A documentary on Arte about the suffering of caregivers last week, another Thursday on Levothyrox, all the health news of the last month can be summed up in these words, confidence and mistrust. I add participation to give life to the former and silence the latter.
Caregivers' and patients' distrust of the medical institution
Qow do we have to wait for quality to finally be reintroduced into the evaluation of care? Its absence is costly, in every respect! I've done a gruesome count of how many people have died as a result of the malfunctioning of our system. Between 40,000 and 50,000 every year, the equivalent of a city like Angoulême or Bastia wiped off the map. I have not been contradicted. Even from a purely financial point of view, to deprive oneself of the quality to judge the price of an act is inconsistent. Thus, a surgeon who has to reoperate because he made a mistake during the first operation pays twice as much to his establishment! Accounting absurdity is brought to its height.
If confidence is to be restored among patients and carers alike, reintroducing quality by abandoning the strictly quantitative approach must become a priority objective. For quality is also a way of restoring meaning to the work of carers who suffer when they are deprived of it by imposing on them the same rules of productivism as in industry, as we saw in one of Elise Lucet's latest programmes  as well as in the fight carried out this summer by the nursing assistants of the EHPAD des Opalines.  The same was true of the outrageous defamation trial held on 19 September against two employees of the Moussaron Medical Education Institute (Gers) who had dared to denounce proven cases of ill-treatment.
Student distrust of general medicine
Desertification will continue; it is only to be seen this year again that medical students will continue to choose specialties such as ophthalmology and cardiology to the detriment of general medicine, which is not filling up its available places. As long as we do not rethink the organization of care, the role and functions of each health profession, desertification will continue to grow and the emergency rooms will continue to saturate.
General medicine is certainly one of the most difficult specialties to practice, both in terms of the knowledge it requires and the availability it imposes, yet general practitioners are still considered second-class doctors compared to their specialist colleagues. Their lower remuneration compared to their specialist colleagues is the most striking manifestation of this. Let us take the only example of ambulatory care, the doctrine of the moment to reduce health care expenses. Its implementation requires downstream practitioners who are available to deal with the consequences of hospitalisation. Where are they when those in practice are already overloaded or even non-existent?
Rethinking the organization of care according to the needs of the population, geography, the aspirations of professionals and digital technology is thus becoming urgent in order to restore the confidence of users and caregivers who witness, and sometimes are victims of, dysfunctions. Not to rethink it among ourselves, as has been the case for decades. The health care system is too complex to imagine that it can be overhauled without inviting all those involved to rebuild it together. Here, participation and collective intelligence are the most powerful levers for overcoming corporatism and resistance.
Defiance of vaccination
It is not new, but it is growing with each scandal, each slippage or contradiction in official and medical discourse. So much so that the defender of vaccination that I am ends up running out of arguments against some of his critics.
I note that when it comes to public health, we always move forward in the same way. First we announce a measure and present it for the good of all, and then, based on this expected collective benefit, we impose and proceed by injunction. To the point of opposing health and school by refusing access to the latter to children who have not been vaccinated!
The public health argument is admissible. After all, why would we let a whole class become infected because a parent refused to vaccinate his child? So it is not the argument that is at issue but the way in which it is enforced. To decree and not convince, to order and not persuade, as if France were populated by irresponsible and naive parents. Proof that one can be scientifically right and politically wrong. When will a State that considers its citizens as responsible people and does not hesitate to put on the table the benefits as well as the risks - they are so minor here -, the certainties as well as the doubts? When will there be politicians who, rather than imposing their decision, will share it? At the very least, we would be assured of the support of an immense majority of French people, and the vaccination rate would be no worse because in any case trust is not decreed, it is shared.
Defiance of Levothyrox®, the birth control pill and, more broadly, medications.
The list goes on and on. After statins, the Mediator®, the 3rd and 4th generation contraceptive pills, the Depakine® and now Levothyrox®. All these cases, and the human tragedies they underlie, need we remind you, reveal the serious shortcomings of our drug supply chain: lack of rigor and transparency in marketing authorization notices and in pricing, lack of post-marketing control, limited and often under-influenced knowledge of prescribers' pharmacology, inadequate security of dispensing in pharmacies, amateurism in providing information to professionals and the public, and so on.
With each "affair" mistrust sets in a little more. For example, women who give up hormonal contraception because they feel they have been lied to and have lost confidence. I have read and listened to many reactions on this subject. With the exception of Family Planning, I've heard many gynaecological specialists who had been the promoters of these pills come and explain that if women had changed, it was simply that they had become "green". This is to make us forget a little quickly the beating they have been subjected to by these same specialists. How can we continue to trust someone who has shown that his "holiday conventions" paid for by a laboratory were worth more than the health of his patients?
As a kind of cut and paste of the news.
You don't need to be a fortune teller to see the main dysfunctions in French health care. Thus, it was easy to foresee all these themes which, unfortunately, are in the headlines of this last month. But we need to go beyond this factual reading and explain why and how we have come to this point and show that there is another approach, an approach which first of all recognises this growing mistrust of our health system and which, on this basis, lays the foundations for a participatory mode of governance in which this essential trust between the patient and his doctor, between the citizen, the professional and the State, can be rebuilt. Paul Ricœur, a philosopher dear to the eyes of the President of the Republic, did not say the opposite: "The care relationship is a therapeutic alliance, a pact of care based on trust. »
Perhaps yesterday the State could have proceeded by injunction, but we are no longer in the 19th century and in the hygienist era, patients want to be co-actors in their own health, as indeed the law of 2002 invites them to do by instituting shared medical decision making. There cannot be a discourse that places the "patient at the centre" and political acts that say exactly the opposite. The citizen of 2017 no longer wants to be "prescribed" by "prescription" vaccines or changes in the composition of medicines, he wants clear and reliable explanations. Not that they refuse this or that advice, on the contrary they seek it, but they expect this advice to be accompanied by arguments and pedagogy.
The need to participate in decisions about one's health, as well as in major public health issues, has become a requirement; one only has to listen to the public debate on euthanasia to be convinced of this. And this requirement is an opportunity to transform our system. It expresses the willingness of a majority of us to get involved in favour of a medicine that is strong in the values of the National Council of Resistance, equal access and universality, and at the same time rooted in its century. The example of Levothyrox® and the digital alert of adverse events by patients themselves are indicative of this paradigm shift. The problem, the major obstacle to seizing this opportunity, is that a significant number of health professionals are not ready for it and politicians do not seem to have perceived it to its full extent.
Antoine Vial is a public health expert and co-founder of the Forum des Living Labs en santé et autonomie. He has been at the head of multimedia projects for health professionals (television, Internet) as well as for 20 years as executive producer and presenter of medical programs on France Culture. He was a member of the Information and Dissemination of Medical Information Commission of the French High Authority for Health (HAS). He is a member of Prescrire's Board of Directors.
Author of " Santé, le trésor menacé " - Editions L'Atalante
1] Cash investigation France 2 - 14 September 2017
2] Three months of strikes to denounce working conditions that lead to the abuse of residents.