The Physician Supply in France. The National Council of the Order of Physicians (CNOM) issued an Atlas describing the supply of doctors in France. The major points covered in the Atlas centered on feminization, growth in the number of retired physicians, a decline in the shoift to over-doctored regions and an increase in the number of doctors trained outside France. The total number of physicians enrolled in the Order was 271,970 as of 1 January 2013, with 215,865 fully active in practice and 56,105 retired or semi-retired. Part-time doctors are responsible for the small recent increase in the number of "effective" physicians with an increase of 8%, while the number of registered physicians in active practice decreased slightly (- 0.12%) in the last year. Specialists grew in number while generalists fell...this trend is anticipated to continue over the next decade. Of practicing physicians, 92,851 are in private practice and 85,876 are employees (65.8% of these are in hospitals); 20,558 have a mixed practice structure. The distribution of physicians continues to show a pattern of high density in the south and around Paris and lower density elsewhere.

It is Status Quo for the Numerus Clausus

The Official Journal of France (Our Federal Register), announced on January 11 the exact numbers of students who would be allowed to move into the second year of medical training in France in the coming fall. This number, the numerus clausus, effectively controls the supply of physicians in France as there is little immigration or emigration. The number is set by the central government after discussions with “experts” and politicians. The selection is quite rigorous as 56,000 students enter into a first year of preliminary health studies that qualifies them for consideration (première année commune aux etudes de santé—PACES). All the students take an examination and the numerus clausus sets the cut off point for selection to advance. The “success” rate of 13.5% for medicine is actually a bit misleading as pharmacists (3,095), dentists (1,200), and midwives(1,016) also are admitted from the PACES group. The numerus clausus is a very blunt tool to manage physician supply and it has created both potential surpluses when it stood as 8,600 places in 1971 then being cut back to 3,500 places in 1993 creating a perceived shortage. It was raised to 7,100 in 2007 and the current figure has held steady for the past 4 years. Overall supply is but one of the concerns in the French health care system. The very unequal distribution of physicians in France has generated ministerial attention to the problem of “medical deserts”, places in France with few, if any physicians. The minister of health, Marisol Touraine, in December presented a plan to eliminate these underserved areas with a “grande mobilisation” that would combine some limited inducements in the form of bonus payments with a series of structural reforms promoting team care, telemedicine, and support for the training of generalist physicians.

Probiotics make you fat?

Le Quotidien du Médecin reports a French research team found that taking probiotics can make you fat. Taking Lactobacillus acidophilus is associated with ignificant wight gains in animals and people. That makes sense, as L. acidophilus is used to fatten up chickens. BUT, Lactobacillus gasseri was associated with weight loss in humans and animals. The report comes from a team led by Professor Didier Raoult and reported in Microbial Pathogenesis, published on line May 24,2012.

Why is there less obesity in France

We are discussing how to include obesity or overweight rates in the America's Health Rankings here at the annual meeting of the Scientific Advisory Committee. Jonathan Fielding, Leah Devlin, Glen Mays, Steve Teutsch, Marthe Gold, and others are pitching in to the discussion. The French have largely avoided the trend toward greater obesity rates. Why is this?

Antoine Flahault, Dean of the École des Hautes Études en Santé Publique (EHESP) commented on this recently in his blog on the EHESP web site. Here's a translation.


Among the 30 OECD countries, France is the seventh from the bottom in rates of obesity. How did France get to this point with the fattest national diet in Europe (42% of food energy in France comes from fat). France is the largest sugar producer of Europe and the largest consumer of bread and cheese, the two largest providers of salt in food today.

Could it be that the French exercise? This is unlikely; we have the second worst place in terms of proportion of adults exercising at a recommended level in Europe (less than 25%, compared to an EU average above 30% with the Netherland at the top at 41%). It is probably not the "genetics" of the French; it must be heterogeneous. It is almost impossible to believe that it is the consumption of wine, which has steadily decreased since 1960, parallel to the decrease in cardiovascular disease.

Determinants of control of obesity in France might be essentially cultural: we are one of the few European countries to continue to have three meals a day and eat nothing (or almost nothing) between meals. Our children continue, for the most part are raised this way. Thus it would seem that even with a diet with the worst possible nutritional composition, if it is small (the new French cuisine providing the model), and if it is eaten only three times a day, it is not easy to get obese. Obesity rates in French children are the lowest in Europe and did not tend to increase in last decade. There are a few studies (North American) showing the link between regular family meals, exposure to television screens and video games for less than two hours a day associated with a low prevalence of obesity. As long as the French retain that cultural advantage, they may be protected against the obesity epidemic across our borders and almost everywhere else in the world.

AFSSAPS now ANSM as Mediator scandal slowly resolves.

The French equivalent of the FDA was reorganized and renamed in what the French government hopes will be the final chapter of the Mediator scandal.

AFSSAPS, the Agence Française de Securité Sanitaire des Produits de Santé, was found lax in not removing the drug benfluorex (Mediator®) from the market for many years despite strong evidence that it caused harm. The drug likely caused 500 deaths and at least 3500 hospitalizations related to valvular heart disease in France between 1979 and 2007 when it was finally removed from sale.

The French Parliament passed a law in December 2011 that establishes a new agency, the National Agency for Medicines and Health Products Safety (Agence Nationale de Securité du Médicament (ANSM). The new agency is headed by Dominique Maraninchi who was moved to AFSSAPS in the middle of 2011 from the French National Cancer Institute.

The drug is closely related to one that has been used to treat obesity and diabetes (benfuorex is related to fenfluramine, known more widely as one of the Fen-Phen pair).

The "Mediator scandal" occupied the front pages of French newspapers for much of 2011 after the government auditing agency, IGAS released "A devastating 244-page report on the affair … (and) accused the pharmaceutical company Servier, headquartered in the suburbs of Paris, of misleading authorities about the true nature of benfluorex, which was sold under the brand name Mediator."

The first case of valvulopathy due to Médiator in France was reported in 1999, but no action was taken. The first Spanish case of valvulopathy was reported in 2003, prompting the drug to be banned there in 2005. The US FDA removed fenfluramine from the market in the fall of 1997. The manufacturer of two marketed products derived from the compound, Redux and Pondamin, Wyeth, was the target of a class action lawsuit that may lead to them paying up to $5 billion for damages.

Equality and Solidarity: A Manifesto for the French Health System

A group of senior academics and policy leaders in health released a "Manifesto for Equality and Solidarity in Health" this past September. The Manifesto has attracted a good deal of attention as it was signed by a long list of French opinion leaders and personalities (including a few well known actors). I learned of this during my last trip to France to teach and had the chance to listen to one of its main authors, Didier Tabuteau, discussed the Manifesto at one of the EHESP regular Thursday seminars in Reid Hall where I teach.

I had expected a more impassioned presentation that focused on the justice of an egalitarian health system rather than the recounting of the history of the financing of the health system and the effects of macro-economic trends and realities on its ability to continue to provide services to all but a few in the population.

But the emphasis on the realities of public finance for health care and how it interacts with the larger economy is just the kind of discussion that is occurring in the United States as we begin the understand the limitations of the Medicare system and its finances.

Tabuteau held that the "Secu," the French social security system that is the overall financing vehicle for health services in France, was not doomed to end up in a "hole"(trou). He argued that a continuous adjustment process was necessary to titrate the tax rates that would support healthcare and that titration would rise or fall with the economy.

One point he the authors made make in the Manifesto that he didn't touch on much in the presentation at the EHESP was the "crisis of identity of professionals." According to the authors, doctors and other health care workers are experiencing a "profound malaise" accompanied by a steep decline in their conditions of work; "primary care physicians are living through a crisis that is without precedent" and students choosing to enter the field of medicine are facing hard choices.

The Manifesto speaks of and condemns an "ideology of management" (idéologie gestionnaire) that is affecting prices and costs as "the number of private operators, notably international groups, are investing massively in the health field, seeking to find profits..."

The Manifesto ends with a series of recommendations, primarily to increase reimbursement for care, especially long term care; the "reconstruction of a better payment system (convention) for private doctors; a "re-founding" of the public hospital system and the institution of a "true system of sanitary security and collective prevention."

French survey reports a long wait for the doctor

Almost 60% of French people surveyed say they have given up going to see a specialist because the delay was too long for an appointment. This result from a poll by the IFOP (Institute Francais d’Opinion Publique) Jalma consulting firm, published in the Journal du Dimanche (JDD) and reported in Figaro, November 13, 2011.

According to those interviewed, it took an average of 103 days to see an ophthalmologist, 51 days a gynecologist, 38 days for a dermatologist, and four weeks for a cardiologist, otolaryngologist, psychiatrist or a rheumatologist.

Getting in to see a specialist in a hospital practice is also hard. A referral to a specialist means a wait of 31 days for a hospital-based cardiologist or 29 days for an office visit; seeing a hospital radiologist takes an average of 21 days or 13 days to see a radiologist in their office.

When the wait seems too long, people choose to go to the emergency room: 27% of respondents say they have used the ER for reasons of time or cost. Up to 58% of respondents say they have given up on at least one appointment with a specialist because of the wait; 33% have done so several times. Some 28% have given up because of geographic distance.

To see a general practitioner, the period is much shorter and is, on average, four days. However, 15% of respondents say they have not made an appointment with a GP because of the distance to the office.

The perception of delays is different depending on whether you ask patients or practitioners. Jalma conducted a parallel survey of 600 doctors who gave different results, reporting much shorter waits.

"There is a big gap between perception and reality for the French. The wait for an appointment described by the doctors are much shorter. This means that practitioners and their patients are not available at the same times," is how Matallah Mathias, president of Jalma, interprets the differences. He suggest that specialists need to adjust their schedules for their patients: "Many will hate this conclusion but specialists must make the change in how they operate to increase access," he argued.

The survey was conducted online from August 29 to September 4, 2011 with responses from a representative sample of 1001 people 18 years or older.