I spent an enjoyable and educational 4 days in Aarhus at Skejby Hospital as part of the annual ENTOG exchange, a trip generously sponsoring by Shire Pharmaceuticals . Aarhus is the second largest city in Denmark and the principal port, situated on the peninsula of Jutland with a population of almost 300,000. The hospital where I was based is part of the Aarhus University Hospital network. The Department of Obstetrics and Gynaecology is a tertiary centre with almost 5000 deliveries per year, 36 inpatient gynaecology beds, a suite with 6 operating theatres (including 2 for labour ward use) and a recently opened day surgery unit. The Unit has 23 consultants and 22 trainees.
The readiness of both staff and patients to speak English never failed to impress and added much to my understanding of the Danish system of Obstetrics and Gynaecology. Although there are many similarities to practice in the UK in terms of the range of conditions seen and management, there are significant differences in organisation of services and training. In the era of the European working time directive and concerns on its impact on training, it was this aspect of Danish obstetrics and gynaecology I found most interesting. In Skejby hospital, doctors work a 37.5-hour week. The day begins at 8am with the morning “conference” which all doctors must attend. The trainee or consultant from the previous night shift presents interesting cases for discussion. The meeting lasts for 30 minutes and ends with the duty consultant going through the rota confirming the day's emergency duty cover. This is an essential part of the morning meeting because with the shorter working week, the rota for theatres, clinics and emergency duties is a very complicated affair! . The working day ends with the afternoon conference at 3pm when a handover of patients to the team covering out-of-hours duty. Although two meetings a day might seem a little excessive I got the impression that these conferences ensured effective communication and handover of patient care as well as a chance just to catch up with colleagues.
Trainees work 1 in 8 late shifts until 9pm and 1 in 12 weekday nights (Monday to Thursday), weekend nights (Fri-Sun). Weekend days are split. Notably all consultants are resident when on-call. In Skejby, there are only a few general obstetrics and gynaecology consultants, yet all consultants cover both obstetrics and gynaecology out of hours. This system has been in place working well (reportedly with only a few grumbles!) for several years. Although consultants only do between 1-2 nights per month and 2 weekends per year, it does mean that labour ward might be covered by a gynaecology subspecialist who may not have done obstetrics since finishing training. Another notable difference to the current UK system is the lack of the clinical firm. Apart from urogynaecology and gynaecology oncology, trainees do not seem to work with a particular consultant. While this loss of the “firm” structure is certainly one of the disadavantages of the shorter working week, the greater involvement of consultants in day-to-day care of patients ensures continuity in patient care. Protected training weeks, discussed below, appear to offset the loss of “apprenticeship” and mentorship, oft quoted attractions of a firm-based approach to training.
At my first morning conference, my age or more precisely, my youth, was the subject of much discussion. Initially flattered, I quickly realised once my blushing subsided that age is one of the dramatic differences between Danish and UK trainees. The average age of commencing the Danish equivalent of specialist registrar training is 37 years. Most Danish medical students graduate around the age of 27-28 years having started university later than their UK counterparts. They then enter an 18-month internship, rotating every 6 months between medicine, surgery and general practice). After this those wishing to specialise in obstetrics and gynaecology undertake an “introduction” year, similar to old-style senior house officer post. As the name suggests, this serves as a basic introduction to the speciality with specific basic training objectives for example, management of acute gynaecology emergencies learn how to do transvaginal scanning.
Entry into the 4-year specialist training programme is highly competitive and operates on a points system. After introduction year, trainees enter what is known as a “side-education”, specifically working towards the 9-10 points required to compete for training position at one of the larger university hospitals in Denmark. This can take between 3-7 years. Points can be gained in a number of ways- a year in surgery is worth 2 points, gaining a PhD 5 points, a first author publication 2 points. It is argued that such a system ensures that only the most dedicated and brightest candidates are appointed to the training programme and encourages a broader basic training. Many undertake a PhD and therefore have good grounding in research methods. However, although Obstetrics and Gynaecology is still one of the most competitive of specialties, recruitment has fallen over the past few years. The duration of side-education and age at entry to specialist training are cited as 2 main factors in this downturn.
Specialist training is a 48-month programme, with the first year spent in at a university hospital, followed by 6 months in surgery (abdominal surgery), 1.5 years in a district hospital, and a final year back in University hospital. After this, one can choose to undertake 2-3 years of subspecialist training or become a general consultant. In the two years in the university hospital, all trainees have 9 weeks of protected training when they are not available to normal clinical duty or emergency duty. For example, 2 of these weeks in first year are dedicated to obstetric ultrasound training where a trainee will have their own daily list alongside a senior ultrasonographer and will be trained up to level 2 obstetric scanning. Other protected training weeks include fertility medicine and “benign” gynaecology. There are in addition, 30 days of courses (year 1), which cover logbook standards and are organised by the Danish College of Obstetrics & Gynaecology. In Year 4, there are 20 days of mandatory research training and 8 days of management and leadership training.
There is less formalised training in the 1.5 years spent in the district general where trainees aim to consolidate skills and gain surgical experience. This can be problematic as many district units have less than 1500 deliveries and trainees report great disparity in obstetric experience. Also, as in the UK, there is increasingly less exposure to major gynaecological surgery with increasing endoscopic surgery and referral of gynae oncology and complex surgery to major centres such Aarhus.
I was rather surprised to find that there are no national or specialty-specific Danish exams. Assessment is competency-based and all trainees have a logbook which follows a national curriculum, both of which are based on the UK RCOG system. Trainers in Skejby Hospital are pioneering a multi-source feedback system of trainee evaluation, also known as 360-degree feedback, which has proven popular with trainees. This is similar in principle to the RCOG team observation (TO2) exercise but with notable differences including its online completion by assessors nominated by the trainee themselves. Trainees must also “self-evaluate” as part of the appraisal process.
In summary, the trip provided tremendous insight into a culture where the work-life balance is of paramount importance and where it would appear that doctors can be trained to a similar standard to the UK in less time provided that that time is well-organised and subject to robust assessment of competencies. In this regard I think there are important lessons to be learnt from the Danish system. The specialty in Denmark however have problems common to those faced by us in the UK, in particular with recruitment into the specialty. Tackling this issue may be difficult to address in their current system of competitive entry into specialist training through “side education”.
Fortunately, it was not all work and no play. One clear advantage of the shorter working day was that I got to see Aarhus and visit its wonderful museums and old city centre. My hosts were very generous with their time and efforts. The final 2 days of my trip were spent in Copenhagen at the ENTOG conference where research and training in the specialty were up for discussion alongside hotly debated issues of assessment of competency.
Brenda Kelly
December 2006