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  Gynaecology in France: how can access to services and quality of care be achieved?
By Jean-François André
20/10/00

If you would like to discuss issues raised in this commentary, contact Jean-Francois at <jeanfrancoisandre@hotmail.com>

The main source for this commentary is 'Polémique autour de la gynécologie médicale', in Bulletin de l'Ordre des médecins, May 2000.

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 and obstetricians

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 reform

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 AND DIAGNOSTIC

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 CONSULT?

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.

CONCLUSION

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.

 
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