Healthcare systems and training programmes vary significantly across the world. By learning about other healthcare systems, we can identify blind spots in our own system and continue to improve training. Sofia Anastasiadou, an ENT Registrar in South West England, describes her experiences in ENT training, having moved from Greece.
Working in two different healthcare systems is definitely a challenge and presents a lot of advantages and disadvantages. Even among Western countries, healthcare systems seem to differ a lot regarding their priorities, principles, guidelines and funding.
Having worked as an ear, nose and throat registrar in both Greece and in the UK has left me with the impression that no healthcare system is perfect, and that the two countries have different strengths and struggles. It would be excellent to advise each other and acquire improvement ideas, wouldn’t it?
Greek vs. UK healthcare
First, working in Greece as an ENT registrar involves a multifactorial role, being simultaneously the ward doctor, the outpatient doctor, the theatre doctor, and the all-I-can-do doctor. This means that all members of the ENT team share equal rights on all sectors of the specialty regardless of the stage of their training. This essentially qualifies them quickly with exposure to a great variety of subjects, including how to deal with emergencies and how to acquire basic surgical skills. However, the stress that rushes in on the first on-call night is undeniable, since there is no difference in their duties compared to a finishing ENT registrar. On the other hand, the UK training system separates the trainees into core surgical trainees, junior registrars and senior registrars that all have different grades of roles and responsibilities as well as different benchmarks to achieve to proceed with their next step of training. This is helpful to diffuse stress and to make clearer what is needed to progress as an ENT doctor. It also prevents highflyers from finishing too early for their skill level, ensuring that by the end of the training programme, the surgeon is safe and competent.
Second, the UK offers a nearly 100% compliant shift system with European Working Time Directive (EWTD) that respects the rest time of doctors, acknowledging the need to be off work as much as the need to be at work. As a result, doctors rotate on a regular basis between day shifts, night shifts and days off to ensure a healthy work-life balance. This seems like a far dream for Greece, as the work schedule is nowhere near the EWTD. Staffing issues, the inability to fund locum shifts and the perception of tiredness as weakness are the three major factors of the system failure. I will always remember when I was doing a 48-hour shift resident in hospital, telling my boss that I was scared to operate due to tiredness. The response was; “I understand but remember, the weak are getting tired. You do not want to be weak.” I always found this outrageous, but I guess it is again a matter of perception; old school prestige of traditional representatives of surgery. By the way, for those who want to know, I felt embarrassed so still proceeded with the operation despite my fear. The operation finished well.
"Working in Greece as an ENT registrar involves a multifactorial role, being simultaneously the ward doctor, the outpatient doctor, the theatre doctor, and the all-I-can-do doctor"
The third important difference that I believe creates a gap between the two systems is how the subspecialties are structured in each country. It is very unlikely to find a young recently qualified ENT surgeon in the UK that occupies every ENT subspecialty and is employed as a general ENT consultant. On the other hand, in Greece the limited patient number as well as the fellowships that are extremely rare, lead the way to a general ENT specialist consultant that can safely achieve basic ENT procedures and refers all complex cases to either big centres in the capital or even abroad. I am not sure about super-subspecialisation nowadays; I was always seduced by the idea of being able to deal with a variety of things, but this is another subject to consider.
Last but not least, in terms of auditing processes either regarding patient safety, patient experience, equipment or even training standards, the countries are again very dissimilar. ‘Audit’ as a concept is very popular in the UK. For example, in ENT we audit patient numbers, patient happiness, failures in theatres, equipment issues, postoperative complications, hygiene on the wards, doctors’ working hours, referrals from and to departments, and many more. The audit process is important to maintain safe practice and also frequently assesses if the quality of care is up to date with national and international standards.
"Greek Mediterranean mentality encourages professionals to bond closer with their patients, creating sometimes a personal relationship with sincere interest and devotion"
This assessment in Greece is more person-driven rather than system-driven I am afraid. In my home ENT department, consultants were working closely as a team, assessing themselves and the overall performance of the services; however, what if this does not happen? I am happy that I could rely on my seniors to ensure high standard of quality of care but what if some seniors are not keen to get involved with this subject? Standardisation of the procedures, central control and formal assessment tools are key to maintaining a high quality of care. Relying on individuals that go the extra mile is certainly sweet but not reassuring.
Overall, both systems focus on effective treatment of their patients at any cost and also have wonderful professionals that are excellent doctors and trainers, as well as keen juniors and respectful patients. The differences are mostly systemic, and they require careful assessment and amendment wherever is needed. Greek Mediterranean mentality encourages professionals to bond closer with their patients, creating sometimes a personal relationship with sincere interest and devotion. British professionalism ensures high quality of care for everyone irrespective of background or social status. Combining the experience of both systems, keeping the positive aspects, creates the optimal result in healthcare.