The Express: The New Popular Front wants to ban the establishment of general practitioners in the best-off areas, if he manages to form a government. How do you judge this proposal?
Paul Struck: It’s interesting, but I don’t think it can solve the problem. Three-quarters of French departments have lost medical density in recent years. Everyone in France is faced with difficulties accessing care. There are shortcomings everywhere, even in the best-equipped departments, and in all specialties. With this measure, the left risks alienating doctors, who are very attached to freedom of establishment. And at the same time, making patients tense in places where they will not go.
One of Emmanuel Macron’s flagship measures was to allow more doctors to be trained, by removing the numerus clausus. Was it necessary to do this?
Yes, but again, that won’t be enough. It takes 10 years to train more doctors. So it will take years before we see the effects of the removal of the numerus clausus, which was only enacted in 2021. The first promotions should arrive in 2031. In the meantime, the population will have increased and aged, and the demand for care will have increased too, because many diseases are age-related. This is also one of the current problems: beyond a poor distribution of staff across the territory, the demand for care related to chronic pathologies is exploding.
The question of the number of graduates is therefore, in reality, only part of the problem. And then what will these doctors do, once trained? The opportunities for general practitioners are today much more numerous than before. Some become medical journalists, others work in hospitals, others carry out missions for companies. Some decide to do largely cosmetic injections… Not all of them will swell the ranks of medical deserts. It is clear that the response to be provided must be multiple.
From what you say, there is no right answer. So there is no solution?
No, that’s not what I’m saying. But access to care is not limited to the simple number of doctors available in a given area. Part of the problem also lies in the fact that the French no longer have the same expectations. The population wants a quick, easy response. This is partly why they turn to emergency rooms, for example. Many studies have shown that the consumption of emergency care is not necessarily linked to medical density. Some countries have many more doctors than France, and are also seeing the use of emergency rooms increase. In reality, the entire system is no longer adapted.
What would be the priority then, according to you?
The urgent need is to have a reliable dashboard. If medical deserts persist so much, it is because our knowledge of medical demography is not detailed enough. The system works blindly, on instinct. We know where the doctors are, and how many there are, but that’s all. No data is available on the procedures they perform, for example. Do they vaccinate? Do they insert IUDs? Do they perform abortions?
We could go further. Who takes a lot of patients? Who takes few? Who only does scheduled care, planned in advance, follow-up? Who only does non-scheduled care? Few solutions allow doctors to exchange this information, in order to organize themselves. The organization of the care offer is still very archaic. We know better the availability of Uber drivers than the actual care offer in the country. This is not normal.
The problem of medical deserts dates back to the 2000s and has only gotten worse since then. Isn’t saying that we need to take the time to see things more clearly a way of putting off implementing restrictions on establishment? The public authorities have not dared to impose them until now. But more and more experts are calling for…
No, I am convinced that in order to act, we must first master medical demography. The reverse is also true: we must also analyze in detail the expectations of patients, their consumption habits. To better respond to them, and also, if necessary, set limits. With these figures, we could for example identify patients with high demand, and better treat them. Perhaps we will still have to impose restrictions on doctors, in the end. But in this case, we can do it intelligently.
Teleconsultation has often been presented as a solution, particularly in the media. What will it change?
Teleconsultation does not offer exactly the same service as face-to-face consultation. The population understands this, by the way! We see that the practice is not exploding, despite the fact that it is easier to settle for a remote appointment. I think that we need to develop these services especially where there are mobility issues, when people do not have a means of transport, or when they are immobilized. This is the real advantage of this technology.
Teleconsultation can also be useful to get rid of certain administrative formalities, for example. And also, to confide. This is an unexpected effect, which I observe in the exercise of my profession. It is sometimes easier to talk about intimacy, mental health, behind a screen, and without needing to be accompanied as is often the case for physical appointments. But you can’t replace a doctor with a screen.
Health Insurance is counting on an increase in administrative assistants to allow doctors to see more patients. Are you too?
Yes, we must continue to promote these administrative assistants. Germany does it, and has had good results. Many doctors remain cautious, and that’s normal. You don’t change 15 years of work habits like that. Especially since there is always the fear that these assistants will end up deciding questions for which they are not qualified. But I think that in the end, it’s a win-win. It can allow for a faster, better quality appointment.
What avenues, in your opinion, have not been explored enough in the public debate in recent years?
We rarely talk about recruiting people from rural backgrounds into medical programs. There are not many of these students on the benches of faculties. They do not necessarily think about medicine, they self-censor or do not have the means to embark on such studies. But studies conducted on the subject show that it is an interesting lever. Because people tend to settle in cultural and geographical areas that resemble what they knew growing up.
.