EXPLAINED: The ‘absurd slaughterhouse’ that leaves France with a shortage of doctors

France has a scandalous shortage of GPs in rural areas and the reason has much to do with the country's "terrible and absurd" university system for training doctors. John Lichfield looks at whether France can finally resolve a longstanding, ridiculous and very French problem.

EXPLAINED: The 'absurd slaughterhouse' that leaves France with a shortage of doctors
Medical students protest in France. AFP

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.”


Healthcare in France: The essential French language you'll need if you're ill

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.

Member comments

  1. Medicine apart, the problem is that everyone who passes BAC is entitled to go to their nearest university. A large proportion of those have already dropped out after their first year.

    Our experience, in Maine et Loire (49) is that all incoming GPs are women, mothers of children, who choose general practice to fit in with their personal commitments, i.e. family comes first, patients after. Absolutely fine if you choose to be ill between certain hours and on certain days of the week, otherwise you have to choose to go to A & E and, if your only choice is A & E in the hospital in Saumur, curl up your toes and die!

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OPINION: France’s ‘slow train’ revolution may just be the future for travel

Famous for its high-speed TGV trains, France is now seeing the launch of a new rail revolution - slow trains. John Lichfield looks at the ambitious plan to reconnect some of France's forgotten areas through a rail co-operative and a new philosophy of rail travel.

OPINION: France's 'slow train' revolution may just be the future for travel
The slow trains would better connect rural France. Photo: Eric Cabanis/AFP

France, the home of the Very Fast Train, is about to rediscover the Slow Train.

From the end of this year, a new railway company, actually a cooperative, will offer affordable, long-distance travel between provincial towns and cities. The new trains – Trains à Grande Lenteur (TGL)?– will wander for hours along unused, or under-used, secondary lines.

The first service will be from Bordeaux to Lyon, zig-zagging across the broad waist of France through Libourne, Périgueux, Limoges, Guéret, Montluçon and Roanne. Journey time: seven hours and 30 minutes.

Other itineraries will eventually include: Caen to Toulouse, via Limoges in nine hours and 43 minutes and Le Croisic, in Brittany, to Basel in Switzerland, with 25 intermediate stops  in 11 hours and 13 minutes.

To a railway lover like me such meandering journeys through La France Profonde sound marvellous. Can they possibly be a commercial proposition?

Some of the services, like Bordeaux-Lyon, were abandoned by the state railway company, the SNCF, several years ago. Others will be unbroken train journeys avoiding Paris which have never existed before – not even at the height of French railway boom at the end of the 19th century.

The venture has been made possible by the EU-inspired scrapping of SNCF’s monopoly on French rail passenger services. The Italian rail company Trenitalia is already competing on the high-speed TGV line between Lyon and Paris.

The low-speed trains also grow from an initiative by President Emmanuel Macron and his government to rescue some of France’s under-used, 19th century, local railways – a reversal of the policy adopted in Britain under Dr Richard Beeching from 1963.

The cross-country, slow train idea was formally approved by the rail regulator before Christmas. It has been developed by French public interest company called Railcoop (pronounced Rye-cope), which has already started its own freight service in south west France.

Ticket prices are still being calculated but they are forecast to be similar to the cost of “ride-sharing” on apps like BlaBla Car.

A little research shows that a Caen-Toulouse ticket might therefore be circa €30 for an almost ten-hour journey. SNCF currently demands between €50 and €90 for a seven-and-a-half-hour trip, including crossing Paris by Metro between Gares Saint Lazare and Montparnasse.

Maybe Railcoop is onto something after all.

The company/cooperative has over 11,000 members or “share-holders”, ranging from local authorities, businesses, pressure groups, railwaymen and women to future passengers. The minimum contribution for an individual is  €100.

The plan is to reconnect towns ignored, or poorly served, by the Train à Grande Vitesse (TGV) high speed train revolution in France of the last 40 years. Parts of the Bordeaux-Lyon route are already covered by local passenger trains; other parts are now freight only.

In the longer term, Railcoop foresees long-distance night trains; local trains on abandoned routes; and more freight trains.  It promises “new technological” solutions, such as “clean” hydrogen-powered trains.

MAP France’s planned new night trains

For the time being it plans to lease and rebuild eight three carriage, diesel trains which have been made redundant in the Auvergne-Rhône-Alpes region.

There will be no space for a buffet or restaurant car. Restaurants and shops along the route will be invited to prepare local specialities which will be sold during station stops and eaten on board.

What a wonderful idea: French provincial meals on wheels; traiteurs on trains.

Olivia Wolanin of Railcoop told me: “We want to be part of the transition to a greener future, which is inevitably going to mean more train travel.

“We also want to offer journeys at a reasonable price to people who live in or want to visit parts of France where train services have all but vanished. We see ourselves as a service for people who have no cars – but also for people who DO have cars.”

Full disclosure. I am a fan of railways. I spent much of my childhood at Crewe station in Cheshire closely observing trains.

Three years ago I wrote a column for The Local on the dilemma facing SNCF and the French government on the 9,000 kilometres of underused and under-maintained local railway lines in France. Something like half had been reduced to low speeds because the track was so unreliable. Several dozen lines had been “suspended” but not yet officially axed.

The government commissioned senior civil servant, and rail-lover, François Philizot to study the problem. After many delays, he reported that much of the French rail network was in a state of “collapse”. Far from turning out to be a French Beeching, he recommended that a few lines might have to close but most could and should be saved – either by national government or by regional governments.

Since then the Emmanuel Macron-Jean Castex government has promised a big new chunk of spending on “small lines” as part of its €100 billion three year Covid-recovery plan. Even more spending is needed but, for the first time since the TGV revolution began in 1981, big sums are to be spent on old lines in France as well as new ones.

The Railcoop cross-country network, to be completed by 2024-5, will run (at an average of 90 kph) partly on those tracks. Can it succeed where a similar German scheme  failed?

François Philizot suggested in a recent interview with Le Monde that a revival of slow trains might work – so long as we accept that a greener future will also be a less frenetic future.

“When you’re not shooting across the country like an arrow at 300 kph, you can see much more and you can think for much longer,” Philizot said.

Amen to that.