The Differences between the French and British Medical Education System

Introduction

Medicine as a subject is extremely diverse. There are many different components and skills which need to be taught to students during their undergraduate years. These range from the theory of the degree to bedside manner and clinical skills. This variety has meant that different medical schools have built up their own unique way of teaching the course. Emphasis is placed on different parts and different ways of learning are being tried.

In England, Oxford and Cambridge separate their non-clinical and pre-clinical years. Manchester Medical School uses problem-based learning to teach, and Bristol University integrates clinical years in to the first two years. However, the General Medical Council ensures that, although variations between schools exist, all education is in the United Kingdom is standardised and that essentially, the education is the same.

In this way, medical education in France has its own regulations and therefore the system has developed differently to that in the UK. There are certainly core similarities between the two countries, which as medicine is a universal and professional degree, never change. Yet, on the whole, medical teaching in France is somewhat different to that in England.

In comparing the two systems, I am using Bristol Medical School and the hospital Pitié Salpêtrière, Paris, as my sources of information.

Getting into Medical School

In England, success in getting a place to study medicine depends on A-level results or equivalent. The course is so competitive at entry, that grades are one and the main way of separating out candidates. Universities also look seriously at the candidates application form, where there are statements by the applicants and teachers. Evidence of medical work experience, involvement in extra-curricula activities and a commitment to medicine is sought. Other methods include small tests set by individual universities, and interviews. Entry into medical school is a highly selective and competitive process. Emphasis is placed not only on students with the right academic grades but on those who seem dedicated and have the overall potential to become a good doctor.

In France, any student can study the first year of medicine regardless of their baccalaureat marks. The first year of a medical school, may take around 1000 students and consists of general science lectures. Throughout the year, students work incredibly hard against their peers to ensure a place in the next year. The exams are a competition, with only about 20% getting through.

The French selection process has no other criteria than comparing grades. This gives all students an equal chance. They have all had the same teaching for a year and exams are the same. No-one can claim that certain candidates have advantages that others do not. A topic which has raised much debate in England.
However, even though the first year at medical school in England can be challenging, the undergraduates have already ensured their place at university. As long as exams are continually passed, little risks their place on the course and their is no competition between students. In France, competition is fierce and students have to battle between each other for the few places to continue on the course. It can be argued whether such practise is healthy the year after leaving school, which for is seen for many British degree courses as a time of readjustment to a knew education system.

Medicine is a course which relies on skills other than intelligence. Selection simply on grades means that the French are looking for no other skills in their doctors. Intelligence is not the most important factor. Although all medical schools in England have their own application systems, in general their is emphasis on more than just grades, aiming at producing more diverse and skilled doctors.

The Pre-Clinical Years

In England, most medical schools have now adopted an integrated education system. This means that although the first two years are mainly reserved for teaching of theory, there is still a certain amount of clinical teaching. This aims at introducing students to clinical skills and perhaps giving some motivation through the harder theory-based part of the course.

In France, partly due to the selection procedure, the first two years are purely lecture based. Clinical teaching is limited, if there is any. This ensures a good grounding in scientific knowledge, of which the French level is very high, but gives the students no taster of what real medicine is like, and gives them no previous experience for the first day when they enter the hospital.

The Clinical Years

The French have four clinical years. Each year is divided into three month hospital placements. In that time, each student will be allocated to a ward of a department, along with some other students from that year. In each department, there will be students from all years working along side each other. The number of students varies depending on the size of ward, but generally there are about six students.

On the ward, French students play an active role. This varies in every department, but often students have their own patients which they must clerk, and check on daily. Jobs such as ringing up for results, taking ECGs, arterial blood gases, writing notes during ward rounds and keeping files in order and up-to-date, are all jobs performed by the students.

Students work in the hospital every morning, but often have to cover weekends, or the afternoons between them eg. similar to being on-take.

Teaching

Bristol Medical School teaches the clinical years through hospital placements. There are very few lectures. Teaching is mainly on experience. By attending ward rounds, going to clinics and theatre, following the doctor on-take and clerking patients, experience and expertise rapidly increases. The more time spent in a hospital, the more opportunities arise to practise skills, see interesting cases, and learn from the doctors.

Throughout the clinical years, much emphasis is placed on patient contact. In England, students are taught that 80% of a diagnosis should come from the history and 20% from the examinations. Investigations should only confirm the diagnosis. Therefore, much teaching time is dedicated to improving clerking skills, and communicating with patients. So called bedside teaching.

In France, the mainstay of formal teaching comes in the afternoon, when there are lectures. Each year has series of lecture blocks covering different topics. Afternoon, and sometimes evening lectures continue for the four clinical years. Regular lectures ensure that the French students keep up-to-date, and continue improving their medical knowledge. It insists that they have a very high level of understanding which they can then apply to their morning hospital placements.

There are often teaching sessions during the morning hospital placements. These sessions involve all students from the different years on that attachment. The fact that all students are taught together has its advantages. The lessons are of a high standard as they often focus on the final year students. The medics in their last year also benefit from listening to questions and difficulties posed by the younger years.

The teaching the students receive actually on the wards is haphazard. It depends on doctors taking time out to look at a radiograph with a student, see a patient or go through test results with a student. Therefore, individual students may have a lot of ward teaching or none at all. No official bedside teaching seems to exist.

This is where the main difference between French and English medical students lies. The English emphasise bedside manner, and examination skills. The French are taught very little of this and are left to develop their own disjointed examinations. The French place their emphasis on knowledge. Their ECG understanding, radiograph reading and investigation interpretation is of a more advanced standard than their English peers.

The other key difference is in peer-assisted learning. The French medics spend mornings mixed with all years. This means that a lot of teaching comes from students in the years above. More often than not, they are the people more available to help a student look at an MRI scan or give an opinion on the differential diagnosis. ‘Peer-assisted learning’ is a fantastic way to learn, as the older students have more time, often explain things in more simple and practical terms, and can themselves be practising. In Bristol, this idea has been recognised and is starting to be introduced.

Responsibility as a Medical Student

In England, medical students hold no responsibility until they graduate. On the wards they hold no precise role and are not expected to ‘work’ on the wards more than their learning and teaching dictates.

In France, the medics have a job to do on ward, and are paid. They do many of the menial tasks for the junior doctors, and help the nurses with practical procedures. Officially they are still undergraduates and so therefore carry no legal responsibility. They are always under the supervision of a doctor. However, they do hold some responsibility and without their input, the ward would not function as efficiently.

With this responsibility, the French learn fast how a hospital works. They spend four hours every morning on the same ward for three months. They learn about the paperwork, the exact roles of the doctors and nurses, and the commitment that is needed. They are an integral part of the system. By doing the menial tasks, subconsciously, the French students pick up more about hospital life.

Yet in England, there is more emphasis on reaching defined learning objectives than in filling in forms. This is not seen as a students job, nor a worthwhile task. The English students are allowed more time to full fill their syllabus by seeking different experiences throughout the hospital, in clinics, surgery and the wards. The experience the medic gets often depends on the experiences they seek. Yet in this way, they are able to have a much wider range of experiences than the French. Although, the French gain more in depth knowledge in the places where they have spent their attachments.

Rotations

Dependant on the university, every clinical year rotates through set placements in the hospital eg. in year three, there are attachments in psychiatry and orthopedics, in year four attachments are in pediatrics and old age medicine. By the end of the fifth year, every important speciality should have been covered, giving students a broad range of knowledge and experience when applying for jobs.

In France, years will have certain obligatory attachments. In year three, neurology and ENT must be clinically covered and in year four, emergency medicine and intensive care. In each year, there are free placements where the students can choose from a range of specialities. This allows students to develop interests early on. If a speciality is not an obligatory placement, it can mean that a student may never get clinical experience there.

The French must have a system for deciding what is a obligatory and what is not. In every year, there is an element of choice, and so interests can be tailored early on. However, it may mean that throughout undergraduate medicine, a student has no practical experience in a subject like rheumatology or respiratory medicine. Even if students are not planning on specialising in such areas, surely a broad range of understanding and experience is required to treat patients. A patient coming in with a heart attack, may well have arthritis!!

Practical Procedures

In England, students learn and practise practical procedures over the three years. Most skills, eg. taking blood, are formally taught, but then responsibility is with the student to keep practising the skill. Students are not regularly required out of duty to be taking blood for the nurses on the wards, but may be encouraged merely to improve. Again, emphasis is on the students learning and practising.

Certainly in the respiratory department of the Pitié Salpêtrière, students take all the arterial blood gases. This is an excellent way for the medics to increase their confidence. It is their job to be taking the blood, so have to learn quickly, and naturally improve fast. Maybe in England students regularly doing the blood rounds would increase competency quicker and ensure that not just the confident students, who actively seek practise, improve.

It seems like the French medics also have more opportunities to try more complex procedures. Students on-take in accident and emergency in the Pitié Salpêtrière often get to do lumbar punctures!! In England, such advanced skills are performed by house officers. Maybe this is giving students too much responsibility too soon, but at least it must serve to increase competency for when the student suddenly becomes the ward doctor.

Exams

From year three onwards, British medical students not only have written exams, but also OSCEs: objectively structured clinical exams. These exams test clinical skills. They include examination, history taking, communication skills and practical procedures: an integral part of the course on which the English place a lot of emphasis.

The final exams in year five also consist of not simply written papers but more complex clinical exams testing all skills that will be needed the year after as a junior house officer.

In France, there are no clinical exams, not even for the ‘internat’ (their final papers). Exams are all written, and are often based on case studies. By doing case studies, the French are trying to test medical knowledge in a more realistic way, yet nothing is the same as an exam where you talk to and examine the patient directly.

This confirms the main difference between the two systems. The French place much emphasis on knowledge and the English, although recognising that knowledge is vital, also want their students to be to a standardised level in practical skills. The French do use their ward placements to officially assess students. This could be seen as better than an exam, but it does not seem that communication skills, examining and practical procedures are ever formally watched.

Student life

Student life in England has grown to mean more than just the academics. Medicine especially is a course which offers much more. In most universities, medical societies, run by the students, offer sports teams, music groups, put on plays and hold social events. Medics are notorious for not only working hard for their degree, but also getting involved in many other activities.

In France, student life is not so diverse. The opportunities do not exist to be involved as a student in much more than the degree. University is about working and medicine is less of a community. The exam competition in France mean that the students work fervently. That is not to say that the English do not work hard! but that in England, student life can be used to gain interests out of medicine. Social skills and team playing are all vital requirements and make for more well-rounded doctors.

Conclusion

How a country trains their medical students determines how medicine is practised in that country. France and England have evolved different ways of educating their future doctors. Each course has flaws, but as a whole, the two courses work to produce highly knowledgeable and experienced junior doctors.

Medicine is a huge subject and as long as the essentials are taught, there can afford to be differences in training. The medical degree is only a few years. Doctors practise medicine for much longer than they train. It is after the basic training, that doctors really begin to learn, specialise and become experts. Good undergraduate teaching is a vital grounding. France and England have both found different but thorough ways to provide their medical students with grounding enough for them become some of the World’s leading doctors.