Teleconsultation in geriatrics: impact on professional practice.

UNLABELLED: Teleconsultations in medicine are encouraged by authorities and decision-makers to improve access to specialty services for isolated patients. For elderly patients in geriatric hospitals, they thus avoid trips to consult with specialists. However, teleconsultation can modify clinical practice and it may be abandoned for reasons not related to technical issues. Qualitative research on the impact of teleconsultation on medical practice and organisation are thus crucial for an understanding of the changes it can generate. METHODS: We used qualitative methods to analyse the impact on professional work practices and care organisation of an initially experimental and then permanent teleconsultation system using a video conference system set up between a geriatric hospital and a tertiary care hospital. Sixty-six teleconsultations (56 during the experimental phase and 10 when the system was in routine use) were observed and ten semi-structured interviews were carried out with the actors in the teleconsultations. RESULTS: Our study shows that the uses of teleconsultation affected work practices of both the consulted specialist and the geriatrician who participated in the consultation alongside the patient. The interactions of specialists with the patient were more difficult than in a face-to-face setting and delegation of the clinical examination of the patient depended on a specific form of cooperation and on trust in the person doing the examination. New kinds of relationships between health professionals contributed to sharing and transmission of knowledge between practitioners. While teleconsultations established alliances between geriatricians and specialists, they none-the-less called for a certain humility on the part of geriatricians. In order for these relationships to become routine and to facilitate interaction among participants, the project manager carried out important work during the experimental phase of the teleconsultations by organising these interactions. Finally, the teleconsultations went through several local reorganisations, especially within the geriatric hospital. These included changes in the geriatrician's schedule and the added presence of an assistant knowledgeable in telemedicine. CONCLUSIONS: Specialists found the system used for teleconsultation between a geriatric hospital and a tertiary care hospital to be suitable for their consultations. The main advantage brought about by the teleconsultation system studied resulted from its collaborative nature, which created relationships between health professionals. This resulted in improved care for elderly patients. However, using the system required effort on the part of both the specialists and the geriatricians. Adapting to the system was facilitated by coordination work carried out by the project manager during the experimental phase that created a favourable context for cooperation between actors, allowing diagnoses to be made at a distance. Finally, teleconsultations do not appear suitable for all specialties, by reason of the limits imposed on the delegation of tasks, or to all situations. They require setting up new forms of organisation that must be encouraged by decision-makers.

Results of a 4-year study on 15,447 medical abortions provided by privately practicing general practitioners and gynecologists in France.

BACKGROUND: The main aim of this study was to determine: (1) whether early medical abortion at home is a reliable and safe method when provided by physicians in their private practice outside abortion facilities, and (2) whether early medical abortions at home supervised by general practitioners (GPs) in their private practice have the same efficacy rate and the same safety as those supervised by gynecologists in their private practice. STUDY DESIGN: The data are drawn from a prospective survey of 15,447 in-home medical abortions up to 49 days after the last menstrual period (LMP), provided within the Ile-de-France abortion network between privately practicing physicians and hospitals (REVHO: Réseau entre la ville et l'hôpital pour l'orthogénie), from 2005 to 2008. RESULTS: Approximately 150 privately practicing physicians participate in the REVHO network, and over half of them are general practitioners. Three physicians, called the main providers, performed over half the medical abortions. The overall efficacy rate was 97.43% (96.48 % for the gynecologists, 96.44% for the general practitioners, and 98.31 % for the three main providers). The rate was higher when abortion completion was determined by a decline in serum human chorionic gonadotropin rather than ultrasound. CONCLUSION: Early medical abortion at home supervised by gynecologists and GPs practicing in their private offices is a reliable and safe method. Promoting networks such as REVHO increases local accessibility to this type of abortion in France.

[Remote medical consultations in gerontology]. / Les téléconsultations médicales en gérontologie.

Experimental teleconsultations have been set up between a university hospital and a public geriatric hospital in Paris in order to facilitate elderly patients' access to specialist consultations. Caregivers have had to accept major changes to their professional practices (delegation of tasks, sharing of knowledge, etc.). This new telemedecine scheme represents huge progress in patient care.

Between clinical medicine and the laboratory: medical research funding in France from 1945 to the present.

By focusing on funding methods, this paper considers the way in which medical research eventually led to the science-based medicine that is prevalent in France today. This process seems to have taken place in three stages during the second half of the twentieth century. In the 1940s and 1950s, two major events occurred. The first was the creation of a national health insurance fund in France, which opened up new reasons for, and ways of, funding medical research. The second was the development of antibiotics, which triggered a revival of clinical medicine. In the 1960s and 1970s, a proactive government science policy allowed the life sciences and medical research to come together in the wake of a burgeoning new science: molecular biology. Thus, in 1964, the creation of the National Health and Medical Research Institute (Institut national de la santé et de la recherche médicale or INSERM), destined to "molecularize" medical research, was seen as the fulfillment of the government's ambitious research policy. Today, with medicine irreversibly embedded in scientific and technical rationality, health has become a major issue in modern societies. This paper therefore touches on some of the key features of biomedical research, including the revival of funding systems for clinical research and the development of a system of research grants that was made possible by patient organizations and the creation of new funding agencies.