Egora.fr: The CMGF 2024 congress is dedicated this year to “myths and reality in general medicine”. What do you mean ? Is it a question of demystifying the exercise of the specialty?
Professor Paul Frappé: The idea is to focus on the myths that we may have in health in general, and more particularly in the field of care and general medicine. This theme also refers to the story dimension in care, on which we undoubtedly need to place more emphasis. It is not enough to offer the right care, it must also be included in the patients’ life course.
The anthropologist Jean-Loïc Le Quellec will also host the keynote closing on the question of science and myths.
A plenary session will be devoted to periodic certification, in theory compulsory for all health professionals since January 1, 2023. Where are we with its implementation, in practice?
Periodic certification is in force but there are no benchmarks available yet. Each national professional council (CNP) was called upon to construct a framework, that of the general medicine specialty was therefore developed by general practitioners. We must now homogenize these different standards to provide a certain consistency, and prevent each profession from taking a different direction, even if the HAS had provided benchmarks. The DGOS is finalizing this work, before being able to make these repositories public… It is still “for soon”but we can bet that the recent appointment of Nadiège Baille to the presidency of the National Council for Periodic Certification, which has remained vacant for a long time, will allow us to move forward effectively!
“We find ourselves a bit faced with a politics of numbers”
The issue of work stoppages will also be the subject of a session. The Government continues its quest for savings on these expenses. After the MSO-MSAP of several hundred general practitioners, Health Insurance intends to strengthen the relevance of prescriptions by more widely imposing the use of duration benchmarks by pathology. What is your position on these documents?
Of course, general practitioners cannot be impervious to health insurance management issues or to societal issues… But we must maintain meaning in these actions. Today, we find ourselves faced with a bit of a politics of numbers. What has been contested in MSO-MSAP is the feeling of injustice felt by some, who can be sanctioned for things that are somewhat beyond the reach of practitioners.
The frameworks are of interest, they can even be extremely practical as tools for dialogue with certain patients. This avoids direct negotiation between doctor and patient, by bringing a third party into the discussion and can raise awareness of the initial wish.
But it must remain a reference. If it is used as a stupid and mean tool of constraint, by preventing individualized care, we will again have this loss of meaning.
Still in this quest for savings, Health Insurance wishes to include in the future conventional agreement 15 relevant quantified objectives: on work stoppages but also on the prescription of antibiotics, analgesics, imaging, on the hyperpolymedication, etc. Do you subscribe to this approach to medicalized control of expenses in both form and substance?
It is normal for Health Insurance to monitor certain expenses and that this leads the profession to modify certain practices. The challenge – we come back to this – is that these are objectives which make sense and which are shared between the parties. We have seen this clearly with the Rosp: if we put money in relation to objectives which are either not consensual, or are quantified “judgmentally”, there is no support and that does not helps no one: neither Health Insurance, nor society, nor doctors.
“It’s a bit of a shame that remuneration becomes a surprise bag”
Would you like to be consulted, as CNP, on the definition of these relevance objectives?
At previous conventions, Rosp documents have been created. The last proposal was not necessarily used in a constructive sense, which dampened the drafting of new collegial proposals this year.
Last year, during the congress, we highlighted the loss of meaning of packages, due to the fact that their payment is totally detached from the effort they are supposed to remunerate: certain months, enormous sums are paid to doctors and the following month, there is almost nothing. The indicators are too numerous and calculated in such a way that they do not allow the doctor to say “if I modify this thing, there will be a direct impact”. The doctors wait for their package on a certain date and each time it’s a surprise. It’s a bit of a shame that remuneration becomes a surprise bag: it’s a lot of money, but it doesn’t directly reflect the effort.
Everyone agrees that the number of indicators must be restricted. And if payments could be standardized throughout the year, it would be more noticeable.
The Cnam wishes to eliminate the Rosp in favor of a prevention package with a limited number of public health indicators (vaccination, screening and monitoring) but which will be valued patient by patient. A doctor would thus receive 5 euros more for the patient who has correctly screened for colorectal cancer… Is this a good way to promote prevention?
Has Rosp really disappeared? I think we give it another name… These proposals make remuneration directly dependent on patient behavior; there is no better way to tell doctors to choose the most reliable patients… Of course, humanly, no one will do that… but again it is a waste of meaning!
I think we must mourn the valorization of certain issues when they are not accessible to an indicator which is both centered on the doctor’s practice, reliably quantifiable, adapted to the patient profile of each doctor, and whose societal and scientific relevance is consensual. If all these boxes are not checked, it is better to use this money elsewhere.
Still on the subject of prevention: has the CMG been asked to define the content of the prevention assessments which must be put in place?
We participated in the discussions. We were quite enthusiastic at the beginning: it was an opportunity to recognize an activity that has existed for a long time among general practitioners, to structure it further. In fact, given the current rate (30 euros for 45 minutes), we understand that it is not aimed at general practitioners… it will undoubtedly evolve.
“Everyone would like general practitioners to spend more time on their specialty”
The new model of the general medicine DES continues to arouse controversy. After the Deans, the presidents of CME in turn warned of the “deleterious consequences” of reducing the duration of the internship in the pediatric department (from 6 to 3 months). Do you share this concern? ?
At university, we are well placed to have every week someone who comes to tap the general medicine coordinator on the shoulder to tell him that “general practitioners know nothing about… [et là vous mettez ce que vous voulez]let us do general being transversal, everyone would like generalists to spend more time on their specialty, sometimes forgetting that it is a specialty in its own right.
If we really want interns to learn general medicine, by applying to the letter the logic defended by the presidents of CME, we should do 100% of the internship in general medicine… There is a need to open our eyes during the general medicine internship certainly, but we are no longer in the discovery phase like in the externship.
At the same time, we must not turn a blind eye to the fact that this creates a staffing problem in pediatric services…
