Great food, wines, fashion, and the best healthcare system in the world. What better reason for Mitesh Desai to undertake an Erasmus exchange in France

Coming from a British medical undergraduate education system--partaking in the occasional ward round, taking a history, and examining the odd patient while constantly getting under the nurses' feet--my arrival in Rennes, France, was nothing less of an utter culture shock. France's health system has been rated by the World Health Organization as the best in the world.¹ I went there on an exchange scheme, the European Community Actions Scheme for the Mobilisation of University Students (Erasmus). This scheme enables students from over 30 European countries to study in another of these countries.

A nurse at reception heralded my arrival by going on a frenzied search for the interne (house officer) who took me into the salle des externes (medical students' office). After a quick "bonjour, je m'appelle," I was offered a quick overview of the ward and a little tour around the office to show me how the documents were filed. After the exchange, I found myself standing in the middle of the room, searching for a friendly face who could take me under their wing and show me exactly how things were done.

Unlike in the United Kingdom, the externes have a very specific role that ensures they're actively involved with the care of patients. Each patient has a designated externe, who keeps the patient's folder up to date. Externes are expected to carry out various procedures from recording an electrocardiogram, performing an ascitic tap, and even suturing and plastering. Students must do gardes (on-calls) that work on a rotation system covering 365 days of the year.

With this workload and the highly competitive nature of medicine in France, it is not surprising that the "looking after number one" attitude is so endemic among so many externes.

If communicating in a foreign language wasn't difficult enough, I had to decipher the three letter acronyms that the externes and doctors were fond of using. This was confounded by the use of brand names for medications rather than the generic form with which I was better acquainted.

Doctor-patient communication

In a country where patients seem to be well informed about health issues it's paradoxical that doctor-patient relationships are considerably paternalistic. The doctor is invariably right, and he or she will have no hesitation to scold you about your lethal drinking habit or for not complying with treatment, no matter what may be the underlying psychosocial cause.

Tant pis if the doctor wants to palpate your inguinal lymph nodes even though there are no screening curtains. Or, if your chest x ray shows a well circumscribed opacity, don't think you'll always have the opportunity to ask questions before the doctor leaves with his band of medical students to continue the ward round or answer his bleep.

Informed consent seemed to remain an ideology. Being told the possible complications of a procedure is rare. Even HIV screening is routinely done without pretest counselling and prior informed consent obtained.

La vie française

As exciting as it was to move to Rennes for four months, life was not all "du pain, du vin, du Boursin" and the "va-va-voom" soon became "je ne sais quoi faire."

My heart sank as I walked into my room at the cité universitaire (halls of residence). The brown wallpaper on the walls was torn, and a fine mist of dust covered the wooden furniture and tiled grey floor. The room was barren and offered no warmth--the heating was not working properly. At the time I could not imagine what it was going to be like living in this concrete tower.

But, the physical surroundings were nothing compared with the constant harassment of cleaners and administrators of the halls. As I was staying for the last three months of semester one and the first month of semester two, the administration could not cope with the fact that I had not wanted to sign a contract and therefore pay for the entire semester. Despite several polite attempts to negotiate, I was faced with several refusals to be seen and the phone was even slammed down.

Birds of a feather do flock together

Rennes is a rather small and isolated city. As with many student cities in France, the city centre had much to offer during the weekdays but was much quieter on the weekends, when most of my native friends would return home. It was clear that the people whom I was to befriend were going to be others like myself, who had been plucked from their vibrant home cities and transplanted in Rennes.

Be they German, Spanish, Italian, Irish, or American we found a bond. We faced the same difficulties yet had the same will to have fun. We'd make up our own broken version of French, but we understood what it was like working in a foreign language and country.

It was then that it dawned on me that I had completely ignored the many foreign students that had come to Manchester. Despite an impeccable awareness of the issues of doctor-patient communication, the care of "our own" may continue to be neglected. How much effort do we make when a new person joins our team? What if that student or doctor is from another country and their first language is not English, albeit that they're fairly proficient? By our behaviour do we isolate or incorporate others into our teams?