Hey all,
I have dual US/Irish citizenship and have a few questions for any IMGs or EU citizens who practice anesthesia over there:
1. What's it like? Is there a strong critical care aspect? Is there as much specialization?
2. What is the CRNA situation over there? Same threat to career potential?
Im a physician who practice anesthesia in Denmark, one of the Scandinavian countries.
I'm a senior resident and will be a specialist next year.
In Denmark Anesthesia comprise the following:
- Anesthesia proper (OR anesthesia)
Nurse anesthetists are common in Denmark and every OR in the country has them. Nurse anesthesia is one of only a few specialties of nursing in the country. It takes 2 years to become one. They are only allowed to provide anesthesia under the direct attendance of an anesthesiology physician. They have the competency of setting up the OR, drawing medicine, intubating and monitoring the patient during anesthesia. They are not allowed to provide advance airway management, advanced vascular access (central venous access, arterial line etc.) or blocks or any kind (spinal, epidural or peripheral nerve blocks). They are also not allowed to premedicate the patient, decide the type of anesthesia or obtain informed consent for anesthesia. So in the every day life of most ORs around the country nurse anesthetist stay with the patient in the OR during anesthesia and the physician attend during induction, block and vascular access etc. and in complicated cases. During resident years physicians are the sole primary anesthesia provider. They are the ones staying in the OR with the patient during anesthesia, which in Danish slang is called to sit on the patient. Residents mostly get the more complicated and challenging cases.
It is an ongoing battle for nurse anesthetist to hold on to their competencies and some of them a very reluctant to let new residents learn anesthesia and get time in the OR. The quality of care is generally good among nurse anesthetists, but life is a bit affected by their presence. Due to their limited and restricted competencies, they like cook book anesthesia where everything is pre specified and is written down in department documents. These written down recipes are often very basic and some nurse anesthetists find it very hard to deviate from them even the slightest bit, which sometimes makes life tough.
- Critical care medicine only anesthesiologist practice critical care medicine in Denmark. This is primarily based on tradition. In Denmark the invention of positive pressure ventilation for patients with respiratory failure is attributed to the Danish Anesthesiologist Bjorn Ibsen, who during the polio epidemic of 1952 made teams of medical students manually ventilate bulbar poliomyelitis patients who had been tracheostomies. And partly because these early critical care facilities were run by anesthesiologists, they essentially got the monopoly on Critical Care Medicine.
- Pre-hospital, emergency and trauma care
This tradition has also placed the anesthesiologist as a central figure, in the treatment and triage of the acutely ill patient; both in the pre-hospital setting, where anesthesiologists has the role of advanced paramedic in both helicopter and regular ambulances; and in the hospital setting, where anesthesiologists runs to all kind of code calls and also maintain the role of trauma team leaders in most hospitals settings. There is no emergency medicine specialty in Denmark.
- Pain medicine. The subspecialty of chronic pain management is not exclusive to anesthesiology. Subspecialized anesthesiologists mostly provide non-malignant pain management, whereas oncologists sometimes provide malignant pain management especially in recent years.
Popularity. Anesthesiology has gained interest among medical graduates in recent years and is now considered among the most popular specialties in the country.
Working conditions in Denmark are subject to very little legislature (hardly any). So there is no minimum wage or maximum working hours set by law. Instead the Unions of the employees and the organizations of the employers reach settlements every 3rd year. This is referred to as the Danish model in the rest of Europe. In the case of Doctors; settlements are reach between the 3 large Doctors Unions (employees) and five Regional Governments (Denmarks Government run Health Care System is divided up into five publicly elected regional government, that in the case of heath care is the employer)
The settlement varies very little over time. It serves as the contract under which Doctors in the government run health care system work. There are two different unions representing Doctors working in Hospitals. The resident union and the consultant union. What makes it a bit complicated is that if you are a specialist you can work under both contracts. The settlements of these two unions vary a little in terms of working hours and pay. Generally speaking there is no maximum working hours, but if the Doctor works more than 37 hours per week, he/she has to get paid overtime. The 37-hour work limit is averaged over 3 months, so after 3 month your hours get counted and overtime is paid. Generally speaking you work much more than 37 hours per week. So you get paid overtime, which makes the salary much more than what the contract at first appearance give you the impression of. To give a feeling of work time and salary I can say for my part that I over the last seven years worked on average 50 hours per week. I have earned around 450,000-550,000 kroners per year (80,000-100,000). I can also say that Specialists earn around 700,000-1000,000 kroners per year (140,000$-180,000$)
Due to the limited working hours (many weekdays off) many anesthesiology specialists and residents work extra jobs.
There is a small private hospital sector in Denmark (2-4% of the health care market) that employs many anesthesiologists. Anesthesiologists are used in many government paid independent small practices like ENT, orthopedics, urology etc. Anesthesiologists are used in Ambulance services (the aforementioned advanced paramedics) and in air plain retrieval services. Taxes in Denmark are notoriously reputed as being the highest in the world. Taxing like in most other countries is not strait forward, but in a normal physician salary range I would say that you should expect to pay around 40-45% in the end of the day if you have some mortgage you pay off and some other tax benefits to chose from. On the other hand you dont have to pay for your childrens education, you dont have to pay health insurance and malpractice insurance is ridiculously low (200 kroners a year = 40 $!).
Vacation is five weeks and there are really good arrangements for maternity leave. Denmark is based on both parents having full time employment, which explains the nice maternity leave settlements in most fields of work. As a government employed Doctor you have right to 6 month full paid leave and 6 month of half paid leave. This can actually be split between the mother and the father and off cause requires some paper work.
Danish medical education is taught in three universities, the largest and most prestigious being the University of Copenhagen. The curriculum is 6 years. In Denmark students attend University directly after Gymnasium which correspond to the last 2 years of high school and the first year of college. Students get their bachelors degree after three years of medical studies (corresponding to graduating from college?). The last three years in medical school are devoted to clinical courses and clerkships. Students study pretty hard in medical school averaging 50-100 hours/wk. depending on commitment. Students often work in the rather long summer vacation as nurse assistants, respiratory therapist and in sub-internships in hospitals and private practice. There is a strong student union (also started during the polio epidemic in 1952), which provides good working conditions and a salary ranging from 120 kroners (app 25 $) to 240 kroners (50 $) per hour depending on time of day and medical student year. Medical education is provided free of charge by the Danish government and the government also sponsor a student stipend, which is available to all Danish students. It amounts to approximately 4000 kroners per month (800 $), but is raised a bit if the student has children. If the student chose to get the stipend there is a maximum amount they can earn alongside getting the stipend (7000 kroners per month app. 1200$).
Specialization. After graduating from medical school a one-year internship is mandatory (until recently it was 1½ years medicine/surgery/family medicine). The intern has to do ½ a year in internal medicine. The other ½ year is either spent in surgery, orthopedics, family medicine or psychiatry. Internships are assigned to the graduate by a lottery held by the Danish medical board.
After internship you have to get an introductory residency in anesthesiology, which last 1 year. You can get these introductory residencies by applying locally and getting an interview. It seems like a rather random process who gets them and who doesnt. The introductory is evaluated by the supervisors of the program according to certain standards and the introductory resident is either encourage or discourage to pursue/give up the specialty. After the introductory residency, the graduate has to qualify for the real residency. This period is often referred to as pre-residency and is characterized by employment in non-accredited positions, while the graduate tries to earn qualification by taking courses, teaching, doing research and patient safety work (some graduates do a 4 year PhD during this time).
The period can last from 0-7 years. For anesthesiology it usually last 2-3 years.
The application for residency is a rather complicated process, with a lot of paper work. 1/3 of applicants get a chance of an interview. The interview last about 30 minutes and all the programs directors a present (30 people!). Eventually 1/4 of applicants to anesthesia residencies get into residency (all applicants has to have done the introductory residency).
Anesthesiology residency is four years. Residencies in most other specialties last 5 years. It consists of 1½ years in a medium sized hospital. 1½ years in a large university hospital (three different, one for each university in Denmark)
And lastly 1 year as a senior resident in a medium sized community hospital.
There are no exams during residency, but the resident has to pass 18-20 different major competencies, which are evaluated in an examination like format in a clinical setting by the supervisors of the program. The resident also has to pass 40-50 minor competencies, which are not evaluated in an examination like format and have to document amount of cases by logs. A long side the clinical work, there are didactic courses for all residents amounting to approximately 200 hours during the 4 years.
Sub-specialization has been emerging for the last five years or so. Scandinavian Society of Anesthesia and Intensive Care offers several fellowships like programs. However the applicant has to work with his/her current employer to get it arranged. The programs are generally 2 years consisting of rotation to different departments in Scandinavia (mainly university affiliated) and courses that also rotate to different locations in Scandinavia. There are currently programs for pediatric anesthesia, critical care medicine, obstetric anesthesia and presumably someone are working on a regional anesthesia program.
There is also ongoing work to make anesthesia specialization more uniform throughout Europe. The European Union of Medical Specialists is supposedly working toward uniform standards of specialization (presumably with the intention of making is easier to get recognized throughout Europe)
US medical students/doctors fall in the same category as graduates of non-European countries, which make the rules somewhat stricter - unfortunately.
US student have to learn Danish and pass a Danish exam in order to be able to apply for admission in a Danish medical school. You can apply if you have the following exams.
http://studier.ku.dk/internationalstudents/foreignstudents/othercountries/
1. High School Graduation Diploma + 1 year of higher education studies (e.g. college studies in relevant academic subjects) or equivalent supplementary studies.
2. High School Graduation Diploma + 3 Advanced Placement Test within academic subjects.
3. High School Equivalence Diploma (General Education Development) + 1 year of higher education studies (e.g. college studies in relevant academic field) or equivalent supplementary studies.
You would not be eligible for the state sponsored stipend and would have to pay a yearly tuition fee of 125,000 kroners (18,000$) unless you have a Danish or a EU citizenship or have a permanent residence permit in Denmark (very hard to get due to a right wing government that is very strict on immigration). So it would be preferable to have a Dual citizenship of a EU country.
A limited residence permit is easier to get and you would need it to study in Denmark.
US med Graduates has to get a Danish medical license. All US medical schools should be listed in the Avicenna Directories, that the Danish Medical Board uses to verify medical graduate credentials. Foreign Grads then have to pass with honors a Danish language exam (level 3), which is a pretty tough requirement. They also have to pass a Danish medical exam for international graduates. It consists of a 4 hour written essay exam and a 2-hour OSCE exam. Theres also a course and an exam in Danish medical legislation that you would have to pass. All exams are in Danish.
After passing the exams foreign medical gradiates have to get a trial position that last a minimum of one year. This position is equivalent to internship and has to be positively evaluated by the head of the department every 3 month. When the Danish Board gets the evaluation the foreign graduate is eligible to get a permanent Danish license, which is valid until the Doctor turns the age of 75 years.
US specialists need only have 6 months in a trial position in an anesthesiology department that has residency programs. The US specialist can apply for his/hers specialization to get recognized as a Danish specialist license. An ACGME accredited program would get recognized for sure. Otherwise specialist requirements are the same as those for non-specialized graduates.
