In 1630 this university graduated the first medical doctors of the Americas and amongst the graduates some Native Americans included. In Ecuador, medical school begins after graduating high-school. There are two options; applying to public or private universities. Both private and public university select their candidates based on entrance exams. Public universities are free while private universities cost around 6,000 - US$12,000 a year. In most universities, the carrier lasts for 6 years. After graduating, students obtain a degree of “médico” or "médico cirujano", depending which one is offered by each university. Both degrees are equivalent to doctor of medicine (MD). After graduating from high school with a Baccalaureat, any student can register at a university of medicine (there are about 30 of them throughout the country). Until 2018, at the end of the first year, an internal ranking examination took place at each of these universities in order to implement the "numerus clausus". This ranking examination and the "numerus clausus" has since been abolished. First year consists primarily of theoretical classes such as biophysics and biochemistry, anatomy, ethics or histology. Passing first year is generally considered very challenging, requiring hard and continuous work. Each student can only try twice. For example, the Université René Descartes welcomes about 2,000 students in the first year and only 300 after "numerus clausus". The second and third year are usually quite theoretical although the teachings are often accompanied by placements in the field (e.g., internships as nurses or in the emergency room, depending on the university). During their fourth, fifth and sixth years, medical students get a special status called ""externe"" (In some universities, such as Pierre et Marie Curie, the "externe" status is given beginning in the third year). They work as interns every morning at the hospital plus a few night shifts a month and study in the afternoon. Each internship lasts between three and four months and takes place in a different department. Med students get five weeks off a year. At the end of the sixth year, they need to pass a national ranking exam, which will determine their specialty. The first student gets to choose first, then the second, etcetera. Usually, students work hard during the fifth and sixth years in order to train properly for the national ranking exam. During these years, actual practice at the hospital and in conjunction with some theoretical courses are meant to balance the training.