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Free consultations at 25, 45 and 65? A false good idea, by François Bourdillon

The Minister responsible for Health wishes to offer the French free medical consultations at "three ages of life, 25 years, 45 years and 65 years".

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Free consultations at 25, 45 and 65? A false good idea, by François Bourdillon

The Minister responsible for Health wishes to offer the French free medical consultations at "three ages of life, 25 years, 45 years and 65 years". This is the first preventive measure announced by the Ministry of Health and Prevention, titled unprecedented for this ministry. For the Minister, we are finally entering "the era of prevention". The logic is that of the check-up: make a regular assessment on the basis of specifications adapted to each age. At 25, it would be a question of "taking stock of vaccines, physical activity, possible addictions or difficulties linked to the start of professional life". At 45, the examination would focus on cancer screenings and “an assessment of physical activity and possible mental health disorders”. Finally, at age 65, the examination would focus on "the prevention of loss of autonomy, screening for cancers and all diseases that can be prevented".

This idea is old, at least for retirement age; traces of this can already be found in the national plan to age well 2007-2009, then in the 2019 report of the consultation on old age. The first reactions are mixed: some are favorable because a priori common sense; others are more dubious, especially those who think that general medicine is already having a hard time fulfilling its care mission in a context of shortage. On the side of public health specialists, it is underlined on the one hand the absence of scientific data making it possible to support such proposals and on the other hand a measure of prevention very centered on the care even though to change the behaviors and environments conducive to health, health education and promotion strategies must be developed.

It is also recalled that there are, in France, health check-ups in health insurance health examination centers or screening for breast, uterine and colorectal cancers which deserve to be supported to improve its performance. Finally, some underline the cost of such a measure (a cost of €150 per consultation is mentioned, excluding additional examinations); cost which requires debate as to the prioritization of the use of such a mass of money while prevention structures such as maternal and child protection, school medicine and occupational medicine are sorely lacking in resources.

Many reports have been written on this subject. The latest is that of the High Council for Public Health in 2009. It underlines the "very weak evidence concerning the interest of a periodic consultation for dedicated prevention". However, he mentions an interest in experimentation in the cessation of activity, among adolescents in order to "constitute a personal medical file which will follow him throughout his life", and for the unemployed. The recommendations of this report ultimately relate more to the promotion of preventive practices in general medicine than the establishment of preventive consultations.

General practitioners are supposed to provide preventive care (screening, health education, etc.) and contribute to the promotion of health. They are essential links. What about today ? Let us examine three classic examples of preventive practices in general medicine: screening for cancers and that of arterial hypertension and taking into account the determinants of health such as tobacco, alcohol and nutrition.

Can do better in cancer screening

The participation rate in colorectal cancer screening in France is only 30%, even though it is one of the most frequent tumors and the second leading cause of cancer death in men (3rd for woman). In terms of breast cancer, the screening rate is constantly decreasing with a participation rate in 2020 of 43%. Isn't the priority to review the organization of this screening in order to breathe new life into these essential secondary prevention systems?

Can do better in monitoring high blood pressure

High blood pressure is a major risk factor for cardiovascular disease. In France, in 2015 according to the Esteban study, 30% of the population was hypertensive. Among hypertensive people, 47% were treated with an antihypertensive drug and among these only 55% had controlled blood pressure. In other words, only about 25% of hypertensive people in our country are treated and balanced. There is undoubtedly a lot to be done in this area in traditional medical consultation.

Taking into account the consumption of tobacco, alcohol and nutrition must be regular

Alcohol, tobacco, nutrition, physical inactivity and physical activity are considered major determinants of health. In these areas, the attending physician participates in the National Public Health Strategy and dedicated national plans. It is expected that these issues will be regularly addressed in consultation and on an ongoing basis, and especially not once every 20 years. In other words, the attending physician must take an interest in risky behavior (tobacco, alcohol, nutrition, etc.), proposals for cancer screening, psychological suffering, hearing loss. .. throughout life and to seize the opportunities offered by consultations to develop preventive clinical approaches.

Targeting those who do not consult is a very difficult problem to solve. Thus, experience shows that the health insurance oral check-up affects more those who have good oral hygiene, and less the target people. The same is true for its support program for diabetics (SOPHIA), which tends to reach the diabetics with the best follow-up. This is why the Health Insurance also offers preventive health examinations as a priority to people who are far from the health system and in a precarious situation, who do not benefit from regular medical monitoring carried out by the attending physician. It is carried out in 85 health centres. What is the outcome of these exams? What is their added value compared to that of the attending physician in isolated practice and in a multi-professional health center?

To conclude, it is consensual to say that we must develop prevention, the poor relation of our health system. The measures expected are numerous, particularly in education and health promotion. The priority in prevention is not to identify problems once they have arisen, but to ensure that the physical, societal, cultural, economic and regulatory environment prevents them from occurring. The free prevention consultation tends to be the tree that hides the forest and the complexity of the underlying phenomena. It is not possible for the doctor to correct all this.

Preventive medicine is only one aspect of prevention, even if it remains a priority. Prevention in general medicine is to be included in daily practice, rather than in the form of periodic examinations. Especially since health insurance has 85 dedicated centers. A policy for the promotion of preventive medical practices requires consultation with professionals in the field, and should lead to the financing of a public health team to establish prevention benchmarks, promote the measures decided on and evaluate them based on previously defined indicators. .

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