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Bull World Health Organ vol.86 n.10 Genebra Oct. 2008
The French country doctor: caring for the sick through the centuries
Scientific and social advances may have affected aspects of their work but these general practitioners continue to play a vital role in delivering primary health care to France's rural population. Reporter Nira Datta and photographer Chris Black went to the village of Genouillac to see how the doctor's role had changed in 50 years.
In 1958, World health magazine reported on Dr Edmond, a country doctor in Genouillac, in the central French region of Limousin. On the occasion of the journalists' visit, the doctor had just sat down with his family to Sunday lunch when he was called away to treat a patient in his household surgery. After donning his white coat, the doctor made an incision in the patient's right hand, extracted a wood splinter, before disinfecting and bandaging the wound. The emergency over, the doctor returned to the empty dining room, hoping the doorbell and telephone would remain silent long enough for him to finish his solitary meal. "For 40 years it's been like that day and night. I can't call my soul my own. I belong to them," he said.
Edmond shown here in two pictures by French photographer Robert Doisneau was carrying on a centuries-old tradition of round-the-clock primary health care in rural France. Since the time of King Louis XIV (16381715), the country doctor has been an integral fixture of French rural life, attending to the basic health needs and more of villagers. That tradition is carried on today in Genouillac a village of some 575 people by Dr René Nicolas. The world in which he operates is much changed from Edmond's time, but despite the major advances in medical care, and the social, economic and cultural forces that have impacted on life even in remote communities, the work of the French country doctor, at its core, remains much the same. Country doctors still offer the personal, one-to-one care that hospitals and specialist clinics cannot. Empathy, trust and an intimate knowledge of individual case histories these are their stock in trade.
Several developments, however, have threatened to erode the role of the country doctor. The advent of tarmac roads and telecommunications, for example, have brought advanced scientific treatments within reach of otherwise isolated villagers. But perhaps the most pressing problem has been the difficulty in recruiting young doctors. The French government has been working on ways to attract more doctors to the countryside to counter what the Lancet described as "a dramatic decline in practitioners in an increasing number of rural regions". In a 2001 article, the Lancet suggested perceived harder working conditions were dissuading young doctors from settling in rural areas. In central and south-western France, in particular, hundreds of practices closed between 19962001 when the local doctor retired.
Genouillac is a case in point. Five of the seven doctors practising in the region are over 50, including Nicolas himself. Indeed, the ageing of rural doctors is part of a larger challenge providing health care for an ageing population. Much of Nicolas's daily work involves treating the elderly. The work of country doctors such as Nicolas is in danger of being diminished also as a result of operational changes and the more litigious, aspirational world we live in, according to Dr Guenael Rodier, who completed a medical degree in his native France and now works as a programme director at the World Health Organization (WHO) in Geneva. He refers to today's French rural doctors often having to wear a "legal straitjacket" and no longer able to take initiatives for fear they could be challenged.
"I come from a rural part of France," he says, "and when I was back there recently, one of my nephews had a cut that needed a few stitches. I could have done this myself but I didn't have any equipment, so I had to take him to the emergency room in the hospital. No general practitioner would have been willing to do it because they don't want to take the responsibility (because of the legal implications)."
"In the 1950s, there was not the same level of accessibility to treatments, so country doctors had to provide a lot of treatment on site. But now, patients move all the time, many people change their personal doctor frequently and use the emergency services system. The patient's expectations have changed. People look for the best treatment and services, so they all want to go to Paris or other bigger cities, where they can access larger hospitals. Country doctors can't perform the same procedures as they did in the 1950s. Back then, the personal relationship with the doctor was more important. Nowadays, people look for the personal touch only for day-to-day things. When it starts to get serious, they prefer to talk to a specialist," Rodier says.
The supposed diminishing role of the country doctor must be placed, however, in the context of a relatively strong French health system overall. The world health report 2000 ranked France's health care system among WHO's then 191 members as providing some of the best care in the world. In 2002, average life expectancy for women in France was 83 years (one of the highest in the world) and 75.6 years for men; and the system is constituted to ensure equitable geographical coverage and efficient interaction between the different sectors (i.e. public and private hospitals, private practitioners, medical auxiliaries, the pharmaceutical industry).
Nicolas, for one, is more positive in his appraisal of the country doctor system. The system continues to work well, he says, and is facing the challenges cited by Rodier by adjusting to modern changes while maintaining the personalized service that has served patients so well for centuries.
The decreasing number of rural practitioners has not caused as much hardship as some might believe, he says: "There is better organization now," he explains, "a system of night and weekend on-call service. We rotate among the seven doctors in the area, so once every seven nights and once every seven weekends I am on call. When I first settled in Genouillac, I would work from 8 am Monday to midday Saturday without interruption, plus the weekend on-call system was in place."
Nicolas even sees a positive side to the rationalization brought about by the decreasing number of rural practitioners, and the tendency away from doctor exclusivity. "I am the only doctor in Genouillac, but colleagues living in surrounding towns will visit a patient in Genouillac, as I visit sick people in their towns. This is most important because there needs to be a relationship built on trust between the patient and the doctor for the treatment to work. The patient has the choice between several practitioners and will confide in the one that he trusts the most."
Nicolas welcomes the advent of advanced scientific treatments but does not feel threatened by them. "In the 26 years of my practice, I have only delivered three babies and these were 'accidents'. We now have medically advanced and more effective treatment, so there is more hope that we can cure the patient. Before, country doctors felt impotent at times, but things have improved.
"However, the relationship between the doctor and the patients remains a fundamental part of the treatment. Scientific developments have changed the manner in which I work but the dynamics of patient-doctor interactions are the same. I have patients who consult with me directly after leaving hospital to verify that prescriptions are correct. There remains a strong bond of trust with the country doctor."
Of course, the country doctor still has his frustrations, the scarcity of specialist care for one. But to critics who say country doctors do not have the time or resources to devote to preventive medicine, he says patient apathy is as much an impediment to preventive health practices as the over-stretched rural doctor. "With diabetes, for example, it is hard to motivate people to take preventive measures. It is only when the disease is well advanced, that people start asking themselves questions."
He says the country doctor does have a part to play in preventive care but as part of a top-down approach. "We should continue to encourage people to have systematic check-ups and screening for the main diseases, and offer these for free."
Expanding on this theme of the compatibility of modern and traditional medicine, Nicolas says: "In medicine, there is the technology on one side, and on the other, the relationship with the patient. For me, it is a 50/50 distribution. For a sick person to heal, there is a need for technology, but there is the human side. A patient who trusts his doctor and keeps a positive attitude will heal better than someone that has the same pathology but does not trust his doctor or have high spirits. The most important thing is to strengthen the patient's morale."