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Éric Guéret, director of ‘‘Premières Urgences’’: Is there a political will to destroy the French public hospital?

20 August 2023 Interviews   13581  

For six months, director Éric Guéret filmed the daily life of young medical interns in the emergency department of the Delafontaine hospital in Saint-Denis, a Paris suburb. The result is a touching and ambitious documentary, Premières Urgences (released in cinemas on 16 November). As patients pile up in the corridors, the five interns (Amin, Evan, Hélène, Lucie and Mélissa) do their best, with courage and self-sacrifice, despite a glaring lack of resources.

Interview By Cédric gouverneur

Why did you choose this hospital in particular?

The Delafontaine hospital is just what we were looking for: it is an establishment like most French people encounter when they go to the emergency room. It is not in the countryside, nor in a city centre, but in this peripheral France, confronted with medical desertification. The emergency room is confronted with all the social difficulties: impoverishment, isolation of the elderly, violence… Doctor Mathias Wargon, head of the emergency room at this hospital, is wont to say: “What no one wants to see, we take care of”. More prosaically, this hospital is not very far from my home: I film alone, which gives me flexibility and proximity. I leave in the morning with my camera and my backpack, I never know if I’m going to stay for two hours or spend the day or even the night there. I saw the medical team a week before the shoot: they chose me. The hospital environment is suffering, the people who work there have a lot to say: when you bring a sympathetic ear, you are well received. Five interns agreed to be filmed (the others are off camera). I filmed between November 2020 and May 2021. Post-production took time. But if I had shot my film more recently, believe me it would have been even worse. Because yes, the situation is getting worse and worse!

In your film, the viewer is totally immersed in the world of the emergency room, we know nothing about the life of the interns outside.

It’s a closed-door setting, a unity of time and place, with a very strong dramaturgy: we enter this veritable liner that is the hospital, a just-in-time machine that operates 24 hours a day, out of time. Sometimes you have to look outside to see if it’s day or night, if it’s autumn or spring… It’s stifling, but that’s how a hospital lives. In any case, we were in the middle of Covid at the time, so there was very little social life. However, some elements of the private life of these interns do come through.

The interns are courageous, motivated, but sometimes overwhelmed by the difficulties. One of them talks about his confusion when he has to tell a patient about a serious diagnosis.

I was surprised that the interns were so quick to find their feet and so effective in the field in performing medical acts: there is no doubt that we have excellent medical schools in France! On the other hand, empathic and social management is lacking: interns are expected to learn on the job how to announce a severe diagnosis, but in my opinion, it would be a good idea to add courses on approaching patients in distress.

An intern testifies to her desolation regarding the reception of battered women.

It is a pity that emergency rooms are not more involved in the fight against domestic violence: victims arrive at the emergency room and we have to know how to identify them (they often claim to have fallen down the stairs). Staff should be made aware of how to detect such violence and should be taught how to direct victims (at least a leaflet with the contact details of associations and the steps to take). The worst thing is that the Maison des Femmes de Saint-Denis is located right next to the hospital!

Many emergency patients are in psychiatric distress

This is what shocked me the most. We discover the bankruptcy of psychiatric care in France. Psychiatric patients are clogging up the emergency rooms and exhausting the teams. And this situation leads to abuse of patients! Dr. Wargon recognizes that in the emergency room, we do to crazy people what we no longer do to prisoners! Emergency physicians often have no choice but to “sedate” and strap a patient to a stretcher, sometimes for days, so that he or she is not a danger to himself or to others, while waiting for a place to open up in psychiatry. It’s a daily occurrence, it’s terrible. The shortage is immense. The vast majority of women on the street have psychiatric problems. In France, the non-dangerous crazy people are on the streets, the dangerous crazy people are in prison. The street is making up for the shortage of psychiatric care!

Due to the lack of places, doctors and interns spend hours on the phone!

Overwhelmed, doctors have to look for places in other facilities to accommodate their patients. They are constantly faced with this difficulty. The fact that staff spend their time on the phone looking for available beds is expensive! Add to this the administrative red tape, the computer that crashes, the printer that has been out of order for years, the toilets that have been broken for weeks…

One patient even arrives at the emergency room with a gunshot wound…

I saw several, but only one agreed to be filmed! This shows how important hospitals are in areas where there is nothing left… The public hospital remains the only open door to seek help. It is therefore vital that it is there, open and accessible. Many French people end up in emergency rooms because they have no doctor to treat them: some have symptoms resulting from undiagnosed and metastasized cancer! The emergency room takes care of patients from a town medicine that is no longer there. The department of Seine-Saint-Denis is on the way to becoming a medical desert, like many urban areas! Yes, medical deserts are not only found in rural areas! And the situation is going to get worse over the next few years for demographic reasons, as many doctors are retiring. And nobody wants to take their place.

How can we solve this equation of medical deserts?

Inequalities in access to health care in France are due to the fact that there are absolutely no constraints on the freedom of installation of private doctors: they settle where it is good to live, in city centres, in the mountains, on the coast… Imposing a place of installation would dissuade medical students from embarking on such long studies. And the liberal doctors’ unions are keeping a close eye on this. The MPs do not dare to tackle this.

In such a context, the interns seem all the more courageous

They are courageous, they have the vocation, but they often leave to work elsewhere… As the situation in public hospitals is constantly deteriorating, it is becoming more and more difficult to find staff who will stay. Departments are being closed due to lack of staff. The real difficulty for the hospital is to remain attractive for the nursing staff. The system was based on self-sacrifice, but goodwill is no longer enough. People are burnt out. The dikes were still holding before Covid, the carers fought to hold the boat during the pandemic, they were applauded. But then they perceived the “Segur of health” as a humiliation, with its 183 euro bonus. The lessons of Covid have not been learned. The recognition of the staff is not there: you are adored, you are indispensable… but you continue to be badly paid and beds are closed. Interns often leave the public hospital for the private sector or a doctor’s practice. Most emergency doctors are foreigners: Romanians, Africans, North Africans… Without foreign doctors to save them, the emergency services would collapse. France trains doctors, but does not give them the desire to practice.

Nurses and care assistants complain about their pay checks.

They are so poorly paid that, even in Seine-Saint-Denis, rents are too high for them: they have to put up with long journeys by public transport morning and evening… The salary of a nurse is a deterrent! Under Sarkozy, the famous “activity-based pricing” (T2A) has transformed the public hospital into a company. The logic is to make savings at any cost. The result is that the hospital no longer has the means to function properly and to keep those who work there. The solutions are well known: more resources and more attractive salaries. One wonders whether there is not a political will to destroy the public hospital, as a strategy of degradation.

Premières Urgences, a documentary by Éric Guéret, produced and distributed by Haut et Court, 96 minutes.