Fall 2018 (Volume 28, Number 3)
France and Canada: Rheumatology on Both Sides of the Atlantic
By Laëtitia Michou, MD, PhD
Never during my medical studies in France had I foreseen becoming a rheumatologist in Canada. And yet, in a few weeks, I will be starting my twelfth year as a clinical researcher in rheumatology in Québec. My passion for research gave me the courage to venture to the North American continent.
When I arrived here after several years in university hospitals in Paris, I was quite surprised to see such a large number of female rheumatologists, including in university settings. However, in absolute terms, there are 3.4 rheumatologists per 100,000 people in France, compared to only 1.2 in Canada. The absence of an intra-hospital hierarchy and the commitment to gender parity, regardless of seniority or type of practice (university vs. non-university hospital or a private office), were quite pleasant discoveries.
In France, rheumatology is a broad field that encompasses systemic inflammatory diseases, metabolic bone diseases, so-called interventional rheumatology with ultrasound/X-ray-guided injections and even vertebroplasties, and management of bone metastases and multiple myeloma, whereas collagen vascular diseases are frequently managed by internists rather than rheumatologists. The psychosocial dimension given to care in France undoubtedly contributes to rheumatology patients' well-being, for instance, by covering physiotherapy, occupational therapy, dietitian and psychological consultations, as well as prescription costs for medical devices such as orthoses.
In the last decade or so, rheumatologic management of patients in France has seen two very relevant improvements. Specifically, the creation of reference centres for rare diseases allows for hyperspecialized multidisciplinary management of these diseases, defined by a prevalence lower than 2 per 1,000 (for example, scleroderma, Sjogren's syndrome), with clinical research being an integral activity of these centres. Thanks to a directive from the European section of the World Health Organization, therapeutic education of patients with chronic diseases has become more accessible in France. These individual and group education programs are now integrated into the ongoing management of rheumatology patients.
In Canada, the practice of rheumatology is more individualized, sometimes with minimal multidisciplinary support, which makes it a more "responsible" practice in terms of health-care costs. It is a given that the fee-for-service system for doctors, including those in university hospitals, and the desire to keep Canadian public hospital budgets balanced, largely explain these differences. Let us hope that the many reforms of the Quebec health care system will allow family doctors to be more actively involved in the co-management of patients with chronic diseases, and will help these patients better navigate a rather complex system that is not well known to the public.
In this era of globalization, rheumatologists' concerns are becoming standardized at a remarkable rate. On both sides of the Atlantic, we are now debating medical cannabis, medical assistance in dying, and disruptions in the supply of certain drugs and, of course, the shortage of rheumatologists.
Laëtitia Michou, MD, PhD
Rheumatology Division, Department of Medicine
CHU de Québec-Université Laval