|
Paediatrics
in Réunion
by
Pascale du Pre - Edinburgh
Population: 750 000
Language: French
Capital: St Denis
Currency: Euro
Int Code: +262
Réunion is a small and
beautiful volcanic island in the Indian Ocean.
The island is run as an overseas department of France.
French culture dominates every facet of life and the Réunionnais
are proudly French speaking. Yet
the French atmosphere has a firmly tropical twist, with subtle traces
of Indian, African and Chinese cultures.
The island has terrific surfing and diving and the hiking and
beaches are spectacular. There
is even a live volcano that erupts every few months.
The island has a very young population and the night life is
great. French speaking is
essential.
Medicine
Medical
care is run on both a state (compulsory national health insurance) and
private healthcare system. Access in both public and private services
does not usually require referral.
The public services tend to cater for inpatients, whereas the
private (e.g. GPs) tend to cater for outpatient services.
 Climate
Hot,
rainy summer from December to April and cool, dry winter from late
April to October. The
east coast is considerably wetter than the west.
Temperatures in the summer average 22oC during the
winter to 29oC in the summer.
St
Denis
With its brasseries,
bistros and café culture is a perfect reproduction of metropolitan
France. The beaches and best night life are ½ hour drive down the
coast and it is worth hiring a car.
HOSPITALS
Hopital d’Enfants
60
Rue Bertin, 97400 Saint-Denis Cedex.
Tel: 02 62 90 87 00. Fax: 02 62 90 87 10.
Email: hop.enfants@wanadoo.fr
The hospital: A
small paediatric hospital with
a terrific team of five consultants and six house officers on 6-month
placements from mainland
France. There are up to 15 day-case admissions to see every day as
well as two wards of 40 or so patients and a walk-in clinic.
Elective notes: Hand
over takes place over coffee and croissants! The doctors are very
friendly and welcoming. French
is the official language but many of the patients speak Creole. There are many great experiences to be had and your work is
that of a house officer; clerking, ward work and clinics. This elective is great for experience in general paediatrics
with a huge range of both standard and rarer syndromes. It has all the advantages of a modern healthcare system and
in a tropical environment. Lunch
in the hospital is provided and very good.
Afternoons are spent in the hospital or at the beach depending
on the number of admissions!
 Accommodation:
Not
provided but the hospital can put you in touch with the current house
officers.
Centre Hospitalier Départemental Félix
Guyon
Bellepierre
97405 Saint-Denis Cedex. Tel: 02 62 90 50 50. Fax 02 62 90 50 51.
The hospital: The
CHD is the main general hospital in St Denis with all the general
medical specialties. Paediatrics is mainly adolescent and haematology/oncology
although the neonatal unit and paediatric A&E were recently
transferred here from the Hopital d’Enfants.
OTHER HOSPITALS IN REUNION:
CHG BP 350 97448 Saint-Pierre
Cedex Tel: 02 62 35 91 43
(There
are also others in St Paul and St Benoit)
Pascale's actual elective
report:
AIMS
I wanted to use
this opportunity to set myself the challenge of undertaking an
elective in a totally French-speaking environment.
At the same time, I wanted to do an elective in Paediatrics
since I have always had a strong interest in child health.
Yet also I was keen to work as an important member of the
medical team while obtaining good practical hospital experience for my
future career in medicine.
Reunion
While I wanted to
spend my elective perfecting my medical French, I really wanted to
travel beyond Europe. Réunion provided the perfect solution; a slice of Europe in
the Indian Ocean! At the
same time, Réunion offered the combination of both a modern
paediatric hospital without being a teaching environment and a safe
environment for a young girl travelling alone.
Réunion is
totally unique, being a department of France sitting in the middle of
the Indian Ocean. Many people in the English-speaking world are
unaware of these islands in the Indian Ocean. Réunion, unlike the
other islands is still owned by the French. French culture dominates
every facet of life, and the Réunionnais are proudly French speaking.
Yet the French atmosphere of the island has a firmly tropical
twist, with subtle traces of Indian, African and Chinese cultures.
Apart from the vibrant cultural mix, Réunion offers a host of
attractions from the dramatic peaks of the island’s mountainous
interior to the smouldering volcano and gorgeous beaches.
While Réunion has
a population of 700 000, over 25% of the population is under the age
of 25, ensuring paediatric services are in high demand.
The Hopital d’Enfants was situated in the capital, St Denis.
Although officially private, the hospital functioned rather as
a public hospital.
Hopital
d’Enfants, St Denis
The morning
hand-over took place over coffee and croissants. The medical team was
made up of five consultants and five ‘internes’
or house officers. Within the first few days, my role quickly became
that of a replacement house officer following the unexpected departure
of one of the house officers. Alongside
the remaining house officers, I was responsible for clerking patients,
conducting ward rounds, writing up notes, ordering investigations and
even dictating letters. (N.B. all in French!)
Common medical
problems on the wards included sickle cell anaemia, cancers, diabetes,
cystic fibrosis and obesity, while the walk in clinic attracted colds
to head injuries. Aside from these, there was also much in the way of
fascinating pathology. One of my most memorable cases was that of a
child with phacomatosis, whose hair was naturally divided in colour
exactly down the midline; blonde in colour on one side and brown on
the other with a similar pattern of skin hyperpigmentation.
Another case was that of an infant with situs inversus, with an
unforgettable chest X ray.
In my last week, I
was faced with the complicated diagnostic challenge of a 3 yr old with
a 17 day history of unremitting fever with very few, if any, other
symptoms. Despite every
investigation known to modern medicine and seemingly every
differential diagnosis excluded, I was sorry to leave the island
before the case could be solved.
The case was a terrific opportunity to test my academic
knowledge and clinical skills, systematically suggesting and excluding
diagnoses from the common Kawasaki’s and Still’s diseases to rare
tropical infections.
Other challenging
cases included the numerous children coming from families with severe
social problems, for whom there was really no system of social
support. I spent a few
days at the new ‘victimologie’
unit at the central hospital in St Denis dedicated to children
suffering from physical and sexual abuse and often incest.
Similarly the adolescent ward in the hospital was filled with
young teenagers following attempted suicide while the operating lists
and surgical wards were filled with young children sent over from
neighbouring islands alone for life-saving surgery.
French
Healthcare
In France,
physicians work in either of two medical environments: public
hospitals or private practices. After 7 years of medical school, medical graduates decide
whether to follow the route of public hospital medicine specialising
over the next four years as a house officer doing 6 month rotations. After four years these doctors are effectively hospital
consultants. Only 25% of
physicians work in public hospitals.
These are essentially public servants, paid a fixed rate by the
government. For those
that choose the equivalent to our ‘GP route’, the four years
following medical school are spent in paediatric and A&E
placements and a GP placement. After
the four years, they can open their own ‘cabinet’ or GP practice. 56% of physicians work in private
practices and are paid on a fee-for-service basis[i].
In France, the
healthcare system is mainly under state control with the public system
covering around 75% of total costs.
Half of the rest is paid out of pocket and the rest being made
up by supplementary insurance companies. About 85% of the French have
private insurance. In
January 2000, a means-tested, public supplementary insurance programme
called CMU (Couverture maladie universelle) was implemented to support
patients without funds for private insurance.
As a result,
France is the only country where access to care is unlimited.
Patients can see as many physicians as often as they like.
Patients do not need referrals to see specialists, they just
look them up in the phonebook. Similarly
if one of the patients on the ward needed to be seen by a
dermatologist for example, you simply look up a dermatologist and ask
them to come and see your patient on the ward.
One of the most
striking differences in the healthcare delivery was the role of
nurses. In France, the
nurses take all bloods, do all the investigations and generally play a
much larger role in the hospital team.
Unfortunately this meant that this choice of elective did not
enable me to put into practice my clinical skills since doctors were
not expected to know or perform these skills. A good example was also
the use or lack of use of fundoscopy.
In the French system, doctors do not perform fundoscopy but
have to get an outside ophthalmologist to perform this investigation.
Similarly, since doctors do not take bloods, outwith the hospital
blood tests and X rays need to be prescribed like medication, and the
patients must go to private laboratories to have the tests.
The results are posted to the patient.
More specifically
to paediatrics, the French also had a system of the ‘Carnet de Santé’
the equivalent to the ‘red book’ or personal child health record[ii] – a book issued to
parents at birth that documents all the child’s medical details,
development, immunisations and growth. “The introduction of this
system was to improve communication between health professionals thus
enhancing continuity of care and to increase parents knowledge of
their child’s health and development.”
The concept proved extremely useful during my elective, all
consultations were clearly documented, and provided a clear record of
the child’s development since birth.
My impression, having completed my paediatric attachment in
Edinburgh, was that the French use this facility much more than the
British. It was very rare
to see a child in the clinic without their ‘carnet’. In Britain the personal child health record is not used
beyond the age of five years while the French ‘Carnet’ is used
much more frequently up to the age of eighteen.
[i] Fiscella
K, Frankel R. Overcoming
Cultural Barriers: International Medical Graduates in the United
States. JAMA.
2000; 283: 1751
[ii] Bedford
H. Revisiting the
Personal Child Health Record. Community Practitioner.
2004; 77 (5): 174-174
|
