Dr McConnell - Spain

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Dr McConnell - Spain
Erasmus+ funded Hippokrates Exchange Program
Project no.: 2014-1-UK01-KA102-000412
Participant report
Rebecca McConnell – France – 29 November – 12 December 2015
I have discussed a lot of what I observed in the GP practise I visited in France in the
above section on learning objectives. I would therefore like to concentrate this
section of my report on some reflections I made about two elements of the practice
that I observed in France that was different to our practice in the UK. I have chosen
the titles:
•
Money in medicine
•
Prescribing and ethics
Money in medicine
The one very different aspect of the consultation in France is that a payment takes
place at the end. It was weird for me at first to see actual notes and coins on the
table – or a card reader! – but it seemed to be very normal for the GP and patients.
Along with this, there is a “Carte Vitale” that every patient has to hand over. I think it
is a credit card size card with their social security number on or something and it
goes into the card reader so the computer can register it. I believe it is a way that the
GP can prove they actually had the patient in the room (for when they need to claim
money back from health insurance).
Although most people did pay the doctor, they do get this amount reimbursed to them
(depending on their health insurance details) or at least part of it. Some people don’t
have health insurance and this can be difficult. As far as I could ascertain about 60%
of all health costs are covered by the state and the other 40% is to be paid. Most
people have health insurance through their work that they (and work) pay into every
month – which will then pay the remainder of the costs (depending on the level of
insurance paid for).
If someone develops a chronic problem that is going to need ongoing treatment e.g.
heart disease, diabetes or a cancer then the health insurance will pay a 100% of their
costs and so going to see the GP is free and the medication (but only medication
relating to this illness) is free.
I saw a patient who looked like he had lung cancer, he was grey and cachexic and
smelt of tobacco smoke. He had had an X-ray that was suspicious of cancer but
needed a CT scan for diagnosis. The man had no health insurance so would have to
pay the 40% cost of the scan himself. He also needed to go to a local big town for the
scan. He said that he didn’t have any transport and no money to pay for the scan.
The whole consultation with the GP (who didn’t charge him) was to try and find the
cheapest easiest place to go and to discuss with his son about whether he could
arrange lift for him.
I think that some GPs in France like being paid directly by the patient as this makes
them feel independent of the state. I feel glad that I don’t have to ask for money in a
consultation as I wonder if patients who handover money feel that they are “owed”
something from the doctor (even subconsciously) expect to get something – a test, a
referral, a prescription – out of a consultation that they pay for, even if they don’t
This project is funded
by the European Union.
have an illness that needs any particular treatment or that may not be in their best
interests.
I am naturally suspicious about the independence of private practitioners e.g. even
dentists in the UK and I think this is a prejudice that comes from my background of
having being brought up in a “free at the point of access” system and a family who
believe in state run health (and other) care. I do notice this prejudice when I see my
own patients who have seen a private practitioner and I wonder if the investigation or
treatment was truly necessary (or was not what I would have done).
It was heartening to see the GPs in France investigating, referring and treating in a
similar way to we would in the UK – despite the way they are paid – but I did notice a
lot more prescribing of medications we do not use in the UK and I wondered if this
was because they felt that they did have to give a patient something in return for their
Euros… I think I would feel a bit more pressure to give the patient “something” at the
end of a consultation in which they hand over money… which leads me to my next
topic…
Prescribing and ethics
As I said above, I noted that most patients left the surgery with a prescription. Even
those coming with a cold would often leave with up to 4 medications. Nasal washes
are very common and also paracetamol is not so readily available in France. In the
UK we can buy 16 X 500mg paracetamol tablets for 30p in a supermarket but in
France you can only buy them in a pharmacist (and some of them have quite
restricted opening hours!). Patients asked for paracetamol to be prescribed as they
mostly get the cost of medication reimbursed from their health insurance company.
I heard the GP explaining to patients that a cold is a virus and that antibiotics won’t
help (just like I do at home). But, then the doctor hands over a prescription (with
nasal douche, paracetamol and sometimes other medication to help their cough) and
I wonder if this just re-enforces the patients ideas that they need to attend whenever
they have a cold – because they know they will get something from the Doctor or
they might actually believe that they need to have these meds to help with the cold.
I know that there is a big push worldwide to reduce antibiotic prescribing and I didn’t
see any of the GPs prescribe antibiotics unnecessarily but there is still a big job in
educating patients (in France and in the UK) to the fact that viral illnesses do NOT
need antibiotics. I noticed that the older people were more likely to ask “but don’t I
need antibiotics, Doctor?”.
The GPs in the practice also looked after some of the wards in the community
hospital in Neufchatel-en-Bray. There are 3 wards that are actually a “nursing home”,
mainly for with dementia. The nurses highlight to the doctors any issues or queries
they have about a patient but the patients to not get a “ward round” every day like a
medical ward. The nurse asked the doctor for something for one of the patients. They
have electronic prescribing in place and II noticed that he had prescribed PLACEBO
on her chart. I was surprised. I told them that we were not allowed to do this in the
UK. He explained that this elderly lady with dementia had trouble sleeping and had
asked for a sleeping tablet. He felt that it was safer for the patient to have a placebo
rather than be given sedatives (and then maybe suffer dangerous side effects from
them).
This project is funded
by the European Union.
Placebo tablets are something that was readily available on the ward and I wondered
about the ethics of them. I considered that in my training in the UK we are
encouraged to give truthful information to patients and so the idea of prescribing a
placebo is seen to be “not right” – because we are undermining the patient’s
autonomy – but I understood the reasoning in this case and wondered if we are
“doing less harm” by “lying” to the patient in giving a placebo that we might be
harming by giving medication that might not be in their best interests. I guess the
other option in this case would be to directly refuse the request from the patient –
which may undermine their autonomy.
In summary, there were a lot of similarities in the practice of general/ family medicine
in France and the UK but a few subtle differences that struck me – especially around
prescribing and the ethics of payment at the point of health care.
I would like to again thank Dr Ozanne, Dr Guillerme and Dr Schuers, and all their
colleagues at Medisept, who welcomed me so warmly over the course of my 2 week
placement with them.
This project is funded
by the European Union.

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