The pros and cons of the Swiss residency system

When it comes to choosing a country to spend the coming 30 years of your life working as a doctor there are many factors to keep in mind in order to make the best choice. Maybe among those factors the main ones that come to mind are the salary, the cost of living, the safety and security, climate, quality of working environment, etc.

The residency period may not be as important as the previous ones, given that a 5 year period is dwarfed in comparison with the following 30 years. However this 5 year period is the one you start with and depending on how it is structured, how the process of admission looks like and the requirements to finish it and become a specialist are, it may have huge implications and consequences for the following 30.

Not so sure about it? Well let me show you how a residency system can lock you into unhappiness for the following 30 years of your life. To prove my point I will first explain the Spanish residency system and then I will compare it with the Swiss one.

Starting with How to get into the residency:

In Spain there is a system where the best doctor gets to choose specialty first. Every year there is an Exam that takes place around January for which people prepare for a whole year. Whoever gets a better grade gets to choose which position he/she will occupy for the following 4 years. And then the second gets to choose, and then the third, and so on all the way to the 15 000 yearly participants. It is a very fair system. However it also implies that the motivation and love towards a specific specialty are not accounted for. Do you want to be a dermatologist? Too bad you have the position 3000 since the person who took the last open spot was around 900. Study another whole year again, do the exam and try to be in the top 8% to make sure you get it. It doesn't matter if you were born to be a dermatologist or if you already know everything that there is to know and would become the very best Dermatologist that Spain has ever seen. You pick whatever is left when it's your turn to choose. Either that or you study for another year in your room at your parents house. This system ends up pushing people to end up accepting whatever is left and being unmotivated their whole professional lives because they never wanted to be an oncologist in a small city in the middle of nowhere or a family doctor.

Lets see how Switzerland does here:

In Switzerland there is no entry exam and there is no “choosing system”. In Switzerland as long as you are a doctor and are recognized and allowed to work in Switzerland you can just send an email to the secretary of the Department where you want to work, for example Dermatology in Zürich and that's it. This system is both fair and unfair at the same time, depending how you look at it: Since there is no objective rule that Hospitals have to follow to choose between hiring 2 different doctors, it opens the door for a wide variety of possibilities.

For example, let's say that your dad is a Cardiologist working in the Hospital of Zurich and pulls some strings between friends in the department. That's it, the position is yours. It doesn't matter if the other doctors you were competing with had more experience or have researched, the position is yours. In this case the Swiss system is quite unfair.

Also lets say that you apply for the same position but now you are mister nobody and also a foreigner. you have some experience and they don't even invite you to have a talk. At the same time a coworker who is Swiss but with no experience whatsoever Applies at the same time and does get an invitation to have a talk. Is there a bias? you will never know but it does smell like it. In this case Switzerland seems to be quite unfair again.

Let me give you a third example: You have accumulated some experience here and there and you understand that even though you might not be the most competitive person around, you want to give it a chance, so you apply to every single hospital and clinic in Switzerland that offers Dermatology. Many hospitals decline your application, a couple invites you to have a chat and out of those one of them does indeed offer you a position as a resident in Dermatology for 1 or 2 years. During those 2 years you again apply to every B and A Type Dermatology clinic and because you are already a resident of dermatology one B Hospital does also offer you a position. 2 years later and with an amazing experience in Dermatology an A type Dermatology Hospital signs you as well as a resident in Dermatologist. You worked your way up and over the years you have applied to many many hospitals (to some of them 2 or more times) and despite the many rejections over the years do become a specialist in Dermatology. Was it fair? Maybe you weren't the best at the beginning but you tried your best and you worked very hard, so I would say that you deserve it. Damn right it's fair!.

Next, Changing Hospitals.

Starting with Spain, there is no such a thing as changing hospitals. You chose a position in a hospital and either you finish it or you go back to the exam next year and start from the beginning. Isn't it possible to change hospitals but keep the specialty? Nope.

What if my colleagues are bullying me? Do I have to stand that for 4 years? Yepp, fake it till you make it.

Obviously this part of the Spanish system sucks, there is not much more to say about it.

Now, Switzerland. In Switzerland not only can you change Hospitals, you are supposed to. It's not even possible to finish most specialties without having worked in 2 or more different hospitals as a resident of that specialty. The idea behind this concept is learning from many different people and understanding that there is not just one way of doing things, but many.

In the website  - https://www.siwf.ch/weiterbildung/facharzttitel-und-schwerpunkte.cfm -  that belongs to the SIWF (Schweizerisches Institut für ärztliche Weiter- und Fortbildung) they post for every specialty an official pdf document that specifies the conditions that need to be met in order to become a specialist. 

Continuing with Dermatology for example,as you can see in this screenshot:

One year can has to be done in a second Hospital and 1 year can be not dermatology! There are many more conditions that need to be met in order to become a specialist and these conditions obviously depend on the type of specialty. 

So if you are 100 % sure you want to do a specialty it would be wise to see what the overall requirements are to complete it to plan for the future. Like I just explained, getting a position as a resident is just not enough.

Next, Changing specialties:

Say that you started Internal diseases in Spain and after 2 years you realize that it's not for you, but you really like cardiology. Can you change? no you can't. You can go back to do the exam, land a position in Cardiology and complete it.

In Switzerland, changing hospitals and even doing some time outside of the main specialty is a requirement to complete that specialty anyway, as you could expect making these changes are very easy. So if you start having internal diseases but realize that it's not for you, just apply for cardiology somewhere for next year. It's not only that easy, but since Cardiology also requires you to do 2 years of non-cardiology specific years in internal diseases, those 2 years don't go to waste, but are accounted for.

As a result of this, pivoting between similar specialties until you find the one you love is rewarded, not punished.

Finally, another residency-related topic to keep in mind is doing a second residency. You might think that it's crazy to get a second one, but there are indeed many many people who after 3-4 years as a resident they were not happy with their choice anymore but were not willing to pivot at that point so they finished the residency and then wonder if they can indeed keep going like that for another 30 years of if they want to do something else. Let's compare both countries:

For Spain you probably guessed it, it doesn't matter if you are already a specialist in internal diseases, if you want to start cardiology you start from the very beginning. Simple and boring.

In Switzerland once again you just apply for a resident position for cardiology. 2 of the years of the specialty will be reduced because your experience in internal diseases counts, so the specialty really only takes just 3 years. This can be repeated for a third and fourth specialty. And yes, precisely because it's that easy many people have 2 or 3 Specialties of similar character. Typical combos are Cardiology + Internal diseases or really Anything + Internal diseases, also General Surgery + Trauma/ortho or on the other side Anesthesia + Intensive Care.

I recently interviewed a colleague of mine and fellow doctor and youtuber “ Unmedicoinsvizzera ” who is doing his second specialty in Switzerland. You can watch the Interview here:

The last thing to compare is quality of residency. This is a tough one because it really depends on the quality of the people who teach you and that really is a lottery. For the purpose of this thought experiment we will assume that all the colleagues are always good, nice and engaged in their work (which really isn't the case, but lets pretend)

In Spain since you spend all years in the same department, with the same people under a rigid and fixed plan, you have some positives to draw back:

A rigid rotation will ensure that you do indeed rotate everywhere and that you see and learn everything that you should. Also your colleagues know you and know in which areas you can improve, and have time to help you work on those over time.

The negative is that by following one unique standard you might miss out on the diversity of opinion of the many many other colleagues that you will never meet. If other hospitals are pioneering one kind of treatment but yours isn't, you will become a specialist knowing little about it and that may put you slightly behind in your professional career. 

In Switzerland, once again it's the Opposite. Let's start with the negative:

Moving between hospitals means that you often have new colleagues that don't know you or trust you or don't know what you can do and can't. You are forced to plan very carefully your rotations and fight for them. Otherwise (for example in my case in Anesthesia) you may miss a rotation after 5 years and have done another one 3 Times. You need to provide for yourself and fight to get the rotations you need.

The bright side is obviously, that by seeing how different hospitals tackle the same problem (and trust me every department does things differently) you can in fact double check different ways of treating a disease and different approaches and see what's better and stay up to date. 

There is lots more to say but we will leave it to a different blog post. As you can see despite how difficult and unfair it may be to get a position in a competitive setting in Switzerland when the stars aren't aligned in your favor, it offers a lot of flexibility and allows you to change cities and specialties without hurting yourself professionally.

What do you think about this comparison? Do you think I missed something? Feel free to write in the comments!

LG

Eutopia