Emmanuel Macron considers himself a surgeon not a family doctor. He wields his scalpel where previous presidents might have prescribed aspirin.
In the 230 years since the French Revolution, there have been only two thorough reforms of the methods by which doctors are recruited and trained in France.
Macron, as promised during his election campaign, has embarked on a third.
The present system is ridiculous and everyone knows it is ridiculous. All the same, the proposed reform has run into trouble before it started life this week in the National Assembly’s health committee. Over 1,500 amendments have been tabled.
I have lived in France for 22 years. I adore and respect many aspects of the French art de vivre. There are, however, some non-negotiable aspects of French life which make life difficult for the French.
France often refuses to recognise problems caused by this compulsive Frenchness. Reforming medical training could be simple. It won’t be.
The new approach is intended, in part, to ease the scandalous shortage of doctors in some parts of rural France and in poorer towns and suburbs.
Although France has over 200,000 doctors, it has only 85,000 GP’s – a fall of 10,000 in just over a decade. Almost a quarter of them are expected to retire by 2030.
Replacing them is tricky partly because of a bizarre government policy which goes back to the early 1970s. Each year the government places a numerical limit – or “numerus clausus” – on the number of young people who can qualify for a second year of medical studies.
(Medical students in France sit their end of year exam. AFP)
'It's a slaughterhouse'
Almost 60,000 students each year sit in vast amphitheatres and scribble notes on their medical foundation course. They receive no individual or group teaching.
Only 8,000, or about 13 percent, pass the competitive exam or “concours” at the end of the year. Some are rejected because they are poor students. Many good students are also rejected because the government imposes a national limit, broken down into campus-by-campus limits, on how many can reach the second year.
The system is described by Professeur Patrick Berche, the man who ran it for 14 years, as “terrible and absurd” and “a slaughterhouse.”
A friend of my daughter’s who trained as a medical student in Paris said: “One of the most important things you learn as a first year medical student in France is never to leave your laptop or lecture notes unguarded.”
Why? The failure of one student increases everyone else’s chances of survival. Unattended notes or laptops tend to vanish. Other dirty tricks are available.
There are two explanations for this absurd situation, which has been left undisturbed by successive governments for almost 50 years.
The first is France’s ideological, egalitarian obsession with having no selection for university places.
Everyone passing the Baccaulaureat in science subjects has a right to enrol for medical studies, whether they score 20 out of 20 in the Bac or reach the pass-mark of 10 out of 20. No attempt is made to interview the students to check whether they have the aptitude or temperament for life as a doctor.
The second explanation is the “numerus clausus” policy, which was imposed in 1971 when the health system had too many doctors. Another motive was to reduce the size of expensive medical classes without infringing the principle that university access is open to all.
Huge amphitheatres full of first year students are relatively cheap. Some students reach the second year at their second or third attempt. Others never make it. One former French education minister described this policy as: “Organising a shipwreck to find out who could swim.”
The health minister, Agnès Buzyn, has proposed a law which will abolish the “numerus clausus” and introduce a revised version of the first-year medical curriculum. The aim, she says, is to train an extra 20 percent of doctors a year.
'Reforming France is never easy'
Argument already rages over whether France needs all those doctors. The real problem, critics say, is that too many doctors flock to cities and wealthy suburbs and congregate in lucrative specialities. Small towns have trouble in recruiting young GPs as older ones retire. Training more young doctors will not necessarily help, they say.
Au contraire, says Ms Buzyn. The new system will include an oral examination at the end of the first year to ensure that students have a true medical vocation. It will allow more people from rural and poorer backgrounds to qualify.
The present system favours young people from wealthy families who pay for “grinds” classes to help them to survive the mass cull at the end of their first year. They have ambitions other than treating old people in small towns at €25 a visit (the present Sécu rate).
Argument rages over how radical the Buzyn-Macron reforms really are. Professeur Patrick Berche says the law is a “step in the right direction but will leave us in the middle of the river”.
There will still be a de facto limit on how many places exist for medical students from year two to year nine. There will still be no limit on how many school-leavers enrol in first year medical classes. There will still be brutal exams to thin out would-be doctors after year one and again after year six.
Why not just choose school leavers on the basis of ability and aptitude, as all other countries in the world do save the francophone part of Belgium and Portugal?
The principle that French universities do not select first year students is sacrosanct (although circumnavigated by some institutions). Student unions argue that selection always favours the rich. And yet, as we have seen, the present bizarre system also favours the rich.
Be careful with that scalpel, Dr Macron. Reforming France is never easy.