Anesthesiology in France

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"
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
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
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