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DIFFICULT CHOICES

In the first of a new series looking at how the recession is affecting European eye care, EuroTimes looks at the present state of French ophthalmology

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An international research centre recently concluded that, “no European country is becoming more dispirited and disillusioned faster than France.” High unemployment, non-existent growth and crippling public debt levels have all contributed to a mood of doom and gloom in Europe’s second-largest economy. France’s 5,500 ophthalmologists have been feeling the impact of this crisis, albeit less drastically than many other industries and professions.

As Richard Gold MD, an ophthalmologist in Le Raincy notes, the shortage of ophthalmologists in France has helped to cushion the profession from the worst effects of the economic crisis.

“Despite the fact that the situation is getting undoubtedly worse for doctors, with less income per patient, rising costs, increasing workload and excessive interference from the government, ophthalmology is still a profession where there is no unemployment,” he said. This relative stability in a volatile job market is reflected in the annual survey of French cataract and refractive surgeons that Dr Gold has conducted for the past 16 years.

Interestingly, the percentage of respondents who said that they would opt to study medicine again, and in particular ophthalmology, has remained consistently high over the past five years. Similarly, the percentage of ophthalmologists who would advise their children to study medicine has actually increased in recent years, perhaps reflecting the sense that medicine represents a refuge or safe bet in times of economic precarity.

Urgent action

Less positive, however, is the progressive ‘greying’ of French ophthalmologists reflected in Dr Gold’s survey, with a large percentage heading towards retirement age in the next 10 years. As far back as 2004, ophthalmologists such as Jean-Luc Seegmuller, then president of the National Union of French Ophthalmologists (SNOF), warned authorities that ophthalmology in France was reaching a “critical moment in its history” and that “urgent action” was needed to avert a looming crisis. Almost a decade later, the predicted crisis has now taken concrete form, with waiting times of up to six months or longer to see an ophthalmologist in some regions.

“Half of the current crop of ophthalmologists are over 55 years of age, and for Paris alone we will see around 800 ophthalmologists taking retirement in the next 10 years,” Jean-Bernard Rottier MD, current president of SNOF, told EuroTimes. Part of the demographic problem stems from a decision by the French government in 1986 to put a ceiling on the number of medical specialists emerging from training colleges each year.

With regular pleas to increase the quota for ophthalmology ignored, the restrictions will result in a drastic culling of the ranks of French ophthalmologists from 5,500 today to around 4,000 in 2020. For Dr Rottier, the inaction of successive governments stems from a deliberate policy to undermine ophthalmologists’ traditionally dominant position in the French health system.

“There seems to be a mindset which thinks that it would be a good thing to have fewer doctors, because that would force the profession to delegate more of their tasks to the paramedical professions, as has happened in the United Kingdom and Switzerland,” he said. Furthermore, as Dr Rottier sees it, the profession of ophthalmology is not well understood by the authorities.

“We are typically perceived as specialists who just prescribe glasses or contact lenses, which is not particularly glorious, and hence can be readily replaced by opticians which will cost less money to the State. The other predominant image is that of the technical ophthalmologist who performs LASIK, but which represents only a fraction of our profession. Unfortunately, the medical aspect of our work, which is on the increase, is not sufficiently highlighted and this serves to downplay our critical role in the ocular health of the population,” he said.

Twofold solution

To tackle the shortage of ophthalmologists, SNOF proposes a twofold solution: first, increasing the number of ophthalmologists trained in French medical schools, and secondly, delegating more tasks to orthoptists, the “natural collaborator” of ophthalmologists in France.

In the French medical system, ophthalmologists traditionally work closely with orthoptists who can provide additional examinations, such as visual field tests, strabismus or low vision aid rehabilitation, and also opticians who provide glasses and contact lenses upon medical prescription. The proposal to delegate more tasks to orthoptists comes at a time when the French Minister of Health, Marisol Touraine, is considering the increasingly vocal claims of optometrists to formally recognise their own profession.

Optometry currently has no official status under French health regulations and ophthalmologists believe that optometrists should not be allowed to operate as quasimedical practitioners. “Recognising optometry will be a catastrophe,” argues Dr Rottier. “Our concern is that it will upset the current system of ocular care to such a degree that patients will be confused by the change. Where will this new profession fit in with the current place of orthoptists and ophthalmologists who have worked successfully hand-in-hand for generations with no problems?” he asked. 

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