Christophe Segouin

Cracks and crevices: Globalization discourse and medical education

Globalization discourse, and its promises of a ‘flat world’, ‘borderless economy’ and ‘mobility of ideas and people’, has become very widespread in all fields. In medical education this discourse is underpinned by assumptions that medical competence has universal elements and that medical education can therefore develop ‘global standards’ for accreditation, curricula and examinations. Yet writers in the field other than medicine have raised a number of concerns about an overemphasis on the economic aspects of globalization. This article explores the notion that it is time to study and embrace differences and discontinuities in goals, practices and values that underpin medical competence in different countries and to critically examine the promises–realized or broken–of globalization discourse in medical education.

Country report: medical education in France.

Context  The last 10 years have represented a period of significant reform within both the health care and education systems in France. In terms of its workforce, France faces a shortage of doctors, particularly in primary care.

Educating doctors in France and Canada: are the differences based on evidence or history?

Background  Despite many economic and political similarities between France and Canada, particularly in their health care systems, there are very significant differences in their systems of medical education.

Medical education: it's time for a transatlantic dialogue.

Medical education is in full bloom in North America. Journals such as Academic Medicine and Teaching and Learning in Medicine, grants such as the National Board of Medical Education s Stemmler fund and education conferences in all medical specialties give North American medical educators the opportunity to present work and ideas in a rich array of venues. Although largely American, these institutions have a dab of internationalism about them because of the participation of Canadians. A few Europeans also attend, but we have yet to encounter more than 1 or 2 delegates from Mexico, the rest of the Americas or Francophone Canada.

Factors associated with failure to return for HIV test results in a free and anonymous screening centre.

Free and anonymous screening centres (CDAG: Centres de Depistage Anononyme et Gratuit) are public facilities set up for HIV infection diagnosis in France. Some people visiting CDAG fail to return for test results and are not informed of their serology. This study aimed to assess factors associated with failure to return for HIV test results. Patients visiting the Fernand-Widal CDAG (Paris) for an HIV test in January–February 2011 were eligible to take part in the study. Data were collected with an anonymous self-administered questionnaire. Factors associated with failure to return were assessed using logistic regression models. Of the 710 participants (participation rate 88%), 46 patients failed to return. Not specifying birthplace and not living in the region of Paris were associated with failure to return. Those who perceived no risk of HIV infection and those who felt they were more at risk than other people were both statistically associated with failure to return. Self-perceived risk seemed to be of chief concern for failure to return for HIV test results and should be considered during pre-test counselling.

World conference on medical education: a window on the globalizing world of medical education?

The Association for Medical Education in Europe (AMEE) is a worldwide association for all interested in medical and health professions education (http://www.amee.org). AMEE organizes an annual meeting, the most recent of which (2005) was held in Amsterdam. At this meeting certain countries and regions were better represented than others, while some countries with large populations or a significant role in the history of medical education were almost completely absent from the international scene. At the same time, the themes addressed at the AMEE conference concern issues of international interest, and appear to be leading to internationalization of pedagogical and research methods and policies for educational standards. It is therefore crucial that all parts of the medical education world be well represented. This paper illustrates both the strengths and imbalances of AMEE as a forum for the elaboration of international activities and standards in medical education. Finally, the authors wonder why a tendency to assume international generalizability of concepts and perspectives in medical education is not accompanied by studies that compare and contrast medical education methods, research and values between countries and cultures.

Diffusion et appropriation d’une démarche palliative en établissement de santé

Resume L’objectif de cet article est de faire connaitre le contenu de la demarche palliative en justifiant les raisons ayant conduit le comite de suivi de developpement des soins palliatifs 2002-2005 a elaborer un guide dedie aux etablissements de sante. La cible de ce document est centree sur les professionnels soignants, mais aussi medicaux et administratifs. La demarche palliative facilite la prise en charge des personnes en fin de vie et de leurs proches par une dynamique participative prenant en compte les difficultes des soignants. Une telle demarche ne peut s’operer sans l’activation des binomes medecins-infirmieres et medico-administratifs. Sa reussite est fondee sur l’elaboration d’un projet de soins multidisciplinaire centre autour du malade, en utilisant une boite a outils qui est mise a leur disposition. Cette mallette integre l’accueil des patients et de leur famille, le soulagement des symptomes, l’information, la nomination de referents disponibles au sein de l’equipe en interface avec les equipes mobiles, les unites, les reseaux de soins palliatifs ou autres aides exterieures. Elle comprend la communication au sein du service par le moyen d’espaces de paroles, de reunions interdisciplinaires de discussions de cas et d’analyses de pratiques cliniques et/ou ethiques. Le soutien des soignants est un objectif essentiel de la demarche pour anticiper le burn out au moyen d’evaluations regulieres. Une large diffusion de la culture palliative a l’ensemble des etablissements de sante, dans le respect d’une telle demarche, en lien avec les soins de supports, a laquelle pourrait etre associee l’organisation de forums d’informations et d’echanges sur les soins palliatifs, et l’accompagnement permettraient de repondre plus genereusement aux besoins des malades en fin de vie et de leur entourage.

Financement des traitements endovasculaires des anévrysmes cérébraux : La tarification à l'activité permet-elle aux établissements de santé de financer la prise en charge des patients ?

Resume Methode nous avons calcule les depenses engagees par notre centre pour l’ensemble des anevrysmes cerebraux traites au cours de l’annee 2005. Ces depenses comprennent le materiel de guidage endovasculaire (catheters, microcatheters, microguides) et les implants (coils). Nous avons compare ces depenses aux recettes engendrees par le sejour des patients et au paiement en sus. Resultats le paiement en sus ne couvre que le tiers des depenses de materiel medical utilise. Trois types de depenses ne sont pas financees : le materiel de guidage, les implants utilises mais non largues, les implants de derniere generation qui ne sont pas encore integres a la liste nationale des produits et prestations rembourses. Cette depense n’est pas non plus couverte par les recettes generees par les sejours des patients. Discussion le traitement endovasculaire est depuis quelques annees le traitement de premiere intention des anevrysmes cerebraux. Ce traitement n’est pratiquement realise que dans des centres hospitalo-universitaires mais, dans le mode de financement actuel, il constitue un surcout pour l’hopital. Conclusion cet exemple pose la question du financement des activites innovantes.

Repères pour une qualité globale des soins par la certification et l'évaluation des pratiques professionnelles : une réforme sous haute tension

1. Service de santé publique et économie de la santé, groupe hospitalier Lariboisière Fernand-Widal (AP-HP), F-75475 Paris cedex 10, France 2. Wilson Centre for research in education, Université de Toronto, Toronto General Hospital, Elisabeth Street, Toronto, Canada 3. Laboratoire de droit médical et de la santé, Equipe d’Accueil-1581, Université Paris 8, F-93526 Saint-Denis cedex 02, France 4. Laboratoire d’analyse des politiques sociales et sanitaires (Lapss), École des hautes études en santé publique (EHESP), F-35043 Rennes cedex, France

Les réadmissions évitables des « pneumopathies communautaires » : utilité et fiabilité d’un indicateur de la qualité du parcours de soins du patient

UNLABELLED Unlike Anglo-Saxon countries, the rate of preventable readmissions is not a national quality indicator in France. In the context of the European research project Performance Assessment Tool for quality improvement in Hospitals (PATH), this pilot study provides a tool for health professionals to more easily identify preventable readmissions in order to analyze their causes. The objective of this work was to show the reliability of this tool. METHODS We compared the rate of preventable readmissions occurring within 30 days, for a given disease, collected by analyzing medical reports (the gold standard rate of this study) to the rates of preventable readmissions occurring within 30 days, measured from algorithms using data from the French Programme of Medicalization of Information Systems (PMSI). The data were derived from PMSI data of the Lariboisiere-Fernand-Widal Hospital, a university hospital in Paris. RESULTS The community-acquired pneumonia gold standard rate of preventable readmissions occurring within 30 days was 6.3 %. Five algorithmic tools were used and measured rates between 2.9 % and 7.9 %. The positive likelihood ratios of these tools range from 8 to 308. CONCLUSION This work presents a tool aimed at the health professionals that takes into account the diversity and complexity of the causes of avoidable readmissions, resulting from the quality of medical practice, the variability of the organization of hospital pathways and the links with ambulatory care.