Life as an omnipraticien in FranceLife as an omnipraticien in France: additional dataBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7117.2 (Published 08 November 1997) Cite this as: BMJ 1997;315:S2-7117
Life as an omnipraticien in France
Iain Bamforth completed his vocational training for general practice in Britain before crossing the Channel to practise in Strasbourg. In a system similar to British medicine before the NHS, the going can be tough
While economic liberalism continues to change the face of British medicine, medical care in France has been unwaveringly liberal since its very inception. Much of modern hospital medicine was French in inspiration, and still enjoys enormous prestige in its country of origin, but general medicine suffers in terms of patients', peers', and self perception.1 Primary care is an undeveloped notion.
The basic aspects of medical liberalism were established in 1897, 1930, and 1945 with the fee for service (paiement à l'acte), the liberal charter itself, and universal health insurance Sécurité sociale, or Sécu) respectively. It is one of the great oddities of postwar history that a country with a better and fairer education system and excellent public transport and civic amenities (for which the French pay among the highest taxes in Europe) allows its doctors to sink or swim in a market more capitalist than anything dreamed up by Milton Friedmann.
Medical school in France consists of three cycles. The premedical cycle begins after school, and unlike Britain, is open to any pupil who has successfully completed the science baccalaureat. After examination at the end of the first year, 80% of students are rejected. The second phase, lasting four years, combines theoretical and bedside teaching, with very limited ward duties. In France entry into specialist training programmes is dependent on passing the Internat: almost half of the 4000 students who enter the third cycle of general medicine do so because they fail to pass this examination.
The Internat therefore stigmatises generalists from the start, and, with clinical training falling short of the comprehensiveness of vocational training in Britain, it is not difficult to understand why generalists are seen as “mildly incompetent.”2 Recent measures introduced to lift generalists' status, partly under the pressure of change in Europe, have included an obligatory two years of clinical training, developing general practitioner trainers (généralistes agréés), and creating institutions to regulate postgraduate training.
Tightening the belt
In France there is a fundamental divide between policy, provision of services, and funding. This gives rise to different assessments of needs and arouses mutual suspicion of motives, as in the recent decision to increase patients' awareness of the cost of healthcare to patients by issuing the entire population with a personal medical file (carnet de santé), which also acts as a continuous healthcare record. One year after the exercise, fewer than 40% of patients bring their carnet to the consultation.
Unemployment has worsened a situation in which the Sécu is currently staggering under a total deficit of some Fr37.2 billion (about a third of which derives from the health sector). The Juppé plan, introduced by the last government with the aim of limiting the increase in medical expenditure to 2.1% for 1996 (it was 5.8% in 1995), set up obligatory postgraduate training, provided a bonus for computerising practices, promoted use of generic drugs (which account for only 5% of all prescriptions), and encouraged early retirement.
It is planned that all patients will be supplied with a smart card by the end of 1998 to reduce the enormous bureaucratic cost of processing hundreds of millions of medical treatment forms (feuilles de soins) every year. Current measures under discussion include creating a “médecin référent,” a halfway concession to the idea of a gatekeeper; and articles have even surfaced in favour of the one time taboo of capitation.3
Liberty, equality, fraternity?
The emphasis on liberty makes it possible for doctors to set up practice almost anywhere, provided they do not establish chambers in the same building as a colleague, or in an area where they have worked for more than three months as a locum. Young French graduates commonly work as locums (remplaéants) for many years before selecting a promising place to set up practice. Statistics of how many doctors work in a given area are readily available. As the map of medical “density” in France shows (see figure), provision of health care across the country is topsyturvy. The Ile-de-France region and the Mediterranean littoral have a preponderance of both specialists and generalists, and current statistics suggest that it would take a young generalist 15 years to reach 95% of earning capacity in certain parts of the south of France.
With the emphasis on liberty, the other two components of the revolutionary slogan go neglected. The system is massively unequal, with a small number of doctors (3600) at one end of the scale earning more than Fr2m yearly,4 while at the other end 20% of the profession has an annual revenue of less than Fr200 000,5 which, once professional costs have been deducted (about 60%), leaves less than the minimum guaranteed wage. Such low rates of remuneration compel most generalists to maintain some kind of subsidiary activity.
It is rare to find a generalist with a secretary, so working in a French practice is clearly less conducive to the teamwork British general practitioners take for granted. Only one third of French generalists work in partnership, though the number is growing constantly, as is the number of women; four fifths have yet to acquire a computer.
The daily activity of generalists differs considerably from their British counterparts. The average French generalist sees 22 patients a day and spends 15 minutes on each consultation.6 The consultation is worth Fr110, which is a low rate of remuneration. House visits are still common despite being poorly paid - one patient in four is seen at home. The same study suggests that 9% of consultations are not charged because patients are unable to pay.
It is easy to order diagnostic tests - it is a novelty for a British trained general practitioner to have an x ray reported an hour after ordering it. Patients can also be hospitalised easily. Rather than relying on clinical skills, generalists order screening tests (bilans) with amazing frequency, and indeed, patients have the right to a full screening procedure at the expense of the Sécu every five years.
French medicine is patient centred and specialist oriented
French general practitioners earn on average Fr334 950 a year, less than their British counterparts
Generalists in France are usually recruited by default and suffer from low prestige
The first 10 years of urban practice are likely to be financially precarious. Rural medicine in France is more like British practice
Among the 1916 doctors from other EU countries registered in France are 14 specialists and 61 generalists from Britain
French patients have a high degree of autonomy and can consult any doctor of their choice. This can be defended as a right of citizenship, but it assumes a high degree of self knowledge on the part of the patient, and a naive belief in progress as a limitless expansion of means and ends. A few patients shop around, a phenomenon the French call medical nomadism. Not surprisingly, this leads to a high consumption of medical resources: the average French citizen consults a doctor 6.4 times a year and is prescribed 37.2 drug packs.7 France as a whole spends 9.9% of its gross national product on health, which, at Fr12 276 last year, is almost twice the per capita expenditure in Britain.
British general practitioners are likely to find differences in diagnosis and treatment, highlighted in a recent study of psychiatric definitions.8 French insulins come in different dose strengths, short course corticosteroids are used much more widely, rates of antibiotic and benzodiazepine prescribing are high, and there are about 100 different “venotonic” preparations. I still don't know if “spasmophilia” is something more than a panic attack; on the other hand, it was only the other day I realised that I hadn't seen a case of “ME” since coming to France.
Ominously, in 1996 the number of specialists in private practice in France outweighed the number of generalists for the first time ever. Specialisation is a relatively new phenomenon in French life: until the 1960s, virtually all specialists in France were based in Paris. Fraternity within the medical profession has suffered, with specialists and generalists often pitted against each other in the media, one howling incompetence, the other insinuating that unnecessary activity generates income.
In fact, in the urban setting generalists have become almost irrelevant, or lean towards homoeopathy or acupuncture. In the country, however, where it is less economically attractive for specialists, generalists continue to work much like their British counterparts - treating emergencies, providing antenatal care, and following up patients for a broad range of conditions. The danger this schism represents was recognised by the recent Choussat report, which recommended that generalists should account for 60-70% of the total number of doctors and even contemplated scrapping the Internat, recognising that “it is not possible to make the generalist the lynchpin of the healthcare system if failing the Internat is the main method of recruitment.”9
French doctors suffer from not having a body which speaks for the profession like the BMA. There are several physicians' unions (syndicats) in France, all representing different interest groups: young doctors, joint practices, and specialists. MG-France, the generalists' union most vocally in favour of the Juppé plan's proposal of creating a referral network (filiére de soins) with restricted access to specialists, has scarcely more than 6000 members.
The total pool of doctors in France will continue to grow until the year 2005-8 before starting to decline. It is therefore likely that the next decade will continue to be a depressing time for the profession, with 30 000 doctors too many. In view of that statistic, even the most ardently Francophile British doctor will feel disinclined to risk a return to a situation like Britain's before 1948. My own experience over two years in Strasbourg has been that, despite my market niche, two foreign languages, other money earning skills, a well appointed practice, patients from over a dozen countries, and due attention to quality of care, even a modest livelihood is difficult to sustain. Things may take a generation to change. If convergence is truly what is happening in general practice in Europe,10 then perhaps by 2020 French and British doctors will be able to do what Europeans are doing at every other level: talking together and exchanging experience.
Life as an omnipraticien in France: additional data
Appendix 1. Administrative formalities required for an EEC doctor before setting up as a general practitioner or specialist in France
Present a copy and certified translation of your primary medical degree, along with a confirmatory letter from the GMC in order to have your name inscribed in the list of the Ordre des Médecins of the département in which you intend to work. Provide three identity photographs, a detailed handwritten CV, your birth certificate, and a copy of your passport. Specialists are also required to provide certification of their studies to a level equivalent to the CES (Certificat d'Etudes Spéciales).
Convince the Ordre des Médecins you can speak French.
Submit, before signing, to the Advisory Body of the Ordre des Médecins: - The professional bail Any contract of association (with or without pooling of fees) Any other contract relating to professional activity.
Register your degree at the local Direction Départementale des Affaires Sanitaires et Sociales (normally housed in the main civic administrative buildings, the Cité Administrative) and at the office of the clerk of the main court (Greffes de Tribunal de Grande Instance).
Equipped with your professional identity card (issued by the Ordre des Médecins), request the local Sécurité Sociale to provide you with the all-important medical attendance certificates (feuilles de soins): these are given to patients when they pay and allow the patient to claim reimbursement of consultation and pharmacy charges. You must decide at this point whether you wish to practise as “conventionné” or “non-conventionné” (the choice no longer exists for most doctors).
Inform the retirement fund, the Caisse Autonome de Retraite des Médecins Franéais, 46, rue Saint-Ferdinand, 75841 Paris Cedex 17, of your existence at the latest one month after opening the practice.
Ask the Ordre des Médecins for The doctors' badge (caducée) to enable you to park where you're not supposed to when doing house calls The registered drugbook (carnet é souches) enabling prescription of narcotics and listed drugs.
Arrange to advertise your opening in the press. You are allowed three advertisements at your own expense over a period of one month in a pre-established format issued by the Ordre des Médecins.
Register with the local national insurance contributory fund (URSSAF) at the latest within one week of opening the practice.
Appendix 2. Medical representation
When the Sécu was set up in 1945 a single body, the Confédération des syndicats médicaux franéais (CSMF), represented 80% of practitioners. Its role was essentially to negotiate the terms of the convention between doctors and the Caisse nationale d'assurance-maladie. Today, less than a quarter of French doctors are represented by a union. The CSMF has a membership of 10 300; the Fédération des médecins de France (FMF) 6950; the Syndicat des médecins liberaux (SML) 3860; and MG-France, the union most vocally in favour of the plan Juppé, a mere 6120, all of whom are generalists.
Appendix 3. What is the difference between sector I and II?
Sector II (honoraires libres) was created by the Convention médicale in 1980 and signifies those practitioners who are permitted to determine their own fees, within reasonable limits. In return, these doctors pay higher contributions (cotisations) to URSSAF and CARMF. The majority Sector I (conventionné) doctors are bound by the Convention to charge a set fee (Fr110 for a generalist consultation, Fr150 for a specialist consultation). Between 1980 and 1990, so many doctors converted from Sector I to Sector II (the percentage increased from 7.2% to 26.4% of doctors in private practice) that the “window” was closed: now only former chefs de clinique are allowed to apply for Sector II. Very few doctors choose to work entirely outside the Convention, a category in which patients receive essentially no reimbursement: the latest statistics from the CNAM show that 99% of both specialists and generalists are conventionnés. It is worth noting that vaccinations and certificates are not paid by the state insurance fund in France, and many instrumental procedures attract small fees (Fr37.80 for a cervical smear, for instance). The state insurance fund will reimburse the patient 65% of the consultation fee and prescription charges. The remaining amount, called the ticket moderateur, is met by the patient. Most patients who are better off have supplementary insurance (mutuelle) that reimburses them for the remaining amount, and some doctors will charge patients more if they know the patients have this kind of supplementary health insurance.
Appendix 4. Some French medical magazines that carry job advertisements
Le Quotidien du Médecin, 140 rue Jules-Guesde, 92593 Levallois-Perret Cedex Panorama du Médecin, 46 rue La Boétie, 75379 Paris Cedex 08 Impact Médecin (weekly), 1 rue Paul Cézanne, 75375 Paris Cedex 08 Le Généraliste (twice weekly), 11 boulevard de Sébastopol, 75040 Paris Cedex 01
Appendix 5. Further reading
Georges Tchobroutsky, Olivier Wong. Le Métier de Médecin. Presses Universitaires de France (No 2812 in the paperback series Que sais-je?). Bernard Bonnici. La Politique de Santé en France. Presses Universitaires de France (No 2814 in the same series). Monique Guérin. Le Généraliste et son Patient. Flammarion, Dominos paperback. An up to date account for a popular readership of what a French generalist does, written by a general practitioner lecturer (maétre de stage), who takes her definition of “flair” from Marcel Proust.
Jules Romains. Knock. Originally a stage play written in 1923 by a member of the Académie Franéaise, it was made into a wonderfully funny film with the incomparable Louis Jouvet in 1951. Well in advance of Ivan Illich, it is a hilarious and deeply serious warning about the medicalisation of society (Fil é film videos).
“Médecins: diagnostic d'un malaise.” An informative “physician, heal thyself” article that appeared in the magazine Le Point last year (1996;1236:95-105). A similar article also appeared in L'Express of 18 January 1996.
Several authors. Infiniment Médecins. Collection Autrement. No 161, 1996. An engaging series of essays on the generalist caught napping in the French context between science and the humanities.
Claire Bretécher. Docteur Ventouse Bobologue. A series of brilliant cartoons in two volumes depicting the travails of a put-upon urban generalist (a “bobo” is child's language for something that hurts).
Theodore Zeldin. The French. Chapter 27 “What illness they suffer from, and how they survive them” gets it about right.
The best French language medical web sites are grouped together at the home page of the Unions Professionnelles des Médecins Liberaux: http://www.upml.fr/