The Public Health residency in France

Creation and evolution of the Public Health (PH) residency program in France

Defined in 1982 by the law n° 82-1090 (loi relative aux etudes medicales et pharmaceutiques), and established from 1984, the French residency program of PH (Diplôme d’Etudes Spécialisés - DES - de Santé Publique) was created with the objective of providing a specialization path of excellence that aimed at training doctors in measuring and analyzing the health status of populations, integrating transversal population-based approaches to health.
Since then, many reforms have taken place, renaming the residency program (from “Santé publique et médecine sociale” – Public Health and social medicine, to “Santé publique” – Public Health) and redefining its missions. The last reform (Réforme du 3e cycle des études médicales de 2016-2017) organized the residency around 9 main topics:

• Epidemiology and clinical research methods;
• Health promotion;
• Biostatistics;
• Healthcare economics, administration, and policy;
• Biomedical informatics and e-health;
• Quality, risk management, and patient safety;
• Environment and health;
• Human and social sciences;
• Transversal competences.

The residency today
Today there are 27 different locations all over the country, including the Overseas Territories of France, offering a DES of PH (the full list is available here). The CNG (Centre National de Gestion) oversees the annual organization of the national test (ECN – Epreuves Classantes Nationales), that regulates the access of candidates to medical residency programs. Candidates must have successfully completed the 6 years of medical studies to participate to the test. After the ECN, the national ranking is published, and future residents can choose a specialty and a location based on their position in the ranking. On average, every year, there are between 60 and 80 places available in the PH residency program.
The PH residency lasts a total of 4 years, and it is divided in 3 phases:

1. A “core” phase (2 semesters);  
2. An “in-depth” phase (4 semesters);
3. A “consolidation” phase (2 semesters).

Every semester corresponds to a rotation that is chosen by residents according to their interest and to the knowledge and skills that they have to acquire during that specific phase. Over the 8 semesters, 6 rotations must be done in an accredited PH service/organization/institution, and 2 can be freely chosen among the rotations available in all residency programs. Residents are evaluated at the end of every rotation by the respective supervisor, and at the end of each phase by the local commission of the specialty. In addition, during the last year of residency, an exposition of a personal project must be done, following the format and standards of a scientific article.
An additional year can be added to the program by applying for a specialized transversal training (Formation Spécialisée Transversale – FST). The training can cover the following topics: addictology, hygiene, medical pharmacology/therapeutics, school medicine, medical bioinformatics, and applied nutrition. For residents interested in improving their skills and knowledge in the field of healthcare management, another kind of optional training called “Option administration de la santé” - Health administration option - can be attended at the EHESP School of Public Health (École des Hautes Etudes en Santé Publique), adding an additional year of the residency as for the FST.

Theoretical education during the residency
During residency different possibilities and tools of theoretical education are available:

• An e-learning platform (https://sides.uness.fr/), providing medical residents with courses on different main topics of PH listed above, held by professors from different universities involved in the training of PH residents. This platform also helps residents to keep track of their progression in terms of ongoing and completed rotations, as well as competences acquired during the residency.
• A first level master’s degree in Public Health (more than one master available), normally attended during first year of residency. Usually, the residents can attend the master while doing rotations.
• A second level master’s degree, for which an unpaid leave of 6 months or 1 year can be demanded, putting the residency in stand-by. This master is not a criterion required to validate the residency.
• A research year, to which residents can apply to carry out research projects in the context of a master’s degree or a PhD. However, there is a restricted number of places available for residents coming from all specialties, making this option quite competitive.
• Internal courses and learning activities organized directly by residency schools and coordinators.

​International experiences
Applications for international rotations are allowed during the residency. Each University Hospital (CHU) defines the number of places available and the criteria for evaluating the applications of residents that would like to embark on this experience. Specific programs for national (Inter-CHU) and regional rotations (for example, Echanges HUGO) are also available.

Associations of PH residents
In France, PH residents are supported and can rely on different associations during and after their residency, based on their needs and interests.
The CLISP (Collège de Liaison des Internes de Santé Publique) is the national association of PH residents. Among its main functions, it represents and defends the rights and moral interests of PH residents, it promotes communication and collaboration between residents, it concurs to enhance the quality of the PH residency in France, it promotes the PH specialty and a PH culture, it facilitates the training of PH residents, and it participates and/or coordinates all actions related to the goals of the association.
Other associations of PH residents are also present at local, regional, and inter-regional level, helping PH residents to find more specific information on local programs, to guide them through their choices, and to have a high-quality training and education.
Finally, EuroNet MRPH, the European Network of Medical Residents in Public Health, is a non-profit, international, independent, and non-governmental association made of European national associations of PH residency programs. It connects PH residents from all the countries taking part in the association by organizing teleconferences and meetings, it facilitates international rotations for PH residents, and it creates working groups to produce scientific studies and knowledge.

Careers of PH physicians after residency
The structure of the PH residency program, highly comprehensive and diversified in its offer, consists in a unique opportunity of training and specialization. This provides PH physicians with a very competitive profile, both in the private and public sector.
A study published in 2019 by Guerra et Al., explored the training paths and careers of 563 former French PH residents. Almost all the respondents to the questionnaire (98%) found a job within one month after completing residency. At the moment of the enquiry, they were mainly employed in the public sector (78%), and their main fields of work were epidemiology, clinical research, and biostatistics (36%), medical informatics (18%), and healthcare policy and management (14%). Moreover, 73% of the participants to the study worked in more than one field of public health during their post-residency experience, underlying the transversal employability of the competences acquired during the specialization.

Challenges for the PH residency
Even if the French PH residency program offers a unique opportunity of high-quality training, education, and professional development, it has struggled over the years to find visibility. In fact, since its creation, the PH residency has faced many challenges up to the point that it risked disappearing or to see a reduction of available places in the program.
An improvement of PH education during the 6 years of medical studies preceding residency, as well as a harmonization of the residency programs across the country, are the first fundamental steps to make in order to promote a PH culture among physicians and, more widely, health professionals, and to provide the residency with the visibility and recognition it deserves. 
 
Author
Giulio Borghi

• Medical Doctor and Public Health Resident in the University Hospital (CHU) of Nantes;
• Master's degree in International Healthcare Management, Economics, and Policy (MIHMEP) from SDA Bocconi University;
• First level Master's degree in Public Health from the University of Paris-Sud;
• Strong interest in health inequities and Global Health Issues, having also developed work during the residency in health promotion and education, project management, epidemiology, and quantitative and qualitative research.

Email: [email protected]
Find me on LinkedIn
 
Editor
Nuno Do Amparo
 
References

• Loi nº82-1098 du 23 décembre 1982 Relative aux Etudes Medicales et Pharmaceutiques. Available at: https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000000880032/
• Diplôme d'Études Specialisées de Sante Publique du 28 avril 2017. Journal officiel de la République Française. Available at: http://clisp.fr/wp-content/uploads/2019/12/Maquette-oficielle-du-DES-publi%C3%A9e-au-JO.pdf
• CLiSP. 2022. Collège de Liaison des Internes de Santé Publique. Available at: http://clisp.fr/
• EuroNet MRPH. 2022. European Network of Medical Residents in Public Health. Available at: http://euronetmrph.org/
• Guerra, J. e Dugué, F. 2018. La carrière des médecins spécialistes de santé publique et médecine sociale titulaires du diplôme d'études spécialisées. Revue d'Épidémiologie et Santé Publique: 67. 106-113. Available at: https://www.sciencedirect.com/science/article/pii/S0398762019301300
• Rezende, B. 2010. La formation des internes de santé publique en France. Available at: http://files.clisp.fr/travaux/theses/enqueteDES.pdf