3. The internationalisation of medical education in France

3.1. Introduction

Historically, France has hosted large numbers of foreign medical students, although their number fell between 2010-11 and 2017-18. In 2017-18, around 12 000 foreign students were enrolled in medical schools in France at all levels (first, second and third cycles of medical education), representing almost 9% of all medical students. A more recent development is the growing number of French students obtaining a first medical degree abroad before returning to France to complete their postgraduate specialty training (internship), although their number is still relatively low.

The overall objective of the Ministry of Health is to train enough doctors to meet the needs of the French population, including those living in remote and underserved areas, while respecting the European regulations on people’s mobility and recognition of professional qualifications. Following steep reductions in the numerus clausus policy governing the number of students admitted to medical education programmes in the 1980s and 1990s, the admission of medical students has increased greatly since 2000, and the Ministry of Health has announced further increases in the coming years to try to address the growing shortages of doctors. In its medical workforce planning exercises used as input for education and training policies, the Ministry of Health now takes into account not only the growing number of doctors educated and trained domestically but also those who have undertaken part or all of their education and training in another country as another source of new doctors (Bachelet and Anguis, 2017[1]).

This chapter reviews recent trends in the number of international students of medicine in France and the number of French students going to study medicine abroad, and analyses some of the causes and consequences of these movements. It also examines the admission process for French and foreign students graduating with either a French or foreign degree to the third cycle of medical education in France (internship) and some of the recent measures taken or proposed to ensure that they have the necessary skills (theoretical, practical and language) before admission and throughout the internship period to become good doctors.

This study was carried out from May 2018 to January 2019 and draws on a series of interviews with key stakeholders in the French medical education system, including the Ministry of Health (Direction Générale de l’Offre de Soins and Direction de la Recherche, des Etudes, de l’Evaluation et des Statistiques), the Observatoire National de la Démographie des Professions de Santé (ONDPS), the Conseil National de l’Ordre des Médecins (CNOM), the Fédération Hospitalière de France and the Intersyndicale Nationale des Internes.1

3.2. Overview of the French medical education system, and recent and proposed reforms

3.2.1. The French medical education system is characterised by a strict numerus clausus at entry, but a much more flexible admission system in internship

Since the 1970s, France (like many other OECD countries) has applied a numerus clausus policy to control the number of students admitted to medical schools each year. The admission process for postgraduate training programmes (internships) is much more flexible and based on a national ranking exam (Epreuves Classantes Nationales, ECN); this does not exclude any candidates but is used to allocate new medical graduates to the different specialties and medical schools in France. Box 3.1 provides an overview of the three cycles of medical education and training in France and the current admission process for French and international students.

Box 3.1. Medical education and training in France, and admission process for French and international students

Medical education and training in France is divided into three cycles, which add up to 9-12 years of study, depending on the specialty area.

1. 1. The first cycle lasts three years and leads to the Diplôme de Formation Générale en Sciences Médicales, recognised as a bachelor’s degree. At the end of the first university year of common health studies (Première année commune aux études de santé, PACES), students who wish to pursue studies in medicine have to take a numerus clausus exam, which is highly selective. In 2016-17, only about 12% of students who took this exam for the first time succeeded in achieving a place at medical school; the proportion was 22% among those taking it for a second time (Ministry for Higher Education, Research and Innovation, 2018[2])).

   All students from the European Union (EU) and European Economic Area (EEA) and nationals of the Swiss Confederation and Andorra are entitled to take this exam to be admitted into a medical education programme, following the EU Directive on the free movement of people. For non-EU and non-EEA nationals, however, the quota is set at 8% of the total established intake. In reality, no French medical school has ever exceeded this quota, as the number of non-European applicants is always much lower than 8%. For example, in 2016-17, non-European students represented at most 3% of all students in those universities that accept the most international students, and on average 1.6% of students across all medical schools. For each non-EU or non-EEA student admitted, an additional French candidate can be accepted (e.g. if the numerus clausus in a given year is 8 205 new students and two non-European students are in the first 8 205 candidates, two additional French students will be accepted).

2. 2. The second cycle lasts another three years and is validated by the Diplôme de Formation Approfondie en Science Médicale, recognised as a master’s degree.

3. 3. At the end of these six years of studies, medical students who graduate from the second cycle go through a national ranking exam (the ECN) before entering the third cycle of postgraduate specialty training (internship). All candidates are accepted in the third cycle, but their ranking at this exam determines the choice of speciality for their internship and the university where they will pursue their studies and internship (students with the highest marks choose first).

   All students who have completed the second cycle of medical education in France can take the ECN, regardless of nationality, as they have a French degree. Following the EU Directive on the recognition of professional qualifications, all students with a recognised medical degree from another EU or EEA country can also register for the ECN and be offered a postgraduate training place. For non-EU and non-EEA students who have obtained a medical degree in another country, however, there is a specific internship competition (the concours d’internat en médecine à titre étranger), which offers only a few positions (seven in 2016 and only one in 2017).

   The third cycle of postgraduate training in France was restructured in 2017, based on three clearly defined phases, including regular assessments of the skills and competencies acquired in each phase throughout the training process (Figure 3.1).

Figure 3.1. Third cycle of medical education in France after the 2017 reform

3.2.2. The numerus clausus policy in France has fluctuated greatly since its introduction in the 1970s

In France, a numerus clausus policy for admission to the first cycle of medical education was introduced in 1971, with the goal of ensuring a good match between the number of students admitted and the limited number of training places available in hospitals. Another aim was to prevent too great an increase in the medical workforce, to contain health expenditure growth. Following a few years of stability, the numerus clausus limit fell from around 8 500-9 000 students a year in the middle of the 1970s to 3 500 in the 1990s, due to concerns about a potential surplus of doctors. Since the end of the 1990s, it has started to rise again in response to concerns about potential shortages, to reach roughly the same level in 2017 as it was at the end of the 1970s (Figure 3.2).

In February 2019, the government announced a plan to continue to increase the number of students admitted to medical studies by around 20% by 2020 and to abolish the numerus clausus exam at the end of the first year, while allowing medical schools to have more flexibility in the admission process. In fact, the introduction of greater flexibility and diversification of student profiles and access to medical studies started several years ago, with the introduction of “bridges” (“Passerelles”) for students with 1-3 years of relevant university education, enabling them to be admitted to the second or third year of medical education, but the number of places has remained fairly limited so far.

The increase in the number of students admitted to medical education programmes in France might reduce the number of French students who decide to study abroad.

Figure 3.2. Changes in numerus clausus for entry to medical education programmes in France, 1972 to 2018

Source: ONDPS survey (2019).

 StatLink https://doi.org/10.1787/888933970304

3.3. Over 12 000 foreign students were enrolled in French medical schools in 2017-18 – fewer than in 2010-11

In 2017-18, over 12 000 foreign students were enrolled in medical schools in France in all three cycles (excluding students in the first year of common health studies, PACES), representing 8.8% of the total number of medical students (Table 3.1). Historically, students from Maghreb countries (Algeria, Morocco and Tunisia) have accounted for the greatest proportion of foreign students of medicine in France because of historical ties, common language and bilateral agreements. However, the number and share of students from Maghreb countries have fallen since 2010-2011, and in 2017-2018 they comprised about one-third of all foreign medical students in France.

Students from other EU countries account for a growing number of foreign students enrolled in medical schools in France, with their share increasing from about 20% of the total in 2010-11 to nearly 30% in 2017-18. The largest number of students came from Romania (902) and four countries that share borders with France: Italy (634), Belgium (499), Spain (297) and Germany (295). A large number of students (around 200) also came from Luxembourg, which has established agreements with neighbouring countries, including France, for the education of its medical students. This is expected to change as of 2020, at least for the first cycle, with the planned introduction of a new medical degree in Luxembourg.

About 7% of foreign medical students in 2017-18 came from Middle Eastern countries, a lower proportion than in 2010-11. Students from Lebanon were the most numerous (467) in 2017-18, followed by Saudi Arabia (184) and the Syrian Arab Republic (171). Most students from Saudi Arabia are postgraduate trainees financed by the Saudi government, which subsidises medical schools directly. A small number of foreign medical students come from the Americas (e.g. from Canada, Haiti, Brazil and the United States).

The cost of university education in France, for both domestic and foreign students, in medicine and in other fields of study is very low compared to several other European and non-European countries. Enrolment fees are about EUR 170 a year for the first cycle, EUR 240 for the second cycle (master’s students) and EUR 380 for the third cycle (PhD students). Most of the cost of university education is paid by public sources, estimated at approximately EUR 10 000 per student per year (Campus France, 2018[3])).

To date, university fees have been the same for all students, regardless of nationality (with no distinction between students from France, the EU or non-EU countries), as is the case in several other countries. In November 2018, however, the government announced its intention to significantly increase university tuition fees for non-EU and non-EEA students, while increasing financial assistance for some of them. At the start of the 2019 academic year, tuition fees for students from outside the EEA are expected to increase to EUR 2 770 a year for undergraduate students (first cycle) and EUR 3 770 a year for master’s and PhD students (second and third cycles). While this increase is significant, these tuition fees nevertheless remain much lower than the fees foreign students pay in other countries such as the United Kingdom and the Netherlands.

3.4. The number of French students studying medicine abroad has increased but remains relatively low

It is difficult to know exactly how many French students are enrolled in medical schools abroad as they are not registered in France. However, available data indicate that the number of French students pursuing and completing a first medical degree abroad has increased in recent years, although it remains relatively low. The number of French students with a foreign medical degree passing the ECN exam to get into postgraduate training in France rose from only 13 in 2012 to 134 in 2017; this still amounts to fewer than 2% of the total number of students who took the ECN in 2017 (see Table 3.2).

Among doctors who have completed their training and are registered, the total number who were born in France and completed some or all of their medical education and training abroad before returning to France increased by around 20% between 2011 and 2016 (from 542 to 660). Despite this recent rise, this number still amounted to only 0.3% of all practising doctors in France in 2016.

French students studying medicine abroad can be classified in two broad categories: expatriates “by default” and expatriates by choice (Figure 3.2).

In recent years, Romania has rapidly become the preferred destination for French students wanting to obtain their first medical degree abroad. In 2014-15, about 680 French students were enrolled in the eight Romanian medical schools, and their number increased to over 1 200 in 2017-18. This sharp increase was facilitated by the introduction of programmes provided in French in a growing number of Romanian universities (initially in Cluj, but now in at least three other universities), reflecting a deliberate policy to attract a greater number of French and French-speaking students. The students also need to learn Romanian during the course of their studies, as they need to pass the exam in that language when they complete their degree.

The first wave of French students who studied for their medical degree in Romania have started to apply for the ECN in recent years to complete their postgraduate training in France. Around 90 French students with a degree from a Romanian medical school applied to the ECN in 2015; this number went up to 110 in 2017 and should continue to increase in the coming years.

For these French students, the conditions for admission to medical schools in Romania are far less stringent than those for medical schools in France. Admission is mainly based on their marks at the end of the baccalaureate (secondary school). Hence, the vast majority of French students applying to Romanian medical schools are admitted, including both those who have just completed the baccalaureate and those who have already done one year in university in France but failed the medical entrance exam.

To obtain a medical degree in Romanian medical schools, all international students are required to take the exam marking the end of the second cycle in Romanian, including all the students who pursued their studies in French. Since these students have in most cases spent six years in a medical school in Romania to obtain this degree, passing this exam is crucial, as it means validating a huge investment of time and money (the tuition fees for foreign students in Romania are about EUR 5 000 per year on average).

3.5. Student ranking in the ECN is mainly influenced by the place of first medical degree

Applicants to the third cycle of medical education in France (postgraduate specialty training or internship) fall into four main categories: 1) French students who obtained their first medical degree in France (by far the greatest number, accounting for over 90% of the total in 2017); 2) foreign students who obtained their first medical degree in France (a little less than 3%); 3) foreign students who obtained their qualification in another EU country (just over 2%); and 4) French students who obtained their qualification in another country (less than 2%) (Table 3.2).

Although their numbers remain fairly low, the number of students with a degree from another EU country taking the ECN has increased in recent years, driven mainly by the growing number of French students pursuing their initial medical education outside France. In 2017, of the 328 foreign-educated candidates for the exam, 133 were French, while most of the remainder were Italian (122) and Romanian (32) (Table 3.3).

Most of these students obtained their medical degree in Romania (147) and Italian medical schools (124), with a much smaller number obtaining their degree in Belgium (14). Among those students with a degree from Romania, the vast majority were French (110 compared to 32 Romanian students). By contrast, almost all students with an Italian degree were Italian students (122, while 2 only were French). The main reason for the high number of Italian candidates applying to the ECN each year is that these students have to pass a very difficult exam, with a high failure rate, to be admitted to the third cycle in Italy. Hence, entering the third cycle in France is seen as a good alternative for Italian students who have either failed or are worried that they might fail this exam in their country. The majority of students with a Belgian degree were French students (10 compared to 4 Belgians).

Not all students who register to take the ECN actually turn up to the exam, and some who complete it end up declining the internship post offered, meaning that some positions remain unfilled. In 2017, about 70 candidates with a foreign degree who had registered for the exam did not attend, and 70 who attended did not end up taking an internship post. The number of unfilled internship posts is exacerbated by the fact that other positions are also declined by French students with a French degree, mainly because some use the opportunity to take the exam again the following year to try to improve their ranking.

ECN results show that students who obtained their medical degree in France tend to rank higher than those who obtained their first medical degree abroad, regardless of whether they are French or foreign nationals. Several factors may explain this:

1. 1. students who complete their first medical degree in France have to pass the exam at the end of the first year and may therefore have greater capacity to learn and perform well in exams, leading to a “selection effect”;

2. 2. the content of the ECN is more aligned with the content of the French course than with programmes in other countries;

3. 3. students studying in France have greater opportunities to take specific programmes to prepare for the ECN; and

4. 4. foreign students who have studied abroad may face language barriers.

Among the 8 372 students who took the ECN in 2017, the average ranking of French students who obtained their first medical degree in France was 3 941; that of foreign students who obtained their degree in France was 4 908 for Europeans and 4 945 for non-Europeans. By comparison, the average ranking of French students who completed their studies outside France was just 7 765 (with the highest ranked student at 3 669 and the lowest at 8 360); for foreign students who studied abroad, the average ranking was 7 998 (with the highest at 1 435 and the lowest at 8 372) (Table 3.4). This supports the ONDPS conclusion that the place of qualification is a more important factor than the nationality of students in determining their ECN ranking (ONDPS, 2015[4]).

A number of foreign students with a foreign degree obtain very low marks in the ECN. In 2015, 10% scored less than 100 out of 1 000 (Jolly et al., 2016[5]). This may be due to a more limited knowledge base compared to that being tested in the ECN, but it may also result from more limited knowledge of the French language.

As noted above, the results of the ECN do not affect admission into the third cycle as all students taking the exam are offered an internship post, but they affect the choice of specialisation and the location of the university where students will pursue their postgraduate studies. Given their lower ECN results overall, students with a foreign degree are more likely to specialise in fields that are less popular among medical graduates, such as general practice or occupational medicine. In 2017, nearly half (49%) of foreign-qualified students who began their postgraduate training studies in France were assigned to general practice. This proportion rose to nearly 60% for French students with a French degree, compared to just under 40% among French students who had graduated in France (Table 3.5).

Foreign-qualified students therefore frequently fill internship posts in specialties that may be less popular, but nonetheless in which there are current or expected shortages, such as general practice. Students with a foreign degree are also more likely to do their internship in more remote and underserved areas, such as disadvantaged parts of Ile-de-France, where there are usually a greater number of unfilled internship posts. Although the contribution of these interns is obviously not enough to make up for the shortage of doctors in these areas, they nonetheless help to reduce the tension in the system.

3.6. A number of options have been proposed to strengthen the selection and evaluation of medical students pursuing postgraduate training in France

Consensus has emerged in recent years on the need to tighten oversight and evaluation of the theoretical and practical (clinical) skills of students completing their second cycle of medical studies in France or in another EU country to ensure that they have the required skills to pursue their postgraduate specialty training (internship).

A new certificate of clinical competence (in the form of a practical exam) was introduced in 2016 to evaluate the clinical skills of students completing their second cycle of medical education in France. In 2017, the National Academy of Medicine proposed to extend this certificate to students who have completed their degree in another country and intend to pursue their postgraduate training in France (Bringer, Brunelle and Queneau, 2017[6]). However, it is not clear how such a measure could be implemented while respecting the EU Directive on the recognition of professional qualifications (Box 3.3). This only stipulates a minimum duration of medical education programmes during the first and second cycles for the diploma to be recognised across EU countries (5 500 hours of theoretical learning and practical training, and a minimum of five years of medical studies). It is up to each country to determine the specific curricula, including the balance between theoretical and practical knowledge. The extent of practical clinical training can differ greatly across countries, and students’ access to technical equipment (such as medical imaging) can also vary widely, not only across countries but also across medical schools within each country. These differences can translate into important differences in the clinical skills students have acquired at the end of the second cycle.

In addition to ensuring that all students have a minimum level of theoretical and practical knowledge when they start postgraduate training, it is important that all interns have a sufficiently good knowledge of French to be able to communicate with colleagues and patients. There is currently no examination to assess the French language skills of foreign candidates taking the ECN. In 2017, the National Academy of Medicine also proposed introducing a language test for foreign candidates to avoid compromising the quality of care (Bringer, Brunelle and Queneau, 2017[6]). The EU Directive on the recognition of professional qualifications recognises the right for national authorities to assess the language proficiency of foreign applicants separately from the professional qualifications.

As outlined earlier (Box 3.1), the reform of the third cycle of medical education in France introduced in 2017 provides additional guarantees of the skills acquired by interns at each phase of their internship.

Box 3.4 summarises some of the recent options proposed by different stakeholders to improve the selection and skills assessment of candidates for postgraduate training programmes in France, and to provide better support to interns during their training period.

3.7. Conclusions

The internationalisation of medical studies in France involves both the long-standing intake of foreign students to French medical schools and the more recent development of French students studying at medical schools in other countries. About 12 000 foreign students were studying medicine in France in 2017-2018, accounting for slightly less than 9% of all medical students. Historically, a large number of foreign medical students have come from Maghreb countries, but their number and share have decreased since 2010-11. A growing number and share of foreign medical students come from other EU countries, with the greatest number from Romania, Italy, Belgium, Spain and Germany. About 7% of foreign students come from Middle Eastern countries (mainly Lebanon, Saudi Arabia and Syria), but their number and share have decreased since 2010-11.

It is hard to know the precise number of French students studying medicine in other countries because they are not registered in France. However, their number is rising. For example, the number of French students going to Romania to obtain a first medical degree has increased sharply in recent years, from around 680 in 2014-15 to over 1 200 in 2017-18 (all levels combined). This rise was facilitated by the creation of French language programmes in a growing number of medical schools in Romania, as part of a strategy to attract more students from France and other French-speaking countries. This movement was also supported by the EU Directive on the recognition of professional qualifications, which states that a degree acquired in Romania or in any other EU country should be recognised in all other EU countries. However, the recent and planned increases in the number of students admitted to medical schools in France, combined with the proposed replacement of the numerus clausus exam and greater flexibility in admission conditions, may reduce the number of French students studying medicine abroad.

The main factor determining results in the ECN exam, which is used to allocate postgraduate interns to different specialty areas and medical schools, is not students’ nationality but the place they obtained their qualification. Students who studied in France generally have better results than those who took their first medical degree abroad, regardless of whether they are French or foreign students. These results have raised some concerns about the level of theoretical and practical knowledge of some candidates who obtained their degree in another country, as well as the language proficiency of some foreign students with a foreign degree.

Since they generally achieve a lower ranking in the ECN exam, foreign and French students with a foreign degree tend to end up in specialisations that are less popular among new medical graduates, including general practice. They are also more likely to work in remote and disadvantaged areas, where shortages of doctors are most acute. The posts filled by these interns can help to mitigate shortages, although they are insufficient to make up for all the shortages.

A new certificate of clinical competence in the form of a practical exam was introduced in 2016 to improve evaluation of the practical skills of students completing their second cycle of medical studies in France. In 2017, the National Academy of Medicine proposed that this certificate should be extended to all students who obtained their first medical degree abroad and want to pursue postgraduate internship training in France. However, it remains to be seen how this would comply with the EU Directive on the recognition of professional qualifications. The Academy also proposed introducing a French language test for foreign students who obtained their medical degree in another country, to ensure that they have sufficiently good knowledge of French to communicate effectively with colleagues and patients. This would not pose any difficulties under the EU Directive.

The French government is planning to reform the ECN, which is felt to be an overly theoretical exam that does not assess the candidates’ practical and clinical knowledge sufficiently. Besides putting greater focus on clinical competencies, some university medical schools have also proposed setting a minimum pass mark for this exam, as done in several other countries. These reforms would affect not only students obtaining their first medical degree in France but also those obtaining their degree in other EU countries.

Acknowledgements

The authors would like to thank all the interviewees who provided useful information in the preparation of this case study (in alphabetical order): Marie Anguis, Direction de la Recherche, des Etudes, de l’Evaluation et des Statistiques; Alexandre Bertrand, Bureau démographie et formations initiales, Direction Générale de l’Offre de Soins; Jean-Baptiste Bonnet, Intersyndicale Nationale des Internes; Marie Colegrave-Juge, CNOM; Professeur Claude-François Degos, CNOM; Christelle Gallo, Bureau démographie et formations initiales, Direction Générale de l’Offre de Soins; Marie Houssel, Fédération Hospitalière de France; Claire Marbot, formerly from the Bureau des professions, DREES; Stéphanie Rasse, CNOM; Adam Tornay, CNOM; and Catherine Zaidman, formerly from ONDPS.

The authors are also very grateful to the following people in the OECD Health Division: Gaelle Balestat for her statistical support; and Karolina Socha-Dietrich for her valuable comments on the draft version of this report.