Training of Occupational Physicians in France

1. Training of Occupational Physicians in France JF Caillard . University of Rouen OH Education and Training for everyone every year Strasbourg. ICOH. September 2005

2. France STRASBOURG 60 561 000 inhabitants (63 millions DOM-TOM included) au 1er january 2005 35 527 760 de 20 à 64 ans (source INSEE).

3. Occupational Health and Occupational Medicine in France • First medical aproach in workplaces at the end of XIXth Century • 1874: Creation of Labour Inspection • 1898: First Work Injuries Compensation Act • 1916: « De la main d’œuvre nationale après la guerre » J Leclerc and P Mazel (specialists in forensic medicine): the basis of the content of the future organisation of Occupational Medicine • 1946: Services of Occupational Medicine mandatory by law for every paied worker

4. Basic Functions of Occupational Medicine in France • Activities on the workplace (one third of occ.physician’s working time) • Improvement of working conditions • General hygiene of the workplace • Ergonomics • Prevention of work-related diseases and accidents • Health education • Epidemiology of work-related diseases • Health surveillance of workers • Medical examinations providing job-fitness certificates • Pre-employment and periodic • Return to work • Vaccination • Networking with health and insurance organisations • The Occ.Physician is an advisor on OHS matters

5. Trends in Occupational Medicine along the XXth century • First period : 1900  end of the 50ties • Public health purposes and starting identification of OH hazards and effects – first approach in prevention • From 1960 to 1969 • OM practice mainly focused on medical surveillance • From 1969 to 1988 • One third of the working time to be devoted to working conditions • From 1988 to 2000 • Trend toward primary prevention and multidisciplinarity – planification of activities based upon risk-assessment • From 2004 on • Multidisciplinarity is an obligation – Less medical surveillance – Risk assessment is a priority – National Plan in OH – Innovation encouraged

6. 1 350 000 enterprises 13 000 000 paied workers benefit from OHS +6 000 000 (non private sector) 12 000 000 in 350 interenterprises services 1 000 000 in 750 in-enterprises services 7000 specialised occupational physicians 8 000 staff members (assistants, secretaries, nurses, oh technicians … OHServices Source: CISME

7. Occupational health services are organised and financed by the employers. Direct cost: 920 millions € ½ of preventive medicine expenses By comparison: cost for compensation of occupational diseases in 2002: 1121,46 m€ Source: CISME – ministry of labour OHServices

8. French system of prevention of occupational risks Ministry of Labour National council for the Prevention of OH risks Social Security INRS National Institute of Research and Safety ANACT CNAM Regional Commission of OM Regional Observatory of OH ARACT Social Security OH Prevention Services Institutes /Dpt OM/OHE in University -Hospitals Labour Local Authorities ENTERPRISES Employer - Occupational Health Team Employees representatives - HSWCTC EMPLOYEES Regional Laboratories INVS AFSSE INERIS

9. History of Training and Education in Occupational Medicine in France • First Training Courses existing since the 30ties, particularly in Lyon, Lille, Paris (volountary basis) 1957: a special diploma is mandatory to be employed as occupational physician • 19571977:1 year training consisting only in theoretical • courses: certificat [CES] • 1977  1983: 2 years with one month in a OHS service • for practical training: certificat [CES] 150 I 500

10. History of Training and Education in Occupational Medicine in France 1983: Reform in medical studies: 4 years are needed for all specialties(residency) at the end of 6 years of general learning II [Occupational Medicine becomes a full speciality] • 1983 2004…: 4 years residency after a competition (volountary basis) • (1992:special access for physicians with > 5 years practice): diploma: [DES] • 2005 ….:4 years residency after a national examination (mandatory basis) : diploma [DES] 140 I 250 50 I 70

11. History of Training and Education in Occupational Medicine in France • 1998 – 2000 and 2002 - 2004: for those practicing without any diploma: 2 years theoretical training while continuing practicing: [licence] to be authorised to practice • 2003 – 2006: for non OH Practitionners wishing to join an OHService and be trained during the first period of professional exercise: 2 years: diploma [capacity] 1300 <100

12. Organisation of the training • Institutes/Departments/ Units of Occupational Medicine in 19 University-Hospitals in charge of : • Teaching • Research • Occupational health activities • Clinics of occupational diseases • OH Services for Hospitals, Universities ….. • 27 professors – 35 assistant-professors • Co-operation within a network of professionals, researchers, institute,private organisations at regional, national and sometimes international level

13. National theoretical programme • Introduction to labour sciences • Laws and regulations in OHS • Work physiology and ergonomics • Toxicology and industrial hygiene • Work related diseases • Epidemiology – statistics – computer science • Management of occupational hazards • Miscellaneous

14. DES – Residency Theory: 300 hours Practice: 2 years in clinics (or equivalent) 2 years in OH services, institutions, research centers … Licence and Capacity Theory: 280 hours Practice: work in an OH service during >2 years including 6 months in a University-Hospital (Capacity) Theoretical and practical training

15. Two main issues • To face the shortage of occupational physicians in the country • To adapt the programme and the training methods

16. To face the shortage of occupational physicians in the country • Parameters to take in account:(source. Labour medical inspectorate 2003) • The total number of needed OP is fixed by regulations: - 1 full time equivalent 1500 to 3300 employees (depending of risk assessment) - 66 % of OP are female (5 026) et 34 % males (2 585). - 59 %of OP are more than 50 years old (35,56 % females et 23,50 % males). - 41 % of OP work >152 h/month - 59 % < 152h/month

17. To face the shortage of occupational physicians in the country

18. ESTIMATION DU DEFICIT APRES REFORME POUR LE REGIME GENERAL Année Déficit calculé DARES sms 15% Déficit calculé DARES sms 20% Déficit calculé DARES sms 25% Flux de sortie des internes Départ des médecins du travail à 65 ans Evolution du déficit chiffre DARES sms 15% Evolution du déficit chiffre DARES sms 20% Evolution du déficit chiffre DARES sms 25% 2002 -270 -535 -799 232 98 -136 -401 -665 2003 -136 -401 -665 239 47 56 -209 -473 2004 56 -209 -473 225 45 236 -29 -293 2005 236 -29 -293 225 50 411 146 -118 2006 411 146 -118 225 93 543 278 14 2007 543 278 14 155 120 578 313 49 2008 578 313 49 86 127 537 272 8 2009 537 272 8 86 140 483 218 -46 2010 483 218 -46 86 205 364 99 -165 2011 364 99 -165 86 292 158 -107 -371 2012 158 -107 -371 86 331 -87 -352 -616 2013 -87 -352 -616 86 413 -414 -679 -943 2014 -414 -679 -943 86 432 -760 -1025 -1289 To face the shortage of occupational physicians in the country

19. To face the shortage of occupational physicians in the country • Solutions ? - to lobby in order to get more positions for residency - to increase multidisciplinarity with more « non medical » professionals - to allow trained physicians to practice occupational medicine part-time - to increase the global «numerus clausus »

20. To adapt the programme and the training methods • New regulations and new needs in Occupational Health • Increasing consensus on good practice • Importance of ethics • Influence of international co-operation: - EASOM (European schools of occupational medicine - UEMS (Union of European Medical Specialities - ENSOP (European Network of Societies of Occupational Physicians - Faculty of Occupational Medicine in UK Ewan MacDonald (Occup Environ Med 2000;57:98–105) - American College of Occupational and Environmental Medicine Panel .

21. To adapt the programme and the training methods Working Group of the French College of Occupational Medicine Teachers (waiting more than 5 years for labour market and government decisions on reforms) • Designing of a new programme including/developing new items with 3 main issues for student learning: • Knowledge • Experience • Competence • Opening the discussion with stakeholders (focus groups) before approval

22. To adapt the programme and the training methods • Examples of new items: • Risk assessment • Promotion and maintenance of work ability • Mental health • Environmental health • Public health surveillance • Communication • Management of projects • Team working • Ethics • Research methodology

23. To adapt the programme and the training methods • Specialisation of and co-operation between regional departments of OH and call to the best specialists • E-learning and distance leanrning • Participative teaching • Problem solving • International teaching (European LMD) • Multidisciplinary training for teachers (already done) and students (to be done) • Sharing experience world-wide: « Thanks to the Organising and Scientific Committes of this International Congress »