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Stanford University School of Medicine

The French and U.S. approaches to training doctors

Among the many differences between the U.S. and the French health-care systems is the approach to medical training. While U.S. medical school graduates in 2008 had an average debt of $154,000, French medical students receive their training virtually for free. For example, first-year medical students at the Faculte de Medecine Pierre et Marie Curie in Paris have only one mandatory cost for this year: an enrollment fee of $264.

The amount of debt facing a new physician has many effects on the health-care system. Studies such as this one by the Association of American Medical Colleges show that heavily indebted doctors are less likely to choose primary care fields, and may work more hours, leading to fatigue and possible medical errors.

Here’s a closer look at how doctors are trained in France.

Medical education is made up of three cycles that are provided by 34 universities. The cycles are:

First cycle (PCEM) -- Two years. It consists of general scientific training not delivered in hospitals. There is a competitive exam at the end of the first year. It is highly selective and charts the students towards research, clinical care, biology, etc. The number of students admitted is set by government regulation.

Second cycle (DCEM) -- Four years. The first year is devoted to general medicine training. The three following years are dedicated to pathology and therapeutics. Courses are given in the medicine schools and hospitals.

Third cycle -- Students reach the third cycle only after being certified, and then have a choice between two options:

  • “Résidanat” or general medicine third cycle: Two-year program of theoretical and practical training (rotations in hospitals and a training course with a general practitioner). At the conclusion of the training, the student receives a state diploma of general medicine doctor.
  • “Internat” or specialized medicine third cycle: Four- to five-year program which leads to a competitive exam in such fields as: medicine specialties, surgery specialties, anesthesia, industrial medicine, public health, biology and psychiatry. This specialized studies program culminates with a state diploma of medicine doctor, or DES. DES holders can improve aspects of their specialty by taking Complementary Specialized Studies programs.

My own medical training took place in France, Brazil and the United States, and so I’ve experienced the different approaches to physician training. In general, I found that medical education in France is more uniform and homogeneous because of government control. However, American universities have the freedom and funding to develop truly innovative programs.

If the United States were to subsidize medical education, I believe it would level the field in terms of socioeconomic discrepancies among those who want to become physicians and make it easier for doctors to choose primary-care fields by reducing their debt load, among other things. The drawback is that it would likely increase taxes and may hamper the innovation seen at individual medical schools.

What do you think? Would it be better for the U.S. health-care system if the government helped subsidize the costs of medical education? I look forward to hearing your thoughts.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

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