Doctors in the small French town of Le Vigan are getting older.
In a bid to attract new GPs to replace the three retiring soon, they built — from the ground up — an interdisciplinary medical center, the model having been touted as a way to make general practice more attractive to young doctors.
The trouble is, it’s not working.
In five years of searching for replacements, not a single person has come forward.
“I didn't think there would be such a disavowal of rural medicine,” said Antoine Brun d’Arre, 59, one of the local GPs who set up the center.
And so, despite all their efforts to prevent it, the town in southern France will likely become another of the country's so-called "medical deserts."
Le Vigan, which has a population of about 4,000 and nestles in a valley at the southern end of the Massif Central, is not the only French town struggling to attract doctors. But the scale of the challenges it faces is emblematic of a Europe-wide crisis in which doctors are too far, too few, or too old.
Nearly 7 million people in France don’t have a referring GP. Geographically, 30 percent of the country’s population lives in a region with poor access to GPs, said Guillaume Chevillard, health geographer and research fellow at the Institute for Research and Information in Health Economics.
The outlook? Grim.
There are now more GPs in France retiring than there are new ones setting up practice. The number of GPs already dropped by 5.6 percent between 2012 and 2021. And the next decade will be especially challenging: Though the number of doctors trained has increased in the last few years and the government recently scrapped its caps on medical school spots, those numbers won’t rebuild the workforce quickly enough.
That reality is already hitting home for Francis and Mireille Delabarre, aged 85 and 79, whose GP of some 10 years in Le Vigan is soon retiring.
Mireille, who is miffed she doesn’t yet know who their next doctor will be, is clear on what’s to blame: a decades-old policy called the numerus clausus, which limited the number of student doctors.
The numerus clausus — Latin for closed number — started in 1971. It set out the number of students who would make it past the first year of medical studies. Reining in the number of doctors was seen at the time as an all-around win, explained Chevillard: For the state and national health insurance, this would tame health spending; for doctors, it would mean less competition and higher earnings.
The impact was dramatic.
While in 1972, there were nearly 8,600 spots, the figure took a nosedive 20 years later, to a low of 3,500 in 1993. The decades since have been a slow climb up the curve until the cap was scrapped in 2020.
Still, France had fewer doctors per capita in 2021 than it did in 2012, declining to 318 from 325 doctors per 100,000 people.
The drop is all the more challenging in the face of a glaring reality: France, like the rest of Europe, is aging, and health care needs are growing as a result.
The shortage is such that President Emmanuel Macron proposed a scheme last month to encourage retiring doctors to stay in practice.
Some 10 percent of doctors in France are working in their retirement.
Health care staff shortages aren’t limited to doctors — and they aren’t limited to France.
More than two years into a pandemic that decimated personnel, health care managers and governments alike are scrambling to cobble together a semblance of a workforce.
Europe’s health care worker shortfall — around 2 million — is acutely felt across the continent.
In Greece, first responders are sounding the alarm over slower emergency response times due to a shortage of personnel. England lacks tens of thousands of nurses, reporting a record number of vacancies. Nurses top the list of all occupations experiencing shortages in Finland. Maternity wards in Portugal are struggling to stay open due to a lack of doctors.
"[The shortage of doctors] is really a problem that affects all of our members," said Sarada Das, secretary general for the Standing Committee of European Doctors (CPME), an organization that represents doctors across Europe.
“At its core, it's really that there is the perception that potentially medicine is no longer an attractive career choice, a choice for people to stay in for a whole career. And this will really endanger the sustainability of health care systems in future,” she said.
Das points to numerous issues, including violence in the workplace and burnout, as factors that make it challenging to both recruit and retain staff.
That reality is already threatening the career longevity of Europe's youngest doctors.
Many junior doctors have either left or are considering leaving the workforce due to high rates of burnout and other mental health problems.
“If it's not addressed properly, it's going to create even bigger shortages of doctors,” said Álvaro Cerame, psychiatrist and chairperson of the medical workforce committee at the European Junior Doctors Association (EJD). “We are struggling to provide care for our patients."
Europe's tragedy is that the crisis was preventable.
This shortage was anticipated, and it’s been exacerbated by the pandemic, said Martin McKee, professor of European public health at the London School of Hygiene & Tropical Medicine.
Europe has long relied on foreign health care workers from lower-income countries as a stopgap, he said.
“Clearly, there's a huge problem. And we need to increase the health workforce but I think the difficulty is that other things have overtaken it, like gas prices, the war in Ukraine,” McKee said. “Political attention spans are short.”
The shortage of doctors in France is as much about numbers as it is geography: While cities, including in the Paris region, also suffer, the problem is especially prevalent in rural communities.
To try to beat the odds, the town of Le Vigan has gone all out.
The doctors have set up an interdisciplinary medical center where six GPs work, alongside other team members including a psychiatrist, a psychologist, a team of nurses, a speech therapist, and secretaries.
Children run up and down the modern space's bright hallways waiting to see the doctors, a steady flow of patients young and old rolling in and out of the offices. Appointments can be booked online, and patients' visits are charted in an electronic medical record. The team helps train interns and medical students to show them what rural medicine is all about, even offering them spacious accommodation in the center's top floor.
There's more money on the table: The new doc in town would benefit from a €50,000 signing bonus — up from the previous offer of €40,000 — and significant tax breaks for eight years.
They put ads on Facebook, and in various online fora for doctors. They even hired an international recruiter to help find a colleague in Romania or in North Africa.
Nobody will come.
If they don’t, the medical center will be forced to shut its doors — the costs of running it, some €220,000 per year, would be impossible for the remaining three doctors to bear between them.
“I never would have imagined that we would face potential bankruptcy,” said Bénédicte Gal, 33, one of the center’s GPs.
Had she known it would come to this, she is clear: she would not have moved to Le Vigan. She and her husband share a practice in the medical center, taking shifts between their patients and their three small children. The couple arrived in 2017, choosing the location in part because it had the medical center.
But getting a fresh crew to care for the center’s patients — some 9,000 from Le Vigan and the nearby communities — is proving to be nearly impossible.
For one, new graduates are less keen on the fee-for-service model they offer and the associated administrative load, Gal said. While the majority of GPs in France work in this model, a growing number are working in salaried positions.
There’s also the curse of geography: The town is small, and despite the appeal of outdoor activities in the Cévennes national park — and hunting, for Brun d'Arre — it is more than an hour’s drive from the cities of Nîmes and Montpellier.
Sylvie Arnal, who splits her time between being town mayor and her fashion boutique, worries about citizens possibly having no access to any medical care at all. That looming reality is especially worrisome in a town where one in four people are aged 65 and over — a higher proportion than nationally.
That's also reflected in the doctors' work: In addition to the primary care clinic, they do home visits for elderly patients; provide palliative and end-of-life care at home and in hospital; and care for over 100 patients in two local nursing homes.
Losing the doctors would leave those patients in the lurch.
France's staffing crisis has raised the divisive question over whether doctors should be directed to work in medical deserts by limiting their installation in well-served areas; such measures are already in place for other health care professionals, such as nurses, midwives and physiotherapists. But the government's push to imminently add a fourth year of training, to be done in an underserved area, for doctors training to be GPs has been met with widespread protests and strikes.
Such a plan may backfire, said Raphaël Presneau, president of a union representing doctors training to be GPs (ISNAR-IMG). The move risks undoing the slow but growing interest among medical students towards general practice, the total number of training spots having been filled for two years in a row now, he said.
As it stands, France is looking to make the most of its current physicians' time, shifting certain tasks from doctors' to-do lists to those of other health care workers. A new role, that of medical assistant, was introduced in 2019, with the goal of easing administrative work and freeing up doctors to care for patients.
In the long term, it would also be useful for medical students to more accurately reflect the country's geographic and social diversity, said health geographer Chevillard. "It costs less to have doctors who look a bit more like the different regions than to have urban doctors who have to be provided with all the services they want in rural areas," he said.
But, for now, the need to make the best of the fleet at hand is vital. Despite now setting a minimum number of doctors to be trained based on need, France won't have the same doctor-per-capita coverage as it did in 2021 until 2035, after taking into account the aging of both the population and its doctors.
Tackling medical deserts and the underlying shortage of health workers was never going to be easy, but it's never been more urgent, with patients and health care workers alike suffering the consequences of short-sighted health workforce planning.
Brun d'Arre, whose family has lived in Le Vigan since at least the 18th century, never imagined it would be so hard to convince other doctors to make the town their home, too.
Though he plans on hanging up his stethoscope at 67, he's not firm on that timeline just yet.
"Maybe I'll stay on a bit longer."