the first 3.5 years are considered graduates already, and are granted the title “Sarjana Kedokteran” (Bachelor of Medicine). They can quit at this time and start working non-clinical jobs.
  • The last 1 to 1.5 years are clinical/clerkship years. We do 9 minor rotations and 5 major ones. They differ by duration: minors last 4-5 weeks, majors last for 10-12 weeks. Minor Rotations: Neurology, radiology, psychiatry, ophthalmology, ENT, oral medicine, dermato-venereology, anesthesiology (including critical care), and forensic medicine. Major Rotations: Surgery (including emergency medicine), internal medicine, obs/gyn, pediatrics, and public health. Upon completing the clerkship, we then graduate as Medical Doctors.

Describe your typical day.

  • Pre-clinical: Class starts at 7:30 AM. Some days start with lectures, some with PBL discussions. Labs are usually in the midday. On the last period every Friday, there is a plenary session where the PBL case study that week is discussed with an expert. The day usually ends at 3:00 PM.
  • Clinical: In my hospital, office hours start at 7:00 AM and end at 2:00 PM, while outpatient clinic starts at 9:00 AM. The first thing we do in the morning is write SOAP notes of ward patients, then wait for the attending physicians to come for the morning round. After rounds, activities vary according to department. We may have academic activities, like tutorials or case study presentations, or we may go to outpatient clinic and have academic stuff later in the day. For surgical specialties, most operations commence at around 10:00 AM, depending on the number and difficulty of the cases that day.

If you choose a specialty, when do you have to decide by?

There’s no requirement for that. Age-wise, residency programs only require applicants to be less than 30 years old by the time of entrance.

What are you called at this stage of training?

  • Pre-Clinicals Years: Medical Students.
  • Clerkship Years: Our formal name is “dokter muda” or junior physicians, but we are more often called with our colloquial names, “co-ass”, from the Dutch word co-assistant. We still use a lot of Dutch medical terms in spoken conversations.

Getting Out:

What exams do you have to take?

The law is changing as I’m typing this. There used to be no exam getting out, as each rotation in clerkship already has its own exam. However, the new bill proposes for a national board exam. It is still undecided whether the exam will be a test for theory or clinical skills, or both.

Do most people graduate?

Yes.

When are you finally considered a “doctor?”

When we have taken our Hippocratic Oath at the end of clerkship (and after the board exam, if the new bill passes).

Do you have additional training after MS or do you start working immediately?

Again, the law is under some changes. The new law requires an unpaid 1-year internship in a hospital chosen by the government. After that year, doctors can work independently.

What’s the average debt for attendance?

There is no debt, except for scholarship students. Regular students pay the full fee. Scholarship students will pay back by working for their universities or teaching hospitals immediately upon graduation for a certain period of time, usually 2n + 1.

What are you called at this stage of training?

A doctor. More formally, a general physician.

Being Out:

What’s the average salary?

Depends on where you work. The general rule is the same everywhere: it’s higher in private institutions than public ones, and is also higher in bigger cities than in rural communities.

Is the job security good?

Yes. There is a high demand for doctors throughout the country, especially outside the main islands of Java and Bali.

Can you switch specialties?

Yes, but people rarely do this.

Can you go back and choose a different specialty?

Technically, yes, as long as one has not reached the age of 30 by the time of entrance. However, I have never heard of anybody doing that.

What are you called at this stage of training?

A specialist.

Defeated, Confused, Sad Doctor

What Medical School Doesn’t Teach Us

In the course of our work as doctors we will undoubtedly witness events that change the life of our patients, but coming into medical school I never realized how directly some of these events would also change my life. 

Often in medicine we see people at the worst possible time. Our patients are usually sick or grieving and rarely happy to be in our presence, no matter how great we might think we are. More often than not, they are experiencing things we’ve never experienced, things we understand on a molecular or biochemical level, but not on a palpable, emotional level. We don’t know what it’s like to live in their shoes, so we draw on our experiences, the experiences of past patients we’ve seen and the knowledge we’ve gained in our training and do our best to play the role of both healer and comforter.

  But, as medical students, sometimes our pool of past patients with similar experiences to draw on is limited. How do we ensure we are the best providers for our patients when we may have absolutely no clue how they are feeling? I truly believe that, as medical students, we have a very important role on the healthcare team, but when our experiences are limited what do we base our actions off of?

I believe Social Media has a role to play here.

————————————————————————————————————————————-

  Because I’m interested in Ob/Gyn and Reproductive Endocrinology I keep track, via Twitter and blogs, of several women’s journeys through infertility and pregnancy loss. I have silently watched from the sidelines as they supported each other through loss, openly shared their heartache with strangers and occasionally even expressed what they wished friends, family & medical professionals had done or not done for them while they were hurting. 

So, when I happened to be the first provider into the room to see a woman who was miscarrying, I wasn’t entirely uncomfortable. I’ve never been through pregnancy loss or talked at length with any friends who have experienced it, but it was almost like I had an army of compassionate friends in my back pocket providing me with insight I could not possibly have had otherwise.

Without these women I would have asked a quick list of questions and gotten the heck out of that room, because quite honestly, I would have been uncomfortable and entirely at a loss for what to say without making things worse.

Instead, I knew that this patient likely wanted someone to listen to her story, that she probably would benefit from hearing that this wasn’t her fault and there was nothing she could have done differently or better. I understood how important it was to let her know she was allowed to feel however she felt, whether that be completely devastated, functionally numb or even relieved. She needed to hear from someone else that she was allowed to grieve, that any feelings of loss were wholly valid and that, even though I had no idea on a personal level what she was going through, I was going to do everything I could to support her while she was there.

These ladies are my teachersmy professorsmy examples. Without trying, without being paid, without PowerPoints or lectures, they taught me how to be a compassionate caretaker in a situation I did not understand.

  As I walked out of my patient’s room that day I knew she still had a long road ahead of her, but I was confident that, if even just a little, I had helped her. I left that day realizing that, without my presence in Social Media, the night would have likely gone very differently. I left knowing that nothing in medical school would ever have prepared me to be confident enough to begin to handle a situation I could not possibly understand.

Most importantly, I left knowing she had helped me more than I had helped her, because she had opened my eyes to the fact that everyone around us is a teacher…even on the internet.

Medical school teaches us how to handle situations we can control, ones we can fix or change or at least slow down – not how to handle emotionally-heavy situations where a negative outcome is inevitable and immediate…only experience teaches that.

————————————————————————————————————————————-

 

I wrote this several months ago as a thank you to my Twitter friends who have dealt with this situation publicly and today I finally decided to share it here. So, thank you for letting a bystander hang out in your world every once in a while and for being open about your struggles, losses and triumphs. You, along with all the other patients, activists, and advocates I interact with, both online and off, are making me a more compassionate, informed and confident care giver. You teach me things I will never learn in school, help me keep up-to-date on literature and are a huge asset…not only to me, but to my future patients.

Image: Sura Nualpradid | FreeDigitalPhotos.net
Image: Ambro | FreeDigitalPhotos.net

Santo Domingo Children's Hospital

Medical School in the Dominican Republic

Medical School in the Dominican

Today I am honored to be continuing our Medical Education Monday series with Medical School in the Dominican Republic. Our Mind On Med guest blogger for today is Vera, a 21 year old medical student in the Dominican. She’s starting her 5th year of medicine and is still wide open on the specialty front, but has a special interest in Neurology. She loves blogging, snail mail, singing and coffee (would we even call her a med student if she didn’t love coffee? I think no, but that’s likely the addiction speaking). And, get this, Vera is a Latin dancer! How cool is that?! We should get her to do a vlog lesson for us. Feel free to contact myself or Vera with questions about Medical School in the Dominican! My additions are in orange.

Santo Domingo Children's Hospital
Children's Hospital in Santo Domingo, photo by RIGHT TO HEALTH.

Getting In:

How old is one when they begin medical school?
A regular student who never repeated courses in high school graduates of at the age of 18. You start pre-med after that – when I started pre-med was one year, but now it’s two, so you enter properly to med school at about 20 or 21 years old.

What exams does one have to take to get in?
We actually just have to take the general exam everyone takes to get into college, it consists of questions on Spanish, Maths, Logics, and English.

Is there any required pre-requisite coursework?
No, there isn’t (just the two years of pre-med course work described above).

Is it a competitive occupation?
No, there is a place for everyone interested; the only requisite is to maintain a scoring upon 2.5/4 while you are in premed in order to get in to the med faculty.

What are you called at this stage of training?
Premed Student.

Being In:

How long is it?
6 years

How are the years broken down?
When I started: One year premed, two years basic sciences and three years of clinical training.
Nowadays: Two years premed, two years basic science and two years of clinical training.

Describe your typical day.
Every semester is different. In the current unit I’m on classes begin at 7:00 am with a 2 hour theorical class. Everyday it’s a different subject, this semester includes Peds and childcare, Endocrinology, Gastroenterology, Imaging and Clinical Pathology, Family and Community Medicine and Preliminary Research. After that I go to the assigned hospital for that day and take a 2 hour practical class, again the subject is different each day. About 11:00 am we have a two hour break for lunch, I usually get the chance to go home and eat. At 1:00 pm we are back at the classroom and get out by 4:00 pm, which is when our college and hospital hours end and our duties begin. We are now working in our thesis, so we have about two or three meetings a week (an important amount of hours of work) and the rest is dedicated to study. Usually I stay in week nights (like a little kid =P  [nah! like any dedicated medical student, if you ask me :)]), I’ve learn to value my sleep and I know I’ll do it even more in a few months and years. Weekends are pretty diverse, depending on what’s going on.

If you choose a specialty, when do you have to decide by?
You can have an idea of what field you preferred, but it’s after you graduate that you can start a specialty. You have to take an exam and attend to an interview at the hospital when you are planning to get in; if you are accepted you are good to go. At the interview, besides your personality, the interviewers notice the points you have accumulated along your career as doctor (you win points by papers published, hours in hospital work, an internship year for the government, your graduation scoring, being part of the national medical association and, of course, the interview itself).

What are you called at this stage of training?
Medicine Student. In two semesters I’ll be called Medical Intern (middle of 5th year of med school).

Getting Out:

What exams do you have to take?
To be a doctor you don’t need to take any exam, but to opt for a residency spot you must take a national exam, it is based on a 100% and the minimum to pass it is 70%.

Do most people graduate?
Yes, most people certainly do.

When are you finally considered a “ doctor?”
Right after finishing the one year Internship required in med school and then get your diploma, which gives you the title of Doctor in Medicine (so, if I’m interpreting right, that would be about 7 years into your training including pre-med, medicine and intern year).

Do you have additional training after MS or do you start working immediately?
Doctors have to work a year for the government after graduation (another one year internship, now as a doctor and not a medical intern, in whichever hospital they require you to go to)* in order to get their exequatur (a written official recognition and authorization by the government to which one is accredited to work as a doctor in medicine).
*(The further the hospital, the greater the points you get).

What’s the average debt for attendance?
Well, the cost of medicine career here is about 500,000 RD$, that number into dollars must be around $13,158 USD.

What are you called at this stage of training?
Doctor

Being Out:

What’s the average salary?
The average salary of a resident is about 34,000 RD$ ($790 USD) per month.

Is the job security good?
Jobs have a great availability in our country, the opportunities are better for doctors who work in private clinics or hospitals, although private offices are kind of expensive. Doctors who want to work at a private level have to have the resources or help themselves by loans, which actually pay off when they get established and start working. Not everyone finds opportunities, though.

Can you switch specialties?
Yes you can, but only if it’s related to the field your currently on.

What are you called at this stage of training?
It depends on the years that the specialty you’ve chosen lasts. The word “Resident” adds an R to the name and later the year you are currently on. Ex.: R1, to the residents that are on their 1st year. R2, R3… you guys get the point =P. (This is quite similar to US residency training where we are called “physicians” or “doctors” during our residency training years and PGY1, PGY2, PGY3, etc. to denote our year of residency training. Although, in the US your intern year is equivalent to PGY1). 

Previous Medical Education Monday Posts

Medical School Around the World:

Full Body Physician

My Doctor Has A “DO,” What Is That?

I am honored to have @DrJonathan, a Family Medicine resident from Chicago, guest blogging this week for Medical Education Monday on what exactly a “DO” degree is. After receiving questions on Twitter from two separate people asking if it was “ok” to continue seeing their physician who had a “DO” degree, I knew it was time for this post. Before applying to medical school I truly had no idea there were two types of physicians in the United States and it was interesting to me to learn about Osteopathic degrees. @DrJonathan graduated with his degree in Osteopathic medicine this semester and is now attending residency. Today he has written a wonderful article about DOs geared towards info useful to the general public and next time he will be explaining the differences in licensing and training for students who may be trying to decide between the two paths into medicine! He is a superb writer, you won’t be disappointed.

”Photo

What Is Osteopathic Medicine?

    Despite all the different types of medical professions in America, a physician is the most universally recognized medical profession. Most people associate the word “physician” with an individual who has an MD (Doctor of Medicine). Although most physicians are MDs, they only account for a portion of medical doctors in America. The other type of fully licensed medical doctor in the US is the Osteopathic Physician (DO). Currently, there are over 80,000 practicing Osteopathic Physicians in the United States. They account for almost 10% of all practicing physicians and nearly 20% of current medical students are in Osteopathic medical schools. Osteopathic physicians can be found in any medical field from Pediatrics to Family Medicine to Dermatology to Orthopedic Surgery. Their training includes all the training MD receives: they attend 4 years of college, 4 years of medical school, and at least 3 years of residency. Although they also have their own types, they can complete the same residency training programs, same medical board exams, and earn the same board certification as MDs. They are fully licensed physicians and surgeons in all 50 states, prescribe medications, perform surgery, and independently practice medicine. DOs and MDs work alongside one another in all areas of medicine. They are separate, but equal in their medical practice and theory. The difference lies in the Osteopathic medical philosophy.

    Osteopathic medicine was founded in 1874 by Andrew Taylor Still, a MD. He felt that the medical practices of the day were suboptimal and thought physicians should promote the body’s innate ability to heal itself, prevent disease, and maintain health. He emphasized the muscuoskeletal system in understanding how illness or injury in one part of the body affects another. Osteopathic physicians are taught from the first day of Osteopathic medical school to treat the entire person – not just one body part or system. Their training focuses on the body’s inherent ability to heal itself. They look for ways to restore and maintain health, not just eliminate disease. In addition to learning all that MDs learn, DOs are also trained in the practice of Osteopathic Manipulative Treatment (OMT). OMT is predicated on the theory that structure and function are reciprocally related. Without optimal structure and function, the health of the body suffers. OMT consists of hands-on therapy that helps remove restriction, encourage blood and lymphatic flow, alleviate pain, and return the body to its original state of healthy functioning. Osteopathic physicians can use OMT in every field of medicine in order to restore and maintain health. This additional skills that DOs possess enables them to bring an extra dimension to quality patient care.

    DOs play a vital role not only in helping reduce the physician shortage in America, but especially in meeting the need for primary care physicians. Given the holistic, patient-centered view of Osteopathic medicine, it is not surprising that over 60% of DOs practice primary care in fields such as Family Medicine, Internal Medicine, Pediatrics, and Obstetrics and Gynecology. DOs are also notorious for practicing in rural, underserved communities. Primary care is most conducive to the Osteopathic philosophy of holistic, preventative, patient-centered healthcare.

    The differences between DOs and MDs are subtle, but deep. That does not, however, minimize the fact that they both work for a common purpose: to ease suffering, promote health, prevent disease, and improve quality of life in patients. Osteopathic physicians, however, use their unique philosophy, additional skill set, and all other available medical options to provide patients with the highest quality, most comprehensive healthcare available.

Medicine Across Cultures

Medicine Across Cultures – Medical Education Monday

Today I am honored to have Mat (@lonemat on Twitter) from London guest blogging about his recent medical elective in India, where he spent time interacting with medical professionals from various countries. Not only am I ecstatic to have Mat blogging today because he’s one of my favorite tweeters, but I’m also honored to have him here as he was also involved in the conversation that initially sparked my interest in creating the Medical Education Monday series!

If you have any questions, an idea for the Med Ed Monday series, or attend(ed) medical school in a country not yet discussed (here’s a list) please email me!

Medicine Across Cultures
Photo Courtesy of Idea Go.

Medicine is one of the oldest professions and the Hippocratic Oath, still taken by many physicians, stakes our claim in Ancient Greece. The wording of the Hippocratic Oath would make hypocrites out of many modern doctors, which is probably as good an introduction to a piece on Medicine across cultures as you can get.

I recently spent a “Medical Elective” in India….and before you suspect me of doing a piece on how developed world medicine varies with developing world medicine, let me tell you – I did this elective at varying points with two American doctors, an American medical scientist, a fellow Brit and a Canadian nursing student as well as seeing many Indian students. The gaps between what is know as the “Western” world and India are intriguing and a matter for a far greater person than me to discuss. The complexities are great and I would feel completely inadequate to give them justice, especially after only 6 weeks.

The difference between our student cohorts was enormous and is well worth discussing. The difference between the developing world and western, or “developed,” world is discussed ad nauseum, where as our differences in the western world are often ignored.

Politically we were divergent, but themes emerged:
Americans wanted a more public system – they craved the lack of insurance in England and our freedom to treat everyone we saw evenly. They shared our view of modernization, and were shocked at some financial decisions made in the UK. For example, in the UK most births are midwife led and this shocked a future Obstetrician from the US. American students also couldn’t understand the use of the Copper IUDs versus the Mirena coil where the copper coil is cheaper. Although, I must admit the copper coil is increasingly rare in UK. The US trainees were amazed that if were to have a road traffic accident as a tourist in England, they would recieve the same treatment free of charge as I would. They were also surprised to find that I’d need no insurance at all for my treatment.

Us English students were amazed at the choices available to the American patients and by the prices paid for treatments. Insurance is really a bizarre thing for any Brit, including our doctors!

We, however, proved our similarity over and over again. We agreed on surgical checklists – the WHO checklist being standard! We mostly agreed about antibiotic therapies and were in uniform agreement on hygiene, the importance of the multidisciplinary team, and the role of evidence based medicine.

We were also in agreeance regarding our love of discussing medicine with colleagues from across the world. We were completely different, but ultimately united by our common qualification, our common hopes and dreams, and our common oath, even if it is no longer as formal as the hippocratic oath, to help our patients and do no harm.

ER24 South Africa EMS

Medical School in South Africa

Medical School in South Africa

I am beyond excited to have Medical Education Monday back this week with Renate from “The Regatta” as our guest. Renate is a 20 year old South African medical student in her second year of medical education. She is interested in Pediatric Surgery, but makes sure to let me know that at this stage in her education she has a lot left to experience and is keeping an open mind. Renate speaks two languages fluently (English & Afrikaans), knows enough German to get around and is in the process of learning a couple more languages in order to better communicate with her future patients. How are ALL of my Med Ed Monday guest posters so talented? They never cease to amaze me. When she’s not suffocating underneath a pile of heavy, international edition medical textbooks or practicing a new language, she enjoys swimming, quilting and playing the flute. Thanks for stopping by to read about Medical School in South Africa, if you have questions, feel free to shoot me an email or contact Renate directly!

But first, vote in the poll from yesterday! Pretty please. 🙂

[polldaddy poll=5261349]

ER24 South Africa EMS
Photo Courtesy of Flickr CC User: ER24 EMS (I chose this picture because I found it really awesome that South Africa's first responder team drives the same model of car as me).


Getting In:
How old is one when they begin medical school?
The majority of students study medicine straight out of high school or a couple of years after high school. Most people are around 18 years old when they begin medical school.
What exams does one have to take to get in?
The prospective med student must pass the National Senior Certificate (aka “Matric,” “Grade 12,” or “The Standard 10” if you happen to belong to an older generation) with university exemption.
Is there any required pre-requisite coursework?
You must have both Science and Maths as matric subjects.
Is it a competitive occupation?
Yes, getting into med school is really tough! You must be a top student (85-90% average for matric, preferably 90% or more). Community service can also help. All students applying for med school must fill in what they call a “Value Added Form” (this always made me feel like a taxable object) which covers all extra-mural activities, leadership positions, extra qualifications, etc. There are also all sorts of rumours regarding quota systems for student intake divided on the basis of ethnic groups. I have no idea whether these rumours have any factual basis or not, it’s simply another interesting part of living in South Africa!
What are you called at this stage of training?
One very stressed high school student!

Being In:
How long is it?
The MBChB degree takes 6 years.
How are the years broken down?

  • The first six months of first year are devoted to basic sciences (chemistry, physics, biology) as well as a bit of philosophy, sociology, medical terminology.
  • The second six months of first year and the entire second year the medical student painfully acquires knowledge in the area of the basic medical sciences like Physiology, Anatomy, Immunology, etc.
  • Third and fourth year, as well as the first six months of fifth year, are devoted to more clinical knowledge.
  • From fourth year onwards the student rotates through different sections of various hospitals for morning rotations. In the afternoons there are lectures and evenings are for studying.
  • The second semester of fifth year and the entire sixth year is spent in the hospital as a student intern, once again rotating through hospitals and departments.

Note: This describes the medical program at my university. This is not necessarily applicable at all South African medical schools!

Describe your typical day.
I’m in second year right now, so my day is not particularly exciting! We usually have lectures from 8:00 until 13:00. Lunch break is from 13:00 until 14:00, followed by practicals or tests on some afternoons, depending on the schedule of my particular group. Usually we’re done by 16:00.
This does change periodically though, depending on what block we’re doing! For instance, during anatomy block we finished at 5 ‘o clock in the afternoon almost every single day, while in Block 1 (the very first block at med school) we would often finish at one ‘o clock and be home in time for lunch!
If you choose a specialty, when do you have to decide by?
I’m only second year, so I’m not totally sure. Our undergraduate degree is six years. However, before a doctor can practice in private practice or specialise, we have to complete 2 years of internship as well as 1 year of community service. (Also known unofficially as “Zuma years”, not so affectionately named after President Jacob Zuma, who may or may not have had a hand in prolonging this time period.) As far as I know, any time during the Zuma years is a good time to apply for a specialty position.
What are you called at this stage of training?
While completing the MBChB degree you are known as a med student or student intern (during the last year and a half.)

Getting Out:
What exams do you have to take?
Uhm…Finals? I don’t think we have a fancy name like USMLE…
Do most people graduate?
According to the upbeat and encouraging “welcome to med school” speech that we had to suffer through on the first day of med school, yes, most people do graduate. (I can’t remember all the statistics they bombarded us with!) Having said that, not all students finish the degree in six years.
When are you finally considered a “doctor?”
Once you have completed the six year MBChB degree, then you are a doctor. However, you cannot move into private practice or specialise until you have completed the “Zuma years.”
Do you have additional training or do you start working immediately?
Zuma years are paid work, although I’m told the pay is not very good.
What’s the average debt for attendance?
Lots! I’m not actually sure what the precise number is. Working on a very generalized average, it would cost about R20 000 ($2,953.40 USD) per year of study, which would work out to about R120 000 ($17,720.40 USD).
Is the job security good?
In South Africa, there are not enough doctors for the population, so you should always be able to get a job. It might be somewhere really rural though!
Other random facts:
What the USA call residents we call registrars. Attendings are consultants.

Other Medical Education Monday Posts:

Trip To Betty Ford Institute In My Future

    I was three and she was 24 when we left – for years the alcohol and drugs precipitated the fighting, which brought on the feelings of guilt, which inevitably lead to more drinking. It was a vicious cycle that had to be broken and, no matter how much my he begged my mom not to leave with me, she knew we couldn’t stay.
    He’s a good man, my dad – a smart, hard-working, exceptionally talented man with a detrimental disease that makes people look at him differently when they find out. Two months after we left he checked himself into a rehab facility and, when they deemed him healthy enough to leave, he started taking me along to his weekly Alcoholics Anonymous meetings.
    I get my determination and persistence from my dad, an addict who has been clean and sober now for over 20 years.  I have a deep desire to be the doctor who knows addicts are real people who can be helped, a doctor who is compassionate to the struggles of those with substance-abuse issues and understands that addiction is a disease. One thing I don’t want – to be the doctor who passes over these patients as “drunks” or “druggies” who are passed the point of being helped. After all, there’s a good chance my dad wouldn’t have been around to walk me down the aisle two years ago had someone not believed that, when he finally hit rock bottom in 1989, he could still be helped.

I never got around to writing a post for my amazing Dad on Father’s Day, so I’ll talk about him a little here*. He has overcome so much for me and our family – fighting through the tough hand of addiction and trials he was dealt in his early 20’s, he managed to come out on the other side as an inspiring story of success. He truly is one of the most unfaltering and inspiring people I’ve ever known and I’m so lucky to call him “Dad.”


The fight he fought and the journey we travelled together inspired me to apply for an opportunity that promises to be life-changing – a week at the Betty Ford Institute during my Psychiatry rotation. A big-hearted donor, who fought addiction himself, sponsors four of our third-year students to spend time learning about addiction treatment at the world-renowned Betty Ford Institute during their Psychiatry rotations.


Along with @BChanMed and two others from our school I’ll be spending the last week of August submerged in addiction treatment. Although the other patients will know we are at the center for a learning experience and despite the fact that we will have lectures geared at treatment from a physician standpoint, a large part of our week will be active participation in the unique treatment program put forth by the center. We will learn the ins and outs of treatment by participating first hand in small group and counseling activities with other patients who struggle with various addictions.


The Betty Ford Center is the only US addiction rehab facility currently offering a program like this for medical students and I am so honored to be a part of the Summer Institute for Medical Students


First hand participation has been proven time and again to be pivotal in teaching us to be great physicians, but personal experience has taught me that physician-training in the area of addiction treatment is lacking, to say the least. It is not just those of us who choose Psychiatry as our specialty who will interact with people struggling with substance abuse or addiction – these are afflictions felt by patients from pediatrics to geriatrics and everywhere in between. I am so grateful to have this medical education opportunity and I hope that other programs will take note of the Betty Ford Institute’s revolutionary initiative and increase the number of medical students offered this opportunity by following suit to create similar programs. 

I anticipate a life-changing look into how professionals go about treating those who struggle with addiction and also help in teaching their family to be assets of rehabilitation. I am confident that I can take what I learn in my week at the center and translate that into compassion and understanding for the benefit of my future patients and I hope that this experience will enable me to be a better doctor, a better daughter and a better educator.


*My Step-Dad is also a huge influence in my life and if I were writing a post for Father’s Day he would most definitely be included. I’ve written a bit about him & organ donation advocacy here

Medical School in the UK, Residency in the US

Today’s Medical Education Monday post is one I have been looking forward to reading since he offered to write it for me a few weeks ago! Nick Bennett (@peds_id_doc) is a Pediatric Infectious Disease Fellow in Syracuse, NY and he has a very unique perspective to share with the Mind On Medicine readers today. Dr. Bennett went to medical school (and got his PhD…overachiever…does that mean we call him Doctor Dr. Bennett? I think it does.) in Cambridge, UK, but chose to do his residency in the United States. Medical school in one country, residency in another – what a unique and valuable addition to to this series!! In addition to being a bug-killer extraordinaire, he is interested in teaching communication skills, antibiotic stewardship and software-driven data analysis (from what I’ve gathered on Twitter he’s the owner of some geeky computer skills – something I’ve come to regard highly after marrying a software developer – that stuff is no joke). I hope his information can help someone looking to do something similar, but I can assure you that his story is a great read even if you never plan to practice medicine somewhere other than your country of training…actually even if you never plan to practice medicine at all.

I’m in the interesting position of someone who went to medical school in one country (UK) but completed residency in another (USA). My reasons for doing so are, on the surface, fairly simple (my wife is an American) but it goes a bit deeper than that. One issue that was important was the fact that in the UK the junior doctor jobs often involve moving from hospital to hospital, spending only a few months in the same place. The alternative was to move once and stay at the same hospital for several years. It seemed like a simple decision!

The problem I immediately ran into was – just how the heck do I do this? There was absolutely no careers advice for those of us who wanted to leave the NHS (National Health Service). I’d even been to careers advice forums where the speaker opened with, “This is really for all the scientists here, as doctors have it pretty much sorted out.” Yeah, thanks.

Searching online revealed two basic hurdles – exams and visas. The US assumes that every other medical school in the world has exams that aren’t reliable. You not only have to graduate from your medical school (if it is on the list of acceptable schools!) you have to pass US medical school exams as well – the USMLE Step 1 (the test I take Friday
and 2. For most people this is an annoying formality, but there are two issues here: Step 1 is basic science – you may be many years from your pre-clinical training and hence quite rusty (as I was) by the time you take it – and Step 2 has a heavy US bias, so you have to re-learn minor facts of epidemiology as well as have a basic knowledge of US geography and the medical conditions, typically infections, that are more common in certain states.

The exams are required for certification by the ECFMG – the Educational Commission for Foreign Medical Graduates. Along with your medical school records, passing the Step exams is needed to obtain ECFMG certification, which is required to start a training program in the US as a Foreign Medical Graduate (FMG). It is quite expensive in terms of fees and exam costs, but if you want the training you have to invest the money.

The second issue of a Visa was one I was thankfully helped with by marrying an American! The more typical approach is to obtain a H1B or J1
training visa. These are sponsored by the residency program or the ECFMG, so you have to have been accepted by the program before that can move forward. Not every program will sponsor training visas so focus your efforts on those that do. FMGs are often at a competitive disadvantage compared to US graduates, but some programs are very supportive so it can pay to do your homework about a particular place to find out how they stand on that issue. If you have contacts in a residency program in the US that’s probably the best way to get the inside scoop.

I was very lucky in getting the program I wanted – I was taken “outside of the match” which means I didn’t have to deal with the NRMP (National Resident Match Program), which I gather can be quite stressful and complex, especially for non-US graduates. As such, I’m rather odd in that I can’t offer any advice on visas or matching! I did it through networking and spending time here as a student doing an elective. That kind of exposure is priceless when it comes to applying for a residency position (spending time doing away rotations in places you want to do residency is sound advice for ALL medical students, not just for those looking to go to a new country to finish their training)
.

There are a few websites out there with advice on moving to the US. They’re worth reading to be prepared for some of the inevitable culture shock. Oddly enough, the effect was perhaps weirder coming from the UK. Enough of the lifestyle and society was similar to the UK that when something WAS
different it seemed more of a surprise. Silly things like having to add sales tax onto prices and paying for checking (current) accounts were hard to get used to,  you get used to it, though.

Once I was here a few things became quickly apparent. The first was that although it seemed as if my medical school training gave me an excellent basic medical science background, but I felt wholly unprepared for actual patient care. The US students were given more responsibility and seemed more involved in patient care that I had been. The other FMGs that were starting with me tended to have already completed a residency in their own country. I was lucky in having a graded experience working up from the newborn nursery to the ER and excellent senior residents, but I know that had I started out in the ER things might not have gone so well! My learning curve was near vertical, but I kept my head above water enough to keep going. Once I was settled in it was also clear that despite all I had heard about the “evil US profit-driven healthcare system”
, the actual practice of medicine was basically the same as it was in the UK. Docs still made decisions based on best practice and in the patient’s best interests, at least in the academic setting. Only rarely did insurance ever come into play – usually when patients didn’t have any and we had to cut corners to save them some money.

Later, as a Fellow, I ran into the issue far more frequently, when having to obtain “prior authorization” for treatments that insurance companies would rather not pay for. I’ve also heard and seen more discouraging practices from the non-academic world, which although not unique to the US are far less likely in the system I came from. Everything from pharmacy costs to malpractice premiums is shifted upwards, and it’s easy to see how the US ends up spending twice as much as any other developed country for no additional benefit.

There were several advantages to coming here that I really didn’t anticipate. Back in the UK I recall asking my research supervisor how I could get to be someone like him. He replied that I should focus on medicine for the first 10 years or so before trying to come back to research. When I asked the same of my mentor here in the US he said “Well, you’ll have to wait until at least the second year of Residency…!”  As it happens, in my Intern year I started writing online medical review topics, helped out with clinical trials and started a new medical education initiative for the students. It seems as if people are very willing here to support junior doctors in the kinds of extra-curricular activities that would otherwise have to be put off for years in the UK. That’s not to say that every FMG becomes a world-famous clinical educator or researcher, but that it just seemed to me that the opportunities were better for me here. In addition, it’s very clear that people do all kinds of things with their medical training here. In the UK I felt as if I was being channeled into the NHS and it seemed there was no way to easily merge education or research into my daily activities. In the US it is equally valid to choose private practice as it is to choose academics, industry, or government work – in fact, many mix and match.

I think I got a great education from the UK, and I didn’t leave specifically because I couldn’t get what I wanted there – it was for personal reasons, but it turns out that making this move to the US was a really great professional decision, too.


Past Medical Education Monday Posts

Medical School in the UK Post

Medical Education Monday – Social Media

Today’s Medical Education Monday is going to take a bit of a different direction. I’ve run out of foreign medical students and doctor friends for the time being, so today I’m going to focus on a different aspect of Medical Education – Social MediaIn the mean time, if you know someone in medicine from a country we haven’t covered send them my way – I’d love to have them! If you missed it, you can read through the past editions of Medical Education Monday here

Original Photo Courtesy of Flick Creative Commons User: smemon87
Like other medical student bloggers, my experience has been that, while really wonderful and up-to-date on most all subjects regarding student relations and professionalism, my school has largely ignored the prospect of students or physicians having a presence in Social Media. We’ve had one or two discussions on the subject whereby a (non-tweeting, non-blogging) professor stood at the front of the room and declared “The Facebook” a bad place to spend time. We were basically told not to “friend” patients and that was that. 


This obviously overlooks a very large, and likely more positive, realm of social media – blogs and Twitter. 


Most people use Facebook as a personal outlet – a place to stay caught up with friends and family members. I don’t think any of you need to be told not to friend your patients on your personal Facebook accounts. So, why are we dodging the larger issues? Why are we ignoring the fact that there needs to be a set of rules and examples in place to avoid issues like what happened with the Kansas nursing student who posted a placenta photo on her Facebook*. 


We really need to stand up and demand a defined set of rules for social media use, not because most of us are breaking any rules with our blogs or tweets, but because without one we are all at the mercy of what a school administrator arbitrarily finds to be “unprofessional.” And, as we saw last week with the Twitter & Blogging Physician Professionalism War of May 2011, the definitions of professionalism vary widely amongst people in our profession. 



So, why don’t I simply talk to my school admins and request that a set of rules be put in place? Well, like fellow med student blogger Fresh White Coat said so well, after the lectures and “advice” we’ve been given regarding the use of Social Media I simply don’t trust that a constructive, rather than restrictive, policy will be devised.


That being said, I’m going to take some time over the next few weeks to write some posts about how I feel my use of social media has made me a better student and will make a better doctor. If we can show the nay-sayers just how beneficial the world of Twitter and blogging can be to us as students, perhaps we can move forward in the initiative to get uniform guidance, support and protection laid out. Until then, we are quite literally at the mercy of an arbitrary definition and pliable area of gray. 


I’m going to need your help, though. If you’re a medical student, doctor or patient (that covers basically all of you) please leave a comment telling me how you think social media has positively influenced you. Has it connected you to other students? Other physicians? Given you an outlet to discuss issues that are important to you? Kept you up-to-date? Helped you learn to engage in academic and medical conversations? If you don’t feel comfortable leaving a comment, feel free to contact me.  


Over the next few weeks I’ll compile your positives and many of my own and discuss the pros of social media. We all know the cons and I don’t think I need to waste my time listing that out here, instead I will discuss things like

  • Why I choose not to blog anonymously
  • How Twitter communities of patients and activists have helped me
  • How meeting med students from around the world has been beneficial 
  • Staying up-to-date & aware thanks to Tweeting/Blogging students & docs

I look forward to hearing your opinions!


*I’m not here to debate the rightness or wrongness of this, but for the record I 100% believe the school was in the wrong to dismiss her from her studies.