SENIOR ELECTIVE IN GENERAL MEDICINE WITH SPECIAL REFERENCE TO RHEUMATOLOGY & DIABETOLOGY
AIX-EN-PROVENCE, PROVENCE, FRANCE
Dr Helen Greener
Organising an elective is a pain in the neck. Surfing the web to find a hospital in the area you want to visit with a specialty that will not bore you to death, finding someone willing to take on a strange student from a weird country, scraping together the money to make the whole thing feasible and then deciding what is truly an essential item for your backpack can be time consuming and irritating. Can a girl live without her hairdryer and four different shades of lipstick? Having already been through the process for my junior elective, I know the answer is yes, and so decided to undertake the project myself.
I lived in France before going to University and set my heart on an elective in the South. Not only would I have the opportunity to acquire new knowledge and skills, practice my French and learn essential medical vocabulary but also travel in a beautiful part of world I had never visited before. The obvious appeal of sun, sand, sea and some serious eating and drinking was a peripheral aspect of my decision to apply to a hospital in Provence. It only took a couple of emails before I had managed to con an unsuspecting consultant in a general medical ward into accepting me for a month.
When I arrived at the unit I was immediately struck by the patient-centred set up of the ward. The main ward consisted of 16 small rooms shared by not more than two patients. Each shared room had an ensuite bathroom and its own television while patients with less straightforward circumstances, a young man with terminal lung cancer for example, were accommodated in single rooms with balconies. In light of my previous experience, the layout seemed ideal, for both patients and staff. Patients and their families were afforded a greater degree of privacy while staff were able to concentrate on individual patients without the interference of a busy ward. In fairness, the hospital was a recently built centre and probably not the busiest and I wondered if this coloured my impression of medical care in France. In Glasgow, I have generally found myself in older, larger hospitals. The Glasgow Royal Infirmary, for example, has huge, Victorian style wards with all the seclusion of a traffic island on Spaghetti Junction. The people I met were shocked but not surprised by my horror stories, as healthcare in Britain already has an awful reputation without my additional input.
Originally, I had planned an elective in diabetes and general medicine and the hospital had a well-equipped unit concerned with diabetes and endocrinology. When I arrived I discovered that several members of staff would be on holiday during my stay. It had been hard enough to find dates during the summer when the general medical department was not on summer break (summer break – what luxury) so I was quite disappointed. However, I was able to extend the remit of my original aims and objectives to include rheumatology. My supervisor was head of the internal medicine unit but a rheumatologist by trade. I was exposed to a variety of conditions, most of which I was already familiar with, however, I learned a great deal about the way the French medical system differs from our own.
Firstly, I joined the Diabetes and Endocrinology team on ward rounds. Here I encountered some linguistic difficulties as eponymous diseases are frequently named after someone else. Basedow’s disease for example sounded like an unusual and interesting condition until I realised they were on about Grave’s disease. And this kept happening. I did not feel that I learnt a great deal about the management of diabetes whilst on the ward itself as protocols were similar to those in Britain. However, I attended several out patient clinics where I gained a greater understanding of holistic care and risk factors in diabetes. The clinics were well organised with a wealth of accessible information on offer regarding all aspects of diabetic treatment at all stages of life. The clinic had a wide range of patients on its books and I thought it offered comprehensive, in depth care to all its patients. Apart from several specialist doctors the clinic offered the services of an extremely experienced podiatrist. He used treatment which I had no knowledge of, employing shoe insoles to redistribute weight and change the pressure points on the foot. This proved very effective and was utilised both as a preventative measure and to directly treat pathology such as diabetic ulcers. A diabetic nurse and chiropodist completed the team.
Rheumatological and general medical cases were grouped together. Whilst following this team I quickly acquired more vocabulary. Drugs presented a problem as they tended to avoid generic names, which was rather confusing as many drugs are marketed under different names in different countries. This hindered my progress in learning about management in rheumatology, as I was less familiar with the drugs to start with. However, I did have the opportunity to observe several interventions I was previously unaware of, namely infiltration in spinal disc disease. I felt the threshold for admission in these cases was lower as I have mainly seen this condition in the community and rarely on the wards in Britain. It also seemed that, in general, healthcare professionals have a much more interventional attitude towards diseases with underlying, demonstrable pathology. On the other hand, the use of placebo drugs appeared more acceptable and one of the rheumatologists occasionally used placebos in the management of patients with chronic pain of no identifiable cause. Although I was somewhat sceptical of this approach, we discussed studies regarding its administration and anecdotal evidence of her own, which was quite convincing. She had found it particularly useful in treating fibromyalgia. However, the ethical side of their use was were we differed and I couldn’t help but feel that it required an extremely paternalistic view towards patients aside from the issues surrounding informed consent.
Overall, the level of care patients received whilst on the ward impressed me. But, obviously, such high standards require funding, which is currently lacking in the UK. The financial aspects of the French system were extremely complicated and, perhaps most importantly, healthcare is not free at the point of entry. Although a patient must pay to visit their GP, most of this initial cost is refunded by the state. Hospital stays are not free either; a patient is expected to pay around £70 a night, regardless of the treatment they receive during their stay. Most people have insurance that covers this but, like the American system, certain groups of patients fall through the net. To try to ensure that patients with chronic disease that may become costly are not penalised, around 100 conditions are certified as “cent pourcent”. Thus patients suffering from these conditions are fully refunded by the state. Nonetheless, it saddened me to see several patients refuse further treatment, as the stay in hospital would be too expensive.
I enjoyed my elective in France and felt I had learned a great deal that may prove useful in the future. Although I have spent a great deal of time in country, I had never had the opportunity to be involved in a professional capacity before. It allowed me to be involved in the care of a variety of patients, which was extremely stimulating. I would like to work abroad in the future and I feel better equipped in terms of language skills, an understanding of other approaches to disease and, hopefully, the experience will help me reach my goals in the future. I would strongly recommend the area to anyone considering an elective in France. The hospital was a lovely place to work and the touristy stuff in the area is great. Where else can you see flamingos, bull fighting, gypsies and breathtaking scenery; eat and drink yourself into a coma in some of the most famous restaurants and cafes outside Paris; get yourself a tan that Coco Chanel would be jealous of and still have time to learn something constructive about pain control in rheumatological conditions?
The whole experience was fantastic and thank you for helping me to make the most of it!