At the beginning of May, I was one of two RCOG sponsored, UK trainees who travelled to Belgium to participate in the twentieth ENTOG exchange programme and meeting.
The European Network of Trainees in Obstetrics and Gynaecology (ENTOG) exists to promote the standardization of good quality training in our specialty in all member countries, with its core activity of trainee exchange and subsequent annual meeting acting as a focus for networking and discussion. This event has been held in Hungary, Portugal and Austria in recent years, and this year 40 exchange trainees were hosted throughout Belgium for three whole days and one half day. The annual meeting then followed in Antwerp, alongside the European Congress of Obstetrics and Gynaecology (EBCOG).
Belgium has a North Sea coast and borders The Netherlands, France, Germany and Luxemburg. It has a total population of approximately 10.5 million, of which the majority (6 million) are Flemish, speak Dutch and reside in the North of the country (notable cities being Antwerp, Leuven, Bruges, Ghent). The Walloons speak French, total 3.4 million and reside in the South, with the remainder of the population made up of German speakers living near the German border and ethnic minority groups from countries such as Morocco, Turkey, the Democratic Republic of Congo, Algeria, India and Poland. Although all parts of the country are governed via a central, democratically elected parliament, complexities arise from the differing needs and views of the two main cultural communities. Life expectancy for men is 76.5 (UK 77.2) and women 82.3 (UK 81.6), infant mortality rate 4.44 per 1000 live births (UK 4.85)1 and total fertility rate 1.65 (UK 1.82).2
My exchange placement was at the Universitair Ziekenhuis Antwerpen (UZA) which translates as the University Hospital of Antwerp. Antwerp is a city in Flanders with a population of approximately 500,000. There are 3 teaching hospitals within the city and 3 smaller hospitals without trainees. The University Hospital has 573 beds including 5 delivery suite beds, 22 inpatient Obstetric beds and up to 16 Gynaecology beds (shared with other surgical specialities). There are about 870 deliveries per year. The hospital is purpose built and dates back to 1979, built principally to facilitate the clinical learning of medical students from the University of Antwerp, whose medical faculty was established in 1965.
Dr Martine Hollander was my exchange partner and, along with a Cypriot trainee George Georgiou, I shadowed her for my exchange period. On Sunday afternoon, I was warmly welcomed from the Eurostar and driven to her home across the Dutch border in Breda. She is in her fourth year of specialization, having worked for several years as an independent home birth midwife in the Netherlands, and one of several Dutch trainees on a Belgian training program due to oversubscription in The Netherlands. This cross-border training would add a further dynamic to our many discussions about training, healthcare systems and clinical management throughout my stay. The opportunity to share not only her workplace but also her home for a short time gave me an invaluable insight into her work and training, and the impact of both on her personal life.
The Belgian health system
Health insurance is compulsory in Belgium and contributions are paid by employers directly into nominated health funds. Patients are still liable for a proportion of the fee, the exact amount depending on the particular service or procedure. For example, typically 25% of a standard outpatient appointment will be paid by the patient. Employees can choose a supplementary insurance to ensure the whole fee is always covered, or to upgrade their insurance from the statutory level to gain additional benefits. There are both public and private hospitals, the former funded by the social security system and the latter run as businesses, and patients can choose which they attend depending on location, services offered and proportion of fees they are able to contribute.
Outline of training
The Belgian medical degree is seven years long, with the final 2 years based on the wards as ‘interns’. There is competitive entry for specialist training in Obstetrics and Gynaecology, which commences the following academic year and continues for 5 years if yearly review is satisfactory. Trainees have no fixed curriculum. They are required to sit an extensive theory exam in their second year and to complete a continuous online logbook of practical procedures which is reviewed annually. Each year is spent in a different hospital, and training opportunities vary depending on the type of hospital and consultant interest. Sub-specialisation is available after the core 5 years of training in areas such as reproductive medicine and gynaecological oncology.
Hours of service and expected role
Belgian trainees are certainly not European Working Time Directive compliant, a fact which I found surprising given that not only is it a European Union directive but also that in the UK we have been strict in applying this to medical practice, provoking considerable debate regarding training. In UZA, the trainees were responsible for their own rota and worked a 1 in 6 with prospective cover, including a week of night shift 6 p.m. until 8 a.m. with no compensatory days off. Study leave is minimal with no financial resource and annual leave about 20 days which is hospital dependent. Rotas do vary considerably depending on the hospital and number of trainees. Because there is no tier between the student intern and registrar, and because Belgian culture deems that the Gynaecologist’s role replaces the family doctor for female problems, registrars often find themselves busy with basic annual patient reviews and uncomplicated problems and receive many telephone calls when on call directly from patients asking for basic advice, all of which in the UK would be filtered by the General Practitioner.
My clinical sxperience (observation)
Our days started early with a one hour drive to reach the hospital and handover at 8am. Martine endeavored to expose me to a variety of clinical areas throughout my short stay.
At UZA, theatres are set up much as in the UK. Practice is slightly different: there was no use of the World Health Organisation checklist which has become such an integral part of our theatre routine in the UK, an intern usually acted as the scrub assistant rather than a nurse, swabs and needles were recorded in the patient’s notes rather than on a white board and estimated blood loss was purely the surgeon’s estimate without weighing of swabs.
In the outpatient clinic, the registrars each had their own list of patients. The Oncology clinic contained many breast patients as breast disease (benign and malignant) is covered by the Gynaecologists in Belgium. I was further surprised to find 2 men amongst our list (both with ductal carcinoma in situ). Both female and male registrars examined and scanned patients without a chaperone (routine practice). There was a specialist nurse in the clinic too who gave support to the newly diagnosed cancer patients. Some patients were added on to the list for a yearly review, with no notable Gynaecological history but who just always came for a yearly check. All patients’ records were electronic, enabling easy access to records of previous visits in all specialties, imaging reports and the theatre diaries for booking operation dates from the clinic.
Most consultations were conducted in Dutch, but some patients spoke only French, and some English!
The delivery suite had 2 delivery rooms and 3 labour rooms and patients were moved from a labour room to a delivery room in the second stage. CTG monitors were applied to high risk women, and STAN (Fetal ECG ST Analysis) applied if the CTG became concerning. There was no standard (like our NICE guidelines) to define CTGs. Fetal blood sampling was never performed. Midwives cared for the women in labour, however medical staff were expected to perform the delivery in all cases and in many cases this would be the consultant. The typical length of stay was 5 days following a normal delivery and 6 days following a caesarean section – this time frame was dictated by the insurance fund.
Both Obstetric and Gynaecological management was decided by the trainee and consultant, and there were no published local or national guidelines on which to base care, which is something to which we have become accustomed in the UK.
Ward rounds were standard. The trainee and named nurse formed the core, accompanied by the consultant for some patients. A mobile computer came with us on which patient notes were documented and for me this was quite a novelty!
On call was made up of ward rounds, delivery suite and seeing Gynaecological emergency self and GP referrals. Dress was green scrubs and contact was via the DECT telephone system.
On the fourth day we travelled to the centre of Antwerp for the annual meeting of ENTOG. Present were most exchange trainees, the ENTOG executive and country representatives. Four UK trainees were there: myself and Karen Rose, who had attended the exchange, and Maud and Annii, who are the RCOG Trainees Committee representatives for ENTOG. Three trainees gave a short presentation on their exchange experiences, and then there was election of new council members. Congratulations to Karen who was elected member of the ENTOG committee! Maud also gave an overview of plans already in place for ENTOG 2011, which will be a UK-wide exchange followed by the annual meeting in central London.
The following day’s session, entitled, ‘What is the future of Obstetrics and Gynaecology in Europe?’ saw lectures about medical error, legal issues in training and the importance of the doctor-patient relationship, followed by a debate about the suggested separation of training in Obstetrics and Gynaecology in Europe. There was no clear majority!!
Many thanks to Martine Hollander for hosting me, organising such a varied clinical timetable and wonderful social events, and for adding many personal touches during my week in Belgium; to Prof Yves Jacquemyn, head of department at UZA for making me very welcome and for buying me lunch every day, and to George Georgiou for being my exchange buddy. Thanks also to the RCOG for sponsorship and to Maud and Annii of the Trainees’ Committee for their help and support.
1. Central Intelligence Agency’s World Factbook, USA, 2008.
2. The United Nations World Population Prospects, 2006. United Nations’ Department of Economic and Social Affairs, Population Division, New York.