How training to become a doctor in France differs from the United States

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. According to the Association of American Medical Colleges, 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 is the health promotion manager for the Stanford Prevention Research Center who blogs at Scope at the Stanford University School of Medicine.

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  • Catharine

    I absolutely believe that medical education should be subsidized in the US. But then again, I believe that ALL education should be subsidized in the US. I guess I’m a radical!

  • http://www.trialdox.com TrialDox team

    Thanks for the post, which is a very interesting data point to combine with other data that summarizes the average income of physicians in various countries.

    What is the “ROI” for physicians (general physicians, specialists)?

    One can begin these calculations using data presented here: http://trialdox.wordpress.com/2009/11/19/pay/.

  • Fred Johnson

    Number 1 driver of health care inflation for the past ten years – Medical Education. Before we decide to subsidize it, which I am not opposed to, let’s find out why it costs so much. Are tuition dollars diverted to research in Academic Medical Centers? School loans equivalent to mortgages will continue to drive demand for higher reimbursement rates increasing the cost of health care. If congress ever decides to address the cost of health care, they should begin here. As to the issue of subsidy, Americans subsidize residency, maybe we should shift the Medicare dollars for residency programs directly to Medical schools, what’s the average Medicare subsidy for GME – $70.000 a year ?

    You’ve opened Pandora’s box, please keep it open.

  • John Parmigiani

    May one ask whether in France, one must also spend 16 years in school before qualifying for admission to medical school?

  • alison

    The extremely centralized government in France controls a lot of things – yes, medical training isn’t nearly as expensive as it is in the U.S. but, in an effort to control Social Security expenses, a “numerus clausus” was installed some years ago which limited the number of new doctors. There’s now a real shortage of gynacologists, opthalmologists, dermatologists, and others – 4 month waits for appointments are not unusual. There’s also a shortage of pediatricians – the government has made a 30 minute visit obligatory so the number of children they can see in a day is much more limited than for other specialties. And also a shortage of generalists because their rates have been fixed at a little more than 20€ a visit for years. Advantages and disadvantages of nationalized medecine.

  • MD

    Be careful for what you wish for. Government subsidized medical education will come with strings attached (more likely shackles).

  • Catharine

    MD- good. that’s FAIR.

  • http://crasspollination.blogspot.com Nurse K

    Why subsidize something where you have 2500 qualified applicants for 150 spots…so you can get 5000 applicants for 150 spots?

    This writer conveniently leaves out that the average physician salary in France is $55,000, less than I make as a nurse. I think most people would take the 100K debt plus the 100K+ more per year at a minimum.

    It is also inherently unfair to subsidize one graduate program and not another. PS The govt. already does subsidize medical education at state schools.

  • Jeremy

    @Catherine – Yes, I guess I would consider you to be a “radical” of sorts. I’ll pivot off your response to MD’s comment: Completely subsidized non-medical education will come with taxpayer strings attached. If I’m going to subsidize ALL higher education through my taxes, I want more input than I have now over where that investment goes, or at least more input from my elected officials over where that investment goes. Are you willing to sacrifice the “soft” progams that most people of your (assumed) end of the political spectrum champion? I think the country could get by with considerably fewer undergraduate students studying English literature, Chicano history and feminist studies. That’s just me, but I get as many votes as you do if we’re going to federalize the whole thing.
    @Fred Thompson – Can you cite your source for claiming this: “Number 1 driver of health care inflation for the past ten years – Medical Education.” I would be interested to know where you got this data, because although I see this thrown out frequently, I’m not sure I trust the objectivity of the primary sources for this claim.
    @Nurse K – Thank you for beating me to the punch. Let’s use the this commonly stated factoid: the average graduate from a US MD program will leave $154k in debt. Ignoring the $45-60k salaries paid during internship/residency/fellowship programs, we’ll use an exceedingly conservative estimate of $110k for starting salary for your plain old physician. How long before the wealth of the US MD exceeds the French DES leaving school with no debt and making $55k a year? Unless we’re going to debate whether incentives matter, and whether we want/need our highest performing students to find pursuing an MD a desirable career option, I’m led to believe that lower wealth-building capacity will hurt the overall quality of the physician population. Is that a reasonable assumption?

  • jsmith

    Med education is a lot shorter in France. Eleven years after high school for surgery. Here is is more like thirteen or fourteen. Eight years after high school to be a GP. Here it is eleven.

  • TrenchDoc

    You all have this upside down.
    In out society I was and continue to be happy to pay my own way. I graduated from medical school in 1972 with 20K in debt. In 1977, I started private practice and my salary that year was 30K. So this was a fair deal where I paid my own way and I could bill a “reasonable and customary” fee for my medical services that was based on these market forces. Then in the 1980s we began managed care and the insurance conpanies began to make huge profits by restricting medical charges especially in primary care. Today my income is based on how many people I can see in a day. I gross 30 percent of my collections because of the huge overhead I have in labor costs. Those labor costs are the results of having to hire more nonclinical people in billing and collections, administrative to do prio approvals, preauthorizations, and forms for equipment. It seems fair to me if we continue to pay our on way for the medical education and training BUT we charge fees based on that capital investment as well as other factors such as experience, patient satisfaction, and outcomes. So like France, it has to be all or none. As a patient under the French system. you don’t have as much direct medical costs but you pay higher taxes and have less direct control over your medical care. It is always the GOLDEN RULE stupid. “Them that’s got the gold makes them rules.”

  • http://www.chemistdirect.co.uk Chemist

    Medical or any other education differs in between countries whether it be cost wise or periodic wise. One of my frd is paying big amount to get into his further studies in medical.
    and yea medical education France is a lot shorter compared to US or other few countries but there are many more applicants compared to few spots available