27 October 2010—sitting in a plane taking off from Paris, flicking through the Lonely Planet to Guadeloupe that I had just bought at the airport, I cast my mind over the events of the last year leading me to this departure for a six month post in the French Caribbean…

Keen to build on a background of dual nationality, I was interested in the possibility of spending part of my training as a junior doctor in France. After a bit of research it seemed unlikely that I would be able to do a direct swap of placements. I decided to take advantage of the offer of a year “time out of foundation programme” from my deanery in the UK, with the comfort of near guarantee of an F2 post on my return. My initial idea had been to try to apply for a locum post in France.  These are few and far between and not easily planned in advance; furthermore I wanted to be in a training position, given my junior status. I was advised by English and French colleagues to get a post as a French “interne” i.e. junior doctor in training, so my only option was to sit the “Examen Classant National” (ECN)—the much dreaded national ranking exam—a bit like a foundation and speciality application all rolled into one nightmare…

Having spent a year in France I was well aware of the fearful reputation of this exam, which medical students start competing for from the beginning of their first year.  My reaction was in no way would I be able to manage to scrape through. However I was informed and reassured that this was purely a ranking exam and not actually fail-able.  Moreover as there had never been more applicants than posts I would be sure of a post, just unlikely to have much choice over what or where… The main drive for French students is the choice of speciality, which wasn’t really an obstacle for me as general practice is always the last to be selected in France, and as it happily turns out, that’s just what I would like to do.  I just had to accept the likelihood of not much choice over location…  Furthermore as French rotations are 6 months, starting from November, to fit in with my English sabbatical I would only be able to do one full placement in France.

The ECN is a standardised national exam that follows a set format repeated year after year in a rotating handful of centres spread across France, in mid June.  I was allocated to Tours. The exam was twelve hours long spread over three days, organised with military efficiency, including a passport and convocation check on every entry to the exam hall. The starts were painful, standing at our desks waiting for the all clear from the other centres across France to choreograph a precise and equal turning of the first page. During a dearth of inspiration I tried to count the rows of tables that seemed stretched as far as the eye could see, I calculated there must have been nearly a thousand heads bowed over exam booklets. The questions were extended clinical cases with answers to be written free hand in booklets of blank A4 pages, a cramp inducing contrast to the English MCQ (multiple choice question) tick boxing. More than once as my concentration flagged I fantasized leaving my booklet blank with just my name label at the top, tempted to test out the promise that one could not fail this exam. But the fear of a new category of annulment being invented specially for such arrogance as mine; coupled with the secret if futile aspiration of being able to actually compete in ranking with those that had been working specifically for this exam for six years, led me to pick up my pen again and start thinking about “la plevre,” “les maladies du nourisson” or “les risques des anticoagulants.”

I received my ranking in mid July. As expected, pretty near the bottom of the heap at 6775/6998. But I was glad to at least have escaped the unenviable position, as coined by an English colleague, of being “the worst doctor in France.”

Traditionally the choice of posts is done in person by each student over a two week period in September in an amphitheatre in Paris. The top ranking student takes his pick, choice of speciality and region, then the second chooses from the remaining posts and so on until the last person. The administrators were this year pioneering a system more like the English one in which we could make a number of ranked preferences on an internet database. A post would be allocated based on these if the person chose not to attend at the amphitheatre. As I was sure of a GP post (and little else) with my ranking, I choose this option and ranked the 26 regions in France. As a satisfying example of the variety in people’s likes and dislikes, despite my ranking as the 6775th person I was still able to have my fifth choice of post:  GP training in ‘l’inter-region antilles guyane’ (AG). 

I had become the proud and somewhat awed occupant of a three year training post with a potential for full French GP qualification; in the equivalent of a deanery comprising French Guyana (in the north of South America) and the French Caribbean islands of Guadeloupe and Martinique.  For those unaware these countries are politically considered a part of France (and therefore the EU) and follow the same administrative processes. 

So much for the grand scheme of things, but for the actual post details the next step in this long administrative process was a convocation to Bordeaux for all those that had chosen AG, to another amphitheatre for selections within AG. Again the order of selections were based on the initial ranking from the ECN, and indeed that ranking follows French trainees until they are fully qualified.  As not quite the last to choose I was able to opt for a core medical speciality of cardiology in a district general hospital on the island of Guadeloupe. After a phone-call to the hospital to confirm my choice and to accept their offer of arranging travel, two weeks later I found myself with stethoscope packed, guide book in hand, off to try out being a junior doctor in new surroundings…

Elena is currently working as an F2 in Gloucestershire after training at Bristol Medical School. She has interspersed her UK training with learning and working in the French medical system and finds the resulting comparisons fascinating and stimulating.