French ophthalmologists hopeful for changes with new government

A shortage of ophthalmologists, conflicts over opticians’ role and a need for more health resources are lobbying issues.

STRASBOURG — Representatives of the French union of ophthalmologists here are on a mission. It has been nearly 7 years since the French government mandated a restriction on the number of ophthalmologists trained each year. A resulting shortage of specialists has prompted a call to arms for lobbying ophthalmologists.

Today in France there are slightly more than 5,000 practicing ophthalmologists. Most specialists reside in major cities. This means that already there are geographic gaps that will only widen if the shortage of ophthalmologists worsens.

“In 15 years, there will be more than 20% fewer ophthalmologists than today. By 2020, we will have 44% fewer ophthalmologists than we already have,” said Jean-Luc Seegmuller, MD, president of the Syndicat National des Ophthalmologistes de France (SNOF), the national trade union of ophthalmologists. According to Dr. Seegmuller, eye care staffing resources will decrease at the same time that eye health problems will increase by 15% due to an aging population.

“This problem is critical,” Jean-Antoine Bernard, MD, director of the Society of French Ophthalmologists (SFO), told Ocular Surgery News. “Only 50 to 60 ophthalmologists are graduating from university each year.”

In a country of 60 million that is only one new ophthalmologist per million population per year. In order to maintain enough ophthalmologists to care for the French population, three times as many ophthalmologists would have to graduate medical school yearly, or 180 per year, according to the SNOF.

“Unless swift action is taken, ophthalmology will eventually be greatly crippled by this loss of doctors,” Dr. Bernard said.

Fewer eye doctors

Philippe Sourdille, MD, agreed. “Right now, the average patient treated by the average ophthalmologist gets high quality care, but we really don’t know how long this is possible,” said Dr. Sourdille, head of the Clinique Sourdille in Nantes.

The power to change this situation lies with the political party of French President Jacques Chirac, the Union for the Presidential Majority, a rightist organization that ophthalmologists believe will benefit their cause.

“We believe that the new administration is concerned with our problem, and our voices will be heard,” Dr. Bernard said.

Currently, Dr. Bernard said, the new government is initiating a “slight movement” toward increasing the numbers of practicing physicians and specialists throughout France.

Up until now, he said, ophthalmologists had been voices crying in the wilderness. The French ministry of health (Ministére de la Santé) has come under fire for its current health care policy.

“While decreasing the number of eye doctors available, the former health minister had strong intentions of increasing the number of opticians,” said Jean-Louis Douenne, MD, director of St. John de Luz Clinic, an ambulatory surgery center.

“The government planned to have all basic eye exams performed in an optician shop to avoid paying the expenses of the consulting eye doctor. More and more opticians began to open businesses where they would sell spectacles and contact lenses to patients,” Dr. Douenne said.

In an effort to cut health care costs, the ministry of health began to encourage opticians to set up shop. Opticians are permitted only to prescribe and sell spectacles and contact lenses. Today, in France, nearly 200 opticians graduate yearly from 2- or 3-year educational programs in optics — 150 more per year than ophthalmologists.

Some opticians obtain a 6-month degree in optometry. While optometry as a profession is not officially acknowledged by the French government, the degree is used by opticians to enhance their credentials.

Dr. Douenne said patients who received prescriptions from an optician paid for their spectacles out of their own pockets. However, patients who came to the optical shop with a prescription from their ophthalmologist had their spectacles partially paid for by the health insurance system, Dr. Douenne explained.

In time, the government realized that by cutting the ophthalmologist “middleman” out of the business transaction, health reimbursement fees to referring ophthalmologists could be reduced.

“Ophthalmologists began operating under the assumption that their trade was beginning to be phased out by a government that cared more about the health of their pocket books than the health of their people,” Dr. Bernard said.

“Just like in other industrialized countries, ophthalmologists became less regarded than we used to be. We get less money from the government. This has been a constant evolution,” Dr. Sourdille said.

Limiting opticians’ role

This progression of events prompted an alliance among the SNOF, the SFO, the Federation of the Academy of Ophthalmology and national and local ophthalmological organizations, to push for the re-evaluation of the regulations of the French Ministry of Health.

“All of these organizations are pushing for change,” Dr. Bernard said. “Not only are we asking for the required amount of ophthalmology trainees each year, but we are asking the government to limit the role of the optician to its current regulations.”

“At this point, the new government has not increased the duties of the optician, but we fear there could be an increase in their future role,” Dr. Douenne added. According to Dr. Douenne, the increasing number of opticians, coupled with the former government’s desire to increase their role in eye care, poses a threat to ophthalmology as a whole.

“We feel that it is dangerous for a patient to go solely to an optician for a visual examination,” he said. “Opticians or optometrists do not have sufficient knowledge of ocular pathology to be the only health care worker who sees the patient.”

Dr. Bernard agreed. “Opticians should not be allowed to commit medical acts beyond their realm of prescribing eye spectacles and contact lenses,” he said. “Non-ophthalmologists are not medically qualified to make these decisions. Opticians cannot give comprehensive eye examinations. They cannot detect diseases that present with ocular symptoms like diabetes, cancer, glaucoma or age-related macular degeneration. Opticians can only measure refraction, they can’t measure intraocular pressure, photograph the fundus, or carry out prevention. This is our concern”

“We are worried,” Dr. Douenne said. “By encouraging the population to patronize optician shops, a large segment of the population may be left with undetected diseases that are easily diagnosed in the eye doctor’s office.”

For these reasons, Dr. Bernard said, it is a critical that the SNOF make clear to the government the dangers and risks involved in letting a broad range of vision services fall onto the optician.

Dangers of misdiagnosis

According to Dr. Douenne, some of these potential risks have already materialized.

“Misdiagnoses have already become an occurrence,” he said.

In a recent case, a patient of a colleague of Dr. Douenne visited the ophthalmologist with an extremely red eye.

“The patient had just come from an optician shop with the diagnosis of conjunctivitis,” Dr. Douenne said. “My colleague friend looked closer and discovered it was not conjunctivitis at all, but a severe problem stemming from the brain.”

It is not only medical, but ethical concerns about opticians performing eye care duties that have ophthalmologists feeling the wind of danger.

“We feel that there are ethical dangers surrounding a person who prescribes for and sells their own wares,” Dr. Bernard said. “Who is to say that that person won’t prescribe more often, more than the doctor would, in order to keep a flourishing business?”

“We believe that splitting the duties of prescribing and selling the spectacles is more ethical,” Dr. Douenne said. “The doctor is more likely to prescribe spectacles only if the patient needs them. He will prescribe only the strength or correction needed.”

Comprehensive care

Amidst these concerns, optician shops continue to thrive in France.

“Optician shops are convenient for people to visit. There is one opening up in every corner in the cities. Patients can hop in, get checked for their refraction, receive spectacles and be on their way,” Dr. Douenne said.

“It’s a very easy and accessible way to obtain spectacles — with the shortage of ophthalmologists in France right now, there is a long wait for ophthalmic care,” Dr. Bernard said.

“It’s true,” Dr. Douenne added. “Patients can wait up to 1 month in a city clinic, and up to 6 months in rural areas to see an eye doctor.”

To remedy this problem, ophthalmologists are searching for new ways of putting the focus back on comprehensive care.

“There is currently a partnership in the works that will promote joint ventures between ophthalmologists and paramedical workers,” Dr. Bernard said.

Paramedical workers, specifically orthoptists, are aggressively being integrated by SNOF and the French union of orthoptists into more hospitals, universities and practices to bring more comprehensive care to the ophthalmology unit.

“In the past, a lot of orthoptists would work alone in their offices or in orthoptist centers, but now there is a movement to combine their specialty with ophthalmology,” Dr. Douenne said.

Orthoptists specialize in strabismus, binocular vision and the optical system. They have an understanding of the technology aimed at detection and prevention of ocular conditions, Dr. Bernard said.

“Orthoptists have a real knowledge of paramedical sciences. They are more thoroughly educated in the eye than opticians, and they manage to prescribe more accurately,” he said.

Ophthalmologists hope that with partnerships with orthoptists, ophthalmological services will be seen as more cost-effective by the Ministry of Health.

“By promoting joint ventures, we will be optimizing our resources and offering more comprehensive care in less time than it takes now,” Dr. Douenne said. “This seems to be a much better, safer and more inclusive alternative to optician shops.”

“We are hopeful that the newly elected government will allow us to evolve toward more comprehensive care within the ophthalmology office,” Dr. Sourdille added.

Updating care

To provide comprehensive care, ophthalmologists also need more financial allowances from the government to perform at an optimum level, Dr. Sourdille said.

“We have growing needs. We need to supply more complete care in the fields of amblyopia and childhood vision. Research in age-related macular degeneration and neuroscience also needs to be supported more aggressively. We also need to keep up with new technology and devices. In the field of refractive surgery — specifically diagnostics and evaluation — there needs to be a greater focus on attaining the most advanced systems,” he said.

“Being reimbursed for new technology and offering more hours of education is something that still needs to be defined in the health sector,” Dr. Douenne agreed.

Dr. Sourdille said that French ophthalmologists, and their counterparts throughout Europe, must aggressively “support their national ophthalmic industries more than they currently do.”

“It will become difficult for our younger French colleagues to be listened to, to express their creativity, and to represent the real potential of our country, if we continue to put our trust and our efforts into non-European based companies,” Dr. Sourdille said. “To American industry, we are considered their customers, not their partners.”

According to Dr. Sourdille, the fate of the European ophthalmic industry and other aspects of ophthalmology rests on the ability of ophthalmologists to propose solutions, teach proper personnel, incorporate more paramedical workers and address the situation with political will.

“We certainly need to campaign and lobby on these issues,” Dr. Sourdille added.

“Our union has given us strength and support and will continue to do so until our voices and fears are heard,” Dr. Bernard said. “We are confident that the new government authority will put their trust in our judgement and make amends for the safety of our people.”

For Your Information:

• Jean-Luc Seegmuller, MD, president of the Syndicat National des Ophthalmologistes de France, can be reached at 1, Rue des Pucelles, F 6700 Strasbourg; +(33) 3-88-35-01-09; fax: +(33) 3-88-25-51-90.
• Jean-Antoine Bernard, MD, can be reached at 1 Rue Scheffer, Paris, France; +(33) 1-45-20-57-89; fax: +(33) 1-40-50-68-63; e-mail: jabernard@sfo.asso.fr. Dr Bernard is a paid consultant for France Chirurgie Instrumentation.
• jabernard@sfo.asso.frjabernard@sfo.asso.fr can be reached at Clinique Sourdille, 8 Rue Camille Flammarion, 44000 Nantes, France; +(33) 251-83-32-00; fax: +(33) 251-83-87-19; e-mail: philippe.sourdille@wanadoo.fr.
• Jean-Louis Douenne, MD, can be reached at the Luz Clinic, 64500 Saint John de Luz; France; + (33) 559-513-344; douenne@wanadoo.fr.