The Making of the Self-Reliant Physician: Medical Education in Iceland

Jennifer Neuman, MS II, BA

Disclosures

There is an ethos of self-reliance about Iceland. On a small island at the edge of the arable world, Icelanders inhabit the most sparsely populated country in Europe. The island itself is largely barren and is subject to some of the harshest, most inhospitable climates on Earth. It has no oil, no gas, and few natural resources.

Despite this, the Icelandic people have managed to create one of the wealthiest countries in the world (it has one of the highest per capita gross domestic products in Europe), one of the most prolific countries in the world (it has the highest number of published authors per capita),[1] and one of the healthiest countries in the world (Icelandic men have the longest life expectancy on Earth, and women rank among the top 10).

Their success as a nation is, in many ways, a tribute to their wise use of limited resources. To avoid importing oil and gas, for example, Iceland uses an energy system powered exclusively by hydroelectricity and heat generated from natural thermal springs. On an individual level as well, Icelanders are generally industrious: The country has a negligible unemployment rate, and many Icelanders hold more than 1 job.[2]

In the words of Birna-Anna Bjornsdottir, a popular Icelandic author: ". . .most Icelanders juggle several jobs -- the only way to run a full-blown state and economy with fewer than 300,000 people. The mailman moonlights as a veggie chef, and the DJ teaches kindergarten during the day. Both have a couple of books of poetry out. . . ."

Perhaps it is their history of surviving the elements and of enduring the darkness and isolation of winter that has generated this sense of creativity and self-reliance. Perhaps it is the result of a few exceptional genes that circulate and recombine within this small, homogeneous population. Whatever the explanation, there is something special that drives the Icelandic people. This characteristic can be seen particularly well in Icelandic medical students, many of whom, at the earliest possible stage in their training, take positions in the countryside to learn how to become self-sufficient, self-reliant physicians.

The 1 medical school in Iceland, University of Iceland in Reykjavik, graduates 40 doctors per year. To gain full licensure, medical students must complete 6 years of undergraduate medical education, followed by a compulsory 12-month clinical training program.

Although Icelandic medical students must complete 7 years of training to receive full medical privileges, they are granted an attenuated license to practice as general practitioners after their fifth year. This license gives them full prescribing privileges (except for specific medications restricted by specialty) and allows them to work during their summer vacation. Many choose to work in a rural part of the country and take over the practice of a small-town physician.

The importance of students taking these positions cannot be understated. Although two thirds of the Icelandic population live in Reykjavik, approximately 110,000 people live in small towns and isolated fishing villages, scattered around the perimeter of the island. These people are cared for by physicians and nurses who work in state-funded Health Care Centers distributed throughout the country. Each of these centers is required to provide on-call services 24 hours a day, 7 days a week throughout the year. Some of these centers have more than 1 doctor, but more than half of them do not. In fact, 55% of the Health Care Centers in Iceland are run by either a single doctor or a community nurse. Although these centers are usually located in isolated towns with populations numbering in the hundreds, the strain of being the sole care provider on call every day of the year can be overwhelming. "I would burn out if I tried to be superman," explained one country doctor with whom I spoke. "It can be hard, finding a balance. "

To relieve these doctors, fifth-year medical students in Iceland are offered paid positions to take over their responsibilities during the summer months. Although these students have undergone their primary set of clinical rotations, these summer clerkships are often their first experiences to practice independently. Taking on this level of autonomy can be a daunting prospect; however, it is something that is encouraged and supported within the Icelandic medical culture.

As K., a 25-year-old female medical student who I met in a small rural clinic, explained: "Icelandic students are trained to be very independent, sometimes aggressively so. Coming to the country gives you an opportunity to work on your own . . . to see what you can do when you're put in the situation." "Here," she said, "you learn by doing."

When I met K., she was acting as the sole physician in a small fishing town about 200 km north of Reykjavik. As a fifth-year medical student, she applied for this summer position to gain experience and confidence in her clinical practice. At the clinic in which she worked, she was supported by a staff, including an experienced nurse and a midwife, who helped guide her in her daily practice. This situation was far superior to that of her boyfriend, who was placed in an extremely remote area on the other side of the island, alone, to act as the sole care provider of that region. Still, K., a petite blond woman, who looked younger than her age, held the enormous responsibility of caring for the 1100 residents of her town. She took her own x-rays, drew her own blood, and interpreted the results of the basic tests that she performed in the small laboratory in the clinic. She casted limbs, sutured wounds, and stabilized patients in emergencies before they were sent to larger hospitals for evaluation and treatment.

She would not have had this broad scope of experience if she had stayed in Landspítali, the main university hospital in Reykjavik., a large, high-tech facility, where many of her current tasks would have been performed by technicians, nurses, nurses' aids, and other support staff.

Still, her job came with its fair share of anxiety. She was told that if she had a patient with a massive nosebleed, she should use a Foley catheter to stop the bleeding before sending him or her on the 2- to 3-hour trip to the closest hospital. She read and reread the guidelines for dealing with asthma attacks, myocardial infarctions, and anaphylactic shock. Every day, when she left the clinic, she was required to carry a large suitcase full of life support equipment and drugs, in case there was an emergency during the night. Her biggest fear was encountering a situation like this, and not knowing what to do.

Whereas K. feared the worst, other medical students who I met in the country expressed anxiety over the mundane. E., a student who I met in the north explained: "An MI, an asthma attack . . . these are situations you can train for. It's the rashes and the fevers that really worry me -- the everyday things you don't know what to do with."

But for all the anxiety that they expressed, the medical students who I shadowed were generally positive about the experience that they were gaining. In practical terms, they were learning the skills that they needed to become self-sufficient doctors, taking care of every aspect of their patients' evaluations, from start to finish. Moreover, they were learning to trust themselves, to believe in their ability to diagnose and treat, and to make critical decisions.

When they were unsure of a diagnosis, they consulted their resources, nurses, attending physicians, the Internet, and the 24-hour helpline at the University Hospital in Reykjavik. At night they would retire to their apartments, study, and prepare for their night on call, which could consist of anything from telephone consultation, to patching up victims of a bar fight, to taking a half-hour drive to a nursing home at 4:00 am to confirm a death. At 8:00 am the next morning, they started the whole process again.

K. and E. both talked about how their experience was helping them grow into their roles as physicians. K. explained: "When I first started here, I would walk in to meet a patient; they didn't believe I was the doctor. It threw me off. Now, I know how to handle that situation. I can stay in control." E. elucidated: ". . . the key was to not become overwhelmed and to know when to seek help. . . . It is also important not to become overconfident and get in over your head."

Although both appreciated their summer experience, I was surprised to learn that neither K. nor E. expressed future interest in general or rural practice. K. expressed an interest in cardiology, and E. expressed interest in hospital-based medicine.

In a recent study on a rural preceptorship program in the United States, it was shown that there was a direct correlation between fourth-year medical students who decided to do rural clerkships and those who ultimately entered into rural medicine. Most of the American students who chose these rotations had prior intentions of going into rural primary care or had grown up in rural areas, and used their clerkship experience to confirm their interest in the field.[3] The situation is quite different in Iceland, where about 50% of fifth-year students chose to take rural summer positions and only about 15% ultimately went into rural practice.

Although the 2 groups are not directly comparable, it is interesting to note that for Icelandic medical students, the rural experience is more about personal development than career decision. Both K. and E. took these positions to build and strengthen their foundations as clinicians and to gain the confidence and skill that would help them in their future specialties, whatever they may be.

As medical students, we all undergo the transformation from student to physician. At times, we are guided in this transition; other times, we guide ourselves. In Iceland, a country that is built on resourcefulness, medical students are encouraged to seek out opportunities to test themselves, challenge themselves, and build their confidence from the earliest point in their clinical career.

In the highly formalized experience of medical education, sometimes it can feel like you are being shaped more by processes and protocols than actual experience. This summer I saw what could happen when medical students allowed their experience to shape them. Although our opportunities as medical students differ from those of the Icelandic, I came to appreciate how seeking challenges within our own medical structure can give us the opportunity to begin our own professional transformations, and begin to recognize ourselves as the physicians who we are becoming.


Readers are encouraged to respond to George Lundberg, MD, Editor of MedGenMed, for the editor's eye only or for possible publication via email: glundberg@medscape.net

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