Current challenges of ophthalmology in France

To comprehend the current challenges that French ophthalmic care is facing, one has first to appreciate the system and the changes that have occurred over the years leading to the current situation. French ophthalmic care is organized differently from its British and American counterparts and resembles its European neighbors. It follows a basic principle of the French medical practice which should guarantee a strict separation of medical care and prescription from commercial sales. Ophthalmologists and orthoptists, provide care to a patient, on one hand. Pharmacists and opticians on the other hand, enter commercial transactions with a client. The ophthalmologist is the center of the ophthalmic care, performing regular ophthalmic examination, prescribing glasses, contact lenses and supervising their tolerance, as well as performing ophthalmic surgery. The French ophthalmologist works closely in relation with orthoptists who can provide additional examinations, such as visual field tests, strabismus or low vision aid rehabilitation and opticians who provide glasses and contact lenses upon medical prescription. French patients are free to choose their practitioner and the National Health Insurance, la Sécurité Sociale, covers about 70 to 80% of the ophthalmologists and orthoptists fees whereas fees for optics and even more for low vision aid devices have never been well reimbursed and would be covered by optional private insurances. During recent years, optometrists have been trained through schools of optics and masters delivered by 2 scientific universities. However, their status is not well defined by the Health authorities, their potential fees for private consultations resulting in glasses prescription and delivery would not be covered by the National Health Insurance and their role in the scheme of French eye care is a recurrent and often passionate matter of debate.

The number of practicing ophthalmologists in France is currently estimated at about 5300 (5354 from the last census reported in 2009 by the French national medical council¹). This number has been stable over the past 15 years. Thus, for a general population reaching nearly 63 million, there are fewer than 9 ophthalmologists for 100 000 inhabitants, similar to Germany but lower than other European countries such as Belgium and Czech Republic (10 per 100 000), Italy and Spain (12 per 100 000) or Greece (14 per 100 000).³

Among practicing ophthalmologists, 43.5% are women. In comparison, 38.8% of all medical doctors are female. This percentage is even higher for the age range below 55, corresponding to the feminization of the medical profession.³

About 61% of practicing ophthalmologists are working only in private practice which is usually organized between a private office for ophthalmic examinations and a private clinic for surgical sessions.¹ The distribution of these private practitioners across France is not uniform with a higher concentration in metropolitan areas, the Parisian region and the South of France and a real scarcity in rural areas and in Northern France.

For the past 15 years, especially in metropolitan areas, the traditional model of a single-ophthalmologist private setting has largely been replaced by practices of 3 or more ophthalmologists, with often complementary expertise, who can appoint a secretary, an accountant, orthoptists and nurses. Some of these offices are equipped with the state-of-the art imaging techniques, visual field testing and even with visual electrophysiology. Group practices create a more favorable financial environment for purchase of modern and expensive equipment. Private offices seldom provide space for outpatient surgery. However, some practices can provide laser treatment, as well as, suitable facilities for photodynamic therapy or intravitreal injections. Such settings provide efficient care competing with public services with often dynamic medical discussions within and around the group similar to teaching hospitals, with the only additional pressure of productivity to repay loans contracted for equipment purchase.

Aside from the 61% in private practice, an additional 13% are employed either by small private health centers or public hospitals, including academic centers.¹ Moreover, 26% of practicing ophthalmologists work both in private and public practice, often keeping one or 2 clinical or surgical sessions in the hospital where they have been trained.¹

The average age of practicing ophthalmologists is 49, with fewer ophthalmologists below 45 than above 55, reflecting the progressive aging of the ophthalmic population and rising concerns for the next 10 to 20 years.³ As the current group of practicing ophthalmologist retires, the number of graduating ophthalmologists each year, which is currently around 80, will not be sufficient to replace retirement and will increased disparity in care coverage, especially in the more sparsely populated areas of France. In fact, the number of ophthalmologist would decrease by 35% during the next 15 years.⁴ This projection applies not only to ophthalmologists but also to other specialists such as dermatologists and even to general practitioners. Reasons given for this situation include the selective access established in the 1970s to enter medical school and subsequently to enroll in a residency program in the 1980s, resulting in a 50% decrease of ophthalmologists trained per year. On the other hand, ophthalmology faces challenges generated by the increase of the French population, its aging and also the need to implement novel techniques and treatments as well as to establish a workable plan of preventive medicine. Many professionals have rung the alarm for more than 20 years including the National Union of French Ophthalmologists which has been very active in surveying practitioners, promoting debate and proposing solutions to avoid a critical situation.^{5, 6}

Solutions are currently implemented to face the shortage in ophthalmologists and maintain an up-to-date standard of care, with free access to all. The obvious measure has been to gradually increase the number of trained ophthalmologist per year. Ideally, doubling this number within 5 years would ensure an appropriate replacement for retirement and this would only represent an additional 1.5 residents trained per year for each university center.⁵ Emphasis is also given on improving surgical training with a plan to add a year to ophthalmology residency, passing it from 4 to 5 years. This measure would ensure a sufficient number of well-trained ophthalmic surgeons to serve the additional load of cataract surgery generated by aging of the population. In addition, despite the absence of postgraduate recertification in France, the health ministry has implemented a mandatory requirement for post-university training in 2001.^7,8 Furthermore, the French Ophthalmology Society with the National Union of French Ophthalmologists have produced guidelines on good ophthalmological practice, procedures and example of informed consent forms for special ophthalmic procedures.^9,10 Although these documents have no legal standing, they are valuable in informing and helping ophthalmologists to keep an up-to-date practice.

To ensure better geographical distribution of care, local initiatives have been proposed and encouraged. Some local authorities are providing free office space, surgical facilities as well as facilitating housing and support for young ophthalmologists. In addition, a new status of replacing practitioner, médecin remplaçant, is created to encourage mobility for ophthalmologists unwilling to establish a permanent practice and flexible enough to adapt their activities toward available locum work. Furthermore, well-qualified ophthalmologists from other European countries with no shortage of ophthalmologists have been encouraged to come and practice in France.

Along with increasing the number of ophthalmologists, the other efforts has been to increase the training and recruitment of orthoptists, the “historical partners” of French ophthalmologists and increase the number of tasks that could be delegated to them under medical supervision.¹¹ For the vast majority of French ophthalmologists, this would be the best solution and more logical than introducing a new partner, the optometrist, within the French ophthalmic landscape.

In addition, further efforts have been made to reinforce cooperation between the public and private sector and encourage the creation of health networks oriented toward preventive medicine with the help of telemedicine and mobile ophthalmic units. In collaboration with local ophthalmologists and often at their initiative, campaigns have been organized to improve early diagnosis of glaucoma, diabetic retinopathy, AMD and child amblyopia. Such campaigns are particularly relevant in regions with low ophthalmic coverage. With the aging of the population and the increase of AMD prevalence, efforts are also given to low vision aid rehabilitation. Orthoptists and opticians would be major players in these efforts.

The future will reveal if these measures will be sufficient to fulfill the overall objectives of eye care in France: to ensure an available and transparent system for the patient, to provide ethical care free from conflict of interest, to create an efficient prevention strategy within a coherent public health system, and to moderate the economic cost for the best coverage of entire population.