WHAT causes France’s regional disparities in medical provision ? Answer : doctors have the outrageous privilege of choosing their specialisation and place of work according to their wishes and regardless of patients’ needs. Why is the divide being allowed to deepen between overmedicalised regions (Ile-de-France, Rhône-Alpes, Provence-Alpes-Côte d’Azur) and the others ? Why are general practitioners still being trained and paid cheaply while specialists, who are less useful and cost more in prescriptions, are more favoured ?
Professionals may shy away from the truth, but the fact is that the way doctors are trained is leading to a professional aristocracy. In 1968 inequality of access to medical studies in France was widely condemned and universities were pressured into opening up. But in the early 1970s the creation of the numerus clausus, a cap on the number of medical students entering a second year, reintroduced social selection by the back door. The first-year competitive exam was based on the core subjects thought to attract the best secondary-school students : maths, physics, chemistry and biology. The medical community intended to retain its elite status and so the first-year exam in French medical faculties cruelly reflected this.
The exam is not held just after the baccalaureate (as in other higher-education establishments) and so thousands of students have to squeeze into lecture theatres and swot up on subjects - physics, chemistry, statistics - that are unrelated to care or play little part in its provision. Unsuccessful candidates, some 80% in all, including many who have retaken their first year, are shattered and humiliated. Those who pass are equally shaken : they have been taught to view fellow students as enemies, not as future colleagues. Once this exam hurdle is cleared, they are enjoined to repeat the feat and prepare for a second competition, the internat, long intended to create an elite within the elite.
Proper education reform should aim to give all students in France a solid training that relies on the assessment of knowledge acquired without cramming. But instead, selection continues. How can such an alienating process instil a collective, responsible idea of care and a sense of solidarity in doctors ? This archaic and exhausting succession of contests and classifications promotes the most aggressive, defensive and even the most pathological students, those least bothered about others’ feelings who have as their primary target : their potential power as departmental heads and course directors. As a result, French medicine has been run for almost a century by arrogant teachers who will not concede that patients should be able to discuss their decisions, and who are incapable of teaching the ethics of caring, sharing and solidarity to young doctors.
In Kansas City, Missouri, in the United States, graduates admitted to study medicine after four years at university receive as a welcome gift a powerful book, On Doctoring (1), an anthology of writing on illness, caring, life and death, with passages from the Bible, Jorge Luis Borges, Franz Kafka, William Carlos Williams, Anton Chekhov, Margaret Atwood, Kurt Vonnegut, Pablo Neruda and Arthur Conan Doyle, as well as writer-physicians known and respected in France, such as Abraham Verghese and Jack Coulehan. The doctor in charge of teaching explains that students are given this book "because they’ll learn more about caring reading literature than in the pathology textbooks, where they’ll only learn about medicine".
In Amsterdam would-be medical students are picked out of a hat after secondary school ; each intake reflects an extremely wide range of social backgrounds, aspirations, tastes and cultures. What makes a good doctor, in the Dutch view, is not innate ability but the care with which students are trained. At quarterly meetings, trainee medics are invited to describe their course environment, and the attitude and the behaviour of the doctors supervising them, and routinely to check that these factors are helpful to their training. Each intake elects a representative, who has a right of veto, to the teaching committee. If the students object to a proposed teacher, he is not taken on.
In Germany the training of GPs includes participation in Balint groups. Michael Balint (2), a Hungarian-born British psychiatrist, created in the 1940s groups of about 10 doctors. Each group, led by a psychoanalyst, meets once or twice a month to address the problems of caregivers and talk about desire, repulsion, anxiety, sorrow, anger, aggression, fear and doubt. In Germany (also in the UK, the Netherlands, Scandinavia and North America), it is a given that doctors benefit from reflecting on their flaws and foible, as do their patients. In France, students have always been encouraged to bottle up their feelings. Balint’s methods are decried in most medical faculties and the groups only attract a few hundred caregivers nationwide.
French medical faculties do not know about (or look down on) all aspects of relationships of care. As recently as 1980, patients were being shamelessly exhibited to groups of students in the 19th-century manner. Today, there are still classes in lecture theatres where students must accept their masters’ words unquestioningly ; ward tours by a professor with students in tow still happen, as do consultations where patients are paraded past a dozen gazes. There is no national consensus on the form and content of the teaching of students : from region to region, course syllabuses reflect the personal opinions of the incumbent teaching staff. The French medical community’s distinguishing feature is its unawareness that knowledge is constantly evolving.
Most lecturers can deliver only banal comments on such crucial topics as sexuality, the prevention of abortions and unwanted pregnancies and the screening and prevention of disease, and they display an astounding ignorance of them. Although most, if not all, forms of contraception are on sale in France, the latest surveys (3) show that most unwanted pregnancies, resulting in 220,000 abortions annually, are caused by inadequate or unsuitable information provided by doctors who swear by the pill and reject safer methods such as interuterine devices, contraceptive implants and injectable progestagens. Seventy per cent of French GPs’ appointments are with women, but fertility and contraception are covered in just two hours of teaching, riddled with ineffective and wrong ideas.
Not until 1995 did health minister Philippe Douste-Blazy propose the compulsory teaching of pain therapy in all universities, and only in 2001 did one of his successors, Bernard Kouchner, require all departments to put in place pain treatment protocols. Too much teaching is devised by hospital staff who know nothing beyond their own field. GPs and epidemiologists, attuned to public needs, are rarely involved.
At the end of their studies young doctors are full of insights into the diagnosis and chemotherapy of leukaemia, but start to practise knowing nothing about tiredness, pain, migraines, sexual behaviour, pregnancy, children’s diet, the screening of growth and behavioural disorders, the prevention and treatment of obesity, the monitoring of chronic complaints, check-ups for the elderly or terminal care - the basics of everyday medicine.
There would be better delivery of care in France if we trained enough competent doctors, who were aware of their social responsibilities and attached more value to family medicine, useful specialists (general surgeons are in short supply) and promoted facilities in places that need them. Casualty departments would no longer be overrun by cases of flu and gastroenteritis that could be treated at home, and the social security system would be better off. French hospitals do have plenty of willing students and caregivers, who for 30 years have been pushing to bring in different ways of relating to patients and passing on knowledge, while condemning governmental shortcomings. For several years, an active minority of combative doctors, often with limited resources and facing demoralising administrative obstacles, have been running independent, lifelong-training seminars of a high standard. But the efforts of these clear-sighted and dedicated people are continually obstructed by enemies far more powerful than conservative mandarins.
In medical faculties, the teaching of pharmacology and therapeutics is either non-existent or ill-adapted, and students are not taught to read scientific papers with a critical eye. This hole in their initial training plays into the hands of the pharmaceutical industry, which has phenomenal influence on the French medical community (4). Left to their own devices, young practitioners become easy prey : the trade journals are nearly all, to some extent, funded and controlled by the industry. The exception, the justly famed Revue Prescrire, should be compulsory reading for all trainee medics, but many hospital doctors, also manipulated by the pharmaceutical industry, are unaware of this precious resource.
Faced with medical reps who know all about seduction, flattery, guilt and concealed corruption, uncritical doctors are at a loss, thinking that they are continuing their education by attending symposiums and conferences funded by the pharmaceutical laboratories. So France has become the world’s largest consumer of tranquillisers and antidepressants, and every year unsuitable prescriptions lead to 140,000 people being hospitalised for medicine-related accidents ; 9% die (5).
A properly trained doctor does lots of explaining, provides reassurance (in France, serious diseases are infinitely rarer than benign complaints), educates vigorously, spends time on prevention and, above all, prescribes few drugs and refers few patients to specialists or hospital. But neither drug companies nor medical-equipment makers want such doctors to be the majority. Consider this : unwanted pregnancies are three times more common in women on the pill than in IUD users. A copper IUD costs ?27 and lasts up to 10 years, most contraceptive pills cost ?20 a quarter. Yet French doctors prescribe the pill four times as much as they do IUDs (which they are not taught to fit). Whose interest is served when doctors impose on their patients the costlier and less effective method ? Who turns a blind eye to the thousands of women ill-informed by practitioners who are forced to have an abortion ?
Translated by Paul Jones