Emergency Medicine in France☆,☆☆,★,★★
Introduction
France lies in the southwest corner of Europe, bounded by three seas and six countries. A surface area of 550,000 km2 sustains a population of 56 million. France is divided into 95 départements, similar to counties in the United States. Each département, although not autonomous, has a government that sets the local health care agenda. A democracy since its revolution in 1789, France has strong socialist roots and a long tradition of comprehensive social-security programs. Fully 75% of the total expenditure on health and 94% of hospitalization costs are covered through national social-security programs.1
The département of Essonne is situated just to the south of Paris. More than 1 million people live within its borders, at a density of 600 inhabitants/km2, well above the national average. Essonne is an industrial center with high traffic in people and goods: 1.5 million tons of freight and 86 million travelers move through Essonne by train each year, and 25 million travelers fly through its airspace. The highway traffic through the département is equally important: 7,611 million vehicles * km/year. Several industrial centers, including two nuclear-energy research centers at Saclay and Bruyères le Chatel and a large hydrocarbon depot, are significant potential risks for the population.2 In sum, Essonne is a region with the need and resources for first-rate emergency medicine, both in and out of the hospital.
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Medical Education
Medical school begins in France directly after the completion of high school. The first 3 years comprise basic medical sciences, with a screening examination after the first year. Those who do not pass after two attempts usually go on to allied-health professions. Hospital rotations make up the last 3 years, during which students are paid a small salary. At the end of the sixth year the student receives a certification of clinical and therapeutic synthesis. At this point, an examination may be
Emergency Medicine
As a specialty, emergency medicine does not officially exist in the French system. The most prestigious specialty in the emergency services is that of anésthesie-réanimation, a blend of anesthesiology and critical care medicine. It is a 5-year residency accessible through the internat route. In addition, generalists may do 1- or 2-year fellowships in aspects of urgent care medicine. As in the United States, physicians from other specialties can and do practice in the ED; in France, however,
Current ED Practices
We use the ED at the Hospital Center (HC) in Corbeil-Essonnes as a representative model for EDs throughout France. The département has seven short-stay hospitals, with capacities ranging from 150 to 500 beds. The HC in Corbeil-Essonnes comprises 440 beds. Its ED handles just over 21,000 visits/year (55/day). It accounts for 30% of all hospital admissions.3 Obstetric, neonatal, and pediatric emergency cases are sent, when possible, to a nearby specialty hospital.
During the day, the ED director,
Current Prehospital Emergency Care
France has a sophisticated and modern system of prehospital emergency care. It is two-tiered, with BLS fire department ambulances (VSAB) based at firehouses and physician-staffed ambulances (mobile emergency and resuscitation service, SMUR) based at hospitals.
One or two hospitals in each département, usually university hospital centers (CHU), provide telephone triage, medical control, and dispatch for the fire department and SMUR ambulances. These emergency medical aid services (SAMU) also
Legal and Financial Issues
In the United States, individual states create statutes and regulations governing the operation of EMS. In keeping with the EMS Systems Act of 1973, the federal government provides planning assistance and development funding to EMS regions—more than $530 million since 1974.4 The mandate for EMS in France, however, comes from the federal government's ministry of health. Law 86-11 of January 6, 1986, and decree 87.1005 of December 16, 1987, clarify the mission of the SAMU. Among its duties are
Challenges for the Future
It is likely that the same discussion that took place in the United States some 30 years ago over the accreditation of emergency medicine will occur in France. Given the current oversupply of physicians, some who now work in emergency medicine are resisting the creation of a specialty that might later exclude them from practicing. They are opposed by forces who believe adequate and uniform training for the practice of emergency medicine is necessary. However, many physicians who now practice
References (6)
Francoscopie
Fire Department of Essonne Internal Statistics
(1996)Hospital Center of Corbeil-Essonnes Internal Statistics
(1995)
Cited by (0)
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From the University of Connecticut School of Medicine, Farmington, CT*; the Department of Emergency Medicine, Hartford Hospital, Hartford, CT‡; and the Emergency Medical Aid Service, Essonne, France.§
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Funded in part by a grant from the University of Connecticut School of Medicine.
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Reprint no. 47/1/87278
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Address for reprints: Heikki Erik Nikkanen, 47 Selden Hill Drive, West Hartford, CT 06107-3126, 860-677-6587, Fax 860-521-2742, E-mail [email protected]