If no one is teaching you, you have to learn yourself

When I decided to go to Botswana, there was never a question of whether I would bring my family or not. First of all I wouldn’t go anywhere without them for more than a week or two for selfish reasons, but I also thought it would be a great experience for them. In Sweden kids from other cultures are different, and my kids are part of the norm. I wanted them to learn what its like to be the odd ones out. I didn’t even occur to me to worry about their missing important parts of the Swedish curriculum.

I knew the Swedish educational system was different from many others, that we stress other qualities than theoretical knowledge and are reluctant to encourage good academic results. The teacher will never tell the class who got the highest test scores. There are no grades in public schools before grade 6, and until recently they were actually only given from grade 8. The private schools were earlier not allowed to give the younger students “grade-like assessments“, but I think they can from grade 4 nowadays. It is a controversial issue, since grades and competition are believed to discourage the students with weaker performances. I also knew that we favor understanding concepts over memorizing facts (which we call “sausage stuffing“). As long as the children are reaching that year’s academic and social goals, while enjoying coming to school, the teachers are pleased. No need for anyone to excel.

This view on education applies to higher education as well. In medical school we didn’t have any grades. You passed your exam or you didn’t. Clinical rotations were never evaluated in any formal way. The course coordinator would discuss the students with the other doctors and if there was a problem address it, but as students we never got any feedback from those discussions. In fact, medical students are always complaining about the lack of feedback, not knowing how well they are performing. But Swedes are reluctant to criticize each other, especially downwards in the hierarchy. We like to assume that everyone is doing their best.

I did my second preclinical year in Germany as an exchange student. The structure was different since they studied multiple subjects in parallel, while we were doing every subject separately, so I had to combine courses from two different years to cover everything. Since I wouldn’t have to sit their major exam at the end of the second year, I didn’t have to study too much. The questions for the minor exam at the end of the course were always taken from a selection of questions that you could buy at the copy shop. I guess I was lucky there because it would have been hard for me to study for such an exam. The questions were so different to what I was used to. In Sweden, we were rarely expected to learn details, but more to understand general principles. There wouldn’t be questions about formulas, and if there were seven things listed in the book, they would only ask for five on the exam. In Germany they wanted an exact answer and I passed only because I had memorized the correct answers. (My memory didn’t serve me all that well, though, and the teacher marked one of my answers ”intressanter Satzbau”, indicating that my German offered a new approach to constructing sentences.)

When I got back I had to have my courses recognized by the Karolinska Institute. I went to the director of pathology to discuss what I had done during my time in Germany. It turned out I had only taken the first out of two pathology courses, but should have taken both. He asked me a question about different kinds of lung tumors that I actually knew the answer to and we agreed, on my request, that I should take part in a few postmortems. He didn’t find it necessary for me to do anything else, since “you always learn a lot from living and studying abroad“, as he put it.

Our internships and residency programs follow the same pattern of minimal assessment and feedback. There are occasional compulsory sit-ins, but there is no daily feedback and definitely no ranking among the interns and residents. Who is to say that one is a better doctor than the other?
Any hospital in Sweden can train residents. If it’s a smaller hospital, part of the training has to take place at a university hospital. But there is no accreditation of the residency programs. In fact, I wouldn’t really call them programs. There is continuous teaching, but there is no study plan for the full five years. Instead you are supposed to write your own study plan together with your supervisor, deciding what courses to take and what rotations to do. All the residents go to the same sessions, if you are off on parental leave for a year, you just join the group again when you get back. You don’t actuallly even apply for a program, but for a job at the department where you want to work. For most specialties it is not that hard to get a six month contract. If you do a good job you will probably be employed as a resident after finishing that probation period, which will count as part of your residency. Nobody keeps track of what year a resident is in. You are not expected to work more than the regular 40 hour week. On calls and shift work are considered overtime and compensated with free time and extra pay.
There is no ranking of the different hospitals and it doesn’t really matter where you did your training. Your place of training won’t haunt or help you in your future career the way it seems to do in the US.

The National Board of Health has set the requirements for specialist certification. There is a chapter for every specialty, but they are all quite similar and vague, stating that you have to know how to manage the “common and important“ diseases within that field of medicine. The professional organizations of respective field are responsible for putting together a curriculum. When I was finishing my internal medicine residency that curriculum was being revised, a process that took several years. In the meantime there was no curriculum. They decided to revise the specialist exam, too, so I never got the chance to take it. It doesn’t really matter, since the specialist exams are not mandatory. Actually, the National Board of Health won’t allow the professional organizations to make them mandatory. I don’t know that employers ever ask if you have passed the exam, but I guess doctors who have will at least put it on their CV.

SWESEM, the Swedish Society of Emergency Medicine, has created the most extensive and detailed curriculum of all medical specialties in Sweden. As a young specialty that not many have heard of and even fewer understand the concept of, it was given a top priority to define the area of competence. Our curriculum is similar to the European curriculum and those of other European countries.

But that curriculum is constantly questioned, not only by other specialists, but among the residents and the directors of EM residencies as well. Many directors argue that it is difficult to teach EM resident airway management since patients are rarely intubated in the ED and it is hard to arrange rotations in the anesthesiology department (and we all know that airway management in the OR differs from the ED), besides “why learn something you won’t use and will forget how to do after a while?”
The same argument is used about gynecology, ophthalmology and ENT, at least in the large hospitals. I don’t think doctors working in smaller hospitals in remote areas object in the same way, since they have to be prepared to treat whomever hits the door. But in a small-volume ED, chances are they won’t see the whole spectrum of presentations.
Either way we will all be specialists in the end. Your personal supervisor (one of the consultants) and the head of the department decide when you qualify to apply for a specialist certificate and then the National Board of Health goes through your paperwork to make sure you took the right courses and did adequate rotations. That’s it. That is our specialist training.

A resident in family medicine was doing a terrible job during a rotiation at our department of internal medicine. He lacked fundamental knowledge in medicine and 11the director of our program wanted to fail him, but the director of his program said it wasn’t up to us to do so. He finished his rotation and moved on with his training. This is the downside of our system. As forgiving as it might seem, underachivers are never given a chance to better themselves. No one will tell them that they aren’t good enough and need to try harder, instead they will be regarded as lost causes and other doctors will try to avoid getting involved with them.

I do believe our system needs more structure. Residents need to know what is expected of them and feedback is essential for learning from your mistakes. Reading books and journals should definitely be part of a specialist training program. Knowing your basic sciences helps you understand the principles of clinical disease and I have tried to make up for that year in Germany. But when I hear educators on medical podcasts stress that ”this is something you need to know for your board exam”, I feel pretty good about not having to bother my strained memory with facts that I will easily look up if I ever need them. I just wasn’t taught that way. What is striking, however, is that even without grades, evaluations, promotions and other kinds of encouragment, most of our doctors do well. We provide good care for our patients, following evidence based protocolls, when we find them reasonable, and make adjustments when we don’t. Doctors are never sued for malpractice and since the abolition of the disciplinary committee a few years ago, we don’t really face any consequences when our patients don’t fare well. The only incentive for us to provide excellent care is that we care about our patients. But in the end, I think that is what makes great doctors all over the world. In my experience, the lack of interest in the patient is a much bigger problem than the lack of theoretical knowledge. Still, good doctors always want to learn more.