Health system in France
Health-cost in France is 9.7% of the Gross Domestic Product
(compared to 14.3 % in the U.S. , 9.5% in Germany and 6.9% in
Britain ).
Since 1945 the major part of the population receives free health
care at
public hospitals. In the private clinics the state pays only for
a part
of the expenses, while the other part is paid by the private
insurance companies.
A lot of jobless and low income citizens have no private
insurance.That`s why the rich people are paying a lot of taxes
depending on their incomes to cover this health care.
However, this situation is starting to change since the state
(people- industries - taxes )
can't afford supporting this effort for a very long time .
There is a duality between the private and the public hospitals :
Nowadays the trend is that the Private is taking the market of
schedulded operations and the Public is taking the market of
emergencies, obstetrics, elderly people and high cost operations
and
illnesses (Aids, oncology treatments) .
Anesthesiology practice in France
Private in clinics: Patients are paying the doctors and then are
paid back
partly by the state and partly by their private insurance.
In 1996 the average income of a private anesthesiologist was
44,600 francs/month .
In the University hospitals a Professor (70 positions in France)
has the possibility of a private practice . The salary is 50, 000
f/month at the beginning and 66,000 f/month at the end of career.
Assistant professor`s salary from 30,000 f/month to 50,000
f/month at the end.
Staff anesthesiologist - 20,000 f/month at the beginning to
40,000 f/month at the end.
In non-university and rural hospitals: The same as staff
anesthesiologist (even the head of department).There is a
possibility of private practice.
Demography in anesthesiology
Average age - 42 years old ( men - 61%, women - 39%).
There are 13 anesthesiologists for 100, 000 inhabitants in France
compared to 8.5 in the U.S. and 9 in G.B.
The anesthesiologists in France were pionneers in emergency
services,
I.C.U., emergency aid service and rescue team
on the roads and the mountains. For several years the french
anesthesiologists
have been deeply involved in postoperative care at the surgical
wards.
We are also involved in the global approach of chronic pain
relief.
In obstetrics the epidurals are managed only by anesthesiologists
.
Therefore we have a lack of anesthesiologists in the operating
rooms compared
to other countries.
This relative lack of anesthesiologists is a national problem .
Despite the dynamics of the profession the residents are not
choosing
this speciality : Low salary at the beginning (20,000 francs
monthly), too much
medicolegal risks, night duties. Formerly there was a special
exam
for students at the end of their medicine studies in order to
enter the anesthesiology study.
Nowadays there is only one exam which includes all medical and
surgical
specialities; and the less chosen specialities are obstetrics and
anesthesiology.
We are giving up ICU ,emergencies, road emergency aid
and surgical wards to other specialists and focus our energy on
the OR
and chronic pain relief, but that does not encourage the
residents
in choosing anesthesiology.
Trade union - scientific society and postgraduate training
Anesthesiologists in France are the first and the more syndicated
among the medical professions.
There is a syndicate for the Professors, a syndicate for the
Staff
anesthesiologists in university hospitals, a syndicate for the
non-university hospitals
and a syndicate for the private clinics.
These Trade unions are linked by an intranet ("invivo")
or Fax. The
information goes online and a strike can be very quickly
effective by this way.
In 1993 the night duty was very badly considered and paid 300
f/night duty and 700
f /weekend . A severe strike "on the road" gave us more
decent salary
for night duties ( 1,400 fr /night )
Our Scientific society is the "Societe Francaise
d'Anesthesie -Reanimation"
(S.F.A.R.).
The ICU (Reanimation) can't be separated from the anesthesia
in France. We never introduce ourselves by the word
"anesthesiologist " but always
by "Anesthesiologist AND Intensivist".
The SFAR is publishing our guidelines , a professional review of
high scientific level
(revue de la SFAR or well known as "green review").The
national congress of the
SFAR is taking place in Paris (at the Palais des congres -Porte
Maillot) every year
in September.
The certification is beginning in France and if we want to
continue belonging
to the "French College of Anesthesia and Intensive
Care" , we have to
attend a minimum number of congresses , write articles, give
lectures in our hospital for nurses or internists .No points are
given to practice and number of operations.
Research in anesthesiology
In non-university hospitals there is no actual research.
In university hospitals the research is less important than in
the U.S.,
because of the lack of anesthesiologists
A day-Practice of a French staff-anesthesiologist
At a public hospital the day is begining at 8.30 a.m. and
finishing at
6.30 p.m. , (but most of us begin at 8 a.m. and we are coming
back home at
7 p.m. and we even stay more ).
In 1992 we performed 7,376,000 operations and 96% were done under
general
anesthesia.
In 1995 general anesthesia decreased to 55% :
-midazolam sedation was 20%.
-peripheral nerve blockade - 15%
-Spinal (sprotte 27 gauge) - 5% and epidural (Tuohy 18 gauge ) -
5%.
Nowadays it depends a lot on the individual way of work and mixed
techniques (
epidural for pain relief per and post op + general anesthesia )
are increasing.
The combined spinal+ epidural is not very common yet.
In obstetrics - spinal for C-section is well accepted (98% in our
practice),
because the mother and obstetricians are concerned with a good
Apgar score of
the newborns.
In our experience, 56% of the deliveries are done under
patient-controlled-epidural-
analgesia which are performed only by anesthesiologists.
The anesthesia consultation is compulsory since 1994.
The informed consent is obligatory from 1997.
Anesthesiologists are helped by specialized nurses. These high
level nurses may
survey and run the anesthesia according to the prescription of
the
anesthesiologist but they are not allowed to practice induction
of anesthesia alone . Anesthesiologists are runing two O.R. at
the same time helped by two specialized nurses.
After the schedulded operations time (at 4 p.m.)
anesthesiologists are involved
in postoperative care at the surgical wards. We are spending 25%
of our time on
antibiotics, heparin prescriptions and fluid-electrolytes balance
for the post
operated patients. The central venous catheterizations are made
only by anesthesiologists.
For a long time we have been involved in acute pain relief :
P.C.A. ,P.C.E.A. ,3-1 nerve blockade for postoperative care at
surgical
units.
In a team, one or two anesthesiologists are specializing in
chronic pain relief
in ambulatory consultations.We are working together with
psychiatrists ,
relaxation therapists and we are using our knowledge in regional
anesthesia for
the following injections : celiac plexus, lumbar plexus, chronic-
spinal or epidural,
guanetidine blockade, etc. This is a new field of activity
despite the lack of anesthesiologists .
Denis Peronnet
Denis_Peronnet@invivo.edu