Why French doctors still make house calls

PARIS — The custom of doctors who make house calls is no relic from the past in France, but a more modern innovation.

In the summer of 1966, the doctor Marcel Lascar reported to work on a Monday and learned that one of his heart patients had died over the weekend because he couldn’t reach a physician. Lascar recalled that his bathroom had flooded one weekend and he had no trouble calling an emergency number for a repairman. Why couldn’t it work the same to reach for a doctor?

It turned out it could, and SOS Medecins was born. Today, the service boasts a network of about 1,000 full-time doctors, working through 60 regional associations and covering two thirds of the country, including the overseas departments, said Serge Smadja, the organization’s general secretary. More than 4 million calls per year yield some 2.5 million home visits by general practitioners who treat non-life-threatening illnesses ranging from high fevers to bronchitis, gastric pain to depression.

The doctors carry stethoscopes, but EKG machines, diagnostic equipment for urine samples or blood tests, and even vaccines are also part of the doctors’ wide-ranging arsenal.

In the complex web of French medical bureaucracy, door-to-door service seems straightforward. The cost is slightly more than the standard 22 euros for an office visit and it is reimbursed under the country’s universal health insurance plan. Smadja said patients widely use but don’t abuse the privilege because for most people, "it’s not fun for them to see a doctor.”

“This is the French model of national solidarity, which is expensive to taxpayers, since they are the ones who pay in the end, but that is the inherent quality of the system,” Smadja wrote in an e-mail message.

In fact, Smadja said, the services saves the government money by collaborating with other emergency services as well as the French Institute for Public Health Surveillance. Home visits reduce the burden on emergency rooms and ambulance services, keeping them from becoming unnecessarily overwhelmed, Smadja said.

The SAMU, or Emergency Medical Assistance Service, takes emergency calls, while SOS Medecins responds to non-emergencies, so that calls that don’t require immediate attention don’t hamper the critical care of others.

During the deadly 2003 heat wave, the government learned how valuable the home visits could be. Nearly 15,000 people died that August, many of them elderly.

The public health institute existed prior to 2003, but it wasn’t until the heat wave that it became apparent how useful gathering, analyzing and sharing information about patients would have been. Had the kind of cooperation that developed post-2003 existed, doctors might have realized sooner that so many people were dying and could have taken action. Each night, the data from the calls that come into SOS are fed into a database that is analyzed by the institute the next morning for signs of any patterns.

“Going [to one’s home] provides information that is extremely precious, that we wouldn’t get from an office visit,” Smadja said.

And thanks to a shared database of information culled when patients call SOS, the institute can pinpoint when and where epidemics break out, issue an alert and coordinate a response. This winter, doctors noticed and reacted to a high number of flu, bronchitis and acute gastroenteritis cases, said Daniele Iles, a doctor with the institute. Additional data collected from hospitals and walk-in services showed an increase in asthma.

Despite its track record, SOS is not immune to proposals in France for health care reforms to cut costs and improve efficiency.

For example, the National Assembly is debating whether to allow doctors to choose where they will live and practice or require them to move to regions that are becoming medical wastelands.

While there is no shortage of generalists on the French Riviera, people have to drive long distances to find a hospital in some villages in northern France, Smadja said. But concerns over not having enough doctors in small villages seems to be getting lost in the din over other proposed health care reforms.

Meanwhile, fewer medical students are choosing general medicine. And although more women are entering the field, they are less likely and less willing to join a service that requires working on the weekends and in the middle of the night. The government is considering incentives such as free housing or tax breaks, said Smadja, who did not think doctors should be forced to live somewhere they do not wish.

He also recommended that more medical schools provide training and field experience in emergency medicine, a specialty that requires a vast knowledge and competence in order to administer the correct care and comfort a patient quickly. When doctors discover exactly what it means to work for SOS, they enjoy the challenge, Smadja said.

“When they come to us, they stay,” he said. “It’s a passionate medicine.”
 

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