Management of Cardiovascular Disease by Primary Care Physicians in France: Lessons from the Seine

The paper by Schuster and colleagues ¹ in this issue of the Journal raises provocative questions. “The French Paradox”—so named because of the surprisingly low rate of cardiovascular disease in France compared with other European countries and the United States, and thought due to red wine consumption or other factors—has been the focus of almost endless debate. ² What this survey suggests are other variables that US physicians, insurers, and health systems should consider. A picture emerges of French physicians spending more time with patients, relying more regularly on electronic health records (EHRs), using evidenced‐based guidelines, and, based on questions pertaining to levels of frustration, having more “fun” in the practice of medicine. Clearly much—if not all—of this is directed by the state‐run health system. ³

Should we be surprised that there may be a connection between time spent with patients, use of EHRs, and improved outcomes? Physicians would say, “hardly.” More interesting is greater reliance on lifestyle/counseling and less on medication, despite no added expense to patients. This may validate many study findings, such as those of the Diabetes Prevention Program, which found that lifestyle changes were more effective than medication to reduce the future risk of diabetes. Another interesting observation by the authors is that French physicians probably engage in a more intense interaction with their patients related to cardiovascular disease risk factors. Is this related to having more time with patients, or something else? Perhaps French physicians have longer, more established patient relationships and are more comfortable with intense interactions.

Thus, the provocative questions include: do we over‐rely on medication vs lifestyle counseling, will our investment in EHRs not only reduce waste (overutilization) but also improve outcomes, and is there a link between physician satisfaction and patient outcomes? As the authors state, this is one of those studies that may raise more questions than answers.

Finally, let’s assume, even with limitations, that these findings are true. What can we expect with health care reform and the issues raised by Schuster and his associates? Sadly, given the great imbalance in supply vs demand of primary care physicians and millions of patients who will enter the health care system with some form of insurance, our ability to increase time with lifestyle counseling will not only decrease but will be further constrained. Physician satisfaction is already low and, with reimbursement changes, are likely to further drop. There are incentives to more widely use EHRs. Taken together, one of the central concepts—intensity of the doctor‐patient interaction—will go down, not up.

Perhaps a forward‐thinking insurer reads this paper and considers it a pilot study that incentivizes its physicians to spend more time with patients (at least those with cardiovascular disease), demonstrates attention to lifestyle counseling, and makes guidelines and electronics readily available to its providers. I welcome the opportunity to see what they find.