The ENTOG May 2010 exchange programme brought me to the city of Kortrijk in the Belgian province of West Flanders.
I arrived by train having flown to Brussels on a wet Sunday evening and was greeted by a trainee’s boyfriend whilst she was working in the hospital. I soon learned that Belgian rotas are far from being EWTD compliant as Els had been on call since Friday morning 07:30 and was not due to finish until the Monday evening at 18:00. I was kindly driven to a pleasant hotel (courtesy of the Obstetric and Gynaecology Department in Groeninge Ziekenhuis) which was within walking distance of the brand new hospital. My fellow Turkish exchange trainee had been delayed in Brussels and was due to join me the next day.
I made my way to the gynaecology department the following morning and was warmly greeted by one of the 11 consultants working in the unit who showed me around the two-week old private hospital which had recently been purpose-built for the merger of four smaller local hospitals. The rooms were newly equipped and spacious with evidence of modern technology some of which were still in boxes waiting to be unpacked. I was then introduced to the departments’ two trainees who I shadowed during the exchange. Els was in her third year of Obstetric and Gynaecology training and was keen to pursue a career in gynaecological oncology whilst Ilse had completed her training and was soon due to start her consultant post in another hospital. Both trainees were keen to share their experiences of undergraduate and postgraduate training in Belgium which differed significantly from mine in the UK.
Undergraduate medical school training
There are seven medical schools in Belgium that offer run-through undergraduate training: four Dutch speaking courses in the Universities of Antwerp, Brussels, Gent and Leuven, and three French-speaking courses in the Universities of Brussels, Louvain and Liege.
The Belgian undergraduate medical degree consists of a seven-year programme which is divided by a three-year Bachelor degree followed by a four-year Masters. The Bachelor curriculum focuses predominantly on science, however includes parallel running courses in communication skills, health and society, statistics and epidemiology. The first two years of the Masters degree is again mainly theory based and focuses on the pathophysiology of the various disorders using a systems-based approach. It is not until the final two years of the undergraduate degree that the students obtain regular contact with patients whilst completing their clinical internships.
Workforce planning is considered annually and the numbers of graduates vary from year to year. The admission process to medical school differs in the Dutch and French speaking parts of Belgium. The Flanders students are obliged to sit an entrance exam “Toelatingsexamen” with a calculated numerus clausus, whereas the selection process in Wallonia is based on the results of exams at the end of the first year of the bachelor course.
Belgian medical students are introduced to the specialty of Obstetrics and Gynaecology in their sixth year whilst undertaking a six to eight week clinical attachment. Students who have an interest in pursuing a career in Obstetrics and Gynaecology often have the opportunity in their final year to gain further experience in their specialty of choice. They would at this point apply for postgraduate training which involves a selection process based on their final undergraduate exam results. More than 50% of medical school graduates obtain postgraduate training in General Practice whilst in Flanders only 20-40 students attain a training number in Obstetrics and Gynaecology. There are often more candidates applying for the specialty than there are places and as seen in the UK the female to male ratio is currently 2:1.
Postgraduate training in obstetrics and gynaecology
In comparison to the UK, Flanders has a shorter Obstetrics and Gynaecology postgraduate training programme which is made up of five annual rotations. Trainees rotate between peripheral and central teaching hospitals which are commonly a mixture of public and private organisations. Trainees request their rotations of choice and are frequently encouraged to complete a year of their training abroad in recognised training hospitals in the Netherlands, United Kingdom, South Africa and Australia.
The Flanders trainees are allocated half a day a month for formal teaching in Leuven, which is comparable to the setup in the UK. There does not however appear to be a structured syllabus and the topics tend to be selected by the organising professor.
Trainees are only entitled to five study leave days a year for self-funded conferences. There are no funds set aside for training and trainees therefore often rely on sponsorship from drug companies. The ‘Vlaamse Vereniging voor Obstetrie en Gynaecologie’ (VVOG) which is the Belgium equivalent of the RCOG organises five compulsory courses on CTG interpretation, Ultrasound, Colposcopy, Hysteroscopy and Laparoscopy which have to be completed before the end of training.
Unlike the detailed RCOG curriculum, the Belgium Obstetric and Gynaecology postgraduate training does not have a structured modular syllabus. There is a compulsory exam in year two of training which covers all areas within the specialty. Failing to pass the exam does not prevent progression to the following year of training, however, the exam has to be passed before completing the final year.
All trainees are given access to an impressive electronic portfolio “log book” which is accessible via the VVOG website http://www.vvog.be. The log book has to be updated daily and not only includes the number of deliveries and operations performed but also contains a copy of their rota and daily activities. The log book is assessed annually both by a review board and the trainees’ supervising consultant who completes a summary report “Rapport Evaluatie Klinische Activiteit” which includes subjective opinions of the trainees progress in various areas within the specialty.
The Belgian assessment system, however, does not include a structured feedback system such as the OSAT, mini-CEX and CbDs employed within the UK. Belgian trainees still rely on informal verbal feedback to assess their progress.
Public versus private hospitals
Els and Ilse informed me that there is a significant divide amongst postgraduate training in public and private hospitals. University hospitals in Flanders typically have ~18 trainees on a rolling rota whereas the smaller peripheral hospitals which are often private are only allocated 1-2 trainees.
Training within the larger university hospitals often focuses on academia, knowledge and research whereas the smaller private hospitals provide more hands on surgical experience. That said larger units rely on the presence of trainees for service provision therefore allowing the trainees to work more independently. Patients in private hospitals expect to have their consultant present throughout their care including at the time of straightforward spontaneous vaginal deliveries and therefore these units provide a large amount of one-to-one trainee supervision.
Prior to the exchange I had not had any experience of working in a private hospital and was therefore taken aback when told that a consultant would come in 24/7 for their own patients whether they were on call or not. The consultant of the week’s role was to cover consultants who were tied up elsewhere or on leave. I questioned one of the doctors regarding how this affected his quality of life and he replied that Medicine was a vocation which you have to love and be dedicated to. He did later admit that his salary was dependent on the number of patients he treated and that it would be impossible for a couple to raise a family in Belgium if both of the parents were busy doctors working in private hospitals!
Groeninge Ziekenhuis is only allocated two trainees and therefore Els and Ilse shared a rolling rota between them which included one on call a week (34hr shift) and 1:4 weekends. They were permitted to be on call from home on condition that they were within 15 minutes from the labour ward, however, both trainees admitted spending a great deal of their time in the unit.
Working hours differs largely amongst the hospitals in Belgium and although trainees in larger university hospitals regularly work a 1:7 shift pattern the pay remains similar. Trainee salaries in private hospitals are paid by the consultants in the department whereas salaries in Flanders university hospitals are often subsidised by Leuven University.
During my visit Ilse was on her “labour ward week” which involved covering delivery suite with ~2000 deliveries a year, obstetric and gynaecology triage and the wards from 07:30 to18:00. Together with the midwives she provided intrapartum care and would request the patients’ consultant presence at the time of the delivery.
Having worked in the Netherlands last year I had grown accustomed to having a doctor perform a hospital vaginal delivery as most of the Dutch midwives are independent practitioners based in the community. Unlike the Netherlands, however, Belgium has a very low home-birth rate and the role of the midwife is largely hospital intrapartum care. They are trained to interpret CTGs and perform vaginal examinations to assess progress, however, for litigious reasons and due to patient expectations they have to request a doctor’s presence for the delivery. It felt unusual to me to enter a room with the consultant who then took over the spontaneous vaginal delivery from the midwife and the registrar once the head had descended to the perineum.
During my exchange Els was on her “theatre week” after having done her long weekend on call. Her timetable consisted of a morning in theatre Monday to Friday followed by a mixed obstetric and gynaecology outpatient clinic in the afternoon. In Kortrijk neither Els nor Ilse would see patients in the clinic independently and instead would observe their consultants’ consultation. They would be trained to perform examinations and ultrasound scans under direct supervision.
Although I can appreciate the values of their method of training, especially for junior trainees, as a senior registrar in the UK I would feel frustrated if I wasn’t able to perform independent consultations and enjoy being able to diagnose and formulate management plans autonomously. I was, however, extremely impressed by the trainees operating skills. Throughout my visit the year-three trainee confidently performed a total abdominal hysterectomy, vaginal hysterectomy and most of laparoscopic hysterectomy under the supervision of the consultants. Despite my personal interest in gynaecology, I found that my operating experience in the UK and my surgical abilities were significantly inferior at her stage of training.
After completing five years of postgraduate training ~50% of the trainees become Obstetric and Gynaecology generalists. Research during training is encouraged in Belgium and 7-8 year part-time research training posts are available. All trainees are expected to have at least one first-author publication before becoming a consultant and either an oral or poster presentation.
An increasing number of Belgian trainees choose to complete a further two years of subspecialty training. Ilse had completed further infertility training whereas Els was keen to apply for gynaecological oncology training which includes breast pathology and takes four years to complete.
The department in Kortrijk encouraged both of them to explore their fields of interest. Ilse had regular access to the infertility clinics and during my visit I attended the weekly oncology multidisciplinary team meeting with Els which included the participation of the local gynaecologists, oncologists, radiologists, pathologists, oncology nurse specialists, plastic surgeons, psychologists and the patients GPs. I was impressed by the holistic approach taken for each patient and was taken aback by the video link to the pathologist in the morgue when discussing the deceased patients!
I asked several of the Belgian trainees both in Kortrijk and at the ENTOG meeting in Antwerp what they thought of their training and they all seemed satisfied with their experiences. They felt that they received good quality surgical training with enough clinical exposure and variety and yet were generally encouraged to follow their interests. When questioned about the EWTD they responded that in an ideal world they would choose to work less hours, however, they generally accepted the system as it was. Interestingly, when asked about their motives for completing a year of their training abroad, most of them reported wanting to gain more autonomy and confidence before taking on their consultant posts.
One of the most rewarding results of an exchange programme such as the ones organised by ENTOG is that all trainees involved come away with an appreciation of not only other countries training programmes but also of their own. Both the Turkish exchange trainee and I were in awe of the Belgian’s surgical training programme and felt that we could have benefited from such a year in our training, however, we both agreed that we enjoyed our autonomy in Turkey and the UK and felt that we gained a great deal of essential training from independent practice.
I am really grateful for the RCOG giving me the opportunity to experience the ENTOG exchange programme in Belgium and would like to thank not only the college but also the ENTOG organising committees for an interesting European meeting in Antwerp and the enjoyable social events. I would also like to pass on my gratitude to Kortrijk’s Obstetric and Gynaecology department and my fellow Turkish exchange trainee.
After having experienced the exchange first hand, I now look forward to the challenges of being a part of the ENTOG local organising committee and hope as a team to set up a successful ENTOG 2011 exchange programme and meeting in the UK.