Senior house officer exchange to BelgiumBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7155.2 (Published 08 August 1998) Cite this as: BMJ 1998;317:S2-7155
Katie Darling swapped her London teaching hospital post for one in Brussels as part of a one year exchange scheme for junior doctors
Since 1975, a European Economic Community directive has allowed the free circulation of certain professionals within member states. This legislature enables recognition of primary qualifications so that doctors can gain full registration in any European Union member state without having to resit local examinations, provided that they are citizens of a member state and have trained within the European Union. Despite such freedom to circulate, however, British doctors remain hesitant. There are two main factors that make the English Channel as much a psychological as a physical barrier: finding a job and practising in a foreign language.
The European exchange scheme
In 1977 a European exchange scheme was established between leading academic departments in Britain, Belgium, and Switzerland.(1) The goal was to further medical education by exposing junior doctors to different healthcare systems and cultures. Senior house officers, or the mainland European equivalent, were chosen from teaching hospitals involved in the scheme. At the time, the exchange was somewhat experimental, but was made possible with the help of the European Commission.(2)
Twenty years and nearly 200 candidates later, the scheme has proved successful, with exchanges taking place between 14 departments of medicine from eight countries.(3) Centres in Britain, Belgium, and the Netherlands have been the most active, but exchanges have also occurred in France, Germany, Switzerland, Austria, and Portugal.
Each post is arranged, usually annually, between the heads of the relevant centres, and candidates must apply in their native country. For British candidates, such appointments (for periods of 6-12 months) are advertised in the classified section of the BMJ, usually as part of a two year senior house officer rotation, in such centres as the Hammersmith, St Bartholomew's, Addenbrookes, and Guy's hospitals. Others are also starting to take part. If a candidate is well motivated and two heads of department can get together, an exchange can be organised between any two or even three centres, although planning well in advance is advisable. Heads of departments of potential centres should contact one of the consultants already taking part in the scheme, then establish connections with consultants in the centres abroad.
Candidates suitable for an exchange should have an interest in working abroad, preferably (but not exclusively) with a grasp of languages. Because the scheme has been devised specifically for the exchange of foreign doctors, allowances are made for initial language imperfections. If necessary, “running in” periods spent shadowing other doctors can be arranged, and there are usually no on call commitments for the first four to six weeks. I had some acquaintance with French before starting, but one of my colleagues managed to set off to a Dutch speaking institution being able to say only who he was and that he was a doctor. It was hard at first, but after three weeks he was able to crash bleep the anaesthetists like a local.
Of the three Francophone centres involved in the exchange, Belgium might seem less appealing than France or Switzerland to many. However, after nearly a year here, I find the “Name three famous Belgians” joke wearing thin and the country's lower profile is becoming one of its attractions. Belgians do not flaunt their assets; it is up to visitors to discover them.
The Belgian health service is based on a compulsory insurance system rather than a British style national health service, and membership of a sickness insurance fund (“mutuelle”) is mandatory. Patients pay for outpatient investigations and treatment and are then reimbursed according to social status and grade of treatment (“lifesavers,” for example, are reimbursed at 100%). The system creates a substantial amount of paperwork for doctors at every level, as they have to sign forms justifying certain treatments and imaging procedures as well as endless insurance forms and certificates of hospitalisation.
Belgium lacks the British style of general practitioners acting as gatekeepers, and patients are free to directly consult any physician of their choice simply by making an appointment. This increases the level of choice but necessitates a degree of clinical insight - for example, should hypertension be managed by a cardiologist, a nephrologist, a clinical pharmacologist, or a general physician.
My own exchange has brought me to the 900 bed Clinique Universitaire St Luc in Brussels, which deals with the French speaking community and provides all medical and surgical specialties, and state of the art imaging procedures.
The preregistration house officer equivalent in Belgium is a medical student in the fifth year of study. These “stagiaires” are in charge of clerking patients, ordering bloods, chasing results, and updating notes. As well as a full working day (generally from 8.30 am to 6.30 pm) they have regular on call commitments, but, because they are not registered, they cannot prescribe and do not receive a salary. Extracurricular activities receive little encouragement: being too hung over to turn up to work is not a privilege the Belgian student enjoys.
Although medical studies involve an extensive grounding in theory, there is no bedside teaching and only one formal assessment of clinical examination takes place after the first clinical year. Clinical skills are further overshadowed by easy access to imaging techniques. No postgraduate examination or equivalent of the MRCP is required for specialty training in hospital medicine.
The difference in salary for those being paid is substantial, especially if you take into account the 10-12 hour working days, at less than half that received in London. There is no payment for out of hours work, including on call duty. On the more positive side, the standard of medicine is high, with academic meetings taking place between specialties up to three times daily and access to Medline and the internet possible on the main medical wards.
From a practical point of view, phlebotomy and venous cannulation is a nursing duty, and more responsibility is given to nurses with respect to prescribing than their British counterparts. Practical procedures are often orientated to specialties to the extent that a chest physician may offer to perform a simple pleural aspirate if required for a general ward patient. Neurology is not considered part of general internal medicine and is therefore not included in generalist training.
One feature of Belgian medicine is the concept of “bilans,” a series of investigations that do not necessarily have a direct effect on patient management but which are believed to better illustrate the course of a patient's condition. For example, an ophthalmic opinion (physicians here do not perform funduscopy) and an echocardiogram are performed routinely for patients with hypertension, and standard blood tests are more extensive than in Britain. Because of easy access to a wide range of imaging techniques, together with a system where money goes with the patient, extensive investigations for everything are performed more readily than in Britain.
Francophone emergency services (the “SAMU”) brings doctors (usually accident and emergency specialists or anaesthetists) to the patient, if necessary starting medical care on site. Thanks to SAMU, members of the public who suddenly become critically ill outside hospital can be intubated in their homes by a fully qualified anaesthetist and stabilised by a medical team before being transferred. This gives time for relevant specialists at the nearest medical centre to be contacted so that patient management continues smoothly on arrival.
Teething problems are inevitable with any new job, but coming abroad provides a few additional hurdles. Obtaining registration is rather involved, and even more simple tasks such as finding accommodation and opening a bank account can be challenging if you are not equipped with the necessary vocabulary. There are times when nothing works to plan, and this can be at best challenging and frequently demoralising for the unprepared. This is not a suitable option for the partially motivated.
Effect on career
The official line on recognition of posts worked abroad with respect to training requirements of the Royal College of Physicians is that there is no official line. Unofficially, jobs in teaching hospitals in countries like France, Germany, Belgium, the Netherlands, or Switzerland can “probably” count towards general medical training at senior house officer level. For specialist registrar posts, there is still no answer. Collaboration between different specialist centres is presently under way, with a view to unifying medical training within the European Union and, ultimately, to establishing a system of equivalence for different grades and specialties. Achieving this is some way off and unlikely before the next millennium.
Regardless of how an exchange is viewed on paper, however, this type of sabbatical should be considered an asset to your career. The exchange provides a unique opportunity to practise within a different healthcare system while experiencing other differences on linguistic, cultural, and medical levels. You are obliged to consider aspects of health care, notably on the organisational and administrative side, that tend to be taken for granted at home. Taking time away from a rather membership orientated training programme is also not unhealthy, and, because the scheme operates between teaching hospitals of high standard, you can be sure that medical training will not suffer in the face of more culturally based pursuits.
Since 1975, doctors trained in the European Union have been able to practise in other member states of the European Union without having to sit special registration examinations
An exchange scheme enables doctors to work abroad without going through the local job finding system, and allowances are made for initial deficiencies in language
Belgian health care is insurance based, and patient fees are reimbursed depending on social status and type of treatment received. The standard of care is high
On the down side, the drop in salary is considerable and administrative duties form a greater part of the doctor's workload than in Britain
The exchange provides a unique opportunity to work abroad in a different language without being to the detriment of medical studies
As yet, there is no official recognition of appointments worked in other European countries with respect to general medical training and specialist Calman posts