A second guest post by Dasha Kenlan, UK M4, and soon to be anesthesiology resident at University of Utah.
It’s hard and it takes forever, no matter where you do it.
As Josh and I come to the close of four long years of medical school, after a previous four long years of undergraduate college, we could not help but be curious about what the medical training is like in Norway. And by curious, I meant … we literally inquired about medical training to every single doctor, student, nurse that we conversed with for more than two minutes. By the end of the trip, I could have recited the spiel almost as well as the Norwegians … 6 years of medical school, an internship, specialization training, consultant….
For starters, it is very difficult to get into medical school in Norway for Norwegians. There are 4 schools in the larger cities: Oslo, Trondheim, Bergen, and Tromsø. Our understanding is that you must have the best grades in high school and on test scores to have a chance. Everyone else with the dream of being a doctor must study abroad, or find another dream. Examples where students can go to medical school – Germany, Poland, Hungary, Sweden, Denmark, Australia. The difficulties with going abroad, of course, are cost and language.
Their medical curriculum is 6 years, with no undergraduate degree prerequisite. Our impression was that the pace of the curriculum was also not quite as harsh as in the United States. Norwegian medical students can have part time jobs during the early study years, and get more vacation. We also met a Swedish medical student in the Tromsø hospital that outlined her years of training. Years 1-3 were classwork, then years 4-5.5 were clinical. She was in her 4th year, doing her first surgery and anesthesia rotations in Tromsø voluntarily. Karolinska in Stockholm doesn’t have space for all of their medical students to do rotations at home, so many travel to outpost sites (we do this too at some US medical schools, and all the Caribbean schools). She said she could also apply to do rotations in the US, but had to wait until year 5 or 6, when she had more experience and could be competitive enough.
We worked with the Swedish medical student, and another brand new anesthesia resident who went to medical school in Tromsø, and it appeared that our rotations were similar in that the medical student follows around the resident, and does their best to build their clinical bearings. Procedures happen when the med student feels confident, and the resident is willing to teach them. Some things never change.
One final point about their curriculum, the Norwegian students are also just getting ultrasound training in their curriculum. Ultrasound is one of Josh and I’s special interests, so we had to inquire. The University of Oslo was rolling out a formal program this fall 2017 (rumor through the GP grapevine at the Oppdal conference), and our anesthesia resident friend was hosting brand new ultrasound workshops for the Tromsø students.
A difference between medical training in Norway and Sweden is when you get your full medical license to see patients and prescribe medicines. In Norway, you go to medical school for 6 years, and when you graduate, you get your full license. Theoretically, you could become a resident in a specialty immediately, but most still go through the system where you work as housestaff for 18 months. This is the equivalent of our intern year, but it is comprised of 6 months of hospital medicine, 6 months of surgery, and 6 months of outpatient general practice. In Sweden, this 18 months is still mandatory, and you only get your license after you complete the 18 months. Either way, it seems like most doctors complete an 18 month internship before the begin their specialty training in each country. One caveat to that though, if you are going to become a General Practitioner (GP), then those 6 months of GP during internship can count towards your specialization.
Once you start your internship, or even a little before, it’s time to consider where and in what you would like to do your specialty training. Your rotations during medical school can help you with those connections, i.e. if you did a stellar surgery rotation in Tromsø, they might offer you a position upon finishing your internship. There is no VSAS, no ERAS, no NRMP. Getting a residency sounded more like getting a job, and the training was much more flexible. Residents started at all different points in the year, and there were different numbers per year. When you ask how long the anesthesia training is, the answer is, it depends. Are you doing extra projects during residency that will prolong it? Are you going to have a baby (1 year maternity leave protected!)? Is there a significant need for you to be a consultant in the department (you can graduate early!)? We even met a doctor who works 60% of his time towards a GP residency, and then 40% effectively ‘moonlighting’ in the urgent care clinic. This flexible residency concept was hard to grasp for us, since the US medical training is so micromanaged. In our minds, residency is this many pre-determined years per specialty, everyone starts and finishes at the same time, and the minute-to-minute requirements are clearly spelled out by ACGME. Also, did I mention residency hours are <40 per week? Compare that to the almost 80 hour work week of US residents, and it’s no wonder everyone over there kept telling us that we “work too hard.”
So to wrap up, it’s hard to say if one system is better than another. The respective systems in Norway, Sweden, and the US are impregnated with tradition, culture, and their respective research studies on medical education. If we had decide to become doctors at 18 when we graduated from high school, I may have missed my opportunity to actually become a doctor despite my grades. College gave me the time to explore career options and build my character as a person, while still learning (engineering at that). The fluid residency is a nice idea, too, but their countries are so much smaller than ours. How many anesthesia residency spots are there in all of Norway per year? It has to be no more than 100? How many in the US? Like a 1000. We have to regulate the trainees and the system, and thus NRMP and ACGME were born. I would still like to put in a plug for 40-hour residency work weeks in the US, though.