French ophthalmology at a turning point?
They might bicker about binocular vision, lock horns over LASIK and agonise about the pros and cons of acrylic implants, but when it comes to discussing the future of their profession French ophthalmologists all tend to sing from the same hymn sheet.
Their song, if not actually a lament for a profession in crisis, is certainly an angry and plaintive cri du coeur for radical change across the board.
"Ophthalmology in France is reaching a critical moment in its history and it is essential that appropriate action is taken not just to safeguard our members, but also to ensure that the health needs of the population are adequately met in the future," said Jean-Luc Seegmuller, MD, president of the Syndicat National des Ophthalmologistes de France (SNOF).
There are several pressing problems facing ophthalmologists in France: demographic, political and economic.
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. Although the number of medical students opting for ophthalmology as a chosen career has remained relatively high at about 80 per year, those numbers are not sufficient to maintain adequate coverage for the future.
There are currently nearly 5,300 ophthalmologists in France, serving a population of 60 million people, with most specialists based in major metropolitan areas.
As the current batch of practicing ophthalmologists reaches retirement age, the current quota graduating each year is not enough to plug the gaps in coverage, especially in the more sparsely populated areas of France.
Survey shows widespread concern
A recent survey by SNOF sent to all ophthalmologists in France underscored just how deeply this issue is affecting the morale of the profession in France.
More than 80% of respondents said they believed that the issue was extremely serious, while 84% said that they were very worried for the future and that radical measures were needed to tackle the problem. A massive 95% believed that ophthalmologists needed to take urgent action to defend their interests.
The first obvious step is an increase in ophthalmologists graduating every year, from the current number of 60 to around 180-200, according to SNOF.
Failure to ensure a steady infusion of young blood into the profession will ultimately take its toll on the standard of eye care afforded to the general population. "There can be no underestimating the seriousness of the situation. Ocular diseases such as glaucoma, cataract, diabetes mellitus, age-related macular degeneration as well as visual dysfunction in children require detection and care that cannot currently be totally ensured. And the situation will get worse in the coming years as life expectancy grows longer," warned Henry Hamard MD of the French Academy of Medicine, who recently chaired a team which issued a report on the current situation regarding ophthalmologists to the French Ministry of Health.
To illustrate the point, Dr Hamard said that there are an estimated 500,000 to 700,000 cases of glaucoma that are currently going untreated or undetected in France; another 800,000 diabetics in France were missing out on proper ophthalmic care, while not enough was being done to address problems of age-related macular degeneration which affected an estimated 10% of the population over 70 and 20% over 80 years of age.
Even more troubling, he believed, were the statistics regarding visual dysfunctions in children: "France has a lot of catching up to do in this domain.
One child in every five suffers from visual problems and it has been estimated that 40% of visual dysfunctions in young people are going undetected because of insufficient resources."
Another thorn in the side of ophthalmologists is the changing landscape regarding eye care in France. While ophthalmologists are the acknowledged experts for eye care and treatment, their traditional non-surgical role for conducting eye examinations and prescribing eyeglasses and contact lenses has been steadily eroded in recent years.
In an effort to slash costs, the French Ministry for Health has encouraged an expanded role for opticians, 200 or so of whom graduate annually after following a two- or three-year course. SNOF estimates that there are between 12,000 and 16,000 opticians (24,000 if one includes assistants without the full opticians’ diploma) operating in 8,000 specialist stores throughout France. By giving opticians the right to supply, sell and fit spectacles and contact lenses, the Ministry has effectively taken ophthalmologists out of the commercial equation.
Adding to this sense of grievance is the fact that charges for ophthalmic consultations and refractive and cataract procedures– unlike other medical specialist health care – have remained largely static for eight years – while labour, equipment and running costs for ophthalmologists have all risen sharply.
A particular bone of contention for French ophthalmologists is the increasing number of optometrists plying their trade in France.
Optometry has no official status under French health regulations and ophthalmologists believe that they should not be allowed to operate as quasi-medical practitioners, as this could ultimately undermine standards of eye care for the public.
Tighter controls proposed
Philippe Sourdille MD, of the Clinique Sourdille in Nantes, agrees that tighter controls need to be placed on optometrists: "I have been in favour of optometrists training under ophthalmologists’ control but we should not or will not accept a situation that would lead to UK or American habits.
It is clear to me that optometrists can be excellent cooperators in certain circumstances but they cannot assume the role of pseudo-medical practitioners."
Thierry Bour, MD, an ophthalmologist in Metz who serves on the SNOF commission for rules and regulations, believes even stronger measures are needed.
"We have to look carefully at what has happened in other countries such as the United States, United Kingdom, Canada and Australia where the rise of optometry has frequently led to confusion and conflict and helped to undermine the role of ophthalmologists."
Dr Bour cited the recent survey by SNOF that found that only 3% of ophthalmologists were in favour of optometrists being allowed to ply their trade in France. Despite this, however, a majority believed that laws governing European medical practice would make it next to impossible to actually stop them practicing.
To help counter the influence of optometrists, Dr Henry Hamard, in his report endorsed by the French National Academy of Medecine called for an increase in the training and recruitment of orthoptists, whom he called the "natural collaborators" of ophthalmologists.
He also proposed measures to encourage more ophthalmologists to set up practice in areas currently neglected or underserved by health authorities and to establish a network of low vision clinics in strategic locations around France
While the problems facing French ophthalmology are daunting, the feeling on the ground is that the grass-roots members are finally mobilizing in a concerted fashion to defend both their interests and those of their patients.
Philippe Sourdille argues that nothing less than a "cultural revolution" will help to turn back the tide of years of bad legislation, changing practices and widespread apathy that have contributed to the present malaise.
While he sees the current mobilization in France as an encouraging sign of the determination to effect change for the betterment of the ophthalmic industry, he believes that a pan-European effort is urgently needed to stave off the deleterious impact of U.S.-led commercial interests. "With the growing influence of American industry, we European ophthalmologists are slowly becoming ‘customers only’ or ‘promoters only’ of this industry. What we want, what we need and what we deserve is national and/or European-owned and driven industry to represent, promote and help Europe’s unique creativity in this domain. That would be a real revolution!"
Thierry Bour, MD,
60 rue Serpenoise, 57000 METZ
Fax : 03.87.18.83.94.
Philippe Sourdille, MD,
Tel : +33 545212551
Jean-Luc Seegmuller, MD,
1 rue des Pucelles,
F 6700 Strasbourg
Tel :+33 3 88 35 01 09
Fax: +33 3 88 25 51 90
Henry Hamard, MD
Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts,
28, rue de Charenton, 75012 Paris
Tel : :+33 1 40 02 12 10
Fax : :+33 1 40 02 12 99