Most anglophones living here are impressed by French doctors but the media make it clear that a lot of those men and women in white coats aren’t happy. To find out more meet Daniel Benchimol, Dean of the Faculty of Medicine in Nice.Discontent for some seems to begin in the first year of medical school. As one clearly harassed student told me, “You’ve got to work, work, work and in the time that’s left sleep, sleep, sleep ... and forget about living.” Professor Benchimol offered a more nuanced view of life as a carabin – the familiar term for a medical student: “To start with, I’d say two things. Firstly, entry to the Faculty is open to anyone who has the bac. Like many of my colleagues, I’m not in favour of that but most students are fiercely opposed to any form of selective admission. Inevitably in the first year there are those who don’t make the grade or come to feel that medicine is not for them. And let’s face it, medical studies are tough. There’s a lot to learn. Then I’d say that although today’s students are basically as highly motivated as those of earlier generations, they come out of a different culture in which total dedication to work with personal life taking second place is no longer widely acceptable. For good or ill that’s how things are. Most newly qualified doctors now enter the profession with a wish to have a life outside of medical practice.”
Only one in ten chooses primary care
As Professor Benchimol emphasised, there’s a lot to learn in medicine and the body of required knowledge is growing all the time. “And that’s not just in strictly technical matters relevant to qualification as a physician or surgeon. To give you an example, there’s now more stress on training students in effective communication with patients, something that used to be left to the good sense – or lack of it – of the individual. In Nice we’ve pioneered simulation programmes in which students work with mannequins while the instructor puts the kind of questions patients typically ask and then rates the responses. Special attention is given to the problem of conveying bad news. There are sensitive and less sensitive ways of telling someone they’ve got an inoperable cancer. Then there’s the matter of handling diagnostic or prognostic uncertainty. Multiple sclerosis is a case in point where you often can’t give a cut-and-dried answer about the likely evolution of the disease. These sort of issues demand a careful approach and with the right training a doctor can do much to relieve anxiety and confusion.”
It’s clear enough that today’s young medics are emerging from their six years of basic training better prepared technically and in some ways psychologically than their predecessors. But what is disturbing is that so few of them want to serve on the frontline of medicine by becoming what used to be known as general practitioners and are now often described as primary care physicians. Currently only one in ten newly qualified doctors from the Nice Faculty chooses that field of activity. “That’s correct and it’s unfortunate,” said Professor Benchimol. “Again there are cultural factors at work. In the medical community higher status goes above all to the specialist and that gets reflected in general public attitudes. For most of our students to end up as a généraliste means more or less to be labelled a failure. We’re trying to change the culture by redefining primary care as a speciality in itself. It’s a slow process but it’s beginning to happen.” Well, let’s hope so, I reflected. At the moment there are only 600 primary care physicians working in the Alpes-Maritimes. Over a hundred retire every year and two out of three aren’t replaced.
This desertion of general medicine is not simply a matter of status. There are other issues. Pay and conditions are a matter of grievance. A généraliste will on average earn less than €6000 a month – that’s about two-thirds less than a radiologist – and for that he’ll have to put in well over fifty hours a week, often with weekend and night duty. It’s not easy to have a normal family and social life. A recently retired GP I spoke to in Menton added a couple of points: “Compared with my early days – you’re going back nearly forty years – you’ve got a huge burden of paper work. And then there’s been a change in people’s attitudes, all part of that decline in respect in society. I’ve been shouted at, and insulted by patients several times and a colleague in l’Escarène was punched in the face. Unthinkable, I’d say, in the Sixties.”
A doctor is a healer not a dealer
No surprise that so many medical graduates aim to become specialists or look for salaried positions with shorter hours. Life as a trainee hospital consultant can also be hard but the financial rewards can be very attractive.
Money, of course, is at the heart of many of the problems of the French health care system and doctors routinely take decisions which involve expenditure – from writing a prescription to recommending specific surgery. I asked Professor Benchimol whether he thought this should be more clearly recognised in the medical school curriculum. In the US, for example, dozens of universities now offer joint MD/MBA programmes to equip doctors to take prudent decisions in the use of resources. The Dean was not happy with this idea. “A doctor is a healer not a dealer, and he shouldn’t be over preoccupied with the nuts and bolts of management. At the same time, looking at the deficit of the Sécu, it’s obvious that we need to make the optimum use of our resources but those sort of decisions need to be made on medical grounds. We are, in fact, looking for ways of reforming the system all the time which would benefit both patients and the medical staff.”
So is he optimistic for the future? “Overall, yes. We have, we’re told by the World Health Organisation, the best health care system anywhere, supported by an outstanding medical educational infrastructure and, for all its defects, a high performance social insurance system. Certainly, as you well know, students, GPs, and hospital doctors aren’t all happy but there’s real determination to address their problems.”