The gentian revolution

He was happy with his situation since he had been practising in Thiérac**, at the foot of Puy Mary, in this superb surgery with a close-knit team of five fellow doctors and eight nurses. Biology and radiology facilities completed the picture. Unusual! It was not a question of setting up a hospital but of offering a holistic approach to healthcare provision.

Distributing care. A complicated challenge: providing care is one profession, distributing it is another. We had to think about the care pathway in terms of concentrating actions rather than marking out distinct stages spread out over an endless journey. The idea eventually gained acceptance, but not without difficulty. And yet, when you think about it, getting closer to the patient makes more sense than sending them on a rally without prior reconnaissance. That said, breaking with tradition and obtaining the necessary authorisations – even for a good cause – was not without its difficulties.

In short, in another building adjacent to the medical centre, there was a pharmacy, an osteopath, a fully equipped physiotherapy practice with a rehabilitation pool, two midwives, a psychologist and a large dental practice.

*Gentian, a plant that thrives in the Auvergne mountains, has enjoyed immense popularity since ancient times. It was used by mountain dwellers to make an invigorating drink that is now served as an aperitif to city dwellers. It ‘sets the scene’ for the action. This text is intended to be a realistic fiction, not a fantasy.

Thiérac, an imaginary town

INSTALLATION

Pierre and his colleagues had access to the Clinic-Alpha health centre, a 2030s-style medical practice with a blood and pelvic sampling facility and a branch of a partner laboratory for carrying out routine or urgent tests, managing troponin, D-dimers, blood and platelet counts, haematocrit, creatinine and GFR, blood sugar and HbA1C, inflammatory tests, CRP and the old VS… which was making a comeback, its usefulness having been highlighted by Asian oncology centres. At the specific request of the Auvergne Rhône-Alpes Regional Health Agency, which had finally understood the value of the concept, a few tests for common drugs and toxins were also carried out on site. For more complex tests, the laboratory provided complete results within the day.

The medical centre also had a well-equipped radiology unit, with a digital flat panel detector and a CT scanner managed by a practice in Issoire and another in Aurillac, one of whose radiologists came to Thiérac for half-day shifts five days a week. The machine, which served patients at the centre, operated from 10 a.m. to 3 p.m., but thanks to two enthusiastic part-time technicians who worked ‘old-school’ shifts, full coverage was ensured, with a newly retired colleague based near Saint-Flour coming back on duty for the holiday periods. It should be noted that, economically speaking, the balance sheet was balanced. On the medical side, when the situation was tense, three active retired radiologists supplemented the two teams as needed, including one semi-retired radiologist based in Tahiti, who was not afraid of night shifts (in France)… which were daytime shifts for him!

Obtaining the CT scan was an obstacle course. There had been much talk in high places about this acrobatic feat. But the facts are stubborn and indisputable. Apart from a hardware failure that was repaired within 48 hours, the CT scanner had been fully available for its eighteen months of operation. Two IGAS (Inspectors General of Social Affairs), known for their meticulousness, were sent to conduct an on-site inspection at the request of a radiologists’ union. They produced a glowing five-page report praising the device and demonstrating an unprecedented operating cost/efficiency ratio and unparalleled medical efficiency. The complainants’ case was dismissed.

In this health centre setting, all the general practitioners had acquired the status of internship supervisors, inviting them to welcome interns from neighbouring faculties in Clermont-Ferrand, Limoges and Saint-Etienne – and even from Paris! They provided on-call services in conjunction with senior teams, country doctors, city doctors and hospital doctors with whom they were connected via telemedicine: they were supported, advised, trained and covered. How?

This was where the third level of this disruptive diagnostic armada came in, the one most used on a daily basis: telemedicine, in the form of remote consultations. Not to compensate for the absence of a general practitioner on site – there were four on duty during the day, not counting the interns – but to implement level #2 of teleconsultation, by far the most interesting: calling in a specialist. With diagnostic tools enabling a complete physical examination of the patient, including cardiac ultrasound, any hospital specialist could give an informed opinion.

In fact, the combination of first-rate equipment – present in every examination room – and the ability of its videoconferencing software to communicate with any existing hospital information system, immediately and without prior manipulation (usually refused by IT managers), allowed our Thiéracois to contact all their specialist colleagues, in any discipline, at any time, anywhere in the world, without delay. anywhere in the world. Initially, the practitioners themselves did not believe it, but they were convinced by this asset that changed their professional lives. There was always at least one specialist, somewhere, immediately available. Let’s think about it for a moment: which general practitioner could, under normal circumstances, dream of this type of practice without telemedicine? None. We can also measure the benefit to the patient in terms of precious time saved when faced with a serious health problem, since the faster we act, the better the outcome. And for economists, always on the lookout for cost savings, time is money.

An endoscopy unit was due to open on 1 February. The secretariat, comprising eight staff members, was relocated to Nancy in an open-plan office shared by all healthcare professionals in Thiérac and seventeen other similar health centres and partners across the country, particularly in rural areas. Six of these are in the Cantal department. It should be noted that Thiérac has a population of 2,315. That said, this is more than the Mayo Clinic had when Will Mayo set up shop in Rochester, Minnesota. The town had a population of 128! This did not prevent the Mayo Clinic from becoming the huge medical centre that is unanimously considered the best in the world.

This was what had been created, to everyone’s surprise, on the initiative of Dr Vidal, who had been practising since 1980 and remained in his post until the age of 75 in response to the pleas of his patients, aware that he would not find a successor for a lease running from 2025 to 2070. He approached a childhood friend, a former Parisian academic, also from Cantal like himself, who convinced him with his wildly ambitious project:

Building general medical practices with the expertise of a hospital.

The reality was there, right before their eyes. The health centre extended its activities to the surrounding villages, with some patients in need of specialist care even coming from the neighbouring town to access it more quickly via teleconsultation. Pierre and his colleagues would occasionally lend a hand at the Aurillac hospital emergency department for minor cases during busy periods. The world turned upside down.

PRODUCTION

That night, Pierre, the general practitioner on duty, had sent a patient with intestinal obstruction to Aurillac Hospital with an urgent diagnosis of acute small bowel volvulus. A minor surgical procedure: this precise diagnosis is never made in a general practice. The centre’s ‘added value’ resulted from the combination of this practitioner’s good clinical judgement, appropriate additional tests and the ability to quickly contact a specialist colleague.

Pierre had based his diagnosis on the discovery of a small, forgotten scar from an appendectomy performed fifty-five years earlier, the sudden onset of symptoms, a distended abdomen that was painful to the touch, an inconclusive ultrasound due to gas… and a simple X-ray of the abdomen taken without preparation in a standing position. A wealth of information. It must be admitted that it took two of them, with Marius’s help, to ‘secure’ the patient under Mélanie’s supervision. It was worth the effort: we could see dilated small intestinal loops, central hydro-aerial levels in staircase steps, and no effusion or gas in the colon. A pathognomonic image… for those familiar with this pathology, which Professor Jean-Paul Clot had taught the young medical student, Pierre, at Cochin Hospital a decade earlier.

He almost sent the patient straight to Aurillac for surgery. Just to be on the safe side, he called Frédéric, a radiologist in Ydes, his hunting and fishing buddy and co-driver in their souped-up Simca Aronde P60 – an authentic Bacala, a real rarity – in their summer vintage car rallies. Fred wasn’t even on call, but he probably wasn’t in bed, being a party animal on this festive evening, he thought with a smile. The answer was immediate: “You’re probably right, but do a scan to confirm. Yes, we’ll lose an hour, but the surgeon will ask for it at admission anyway, and it’s likely to take much longer, as you know. Call me back and give me access to your PACS, I’ll interpret it for you. Another exchange between the two doctors 20 minutes later, clock in hand. Bingo. Fred even saw a ‘bird’s beak’, a clear and progressive narrowing of the intestinal lumen, and a ” whirl ‘(whirlpool sign) reflecting the twisting of the mesenteric vessels and intestinal loops around a common axis. Thank you, Frédéric. How knowledgeable these “photographers” are! In short, he confirmed Pierre’s diagnosis, who was very happy to have a ’solid” case to call Géraud, the surgeon on call. Ambulance. Operating theatre. In retrospect, it was an elegant diagnosis, i.e. accurate and quick, confirmed during the operation: early intervention had prevented this athletic 60-year-old from having a piece of his intestine resected (cut out), which would have significantly complicated the postoperative period and left serious sequelae.

‘Good medicine,’ whispered the late Henri Mondor, professor of surgery and member of the French Academy, born in Saint-Cernin, not far from here, who had given his name to the hospital. Pierre was very proud of his clinical deduction and his accurate interpretation, which was confirmed by the scan. It was a small provincial victory over the violent outcry of a few academics in the capital, published shortly before in Le Monde, who had unsuccessfully opposed the installation of a digital radiology machine in health centres. Fortunately, Cantal was out of the picture. And they were out of touch. But Pierre was well aware that he would not have had this flash of insight if he had not been seasoned, or rather ‘osmosed’, by daily contact and direct discussions with the various members of this friendly team of radiologists.

Other highlights of this festive night: a smoker with emphysema was taken to A&E with pneumonia, with test results obtained in ten minutes on the auto-analyser confirming the infection with high CRP and white blood cell counts, and a chest X-ray showing a triangular lesion interpreted by the Tahitian radiologist, who specified a delicate auscultation. The nasty Covid of 2020-2023 was now just a bad memory, but SARS was still rampant and quick action was needed. Once again, the eRosetta medical record provided a list (obtained automatically, without human intervention) of all the drugs taken by the patient – prescribed by doctors he did not even know – enabling him to write an effective prescription… but, above all, one that was not dangerous. Harmful drug interactions remained a significant cause of mortality.

In the same vein, at the end of the afternoon just before starting her shift, eRosetta, the magic file, had saved her from making a potentially dramatic mistake mistake – with a fit fifty-something man who was in pain after a winter half-marathon and was looking for painkillers and anti-inflammatories. He hadn’t told her that he was on Xarelto for “benign” episodes of asymptomatic atrial fibrillation (with no noticeable signs) … diagnosed by his Apple watch and confirmed by the Faculty. That said, anti-inflammatories and anticoagulants, as we know, do not mix well.

Then Mélanie, the intern, had made, with Marius, her experienced trauma nurse, an ultra-fast 3D printed splint for a slightly displaced fracture of the lower end of the radius, known as a Pouteau-Colles fracture, with no detectable neurological damage, scrupulously following the advice of the head of the orthopaedic trauma department on duty at Caen University Hospital, the first available on the network. Competent, handsome, and charming. Mélanie’s cheeks had flushed during the exchange. She had sent him the control image. The surgeon would call the patient back to his home within six hours to make sure that his fingers were mobile and not swollen.

Pierre then sutured a wound above the eyebrow of a young boy, following a fight around the Christmas tree, which was still standing. Barely recovered from his surgical exploits, he prescribed the morning-after pill to a tearful teenager with the face of a Madonna… who was a little tipsy. Mariette and Mélanie made her swallow it with a Coke and some comforting words.

He then diagnosed, via remote ultrasound, a typical case of appendicitis for the Ydes medical centre, fifty kilometres away, helping his overbooked colleague. And one more ambulance for Henri-Mondor… with a solid assessment, not in the anonymity of crowded emergency rooms. In the same vein, still for Ydes, after reading a normal ECG recorded and transmitted by the nurse, he reassured a sixty-something cigar lover who was a bit too fond of the good life and was complaining of chest pains. No under-shift, no Q wave, sinus rhythm. All good.

He had interpreted another, more complex one, following a call from a colleague in Murat, at the home of a patient with a pacemaker. They felt a little overwhelmed! Together, they didn’t hesitate to call on a cardiologist friend who regularly spent his holidays in Auvergne and with whom they enjoyed fishing for trout. The excellent Jean-Joseph, from Strasbourg, was celebrating Christmas Eve in his chalet in the Vosges, lost in the forest six hundred kilometres away. He was not on call but, always available, had called him back from his mobile phone, with weak 3G coverage, and had graciously solved the problem for them in this impromptu meeting of three. In reality, there were four of them, as we mustn’t forget the most important player, Murat’s patient, whom the Alsatian specialist had given a cardiac ultrasound ‘while he was at it’, analysing isolated images captured during the examination, which were of much higher ‘photo’ quality than the video stream. The examination allowed him to make a valid diagnosis, even with the poor connectivity, which was the case. Still, it was time to install Starlink!

Among these notable actions, he had dealt with a few trivial matters concerning accelerated digestive transit – oysters were hitting hard this year – and handled a few other mundane cases.

Happy New Year, it’s midnight* (three hours past), Doctor Schweitzer…

*‘It’s midnight, Doctor (Albert) Schweitzer’, a play by Gilbert Cesbron (1950) featuring his illustrious namesake – no relation – adapted into a film by André Huguet (1952)

REVIEW

Without fanfare, Pierre delivered a clear message: the ‘new’ general practitioner had arrived. He found his practice more appealing, was better paid with a salary supplemented by substantial bonuses for the technical procedures he performed. Freed from the constraints of the old fee-for-service system, he avoided a hellish amount of paperwork. He finally felt appreciated by his hospital colleagues and remained loved and respected by his patients. Pierre had rediscovered the skills of the doctors of yesteryear who performed sutures, infiltrations, collection drainages, complex dressings, excision of bedsores, removal of skin tumours under anatomical-pathological control, burn care, stoma monitoring, etc., avoiding many unnecessary transfers to the hospital emergency department. One third of admissions, according to statistics from the CNAM, the French National Health Insurance Fund. In addition, through (tele)consultation, which freed him from distance… regardless of the distance, the doctor had almost instantaneous diagnostic insight into the full range of pathologies, having called on a radiologist in Tahiti, a surgeon in Normandy and a cardiologist in the Vosges that night, two of whom were previously unknown to him. Overcoming distance means opening up to the world. Opening up the world.

In accounting terms, eighteen patients during the night, five of whom were examined via teleconsultation, including this ‘RCP’, an unplanned multidisciplinary consultation meeting in cardiology. Unplanned, but so effective. This dense and varied picture was reminiscent of the characteristics of public hospital emergency departments in the last century. It measured how far we had come since his colleagues, with little or poor equipment, limited most of their consultations to a conversation – a medical interview – which was certainly important, suggesting that in 2029 all consultations could be conducted over the phone. No, mistake (or fault?): when faced with a large number of patients, a careful physical examination is essential. And when it came to “medical interviews”, resulting from a series of questions and answers, AI voice robots specialising in medicine were arriving. They know everything, gather information in a second, prioritise it instantly (and perfectly), forget nothing, show no subjectivity, are immune to fatigue and are devoid of emotion. Would Jerrold S. Maxmen’s* predictions come true? But, unlike doctors, they could not examine patients. This was an insurmountable handicap. A doctor’s diagnosis needs to be based on all these elements, especially since the diagnostic process is non-linear. Would an anonymous practitioner from the Cantal region prove that good doctors would retain their place?

* Jerrold S. Maxmen, The post-physician era, Medicine in the 21th century, John Wiley & sons, 1976

Pierre had equipped all of Thiérac’s examination rooms with the same modules used in teleconsultation stations for the physical examination phase of the patient, an essential step in the medical consultation. The same optical examination tools, the same stethoscope, and the same ultrasound machine were used as for teleconsultations. The implementation methods were also identical. It was a question of method. At the end of the day, he and his colleagues were unable to say how many consultations of each type they had done, in person or remotely from their computers, as the intellectual approach was strictly identical regardless of where the patient was located. In all cases, they consulted with the help of a nursing assistant either at their side in the examination room or remotely at the patient’s side. An inseparable and formidable duo, in both cases, side by side or remotely.

EPILOGUE

Suddenly, his profession was looking up again. He was proud to be a general practitioner. And relieved to prove wrong the prophets of doom who, in recent years, with the emergence of spectacular applications of this famous generative artificial intelligence, relayed by the inconsequential exegesis of a few armchair scientists, had sown deep turmoil by announcing the imminent demise of the discipline.

The opposite had happened: Pierre used GPT#6.2 on a daily basis. Version #5 had been very disappointing. It was a localised, anonymised version, running on servers located at the health centre to ensure confidentiality. The computer program automatically generated reports based on data captured during the consultation. ‘Ultimate’, his physical companion who recorded everything, facilitated the practice of ultrasound and teleconsultations… what a revolution, he acknowledged! The document was perfectly formatted, saving him time. When he returned to his office, he found two versions on his screen: the first, complete and documented (sounds, images, text), and the second, a summary that was automatically slipped into eRosetta, the file/log he shared with all colleagues and caregivers who would be treating the same patient, either in consultation with him or independently. Beforehand, he carefully checked these documents, correcting them if necessary, either by voice or keyboard. The ‘long’ version, documented in the background, remained accessible at all times to any authorised colleague.

To prepare his presentations for staff videoconferences with other partner health centres once a month, with the university hospital on an ad hoc basis, or for multidisciplinary team meetings when he was involved with one of his patients, he would put on his thin Meta/Luxottica glasses (Samsung, Apple and Huawei made the same ones), which had advantageously replaced the unbearable headset he used in the early days to summarise complex clinical files, biology, drug interactions and treatment schedules.

Magical! All the documents appeared together in his augmented reality field of vision, and with a nod of his head, he called up the one he wanted, which instantly appeared in front of him. Needless to say, he had forgotten about coding sessions, a relic of the past with a process that is now automated. And he spoke… to his glasses to instantly find immediately useful bibliographic references.

What a journey it has been…

He remembered with a touch of nostalgia, as a young fourth-year student on the Parisian benches of the Cordeliers site, the words of this American professor, a public health lecturer in Chicago, cultured as American academics tend to be. This visiting lecturer, associated with Paris-Cité University for a sabbatical year, had predicted a bright and sparkling professional future for general medicine – contrary to the prevailing orthodoxy – alongside which, he said, “the fires of the French Renaissance, from the height of the sumptuous 16th century to the pyrotechnicians of the Grandes Eaux de Versailles, including Lully, would pale in comparison to a sad moonless night.” A delightfully mannered phrase, but one built around a powerful idea.

He added : “Guys, Exhaust the immense resources of the earth before looking further afield. Remember that Laennec’s stethoscope was rejected by the American Medical Association for decades because it created a worrying ‘intermediation’. The idiots! Worse still, we ourselves have not yet adopted in routine medicine the application of the effect discovered in 1843 by Christian Johann Doppler and Hippolyte Fizeau, which would lead to the ultrasound scanner! Our colleagues in obstetrics, who were smarter than general practitioners and radiologists in this case, did not think to explore the foetus floating in amniotic fluid until 1960… by analogy with Russian trawlers, which had been using sonar to locate schools of fish at sea since the 1930s! ».

Everything is already available, he concluded. Everything is right before our eyes. You will find unexpected areas for improvement in your work by consulting all the information available on your patient, compiled by your colleagues. The single file is the secret to optimal efficiency. An ardent obligation, as General De Gaulle would have said. ».

To conclude, he backed up his words with the advice to read, reread and reread again Jean de La Fontaine’s ‘The Farmer and His Children’. Where everything was said.