Monday, November 29, 2010

French Higher Education

A debate in the New York Times takes on French higher education. Basically, many of the writers say that universities in France and the Grands Ecoles as well, are "sclerotic" and unable to spark creativity.

I have replied in a comment:

Higher education is changing in France. There is a trend to greater independence in the universities and the Grands Ecoles. I have helped design and am now teaching in the École des Hautes Études en Santé Publique (EHESP) in new masters degree programs based on the "Anglo-Saxon" model. We are trying to make these programs more applicable to the "real world" where the students will eventually work and we are trying to change the way we teach to reflect the new generation of students and their needs and demands. In October, master teachers from the University of North Carolina Giillings School of Global Public Health met with their French counterparts from the EHESP for a two day intensive seminar on teaching methods. The topics included: the 'wired' student and social media, managing team based learning, and structuring curricula to match the competencies demanded in the workplace. This is just one example of how French institutions of higher learning are recognizing they need to compete more vigorously in a global market. It will take a lot of work to change the patterns of the past, but I see signs that the old order is crumbling. To give an example, on the agenda for the initial organizational meeting to design the master of public health curriculum was the question of which language to use for instruction. I expected a multi-hour debate and a series of polémiques. After no more than 10 minutes, the group of professors, all French, chose English. That, to me, is a strong sign of breaking with the past.

Saturday, November 27, 2010

Médecine de Proximité

The so-called "Hubert Report" was released November 25. This is a study of the future of generalist medicine in France and was commissioned by Nicolas Sarkozy this summer. Hubert is Elisabeth Hubert, a former general practitioner and minister of health. She was essentially asked to come up with a plan to bolster generalist medicine and, indirectly, primary care.

The report focused on expanding he generalist workforce by instituting required clerkships in ambulatory settings. The idea is to involve more office based physicians in training with the hope that this will expose the medical students to the benefits of this form of practice.

There will also be an expansion of the number of slots for an internship year that prepares new doctors for general medicine. They'll still have the opportunity to move on to specialties after the internship, but, again the hope is that many will choose to stick with primary care and community based group practice in general medicine. There is also emphasis on the promotion of multispecialty group practice and the formation of networks of primary caregivers.

The report covers many issues related to the organization of health care in France and the place of independent practitioners (medecins liberaux). President Sarkozy, in his remarks on the release of the report, promised to propose extensive changes in how health care is paid for and structured. He tasked the new Minister of Health, Nora Berra, as well as former minister, Xavier Bertrand and education minister, Valerie Pecresse to forge ahead with reforms to strengthen generalist care and "médecine de proximité", which Google translates as "outreach medicine".

Yann Bourgeuil, head of IRDES, a research center in Paris that has been working on the evaluation of interdisciplinary care and networks of primary care practices commented on the report on France2, one of the main television networks in France. I'll post his interview when the URL is available.

Wednesday, November 24, 2010

Doctor supply drops in France

The question of whether there is an impending shortage of doctors in the US is hot topic these days. I have been appointed to the National Health Care Workforce Commission, created by the Affordable Care Act to help resolve this question and develop the appropriate policies to avert problems, if, indeed they are coming. In France, there have been similar concerns because the number of students allowed to moved past the first year of medical school was constrained by the medicus clausus for so long. Several years ago it became apparent that the doctors in practice in France were becoming older and they were not being replaced by new physcians.

Today, Le Quotidien de Médecin confirmed the trend: "193 943 doctors were active in France on January first 2010. (30.9 per 10,000). This is 5,600 less than a year ago." The data come from the demographic atlas of the profession published by the Ordre des Medecins, the licensing body for French physicians. The Atlas pointed out that the average age for doctors in France is now just above 50 years--in a nation where these is a dispute over raising the retirement age from 60. The new doctors coming in are also changing the face of medicine in France, only 8.6% of physicians are in solo private practice (medecins de ville) and the replacement rate for that group is only 30%.

Wednesday, November 17, 2010

Vademecum for Loi HPST

The ministry of health has developed a guide to the HPST Law and posted it via their web site.

This is not a short pamphlet, but a 162-page tome with a fair number of footnotes. It is, however, divided up into useful sections that explain some structures and relationships. Of more interest to me than many others is the section on "The relations between hospitals and primary care." Basically, they are asking for more coordination between the inpatient and ambulatory care sectors. "Multidisciplinary Medical Homes" (maisons de santé pluri-professionnelles (MSP)) are seen as one of the players in a coordinated system.

The Vademecum says: "The law entrusts the ARS with the responsibility for the organization and funding of the coordination and continuity of ambulatory care (permanence de soins), as part of a system (enveloppe fermé). To do this, each ARS will seek to develop payments to professionals to leverage their participation and to build specific mechanisms suited to the localities and conditions and to share medical resources at the interdepartmental or regional level, including with the hospital sector.

Tuesday, September 7, 2010

A Strike! Of Sorts.

France underwent a sort of general strike today. It disrupted a lot of train traffic but I am told that the Metro in Paris ran fairly smoothly. Elementary schools were hit and there were protests around the nation--but the impact was not overwhelming--you had to read the papers to know it was happening--but I am sure there are some irate visitors who counted on some train, taking somewhere to whom it is a major problem.

Perhaps 200,000 rallied and marched in Paris and up to 2 million nationwide went to some form of "manifestation."

The issue: raising the minimum retirement age to 62. That may seem a bit of an undershot to most Americans as we will soon get a recommendation from the bipartisan committee on the nation's fiscal future headed by Senator Simpson and Erskine Bowes to raise the age for eligibility for full Social Security and Medicare benefits to something above 65.

The health care system in France seemed to be working without interruption today. My friend, a gynecologist, took her bicycle to work instead of trying the busses or Metro. The hospitals I passed seemed to be open and operating and the web site for most medical and health care groups weren't saying much about the strike.

Health benefits are also being examined for austerity moves. Perhaps there will be more strikes in the coming fall.

Monday, September 6, 2010

Re-Open the Radiotherapy Services in Gueret!

I've just come back from a bike ride through the French countryside. We, a colleague in health services research and his friend, a statistician, set off from Ussel just inside the Départment of the Creuse. By most accounts, the Creuse is the most rural and less developed part of France. It is also a great place to ride a bike and visit small villages. Immediately as we began our ride I saw signs that called for the "Réouverture du service de radiotherapie Gueret!" (Reopen Raditotherapy Service in Geuret). Gueret happens to be the capital of the Creuse and recently, June 30th, the Ministry of Health decided to close the radiotherapy services in its main hospital on the basis of a "low-volume equals low quality" argument.

The region is up in arms. There was not a village I passed through that did not have a banner or sign that called for the re-opening. I was able to pick up a postcard with an appeal to the Minister of Health as I toured the tapestry museum in Aubusson. There had been rallies and letter-writing campaigns and a web site dedicated to the issue. It was the issue of the day for this part of rural France.

Our little group talked about this at length and we discussed the need to assure quality and maintain efficiency; but when I asked about the history of the decision I learned that the policy decisions about services like this were being drive as much by human error and lack of quality control as they were by demand and volume.

France has a record of accidents in radiotherapy that appears to be abnormally poor. There is even an English-language journal article that reports on these. Although the radiotherapy center in Gueret opened as late as October 2006, after there had been several reported incidents, the effects of accidents may have swayed the decision by the Regional Hospital Agency to close the rural service. Accidents with radiotherapy services in Toulouse in that year and again in 2007 heightened concern among policy makers. This came as France was also coping with the very tragic effects of a tainted blood scandal that occurred years earlier (1980s) but was resolved in the mid-90s with very controversial convictions including the former health minister Edmond Herve.

Some involved in the radiotherapy decision feel that closing the service in Gueret is a result of over-caution on the part of the ministry as they wish to avoid another blood-scandal type of outcome. Others see it as a very practical decision given there are only 150 radiotherapy patients who use the service and just one qualified practitioner to operate the service.

What is interesting is the willingness of local general politicians to take up the cause of a medical policy issue and to rally the populace to argue on behalf of access for a largely rural population.

Friday, August 13, 2010

A Snapshot of Surgery in France

In the last few days I have been working with the leadership of the American College of Surgeons as they develop policies for the surgical workforce and for surgery in the United States. This seemed like a good time to try to compare the surgical workforce in th etwo countries. The latest summary I could find for France is based on a Parliamentary report from last year on the Future of Surgery (l'Avenir de la Chirurgie). Data for the US surgeon supply comes from the American College of Surgeons Health Policy Research Institute.

On 1 January 2007, there were 24,719 surgeons in France plus 575 surgeons working in overseas departments. This included 16,121 private practitioners (some of whom may also work in public institutions) and 8,597 employed in public institutions. The dominant age of French surgeons is between 50 and 54, representing 21.3% of the total. Just under half, 44.9%, of French surgeons are under fifty years and 34% older than 50. (The US had a total of 135,854 surgeons in 2009, 36.6% were older than 55)

Women make up 23.3% of the French surgery workforce (US 21.3%) with the greatest proportion in obstetrics (37.6%) then pediatric surgery (36.4%) and ophthalmology (43%). The US also has the highest proportion in OBG, 47.1%, then general surgery 14.8%)

The regions with the highest proportion to population are Ile-de-France (Paris), Provence-Alpes-Cote d'Azur, and Rhone-Alpes. In the US the highest concentration of surgeons is in the northeast.

Physicians and surgeons in France may choose to practice completely in the private sector or they may split their time between private and public practice.
- 61.6% in private practice (individual firms, groups, health centers, etc.). This includes 6,532 exclusively in private practice and 6,773 who accept both public and private payers.
- 31.1% are in public hospitals with 4,485 acting as full-time surgeons and 1,057 practicing part time. Teaching hospitals include 2,208 employed surgeons. There are 2,624 FTE surgeons on some form of other contract—for specialized populations, research, management or to temporarily fill staff openings or locum tenens.

By early 2019, the current number of hospital surgeons is expected to decline nearly 30% primarily due to expected retirements. The US surgeon supply is expected to fall by 5-10% by 2025 because there is no growth in training programs and retirements will accelerate.

During 2004-7, the vacancy rate for surgeons in all posts has been stable at 18%, and this steady state is accomplished by the hiring of contracting surgeons.
- 6.4% of all surgeons are practicing in private hospitals; 932 of those are salaried and 347 are exclusively in private practice with 51 in PSPH (Private hospitals caring for public sector patients); 896 were private practitioners in mixed public-private practice.
- 0.9% of the total in another type of setting.

The highest proportion of all surgeons in France are in ophthalmology (22.3%), followed by obstetrics and gynecology (20.9%), general surgery (16.8%), and otorhinolaryngology (11.9%). In the US the largest number are in OBG followed by general surgery then orthopedics.

The distribution by specialty will likely evolve due to career choices among young surgeons and needs of the population. Since 2000 in France, there has been a significant growth in numbers of plastic surgeons while general surgery continues to lose numbers. The same applies in the United States but the greatest growth has been in orthopedics.

Wednesday, June 23, 2010

MRIs in France

MRIs in France, or the lack of MRIs in France
A new survey reported in Quotidien du Medecin this week reveals that France has one of the lowest rates of access to MRIs in Europe. The chairman of the French Society of Radiology, Jean-Pierre Pruvo called the situation a “scandal” in an interview in November of 2009. There have been some discussions of how the new regional authorities, the Agences Regionale de Santé (ARS) will change that, but little has been done according to the annual survey by Imagerie Santé Avenir (ISA).

That survey showed France has 8.7 MRI units per million inhabitants (543 machines in January 2010) and waiting times for a scan average 35 days, the same wait as in 2004. In contrast, Germany had 20 per million, Norway 25, Iceland 19.3; and Italy, 18.6 per million. The Unites States has 26 per million, the most of any country.

The lack of MRI scanners is threatening to derail the French National Plan for Cancer which calls for a waiting time for scan of no less than 10 days. The waiting times vary widely by region with the Pays-de-la-Loire having the longest at 58 days. The shortest waits are in Picardie (22.3 days)

The arguments for expanding the supply of MRI units rests on the grounds of cost reductions. Dr. Pruvo cited several examples of more costly surgery and invasive procedures to resolve diagnoses and initiate treatment.

The concern in the US has been with the overuse of MRIs and CT scanners. A recent NEJM article (Michael S. Lauer, NEJM August 27, 2009) estimated that up to 4 million Americans were receiving doses of radiation that were likely to cause cancer.

Thursday, June 10, 2010

Who's Striking Today

In France strikes are a regular thing. Sometimes causing misery but mostly it’s a focused group of raucous people chanting in front of some administration building making their claim for more money or more time off. What may seem unusual to an American is the regular participation of healthcare workers in strikes

This past month we’ve seen a variation on the theme as nurse anesthetists wearing full operating room garb sat on the railway tracks just outside the Gare Montparnasse, blocking all the trains headed west from Paris or into the city from Brittany. Their complaint was over proposed changes to the retirement age, from age 60 to 61 or 62. The vague proposal was part of President Sarkozy’s response to the need for fiscal belt-tightening.

Generalist physician announced their intent to close their offices on June 18 to “educate the local elected officials” about their need to raise their consultation fee from 22 to 23 euros. “We will not wait any longer,” said the secretary general of the Medecins Generalistes-France, Vincent Rebeille-Borgella.

Doctors going on strike is virtually unheard of in the United States and it is generally illegal with a few exceptions. But in France it is something of a tradition. For example, in January 2020 there was the “Day Without Doctors” where three-quarters of all office based physicians stayed home.

Tuesday, May 25, 2010

Policy-Management Convergence

I've just returned from another week of lectures and sessions with the 1st Year MPH students. The sessions are all day long from Wednesday until Friday and feature a mix of both policy and management. This last week I focused on planning and evaluation for the management side and health reform for the policy part. My French (British and German) colleagues talked about health reform in Europe while I covered the recent US reform process.

It is clear that the health care systems in the US, UK, France and Germany are very different but they have become more different in the recent past than when they started. The German system essentially set the tone for a social insurance based welfare and health system in the 19th century. This was followed only partially by France and Britain and only partly by the US when Social Security was established in the 1930s.

The lecturers all agreed that World War II was a key turning point for health care systems as the European governments were forced by their electorates to respond to the sacrifices they had made during the war. There was a need to reward long-suffering populations with something tangible after either an exhausting victory, a crushing defeat or a humiliating occupation. Food, housing and a revived economy were hard to produce, but a subsidy for health care drawing on the services of physicians and nurses equally caught up in the aftermath of war was well within reach of the governments.

The US, on the other hand, had been the winner and there was no need to reward the population except to make economic recovery fueled by international commercial expansion as "efficient" as possible. The American answer was to allow a tax-exemption for health insurance benefits to propel a new health insurance industry into a major economic actor. The expansion of their market was abetted by the advances in medical science that were also a product of wartime research and innovation--they made medical care more effective and more valuable.

Europe was launched on a road to an expanded post-war welfare state while the US was resisting any form of government sponsored health care system. The economics of medical care as much as the impulse for social justice prompted the US Congress to provide subsidies for specific populations under Medicaid and Medicaid. Meanwhile Europe just absorbed higher costs and greater use into their social insurance structures bumping taxes up slightly behind the costs of these systems.

But all that rises must converge and the common pattern of inflation of medical costs has started to cause alarm on both sides of the Atlantic. The US was the first to react with technical fixes to constrain use and thereby costs. Europe belatedly shadowed the use of DRGs, RvUs and other market adjusting mechanisms when the systems were only slightly falling behind budgets.

Budgets are now under huge pressure in all 4 countries. The fiscal crisis is showing how luxurious the European welfare system is when populations are aging and the cost and value of medical care are rising more rapidly. So now all four nations are looking at each other to find the best ways to control costs. They are converging more rapidly than they fell apart after WWII. They all share a common task of restraining or curtailing costs expansion without reducing coverage.

This is both a policy and a management task because the politics of budgets can only do so much to change behavior and it is behavior that is at the heart of health care costs inflation. This is the behavior of the system, patients, and its professionals. We simply have to manage behavior better

The real convergence is in the management of systems and how we teach the managers. They are now being forced to make costs containment a priority job, putting access, even efficiency, in trailing places.

More about how that is being taught in the next post.

Thursday, April 22, 2010

Cosmetic Surgery in France--A Shift in Emphasis for Women

According to a survey done by IFOP for the newspaper le Parisien late last year, 14% of women reported that they have used esthetic medicine or esthetic surgery for significant procedures. This is up from 6% in 2002. Younger women account for the fastest growth in use of esthetic medicine; 9% of females 18-24 reported they had already had at least one procedure.

The most common surgical interventions are breast enhancement (19% of those reporting a procedure). Wrinkle treatments are second, (18%), followed by “remodelisation of the thighs and/or buttocks via liposuction" which comes in third (13%). This is s shift from 2002 when the most common surgical procedures were hair-removal, nose reshaping and belly reduction. Breast enhancement surgery was reported only rarely 7 years ago.

Most of the French women, 64% of those responding who have had this surgery, say they do this for their own confidence with only 6% saying they did this to please their partner. This, again, represents a change from 2002 when 21% of women said it was for their significant other.

These kinds of medical treatments are not covered by the French health national insurance system and the cost of the work can be significant. For wrinkle injections the charges are between 380€ and 650€ ($490-$610) depending on the parts of the body being treated. A breast augmentation will cost between $4,000 and $5,000 with a “lifting” of the buttocks up to $14,000. The only cases the state insruance will cover are reconstruction of the breast(s) after cancer treatment.

Thursday, April 15, 2010

Patients’ Rights in France

There is an emerging movement to promote patients’ rights and the French Ministry of Health is promoting best practices through a recognition system. The University Hospital of Brest won the “Jury Prize for the work of its ethics committee in developing a mechanism for counseling patients making them aware of advance directives and applying them in all the units of the hospital. The National Union of Association of Parents of Children with Cancer (UNAPECLE) which held a national stakeholder conference to discuss the challenges faced by children and adolescents with cancer. The program included a series of debates involving parents and peers along with caregivers.

A national law outlining patients’ rights was passed in 2002 with three major goals:

To develop a “sanitary democracy” recognizing the rights for all persons in their relations with the health system by instilling the rights of the users as they relate to the health system and creating consistent national and regional policies.
To improve the quality of the health care system by improving the skills of all practitioners, medical training and prevention policy.
To reduce the risk of illness by improving access to health insurance and establishing a system of medical liability that allows for compensation for victims of medical accidents.

I will describe some of the details of this law and its implementation in greater detail, but one section, the last, stands out. Article 61 Creates a presumption of “imputability” for infections of blood by hepatitis C during blood infusions. This is a further response to the tainted blood scandal of the 1980s and 1990s that resulted in a conviction of a former health minister, Edmond Herve of manslaughter in 1999. He received no sentence.

Monday, March 22, 2010

Historic, Decisive and very American

The French view of the health reform debate is both overly optimistic and acute. Media coverage has been complete and the passage of the bills in the House merited front page treatment—but distinctly under-the-fold as the regional elections which were a near sweep for the socialist party was the big news this weekend. Le Monde calls the House vote an “Historic victory for Barack Obama” while Figaro put the news a bit lower on its web page calling it a “decisive vote” but leaving Americans “skeptical” of a reform that is “less ambitious than anticipated” which leaves the country divided. The Figaro clipsthat were on today's website were dominated by pictures of the opponents.

The response to the Le Monde story ranged from overly generous applause calling Obama a “real President” in comparison to the “product” Nicolas Sarkozy (whose party lost big in the recent elections). Another writer called it a beautiful victory, “but who is going to pay?”

Le Quotidien du Medecin gave the story top billing and was more or less descriptive. They are running a feature case “La santé version USA” that has been posted for the last few weeks. That includes a story about a New York physician who admits to over treating because of his fears of a lawsuit and a recounting of the 100 years of frustrated health reform efforts.

Meanwhile the generalist physicians of France (at least those in selected unions) are threatening to “close” their offices in protest on April 8th. They are objecting to the mandated charges that will accompany any paper claims that are submitted and objecting to a lost of “identity” not a loss of income.

Tuesday, March 2, 2010

Establishing Primary Care in France is a Struggle

A recent report commissioned by three ministries describes the effort to establish a primary care network in France to have “run out of steam.” (le dispositif de premier recours est à bout de soufflé). “An Assessment of Medical Homes and Health Centers and Plans for their Deployment” was released January 19, 2010. The report found that very few general practitioners were trained to do primary care and that there were few elements in the overall system that could support the development of multidisciplinary care offered in medical homes or primary care centers.

The term “primary care” itself is not really recognized in France and there are a number of alternative terms used to describe what it might become. New proposals to develop “medical homes” and ambulatory care centers have struggled to gain traction as the French system does not have the traditions or infrastructures to support group practice involving the coordination of care centered on the patient. The recent HPST law anticipates an emphasis on primary care as one way to improve access in disadvantaged areas. This latest report called for incentives to create primary care structures in the low-income suburbs and rural communities.

The report also called for a more practical and specific description of the “medical homes” and primary care (or its French equivalent) as a “brand” to which professionals will relate. This should be accomplished under the new Agences Regionales de Santé (ARS). A new legal framework is also necessary that allows the roles and missions of each of the collaborative professionals to be understood and accommodated.

Paying for care in these new structure will also require new mechanisms especially to balance the payments to nurses and supporting personnel. Bundled payments and incentive systems need to be developed and, again, the ARS regional agencies for health are to have a role in the payment structure. The new medical homes and centers also should be seen as places where multi- and pluri-disciplinary professionals can be trained.

For the full report see:

Wednesday, February 24, 2010

Baby Steps to EHRs in France

France has decided to move completely toward electronic health records—and has committed to universal adoption of a “dossier médical personnel” (DMP). But before that can be done, the system has to get to where all bills are submitted electronically. In September, it was announced that a fine of up to 1 euro would be charged for every paper claim. The principle of this fine system was part of the new law: “Hospital, Patients, Santé, Territoires” (HPST), passed last summer.

In 2008, in France, 86% of clinical offices able to transmit claims transmit electronically but insurers received more than 150 million paper claims. Among physicians, nearly 20% of GPs and over 42% of specialists still used paper claims in 2008. The Mutalités (insurance companies) estimate that a paper claims costs over $2.40 to process while an electronic claim costs only 36 cents.

The fine system didn’t get implemented as planned and there are reports that it will happen this coming May and the fine will be only 50 euro cents.

Tuesday, February 2, 2010

Setting The Limit on Doctors in Training at 7,400 per year

France limits the number of students who are trained in medicine via the numerus clausus. This is a restriction on the number of students who are allowed to pass from the initial year of medical training into the 2nd year. Essentially, the top scorers on the end of year examination are allowed to move ahead.

The limit is set by the ministries of higher education and research health and sport and is set each year around this time. The official notice gets posted on "Legifrance" which posts all official decrees and order. The order for the numerus clausus was released January 21, 2010.

By Order of the Minister of Higher Education and Research and the Minister of Health and Sport dated January 21, 2010, the number of first year students of undergraduate medical studies allowed to continue their studies medicine at the termination of the courses following the tests of the academic year 2009-2010 is set at 7 400, divided between the following institutions.....
The 37 medical schools are then listed with their quotas. These range from 550 (Lille-combined universities) to 8 in New Caledonia and 23 in Corsica.

The ministries pay close attention to the numerus clausus as a mechanism for adjusting overall physician supply--an issue that came to the fore in the recent past as it was apparent that France was going to see a decline in overall number of practicing doctors.

The Observatoire National de la Démographie des Professions de Santé (ONDPS) was established in 2003 to monitor supply and needs for physicians. It strongly supported expanding the training pool.

The numerus clausus fell from a high of 8588 in 1971 to a low of 3500 in 1992. Since then it rose slowly through 2001 to 4100 but, on the heels of several predictions of a doctor shortage, has risen rapidly to the 7,400 level This is slightly less than the 8,000 that was predicted a few years ago as necessary to keep the supply in line with population growth and physician retirement patterns.

EHESP Joins with Other Institutions to Create a Research Consortium

In France there is a relatively unique approach to coordinating research and graduate education through a series of center for research and higher education, or “Poles de recherché et d’enseignement supérieur” (PRES). This mechanism was created in 2006 by the “Pacte sur la Recherche” and was intended to facilitate the process of decentralization in the research and academic community. This is part of a larger trend toward institutional autonomy promoted by the current government. Valerie Pecresse, French Minister of Higher Education and Research, described it this way in 2009:
The development of these centers of research and higher education naturally accompanies the gradual accession of our universities toward autonomy. In these centers, all of the actors in research and education can cooperate and unite their diverse forces to meet their common goals.

Since 2007, 16 PRES have emerged with the most recent being the Université Paris Cité – EHESP, Rennes the latest to organize. This consortium was approved in December and has 7 founding members:
EHESP, (École des Hautes Études en Santé Publique)
New Sorbonne University (Paris 3)
Paris Descartes (Paris 5)
Paris Diderot (Paris 7)
Sciences Po
Institut Physique du Globe de Paris
Paris North University (Paris 13) (associate member)

A summary of the programs and its aims is posted on the EHESP website in English ( This structure will allow for more cross-disciplinary work in public health and allow students and investigators in a wide range of institutions to work jointly on projects.

Wednesday, January 6, 2010

"Permanenciers"—The People on the Phone

In December I was teaching in Paris with a colleague from Chapel Hill. We met prior to the start of his class first thing one morning and he was a little shaky; he reported he hadn’t gotten much sleep and was feeling a bit woozy. “I’ll shake it off,” he said and went into the classroom. I went back downstairs to my office to work and in 30 or so minutes one of the students came in to say that the professor was probably sick and could I come and help.

I went up to the classroom and sure enough, my friend was looking decidedly green and was conspicuously sweating but his skin was cool to the touch. We led him downstairs to a quiet place to sit and gave him water. The students, several of whom were trained physicians or caregivers, were doing some informal diagnosing. One of the young ladies who was in active practice asked for a classmate to go round to the local pharmacy and get a stethoscope and a blood pressure monitor and began to ask questions. “Did you eat? Do you have any pain? When did this start? Do you have a history of coronary disease?” There were some symptoms that fit with a myocardial infarction but no typical pain. The diagnostic equipment arrived, on loan from the pharmacy. His heart sounds were more or less normal but his pulse was rapid. The electronic blood pressure gauge showed a fairly normal 130-90 but the sweating, wooziness and nausea were not abating.

The question was, what to do? Go to a hospital that might be friendly to an American. The American Hospital in Neuilly was mentioned but how to get him there? Was there enough reason to call for an ambulance? The decision was made to dial “15” and contact SAMU, Service d’Aide Medicale Urgente. This connected us to one of the 100-plus call centers in France that handle medical emergencies.

The student/physicians were discussing the situation with the call center and soon were apparently discussing the case with a physician and talking about options. One was to have a “S.O.S. Medecins” or “SOS Doctors” come by. Given the symptoms and the apparent non-emergent nature of the case, that might seem reasonable. After a bit more discussion and some additional checking and more questions, the decision was made to pass that up but to take my colleague by taxi to his hotel where he would be met by an on call physician.

How this was being negotiated was hard to understand but I was told that a “dossier” had been set up for the patient, that if there were any problems or the symptoms became more urgent that I was to call “15” and that they’d be able to connect to his file by name. Further, that a doctor was assigned to the case and available by phone and that we were to go ahead on and the circulating physician would appear at the hotel within the hour.

We got to the hotel and not long after getting the patient into his bed, the call came up from reception that the doctor had arrived. He came up and with dispatch, quickly and expertly interviewed my colleague, checked heart sounds, palpated, and checked eyes and ears.. The discussion was all in English and the doctor was not looking too alarmed nor disturbed. After 15 minutes or so, he opined that it was likely an intestinal infection and that it was “all over Paris” at the time. He offered a few small pills, instructing the patient to take two now and another in an hour and wrote a prescription for more of the same plus an additional drug in case there were bowel problems. When the session was over the doctor took out a small pad and wrote up a bill on a form that was intended to be used for insurance claims. The visit was a “cash-only” affair and the total charge came to 90 euros.

What we had undergone was an interaction with the integrated emergency and urgent care system in France that makes use of a system of communications centers, traveling physicians and various levels of ambulances and patient transportation systems. I knew a bit about this but was fascinated by the fact that a “dossier” had been created and that we could easily refer to that for additional medical care during this episode.

It was not until just before New Years that I got a better idea of what was happening when I read about a series of local strikes of what were called “Permanenciers Assistants de Regulation Medicale” (PARM). When I tried to find out what they were I uncovered a bit of the background to the process we underwent two weeks earlier. The permanenciers (hard to translate, but call them “agents”) were communications specialists who manned the call centers. They are trained in medical triage and are the first line of communication for the rather complex SAMU system. The permanenciers are backed up by physicians who also staff the call centers and who remotely diagnose or refer and make transportation or treatment decisions over the telephone. They are assigned to a case (a dossier is opened) and stick with it until resolution.

In our case, we had the option of having a SOS Medecin come to us. These are physicians who literally cruise the streets of Paris and other cities (or are on call) and make necessary house calls. There are other physician who are ready to attend to less urgent cases, as ours was, with a house call. They function more or less independently but have the ability to motivate a more complex trauma or emergency care system.

But, back to the permanenciers. These key functionaries were striking to get recognition as a specialized and professional cadre of workers as well as a bit of a pay raise. The rolling local strikes seem to have settled down by the first week of January but no resolution to their requests has been reported.