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.