I visited Esbjerg Sydvestjysk Sygehus in Esbjerg, Denmark as part of the ENTOG 2006 hospital exchange programme. Esbjerg is Denmark's fifth largest city with a population of 82,312 (2005). It is located the on west coast of the Jutland peninsula in southwest Denmark. The city was once Denmark's biggest fishing harbour. Esbjerg is now the main city for Denmark's oil and offshore activities.
In this report my aim is to outline the junior doctor training programme in Denmark and to discuss some of the differences to UK practice I observed whilst visiting the Department of Obstetrics and Gynaecology in Esbjerg.
Junior Doctor Training in Denmark
Medical school takes five years to complete. Following graduation all doctors are required to complete an internship lasting 18 months consisting of six months in general medicine, general surgery and general practice. This training period is followed by a ‘Filler Year' during which two month long training periods are spent in specialities such as anaesthetics, obstetrics and gynaecology, paediatrics and psychiatry. During this year doctors collect ‘points' by completing audits and research projects, attending courses etc. These points are required to gain admission to specialist training programmes.
O&G is a very desirable speciality in Denmark, and gaining entry into the speciality is very competitive. Doctors in training often have to spend far longer than a year acquiring points to gain a place in training. To improve their chances of entering a specialist training programme some doctors take time to work abroad and many undertake research. There are no competitive interviews or exams and entry into training is determined by the number of points scored by trainees. At present there are plans to streamline entry into the specialist training.
Obstetrics and Gynaecology specialist training lasts four years. This includes a six month module of general surgery. Half of this time needs to be spent at a University Hospital. There are no exams but trainees need to complete approximately 10 different training courses. Competency based log books have recently been introduced and are similar to those used in the UK. These are signed by the trainees' own Consultants. Meetings with the trainers are not regulated and timing is left to the trainees' discretion. There is no formal annual or final assessment equivalent to the RITA. 360 Degree appraisal has only just been introduced and trainees in Esbjerg were awaiting their results.
Following completion of four years of specialist training a doctor is called a ‘Specialist' for two years. This means that he/she is able to practice independently within the health service but does not have ultimate responsibility for patients i.e. a specialist will not have ‘named' patients. Specialists will practice independently e.g. during night on calls. In practice it appears that specialists still benefit from senior guidance and support during practical surgical procedures during the day. It appears that these Specialist years lay the foundations for a doctor's career. A Specialist's workload will vary according to needs and expertise of the department they are employed in. There are no formal sub-specialisation programmes and if a doctor wishes to pursue a sub-speciality they will need to begin to gain these subspecialist skills during their two years as a Specialist.
Working Hours
All doctors in Denmark work 37 hours per week. An average working day begins at 8.00 am and ends at 15.00 pm. The on call team take over at 15.00 and remain on call until the following morning. The on call rota allows for compensatory time off which means that no one works in excess of 37 hours per week.
In Esbjerg both junior and senior doctors work a 1:8 on call rota. During the on call a senior doctor i.e. Specialist or Consultant will remain on site at all times. The junior doctor on duty can be anywhere from a junior doctor on their ‘filler' year to an experienced O&G trainee. The night duties for seniors can be opted out of after the age of 60. In Esbjerg the Clinical Director and Lead Obstetric Consultant and Lead Gynaecological Consultant do not take part in the on call rota.
Handover
The department in Esbjerg is somewhat unique in that the Lead Consultant feels that the key to a happy working environment is effective communication. In view of this, there are two departmental meetings a day and a more informal 10.20am coffee break which is attended by most members of the team. During the morning meeting at 8.00am a formal handover takes place and all problems that have occurred overnight are discussed. At 1pm there is a further meeting which covers the day's events. In addition, junior doctor teaching is undertaken once a week at this time.
Antenatal Care
As in the UK the majority of antenatal care is provided by Midwives and GPs.
I spent some time in antenatal scanning. Patients are all offered an NT scan and detailed anatomy scan at 18-20 weeks. Most scans are performed by trained nurses who appear to be the equivalent of UK radiographers. Junior Doctors in theory should all gain antenatal scanning experience. I was told that in practice it tends to be difficult to gain adequate experience.
Labour ward
There are approximately 2000 deliveries per year at the unit. The care of normal labour is midwife led. The Caesarean section rate is about 20%. Approximately 2-3% of deliveries occur at home. These are attended by one midwife only. The main differences to practice that I noticed were as follows:
The labour rooms are very clinical and have an almost operating theatre type of feel.
Gas and Air and Forceps are not used. Obstetric junior doctors attend the deliveries in the capacity of neonatal SHOs. In addition all 48 hour baby checks are carried out by the obstetric junior doctors. There are very few protocols compared to UK labour wards. Although the hospital has a very good intranet system, there are very few obstetric guidelines available for download.
Gynaecology Outpatients
Broadly the system appeared to be very similar to the UK. Referrals are made by GPs. The clinics are all general gynaecology clinics but depending on the Consultant's specialist interest, patients are be seen in different clinics. All appointments are made for 30 minutes.
All doctors are trained in gynaecological scanning and all consulting rooms are fitted with a scan machine. This appears to streamline the system because patients leave clinic with a diagnosis without having to wait for results of investigations. In my opinion this is a patient friendly approach. However, I am not aware of the quality assurance and there appears to be no formal training programme for scanning.
Theatre
The theatre system appeared broadly similar to that in the UK, with two lists a day; one main list and one day case list. Although in practice the equipment and procedures are similar to those in the UK, there were some major differences in the way that theatre worked;
a) Timing of surgery - there did not appear to be a formal classification system of timing of surgery for surgical emergencies. Decision of how quickly a case would be done seemed to be at the discretion of the surgeon, anaesthetist and theatres.
b) Consent for surgical procedures - this is obtained in clinic. The procedure is discussed and common complications are documented in the hospital notes. There are no consent forms. Typically, the operating surgeon who often is not the person seeing the patient in clinic, will introduce themselves and briefly discuss the procedure with the patient immediately before the anaesthetic is commenced. Surprisingly on two occasions I witnessed the operating surgeon change the operation in the anaesthetic room. I questioned the lack of forms and many junior doctors seemed to think that written consent forms would soon be a reality, but medical negligence claims did not appear to cause them overdue concern.
Conclusion
Overall, the standard of clinical care seemed to be excellent. Danish doctors aim to practice Evidence Based Medicine and management of patients is very similar to the UK. The main difference is that most Danish doctors are generalists.
Trainees have an excellent work life balance and many stated that the working hours provide plenty of time to enjoy their young families.
Comparing myself to the Year 2 registrar that I shadowed, I feel that my practical skills as a Year 2 UK trainee are more advanced and I practice less under direct supervision. I think the reasons for this are mainly due to reduced hours and a smaller patient population resulting in less exposure to cases and clinical problems. Despite my perception of the effects of reduced training time and therefore levels of experience at a junior level,the standard of care provided by senior doctors appeared to be no different to the UK.
Trainees themselves expressed no concern that their level of expertise would be somehow deficient in comparison to other European countries. Overall, the way of working seemed to be very team orientated. All problems are discussed by the entire department at the daily meetings. Therefore, the junior Consultants and Specialists seemed well supported and supervised allowing them to gain independence at a slower pace long after completing their Specialist training.
Anni Innamaa
December 2006