Medical school in France

In France, the duration of medical school is perhaps the longest to complete in French higher education. Medical school education in France consists of training that is formal and practical. Medical training is mainly theoretical at the beginning but becomes increasingly practical as training progresses. Towards the end of the medical program, French medical students are provided with more responsibilities and are required to defend a thesis. At the conclusion of the thesis defense, French medical students receive a Diploma of State of Doctor of Medicine. French medical students will also receive a Diploma of Specialized Studies (DES) to mark their specialties. Some students may also receive a Diploma of Specialized Complementary Studies (DESC).

History

18th century

Under the old system, medicine was one of four faculties but one reached it generally only after one passage by the faculty of arts (see Faculté of Arts of Paris). Teaching was primarily theoretical and rested on reading and comments of the authorities.

However, as from approximately, but very 1750 timidly, a practical part intervenes, through botany but also the private clinic. Until the Revolution, the surgeons were not doctors but were regarded as simple executants (barber-surgeons).

The university system is removed in 1793 and the medical colleges are replaced, the following year, by four medical schools, installed in Paris, Montpellier, Bordeaux and Strasbourg. With the creation of the imperial University, the medical schools take again the denomination of faculties and their number increases.

19th century century

In the 19th century, in reaction to the very fast technical evolution of medicine and to the mediocrity of university theoretical teaching, the accessible externat and boarding school, hospital hands-on trainings on contest are founded, the boarding school being accessible only to old external. The medical students then start to neglect the examinations of faculty to devote itself to the preparation of these contests, synonymous with elite and quality of the formation. The student could be able at the end of his studies of medicine without same to have seen only one patient, if it had missed or had not presented itself to the contest of the externat.

20th century

Following the events of May 68, the contest of the externat was removed, and all the medical students followed the hands-on training of quality which is the externat, become obligatory (the “external” term disappeared then from the texts, replaced by the hospital “student” term). That corresponds to the teaching hospital ideal (creation of the CHU in 1958): the practice (the externat) and the theory (courses at the university) are reconciled in a single course for all. With the law Faure, the medical colleges become UER (then UFR as from 1984) integrated in a university.

This reform, correlated with the general increase of the population coed, generated a massive surge of students in the services of the CHU. In reaction, it was then founded in 1971 a contest of end of first year of medicine, with a system of numerus clausus.^[1]

Until in the years 1990, any doctor could become specialist, either while passing the selective and hospital way of the boarding school, or by the not-selective and university way of the certificates of specialized studies (THESE) of less quality, thus letting develop a two-speed medicine specialized between “former interns” and “former senior registrars of the hospitals” on the one hand, and holders of THESE on the other hand. A reform thus removed to them THESE medical and returned to the obligatory boarding school for the “ordinal qualification” specialists, through the Diplomas of specialized studies (OF), complements of the diploma for the occupation of doctor of medicine.

The interns were constrained to make a training course in “peripheral hospital”, i.e. not academic, belonging to a regional Hospital or CHR.

Recent Changes

Until 2004, the future general practitioners did not pass the contest of the boarding school. The second cycle was followed from one period called “résidanat”, and which lasted two years and half (three years for new promotions of residents as from 2001).

As from 2004, a new reform intervened. All the medical students must from now on pass the national examination classifying (famous “classifying tests national” thereafter) and make a boarding school. Old the résidanat becomes then the boarding school of general medicine, within the framework of the process of revalorization of this profession deserted in a worrying way.

Starting from the re-entry 2010, the first year will be common with that of pharmacy (in addition to that of odontology and midwife) and the studies of medicine will fall under the process of Bologna.

Organization

The studies proceed in three cycles within a university having a unit of formation and search for medicine (sometimes mixed between medicine and pharmacy), associated with the one of the 29 university hospitals. Their total duration varies nine years (general medicine) at 12 years (another speciality + under-specialization).

First cycle of medical studies

The first cycle of the medical studies (in summary PCEM) is done in two years, a contest at the end of the first year makes it possible to select the students admitted to continue medical studies or dental.

The national texts specify that the teaching of the first cycle and the first year of the second cycle relates obligatorily to the following disciplines or disciplinary units:

• physics, biophysics and image processing;
• chemistry, biochemistry, cellular and molecular biology;
• anatomy, embryology, biology of the development and the reproduction;
• cytology, histology and pathological anatomy;
• bacteriology, virology and parasitology;
• fundamental hematology, immunology and oncology;
• genetics and biotechnologies;
• physiology and nutrition;
• the pharmacology and major classes of drugs;
• epidemiology and the biostatisques ones;
• clinical, biological semiotics and the semiotics of techniques of medical imagery;
• techniques of first aid;
• demography, economy of health and the organization of the health systems.

Teaching must also relate to the foreign languages, epistemology, psychology, the medical ethics and the deontology.^[2]

First year (until 2009)

The first year of the first academic cycle medical is common to the medical studies, odontological, and midwife.

Teaching relates obligatorily to physics and biophysics, chemistry, biochemistry and molecular biology, cellular biology, physiology, the anatomy, the histology and the embryology.^[3]

First year (as from 2010)

The first year of the studies of health (PAES) is common to the medical studies, odontological, pharmaceutical and midwife [4] ^[4](sometimes of kinesitherapy). It is divided into two six-month periods.

To be allowed to be registered in first year of the studies of health, the candidates must justify:

• maybe of the baccalaureate;
• maybe of the diploma of access to academic works;
• maybe from a French diploma or admitted abroad exempts some or equivalence of the baccalaureat pursuant to the national regulation;
• maybe of a qualification or an experiment considered to be sufficient.^[5]

As for any formation of system LMD, the year is cut out in two six-month periods and “units of teaching” (EU) which are seen allotting a certain number of appropriations ECTS.

In first half of the year, the lesson is common to all the dies.^[6] Tests are organized at the end of this one; the badly classified students can be reorientated in other dies of the university.^[7]

With the second half-year, the students choose one or of the EU specific (S) to a die, in addition to the common formation. The students pass a contest to the end of the year leading to four classifications.^[8]

It should be noted that the doubling of this first year is authorized only one and only once. Following two failures with this contest, it is then definitively impossible to be represented.

Second year

The second year (in summary PCEM 2 or P2) consists of four weeks of obligatory and non-remunerated training course male nurse, full-time.^[9] It takes place during the holidays preceding the re-entry by the students admitted in second year of medicine or odontology.

Lastly, a more medical matter, the semiotics, traditionally taught in third year, is at the present time transferred in second year in the majority from the universities, in order to improve the range of the clinical training courses of second and third years (usually called “training courses of checklist” or “training course of semiotics”).

The first cycle of the medical studies follows a national plan, but the organization between the two years varies between the universities. In the same way, there exist three types of teaching:

• linear teaching: each matter is taught separately (anatomy, histology, biophysics, etc). This type of teaching does not require great coordination between the professors, but it can lead to great redundancies, even with contradictions.
• integrated teaching: the students have modules gathering of the lesson of various disciplines around the same apparatus. For example, a module of neurosciences includes/understands the anatomy and the histology of the nervous system, sensory biophysics and the neurobiochimy. The student follows then a cardiopulmonary module, a digestive module, etc
• coeducation: certain apparatuses are then seen in integrated teaching, others in linear teaching.

Second cycle of medical studies

The Medical college of the Montpellier, the oldest in the world

In four years, the student receives a formal training and practical on the various pathologies segmented in modules: transverse modules (more or less interdisciplinary) or modules of body. These modules are the classifying official program of the national examination (see low), and include/understand a numbered list of items which correspond either to pathologies, or with clinical or therapeutic situations.

Third year of medicine

The third year of medicine (in summary DCEM 1 or D1) is one year of transition where the student learns bioclinic sciences (pharmacology, bacteriology, virology, parasitology, etc) which make the interface between fundamental sciences of the first cycle and lesson of pathology. He also learns how to carry out the anamnèse (interrogation) and the clinical examination of a patient at the time of his clinical training courses (called “training courses of checklists”, because the clinical examination linear and is structured, with boxes which one notches) associated with teaching with semiology. He starts the first modules.

Certain universities make begin the hospital training courses in third year, the clinical training course of second year is then developed more.

This year is particularly favourable with the Erasmus exchanges.

Externship

The three following years constitute the “externat”. This term of everyday usage (which is a survival of the old contest of the externat removed following the demonstrations of 1968) does not exist officially. The official texts ^[10] and the internal texts of the CHU and the universities speak about “hospital students”, because the students are remunerated by the hospital complex to which the university is attached. They are paid under limited time contract, attached to a social security office not coed.

The student, under the responsibility for an intern (nonofficial) or of a senior (senior registrar or hospital practitioner), learns how to recognize the various signs of a disease. He does not have at this stage of therapeutic responsibility, nor the right to prescribe. The student is however responsible for his acts (civil responsibility, which requires the subscription of a suitable insurance).

The externat generally consists of four training courses per annum three months each one in services of specialities, chosen by grids at the beginning of each year or quarter, either by classification with the merit, or by alphabetical classification. The training courses consist of five mornings per weeks in the services. Certain training courses are obligatory from the statutory texts (pediatry, obstetric gynaecology surgery, internal medicine and urgencies.), and can then integrate theoretical teaching (the external one is then present at the hospital all the day). Conversely, certain services do not have the external ones, that depends on the agreements made with the university.

Certain universities replaced the half-time (mornings) permanent by one full-time by alternation: the external ones are then present all the day but only 6 weeks over 3 months, the 6 remaining weeks being devoted to the lesson, the examinations, the preparation of the ECN…

During the externat, the lecturing, replaced more and more by directed work, is done in alternation with hospital training courses: this teaching is a true trade-guild, where the external one approaches by “clinical cases” of true situations lived in the services.

The external one must, during its three years of externat, to carry out 36 guards of 12,18 or 24 hours (according to the service and the day of the week), that is to say approximately a guard per month, remunerated 26 euros rough.

The remuneration of the training courses is as for it “symbolic system” (remuneration rough: 122 euros per month in fourth year, 237 euros in fifth year, 265 euros in sixth year ^[11]), but the external student has the statute of paid and cotise to the paid mode of the social security, and the pension fund. The pension fund complementary to external is the IRCANTEC, as it is the case for the interns and the hospital practitioners. The external ones, like any employee, have five weeks of paid vacations.

Since 2004, the second cycle of the medical studies is sanctioned by a diploma (recognized in the European Union [12]^[12]). Module 11 of the second cycle is the old certificate of clinical and therapeutic, essential synthesis to replace a general doctor.

Third cycle of the medical studies

Can reach the third cycle of medical studies (TCEM):

• students having validated the second cycle of the medical studies in France;
• students amenable to the European state or Community, Swiss Confederation, Principality Member States of Andorra left to the agreement on European

Economic space, others that France, holders of a diploma of end of second cycle of the medical studies or of an equivalent title delivered by one of these states.^[13]

Classifying national tests

Tests are organized for the candidates quoted above.

According to his classification, the student chooses his university hospital (and thus its city) of assignment, like his die. This choice is carried out initially by Internet (phase of pre-choice and simulations), the final choice taking place during a “amphitheatre of garrison” which brings together all the students by sections of classification. This procedure makes it possible the student to choose his station by being informed fully of the places available.

The 11 existing dies in 2008 are, with the number of places available, on 5704 stations on the whole:

• General medicine: 3200 stations
• Medical specialties: 885 stations
• Surgical specialties: 550 stations
• Psychiatry: 280 stations
• Anaesthesia-reanimation: 260 stations
• Pediatric: 200 stations
• Gynecology-obstetrics: 155 stations
• Public health: 60 stations
• Medical biology: 40 stations
• Occupational medicine: 54 stations
• Medical gynaecology: 20 stations

In 2005, a thousand of stations were not provided, certain students preferring to redouble rather than to choose a speciality by defect.

Hospital training

Defence of a thesis exercise.

Medical students taking the Hippocratic oath in front of the members of the jury, Paris, 2008.

Although it has the statute of student and that it has a supervision, the intern is already an autonomous professional, since it can prescribe and carry out replacements in liberal cabinets (provided it on the one hand validated a certain number of six-month periods, and on the other hand obtained a “licence of replacement” from the departmental council about the doctors). It acts more than one initial track records that real studies (more especially as France is one of the rare countries to regard the interns as students).

The boarding school of general medicine lasts three years, and is validated when the whole of the six months training courses necessary were carried out (diploma of specialized studies of general medicine) and it is followed of a thesis of exercise. It consists of six months training courses remunerated, being able to be hospital, but also near a general doctor, or of a extra-hospital structure of care. The student takes completely charges his patients, but remains of them under the responsibility of a “senior” (see supra): clinical examination, regulation of complementary examinations and treatment. Teaching is primarily practical there.

The boarding school of speciality lasts four years or more. According to the speciality chosen, the student must make a minimum number of training courses remunerated in hospital services where its role is similar. Its boarding school is validated when the whole of the six months training courses necessary were carried out. It also supports a thesis of exercise generally relating to a topic of the speciality, generally in the last year of boarding school. The speciality is sanctioned by the diploma of specialized studies, after defence of a report, which is sometimes confused with the thesis (thesis-memory, when this one is constant in the last year of boarding school and relates to a subject of the speciality).

The diploma of State of doctor of medicine is conferred after defence successfully thesis of exercise.^[14]

Registrarship and assistantship

For certain specialities and in particular the surgery, it is necessary to make complementary studies. It is of a university clinicat (from two to four years) or about an assistantship of speciality (from at least 1 year). The duration of total formation for these specialities is thus from 12 to 15 years.

See also

• French education system, Higher learning in France, University in France
• Medical school
• Physician
• Medicine
• General medicine

References

1. ^ "Merchant-Antonin, Benoit. The numerus clausus: its side effects, its place in the globalisation of medicine". http://thesesdemedecine.free.fr/wp-content/thesis/NumerusClausus.BenoitMarchandAntonin.pdf. 
2. ^ "Stopped of March 18, 1992 relating to the organization of the first cycle and the first year of the second cycle of the medical studies, article 12". http://www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=MENZ9200733A. 
3. ^ Stopped of March 18, 1992 relating to the organization of the first cycle and the first year of the second cycle of the medical studies, article 8
4. ^ "L631-1 Article of the Code of education". 
5. ^ "Stopped of October 28, 2009 relative to the first year common to the studies of health, article 2". http://www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=ESRS0925329A. 
6. ^ Stopped of October 28, 2009, article 3
7. ^ Stopped of October 28, 2009, article 5
8. ^ Stopped of October 28, 2009, article 8
9. ^ Stopped of March 18, 1992 relating to the organization of the first cycle and the first year of the second cycle of the medical studies, article 15
10. ^ decree n° 70-931 of October 8, 1970
11. ^ "External: the updated statute (2005).". http://www.anemf.org/Externe-le-statut-mise-a-jour-2005.html. 
12. ^ "Access to European Union Law". http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2008:322:0003:0007:FR:PDF. 
13. ^ "Decree n°2004-67 of January 16, 2004 relating to the organization of the third cycle of the medical studies [archive, article 1"]. http://www.legifrance.gouv.fr/WAspad/UnTexteDeJorf?numjo=MENZ9200733A. 
14. ^ "Code of education, L632-4 article". http://www.legifrance.gouv.fr/WAspad/UnArticleDeCode?code=CEDUCATL.rcv&art=L632-4. 

Bibliography

• Jean-François Mattei, Jean-Claude Etienne and Jean-Michel Chub, Of medicine to health: for a reform from the medical studies and the creation of universities of health, Flammarion, Paris, 1997,143 p. (ISBN 2-08-201634-X)