in France: how can access to services and quality of care
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The main source for this
commentary is 'Polémique autour de la gynécologie
médicale', in Bulletin de l'Ordre des médecins,
Gynaecology in France was
recently reorganised but, under the pressure of some women's
groups, the Government has partly backed off from reform.
The question which has generated debate is a difficult one
to resolve. On the one hand, women need easy access to a
gynaecologist; on the other hand, it must be ensured that
those performing gynaecological procedures are capable of
providing a good service, whether they be gynaecologists
or GPs. Many women may prefer to talk about women's health
with a specialist rather than a GP. These questions are
particularly important when it comes to contraception.
THE GYNAECOLOGICAL PROFESSION
IN FRANCE: ORGANISATION
(i) Medical gynaecologists
In France, the gynaecological
profession is divided into two branches: medical gynaecologists,
and obstetricians. The latter are surgeons, and they are
specifically concerned with pregnancies. They help at delivery,
and monitor the pregnancy. They can for example perform
a caesarean section. Medical gynaecoloists, on the other
hand, deal with women's reproductive health in general:
the they can give contraceptive advice, prescribe the pill
or hormonal treatment, or perform a smear test.
(ii) The difficulties of
Recently, the Government,
and in particular its Minister for Health, Madame Dominique
Gillot, thought that the tasks performed by medical gynaecologists
might as well be performed by GPs, and abolished the Diploma
in Medical Gynaecology. This decision gave rise to much
criticism, especially from the Committee for Women's Health,
headed by Dr Dominique Malvy, a medical gynaecologist. Following
this outcry, the Minister decided to partly go back to the
old system. The present system, which emerged from this
debate, is as follows:
1) The three first years
of training in the Diploma of Gynaecology are the same for
both branches of the profession; then, the student receives
two years specific training in the branch of the discipline
they want to specialise in.
2) The Government has undertaken to train a sufficient number
of medical gynaecologists.
3) GPs will be better trained, so that they can do cancer
screening. Their university degree will include six month
practical training in gynaecology.
So far, almost all the parties
have expressed satisfaction with the compromise, apart from
a hard core of Dr Malvy's group. However, some problems
remain, which I will now discuss in turn.
ACCESS TO GOOD ADVICE
Less than a third of gynaecologists
are medical gynaecologists (in 1998, there were 6,634 gynaecologists,
including 1,898 medical gynaecologists; half of the latter
were women). Their number is declining. By contrast, there
are about 80,000 GPs, one tenth of whom occasionally perform
gynaecological acts when they have to.
This has implications for
cancer detection. According to Professor Michel Tournaire,
former president of the National Commmittee of French Obstetricians,
although the global number of smear tests performed each
year was satisfactory, the number of cervical cancers in
France was still too high. The reason was that, although
some women get a smear test every year, the population covered
should be greater. According to Professor Tournaire, one
test every year was enough, but the point was to reach a
greater proportion of women, not just a few.
THE QUALITY OF THE ADVICE
On the other hand, some
are concerned with the quality of GP's future gynaecological
training. According to Dr Josette Grenier, who has supported
Dr Malvy's committee, six months is simply not enough, and
does not guarantee safety of diagnostic and treatment. However,
GPs have protested, in particular through their association,
GP-France. For example, a group of women from GP-France
said: 'Stop pretending that GPs are not capable of performing
a smear test, prescribing a mammography, monitoring a pregnancy
or hormonal treatment, or even to listening to women!'
DIRECT ACCESS TO A SPECIALIST
In France, all patients
have direct access to publicly funded specialist advice
and treatment, without the need to be referred by a GP.
According to Dr Grenier, many foreign countries envy French
women for their right of direct access to a gynaecologist.
However, in order to save Social Security money, it may
be that direct access to a specialist will be cut. Madame
Gillot undertook not to abolish direct access to a gynaecologist,
but some would like this commitment to be stated in law.
WHOM DO WOMEN WISH TO
I have been told that many
French women prefer discussing gynaecological problems with
a specialist rather than a GP, since they may think that
a gynaecologist will understand them better, and will be
better trained to deal with their problems.
This is especially true
of teenagers, who are reluctant to discuss contraception
(and their sexual life in general) with their family GP,
precisely because they regard him/her as an 'extension of
the family'. In fact, according to research, talking to
a family GP seemed to them like talking to their parents.
There has been much debate
over which system is the best, which seems to have been
shaped by the internal rivalries between different parts
of the medical profession. The heavy Social Security budget
deficit is another important factor, which is putting pressure
on the government to reduce the costs of health care, according
to some at women's expense.