Wearied by never-ending reforms, swamped by a soaring workload and ever-expanding duties, undermined by lack of recognition of their speciality by society, the state and the wider medical community, occupational doctors, especially younger medics, may start looking for a change of career.
"Some colleagues I’ve talked to say, The reform is a worry; if it doesn’t suit, we’ll change professions. I sometimes think I could do with a change of career, but I’m not yet ready to just drop occupational health",vouchsafed one occupational doctor in a professional publication. France’s occupational doctors have latterly been taking to blogs, reports issued to the press, and attention-grabbingly titled books to voice the disquiet besetting their profession (see: More information p. 22).
According to official figures at 1 January this year, France had 5 694 occupational doctors comprised of 4 011 women and 1 683 men. At 54.8 years, occupational doctors have the highest average age of all of medical specialities. The average age of occupational doctors in the Centre and Poitou Charentes regions even tops 57 years. As things stand, nearly 75% of occupational doctors are aged fifty and over.
And the projections are sobering. A Ministry of Health study predicts that the numbers could shrink by 62% between 2006 and 2030 with mass outflows to retirement in coming years not being offset by new inflows as fewer medical students find their calling in the profession.
These figures show the scale of the demographic challenge for the secure future occupational health surveillance of workers in general. It is partly in a bid to address this looming shortage that the Ministry of Labour has for almost two decades been working on a major reform of the occupational health system. Why is it still not yet done? In France, occupational health services remain a highly political issue and an arena of contention which broadly pits two diametrically opposing approaches – a health service that serves workers and one that serves the economy –against one another.
It all started in Vichy...
To understand these tensions, we must go back to legislation passed by the collaborationist Vichy government in 1942, when medical services were first imposed on business with the intent of identifying French workers fit to perform the infamous "compulsory work service", i.e., being shipped off in their hundreds of thousands to Germany to replace the German workers sent to fight on the Eastern front.
After the Liberation, the newly-appointed Minister of Labour, Communist MP and former metalworker Ambroise Croizat, sought to make the occupational health services tainted by Vichyism palatable to workers. In 1946, he steered through parliament a new law on occupational health services based on Republican principles like universality ("occupational health services are for all employees"). This Act spells out the remit of the occupational doctor: "The occupational doctor has a purely preventive role. It is to avoid any deterioration in workers’ health by reason of their work, in particular by superintending their hygiene at work, the risks of contagion and their health".
In short, a system meant purely to serve workers, but in which the idea of medical selection of labour persisted, especially through the provision for checking workers’ fitness. The imperative post-War need for reconstruction, a prerequisite for which was the preservation of "industrial harmony", and a new government minus the Communists, worked against the law being implemented in line with its initial ideals.
Almost seventy years on, the 1946 Act remains the cornerstone of the Republican, "French-style" approach to occupational health services. "The French system is based on the principles of the Constitution of the Republic which make protection of workers’ health a basic function of the state, and tasks occupational doctors with carrying out that public policy remit", argues Alain Carré, one of the organizers of "Santé et médecine du travail" a coalition formed to oppose the marketization of occupational health services.
In some professionals’ view, the grindingly slow reforms started in the 1990s to meet the requirements of the EU’s 1989 Framework Directive on health and safety at work are throwing this model into question.
Multidisciplinarity: hopes and mix-ups
Under pressure from the European Union, France made changes in 2000 to give a more multidisciplinary steer to its occupational health system, rebranding occupational health services as "health and safety at work" services. The idea is to deliver real primary risk prevention by buttressing occupational doctors with other professionals like specialised occupational health nurses, occupational health assistants and specialists in other fields (ergonomists, toxicologists, metrologists, psychologists, etc.) known by the acronym "IPRP" (intervenants en prévention des risques professionnels – occupational risk prevention operators). "Multidisciplinarity", which is the main focus of occupational health service reforms in France, has been beset by numerous difficulties in practice. Dissatisfied with how it was being implemented, the government sought to bolster it by passing new legislation in 2011.
"We believe the whole thing stems from a misconception. The government saw multidisciplinarity mainly as a way of addressing the shortage of occupational doctors. But we think the opposite – that multidisciplinary working cannot be seen as a response to the shortage of occupational doctors. Our organization has always favoured the multidisciplinary approach but as a means of improving prevention purely for the benefit of employees. In services with an acute shortage of doctors, the introduction of multidisciplinarity has been disastrous", says Mireille Chevalier, Acting General Secretary of occupational health professionals’ union Syndicat national des professionnels de la santé au travail (SNPST).
Sociologist Pascal Marichalar, who wrote his doctoral thesis on occupational health services in France, argues that multidisciplinarity is a revisited technocratic approach to workplace health issues that reflects the employer’s agenda. "The way in which multidisciplinarity has been implemented is often little more than the technicization of prevention and a shift from a medical practice-based approach and relationship to the employee, with the idea that getting workers to talk about their work is the quickest way into the reality of work, to a technical approach disconnected from workers themselves where the sole focus is on the work environment", he told HesaMag.
The gradual introduction of multidisciplinary working also raises questions about the independence of IPRPs. Alain Carré believes that IPRPs are ambiguously situated: "Looking at the European legislation, their job is to support the employer. I have found that industrial psychologists in particular were unsure whether they should be siding with the employer or the workers. Also, unlike occupational doctors, they are not classed as employees with protection from dismissal which leaves them more exposed to pressure from employers".
Working on his thesis, Pascal Marichalar came to realize what limited discretion these new operators in prevention had: "to get to see an occupational doctor, I just contacted them directly, and they readily gave interviews in work time. Every time I contacted an IPRP, they asked me to wait because they had to get management approval. I had to submit the questions I was going to ask to a senior manager. In some services, I noted that the IPRPs’ offices were directly facing the managers’ offices, so there was a de facto check on what they were up to".
Parity for show
As well as widening the range of players involved in occupational health through multidisciplinarity, the 2011 Act also seeks to bring parity to the boards of directors of intercompany occupational health services, which have long been the sole preserve of employers. They must now have equal numbers of employer and trade union directors. Many observers, however, see this as parity for show because the chairman of the board, who is always chosen from among the employers, has a casting vote in the event of a tie.
"The trade unions were deposited in a management system and can’t get to the point of having quality demands. Where health and safety at work are concerned, it perpetuates a system of trade unions in a negotiation mindset with health on one side and jobs on the other side of the scales", observes Mireille Chevalier. "Occupational health should never be up for negotiation", protests SNPST representative and current General Secretary Jean-Michel Sterdyniak.
The 2011 Act also requires all intercompany services to draw up a "multi-year service plan" that sets the service priorities and is meant to be the link between government health and safety at work policy and the daily work of occupational health services. Jean-Michel Domergue has put a lot into drafting this document for his intercompany service based in Créteil (south of Paris). "We started from scratch and painstakingly worked up a plan that has ended up not much short of 200 pages", he enthuses. The document assigns each (full-time) occupational doctor a maximum 2 800 employees and sets out the multidisciplinary team’s consensus view on how consultations should be organized and even ways of improving the traceability of work-related exposures.
While writing the document was an opportunity for Dr Domergue and his colleagues to re-examine their practice, discuss the profession, in a word, look with fresh eyes at the meaning of their calling, most turn out to be just tick-box exercises. "Most often, the plans have been written by the manager or chairman of the board of directors," admits Dr Domergue.
Commercial pressure is the biggest threat of all to good occupational health service practice. "We are pulled by conflicting requirements: doctors are asked to do increasingly more things, especially in terms of exposure traceability, at the same time as dealing with a growing number of people. We have to select just a number of employees to follow-up. Companies that have paid a fee feel aggrieved if not all medical consultations are held. And as my service continues to sell medical consultations ...", complains Serge Opatowski, an occupational doctor in a Paris intercompany service.
"Intercompany services make an informal division of work between the medical part of the business which employers recognize they have no right to interfere with, and the service organization and administration part, in particular occupational doctors’ work schedules which they feel they have the right to set themselves. But setting these work paces has an impact on the content of work, especially workplace visits which are the poor relation of occupational health services", argues Pascal Marichalar.
In a minority of one
The Labour Code may afford occupational doctors some protection against dismissal or re-assignment, but in reality it is exceptionally hard for a doctor to withstand pressure from a disgruntled employer (see Box A late but committed calling) – particular so when support from employees and union reps is not forthcoming. The employee-occupational doctor relationship is underpinned by probably more complex mechanisms than those that determine that with the employer.
Various of the seven occupational doctors interviewed for this investigation pointed to a lack of training or occupational health culture and a more general lack of strategic vision among employee reps on CHSCTs. "There is a high degree of naivety among the trade unionists. Employers can easily run tactical rings around workers reps with the old pals act", observes Alain Carré. Doctors have also reported getting no support from worker reps on CHSCTs after initiating a notification procedure following serious deteriorations in workers’ health. Without guaranteed support from workers’ reps, many occupational doctors give up the solitary fight.
The unions have always harboured suspicions about occupational doctors, often seeing them as closer to the employer. Jean-Michel Domergue explains this in sociological terms: "Not many occupational doctors come from working class communities, so they naturally feel closer to management than workers".
Alain Carré also sees a sense of class identification, but believes the problem in building a relationship of trust with workers lies with the fitness notice. Like most occupational doctors’ associations, he wants it scrapped as a hangover of the medical selection of workers practiced in the early days of company health services. Figures from a study done in the Vaucluse département showed that issuing a notice of unfitness results in almost every case in the worker losing his job, which is clearly not calculated to endear a worker to his occupational doctor•.
Ehster J.-M., Funds H. et Zimermann N. (2010) Menaces sur la santé au travail. Des médecins parlent, éd. Pascal Galodé, 183 p.
Fernandez G. (2009) Soigner le travail. Itinéraires d’un médecin du travail, Erès, 254 p.
Ramaut D. (2006) Journal d’un médecin du travail, Le cherche midi, 176 p.
For the past twenty years, a group of occupational doctors in Bourg-en-Bresse (eastern France) has published an annual report of anecdotal evidence from doctors about the difficulties encountered in daily practice. These alarmingly-titled documents (“Le désastre”, “Apocalypse Now”, etc.) are available on: http://collectif-medecins-bourg-en-bresse.over-blog.com
Carnet d’un médecin du travail is a sporadically-updated blog of personal thoughts from an occupational doctor http://medecindutravail.canalblog.com. See also Box Blogging to cope.