Initier la PrEP en médecine de ville et envisager la santé sexuelle des personnes en situation de migration.

In June 2020, 32,000 people began HIV Pre-exposure prohylaxis (PrEP) in France. The objective of this work is to propose PrEP for migrants in city medical offices in collaboration with hospitals. This is happening in the Goutte d’Or neighborhood of Paris where one-third of the inhabitants were born abroad [1]. The Goutte d’Or multidisciplinary and multi-site health center (MSP), composed of independent health professionals, hosted this study.The obstacles to overcome are multifold, notably talking about sexuality and presenting a prevention method that is little known to people in migratory situations. In addition, the first prescription of ARVs in this period had to be given by a hospital doctor (until June 1st 2021) [2].The working hypothesis is that general practitioners can overcome these obstacles within the framework of a protocol defining the discussions on sexuality and the organization of a PrEP consultation along with the GP and a hospital doctor within the city doctor’s office.The study took place between March 1st 2018 and October 31st 2020. 180 questionnaires concerning opportunities for PrEP were distributed by general practitioners (GP) and a midwife from the MSP. 43 people were identified as qualifying for the PrEP. 24 PrEP were prescribed, 23 continuously, and one on demand. A semi-directive interview on sexual health was proposed to the 43 people identified for PrEP consultations.The in-depth interviews confirmed that although sexual health may not be the primary interest of the consultants, there are nevertheless real needs that are not often taken into account.

What do patients consulting in a free sexual health center know about HIV transmission and post-exposure prophylaxis?

BACKGROUND: Screening, condom use and post-exposure prophylaxis (PEP) are among existing HIV prevention strategies. However, efficient use of these strategies requires that patients have an adequate knowledge of HIV transmission routes and awareness of risk behaviors. This study aimed to assess knowledge about HIV transmission among patients who attended a free HIV and sexually transmitted infection (STI) screening center in Paris, France, and to explore the patient profiles associated with HIV-related knowledge. METHODS: This observational cross-sectional study included 2002 patients who attended for STI testing from August 2017 through August 2018 and completed a self-administered electronic questionnaire. Based on incorrect answers regarding HIV transmission, two outcomes were assessed: lack of knowledge and false beliefs. Factors associated with these two outcomes were explored using univariate and multivariate logistic regressions. RESULTS: Only 3.6% of patients did not know about HIV transmission through unprotected sexual intercourse and/or by sharing needles. More than one third of patients (36.4%) had at least one false belief, believing that HIV could be transmitted by sharing a drink (9.7%), kissing (17.6%) or using public toilets (27.5%). A low educational level and no previous HIV testing were associated in multivariate analyses with both lack of knowledge and false beliefs. Age and sexual orientation were also associated with false beliefs. Furthermore, 55.6% of patients did not know that post-exposure prophylaxis consists of taking emergency treatment as soon as possible after risky intercourse. CONCLUSIONS: Although the main HIV transmission routes are well known, false beliefs persist and knowledge regarding PEP needs to be improved. Prevention campaigns must focus on these themes which appear as a complementary strategy to pre-exposure prophylaxis to reduce HIV infection.

Who fails to return within 30 days after being tested positive for HIV/STI in a free testing centre?

BACKGROUND: Some patients who test positive for sexually transmitted infections (STIs) fail to return for results and treatment. To target improvement actions, we need to find out who these patients are. This study aimed to explore factors associated with failure to return within 30 days (FTR30) after testing among patients with positive results in a free STI testing centre in Paris. METHODS: All patients with at least one positive result between October 2016 and May 2017 and who completed a self-administered questionnaire were included in this cross-sectional study (n = 214). The questionnaire included sociodemographic factors, sexual behaviour and history of testing. Factors associated with FTR30 were assessed using logistic regression models. RESULTS: More than two-thirds of patients were men (72%), and the median age of patients was 27 years. Most patients were born in metropolitan France (56%) or in sub-Saharan Africa (22%). Men who had sex with men represented 36% of the study population. The FTR30 rate was 14% (95% CI [10-19%]). In multivariate analysis, previous HIV testing in younger persons (aOR: 3.36, 95% CI [1.27-8.84]), being accompanied by another person at the pretest consultation (aOR: 3.45, 95% CI [1.36-8.91]), and lower self-perceived risk of HIV infection (aOR: 2.79, 95% CI [1.07-7.30]) were associated with a higher FTR30. Testing for chlamydia/gonorrhoea without presumptive treatment was associated with a lower FTR30 (aOR: 0.21, 95% CI [0.07-0.59]). CONCLUSIONS: These factors that affect failure to return are related to the patient's representations and involvement in the STI screening process. Increasing health literacy and patient empowerment could help to decrease failure to return after being tested positive for HIV/STI. TRIAL REGISTRATION: Not applicable.

Text Messaging After HIV and Sexually Transmitted Infection Screening: Do Patients' Profiles Matter?

BACKGROUND: Text messaging after sexually transmitted infection (STI)/HIV screening may be a cost-effective means of improving patient care, but it may not be appropriate for all patients. This study aimed to explore the profiles of patients who did not participate in a short message service (SMS) program after STI/HIV testing. METHODS: In October 2016, 396 patients in Paris were screened for STI/HIV and were invited to complete an anonymous self-administered questionnaire. Patients were offered the possibility of being notified by SMS after testing, 68% accepted (SMS group) and 32% did not (no-SMS group). Each of the 100 patients from the no-SMS group who had completed the questionnaire was matched with the next patient from the SMS group. Factors associated with nonparticipation in the SMS program were studied using conditional logistic regression models. RESULTS: Participation in the SMS program was not related to STI screening characteristics (screening results and seriousness of the diseases screened) but seemed to be related to patient characteristics. In multivariate analysis, compared with patients in the SMS group, those in the no-SMS group were more often older, socially less favored (born in Africa or Asia, no university diploma, living outside Paris). They also more often declined to answer sexual questions, which could reflect a need for privacy and discretion. CONCLUSIONS: Although SMS after STI/HIV screening is well accepted, it does not suit all patients. Several contact options should be proposed to comply with patients' preferences and to reduce the risk of nondelivery of STI screening results.

The association between future time perspective and sexual behaviours in individuals attending HIV testing centres.

BACKGROUND: Most European countries are still facing a high burden of sexually transmitted infections (STIs) cases each year. Available literature has found associations between time preference, i.e. the relative weight given by individuals to future outcomes compared to present ones, and various health behaviours such as tobacco or alcohol consumption, vaccination or participation in cancer screening programmes. Our objective is to investigate the role of future preference in risky sexual behaviours. METHODS: We conducted a cross-sectional study using self-administered questionnaires in three HIV testing centres in Paris. We collected data on sexual behaviours, risk perceptions, risk attitude, future preference (Considerations of Future Consequences scale) and socioeconomic and demographic variables. Full data for variables used in regression analyses were available for 1090 respondents. We study factors associated with condom use at the first sexual encounter, with the frequency of condom use and with the number of sexual partners. RESULTS: In the full sample, future preference is positively correlated with both measures of condom use while it is negatively correlated with the number of sexual partners. Decomposing the analysis by risk group, our results indicate that future preference has more impact on sexual behaviours, especially condom use, among men who have sex with men compared to heterosexual men and, to a lesser extent, compared to heterosexual women. CONCLUSION: If future time perspective is confirmed as a determinant of safer sexual behaviours, prevention campaigns could be shifted towards greater information on short-term consequences of STIs.

Can clinical practice indicator relating to long-acting benzodiazepine use in the elderly be easily generated in a hospital setting?

BACKGROUND: To improve the appropriate use of long-acting benzodiazepine (la.bzd) prescriptions in the elderly, the Haute Autorité de Santé (HAS) has developed clinical practice indicators (CPI). The alert indicator (AI) evaluates the prevalence of la.bzd prescription among older people. The mastering indicator (MI) corresponds to the prevalence of elderly with a justified, i.e., appropriate, la.bzd prescription among all the elderly with la.bzd prescriptions. OBJECTIVE: The objective of this study was to test the feasibility of routine generation of CPI regarding la.bzd prescriptions among the elderly in the hospital setting. DESIGN: This was a retrospective study. SETTING: The study was conducted in two university hospitals located in Paris. SUBJECT: Eligible cases were patients aged 65 years and older who were hospitalized in acute care units from January to June 2014. METHOD: The AI calculation was based on information extracted from medical databases from these hospitals. The appropriateness of la.bzd prescription was assessed by a physician and a pharmacist and was based on review of computerized patient records and prescriptions, using an ad hoc algorithm. The MI was then calculated. Variation in the level of indicators was explored according to the characteristics of patients and of their hospitalization using chi2 test. Factors associated with a potentially inappropriate prescription (PIP) of la.bzd were studied using univariate and multivariate logistic regression. RESULT: Among the 4167 patients included in the study, 362 had la.bzd prescriptions, i.e., the AI was 9%. Prescriptions were found to be appropriate for 83 patients, i.e., the MI was 23% and PIP was 77%. The MI varied between 13 and 31% according to characteristics of patients and of hospitalization. In multivariate analysis, factors associated with PIP were age, number of comorbidities, type of care unit, and concurrent prescription of a neuroleptic or hypnotic. CONCLUSION: Generation of the AI was routinely possible but only for acute care units with computerized prescriptions, corresponding to 78% of patients. Production of the MI has required medical record review for all patients with a la.bzd prescription and cannot be automated. However, difficulties in generating the MI have identified areas for significant improvement. Moreover, strategies to improve the care of older people with a la.bzd prescription could be targeted using characteristics of patients and of hospitalization associated with PIP. The future deployment of a single electronic medical record in all care departments would make it easier to mine the data and make possible automated production of CPI.

Is HIV Pre-Exposure Prophylaxis among Men Who Have Sex with Men Effective in a Real-World Setting? Experience with One-On-One Counseling and Support in a Sexual Health Center in Paris, 2018-2020.

HIV pre-exposure prophylaxis (PrEP) is highly effective but depends on patients' care engagement, which is often mediocre and poorly measured in real-world settings. This study aimed to assess the effectiveness of a PrEP program in a sexual health center that included accompanying measures to improve engagement. A retrospective observational study was conducted. All men who have sex with men (MSM) who initiated PrEP for the first time between 1 August 2018 and 30 June 2019 in the Fernand-Widal sexual health center, Paris, France, were included. Among the 125 MSM who initiated PrEP, the median age was 33 and most had only male partners. At initiation, 58% were considered at very high risk of HIV infection, mainly due to a history of post-exposure prophylaxis. During the first year, patients attended a median of three visits (Q1-Q3, 2-4). At 12 months, 96% (95% CI, 92.6 to 99.4) had a successful PrEP course, assessed by a novel metric. These results highlight the possibility of achieving a high PrEP success ratio among MSM in a real-world setting. The accompanying measures and one-on-one counseling by a trained counselor could explain the effectiveness of this PrEP program.

Notification of STI test results by text messaging: Why do patients refuse? Cross-sectional study in a Parisian sexual health centre.

Text messaging has been used to notify patients of results after sexually transmitted infection (STI) testing. This study aimed to characterise the population who refused notification of results by short message services (SMS) and to explore their reasons for refusing. From January to August 2018, 1180 patients coming for STI testing in a Parisian sexual health centre were offered SMS notification of their results, completed a self-administered questionnaire and were included in the study. Factors associated with refusal of SMS notification were explored using logistic regression models. Reasons for refusal were analysed following a qualitative content analysis methodology. In the study population, 7.3% [95% CI 5.8-8.8] of patients refused SMS notification. In the multivariate logistic regression model, male gender and older age were associated with refusal, as were non-French nationality, having forgone health care for economic reasons and being unemployed. Qualitative analysis showed that preferring face-to-face medical contact (32%) and anxiety about the test result (29%) were the main reasons given by patients for refusal. Socially disadvantaged patients may have more limited access to technology and be less at ease using it in a health context. Preference for face-to-face medical contact may reflect the need for human support in vulnerable populations.

[Public free anonymous HIV testing centers: cost analysis and financing options]. / Centre de dépistage anonyme et gratuit : étude de coût et des modes de financement.

The services of general interest provided by hospitals, such as free HIV clinics, have been funded since 2005 by a lump sum covering all costs. The allocation of the budget was initially determined based on historical and declarative data. However, the French Ministry of Health (MoH) recently outlined new rules for determining the allocation of financial resources and contracting hospitals for each type of services of general interest provided. The aim of this study was to estimate the annual cost of a public free anonymous HIV-testing center and to assess the budgetary implications of new financing systems. Three financing options were compared: the historic block grant; a mixed system recommended by the MoH associating a lump sum covering the recurring costs of an average center and a variable part based on the type and volume of services provided; and a fee-for-services system. For the purposes of this retrospective study, the costs and activity data of the HIV testing clinic of a public hospital located in the North of Paris were obtained for 2007. The costs were analyzed from the perspective of the hospital. The total cost was estimated at 555,698 euros. Personnel costs accounted for 31% of the total costs, while laboratory expenses accounted for 36% of the total costs. While the estimated deficit was 292,553 euros under the historic system, the financial balance of the clinic was found to be positive under a fee-for-services system. The budget allocated to the HIV clinic under the system recommended by the MoH covers most of the current expenses of the HIV clinic while meeting the requirements of free confidential care.

[Management and follow-up of patients treated with antiretroviral prophylaxis: an evaluation of professional practices]. / Prise en charge et suivi des patients traités par prophylaxie antirétrovirale : évaluation des pratiques professionnelles.

The care management of patients treated for cases of sexual or blood exposure requires stringent clinical and biological follow-up procedures. Despite the provision of information about the importance of regular follow-up, the number of patients dropping out of screening consultations at the Hospital Lariboisière-Fernand Widal (Assistance Publique-Hôpitaux de Paris) has increased. The main purpose of this study is to improve follow-up for patients treated with anti-retroviral prophylaxis following a known sexual or blood exposure. An investigation based on 5 markers of a targeted clinical audit form ("drop-outs" or lost to follow-up, conduct of HIV serology tests, traceability of clinical, biological and compliance monitoring) was carried out. A review of practices was conducted on the basis of an analysis of patient cases over a six-month period, followed by the implementation and evaluation of corrective measures over a two-year period. A significant decline in the number of patients lost to follow-up was observed. The study shows a significant improvement in other markers: serological follow-up, compliance traceability, and clinical and biological monitoring. These results were observed between 2005 and 2007. Two distinctive effects were identified: improvement in patient care management and the quality of care, and the empowerment of actors, thereby ensuring a certain continuity of action. The decline in the rate of lost to follow-up patients and improved monitoring of compliance and iatrogenic risks confirm these effects. The overall approach is incorporated into an evaluation of professional practices.

Hospitalization for acute heart failure: the in-hospital care pathway predicts one-year readmission.

In patients with heart failure, some organizational and modifiable factors could be prognostic factors. We aimed to assess the association between the in-hospital care pathways during hospitalization for acute heart failure and the risk of readmission. This retrospective study included all elderly patients who were hospitalized for acute heart failure at the Universitary Hospital Lariboisière (Paris) during 2013. We collected the wards attended, length of stay, admission and discharge types, diagnostic procedures, and heart failure discharge treatment. The clinical factors were the specific medical conditions, left ventricular ejection fraction, type of heart failure syndrome, sex, smoking status, and age. Consistent groups of in-hospital care pathways were built using an ascending hierarchical clustering method based on a primary components analysis. The association between the groups and the risk of readmission at 1 month and 1 year (for heart failure or for any cause) were measured via a count data model that was adjusted for clinical factors. This study included 223 patients. Associations between the in-hospital care pathway and the 1 year-readmission status were studied in 207 patients. Five consistent groups were defined: 3 described expected in-hospital care pathways in intensive care units, cardiology and gerontology wards, 1 described deceased patients, and 1 described chaotic pathways. The chaotic pathway strongly increased the risk (p = 0.0054) of 1 year readmission for acute heart failure. The chaotic in-hospital care pathway, occurring in specialized wards, was associated with the risk of readmission. This could promote specific quality improvement actions in these wards. Follow-up research projects should aim to describe the processes causing the generation of chaotic pathways and their consequences.

Assessing the impact of a quality improvement program on the quality and timeliness of discharge documents: A before and after study.

ABSTRACT: Whereas handover of pertinent information between hospital and primary care is necessary to ensure continuity of care and patient safety, both quality of content and timeliness of discharge summary need to be improved. This study aims to assess the impact of a quality improvement program on the quality and timeliness of the discharge summary/letter (DS/DL) in a University hospital with approximatively 40 clinical units using an Electronic medical record (EMR).A discharge documents (DD) quality improvement program including revision of the EMR, educational program, audit (using scoring of DD) and feedback with a ranking of clinical units, was conducted in our hospital between October 2016 and November 2018. Main outcome measures were the proportion of the DD given to the patient at discharge and the mean of the national score assessing the quality of the discharge documents (QDD score) with 95% confidence interval.Intermediate evaluation (2017) showed a significant improvement as the proportion of DD given to patients increased from 63% to 85% (P < .001) and mean QDD score rose from 41 (95%CI [36-46]) to 74/100 (95%CI [71-77]). In the final evaluation (2018), the proportion of DD given to the patient has reached 95% and the mean QDD score was 82/100 (95% CI [80-85]). The areas of the data for admission and discharge treatments remained the lowest level of compliance (44%).The involvement of doctors in the program and the challenge of participating units have fostered the improvement in the quality of the DD. However, the level of appropriation varied widely among clinical units and completeness of important information, such as discharge medications, remains in need of improvement.

Cracks and crevices: globalization discourse and medical education.

Globalization discourse, and its promises of a 'flat world', 'borderless economy' and 'mobility of ideas and people', has become very widespread in all fields. In medical education this discourse is underpinned by assumptions that medical competence has universal elements and that medical education can therefore develop 'global standards' for accreditation, curricula and examinations. Yet writers in the field other than medicine have raised a number of concerns about an overemphasis on the economic aspects of globalization. This article explores the notion that it is time to study and embrace differences and discontinuities in goals, practices and values that underpin medical competence in different countries and to critically examine the promises-realized or broken-of globalization discourse in medical education.

[Analysis of fourteen French national programmes on physical activity and sports as determinants of health from 2001 to 2006]. / Analyse de quatorze actions nationales pour le déterminant de santé activités physiques et sportives en France de 2001 à 2006.

Physical activity and sports are considered as one of the determinants of health. The aim of this study is to review the rationale for the formulation of this public health issue and its integration in national action plans. The study shows that fourteen national programmes were drafted and implemented between 2001 and 2006 by seven institutions. The research methodology was based on crossing data obtained from semi-directed interviews and documents regarding the design, implementation and follow-up of these programmes. For the conditions of the success, the fourteen actions scored an average of 175.0 +/- 66.9 out of 300%. Public health actors and professionals must be given more opportunities to involve themselves and engage in developing stronger relationships and linkages, in particular with the institutional and community settings. In general, the most invested parts of a programme are the structural and operational aspects of activities. Six significant points surfaced from the study: consideration of drug use as an addictive behaviour; recognition of the psychological stress of professional athletes; acknowledgment of youth as being at high risk for doping behaviour; integration of the concept that physical activity and sports must take the benefit/risk perspective into account; and the necessity to promote health. Through the exchange of numerous local and regional experiences, an optimisation of their synergistic connections was made possible on a continuum extending from "health promotion through physical activity and sports" to "prevention of drug-use and doping behaviours". Professionals have been able to develop actions in the above-mentioned domains across this continuum that have, to date, remained isolated. Proposals are made to strengthen these dynamics. Other health determinants and public health priorities could be investigated with the same methodology.

[Equity and planning: a critical analysis of a third generation regional healthcare management program]. / Equité et planification: analyse critique d'un schéma régional d'organisation sanitaire de troisième génération "perinatalité".

The third generation of the regional healthcare organization plan (Sros III) proposes to develop the organisation of healthcare and its management according to evolution of its activities and the populations concerned. At the time of a strategic analysis of SROS III (what we refer to as its perinatal period), the question is whether promoters can move from an approach based on accessibility (egalitarian equity) to a needs-based approach (differential equity), which although more complicated in to apply and implement, was found be much better adapted to healthcare users. The research is derived from an analysis of documents from November 2004 to November 2006. A university public hospital developed the data which supported a proposal to shift from level I to level II. This proposition was retained in the territory's medical plan authorized by the regional health authorities. Health professionals and the architects of the healthcare plan have the capacity to new organizations responsible for taking into account the activities and healthcare needs of the population in order to initiate and establish differential equity.

[Medical education in France and Canada: is there a best system?]. / Formation médicale en France et au Canada. L'un des deux systèmes est-il meilleur que l'autre?

We have compared the conception and organization of medical education systems in France and Canada, taking into consideration key means and processes including the organization of curriculum, the selection of students, certification and licensure. The major objective of this comparison is to illustrate the degree to which the organization of medical education is influenced by the specific history and culture of each country. This is particularly important in an era of increasing internationalization in medical education. In Canada, a federalist orientation means a great deal of freedom for each province to determine its own criteria for medical licensure, and for each faculty of medicine to determine its own selection criteria and curriculum organization. Meanwhile, the evaluation of graduates of medical schools and later of specialties is organized at a national level. France, on the other hand, is much more centrist, and controls the "input" of students to medical schools and the nature of their curriculum. However, France allows each faculty of medicine to deliver a diploma that authorizes physician graduates to practice, without an evaluation of student performance at a national level. We show how the selection and evaluation of students in France are influenced by the French Revolutionary principles of "liberté" and the education of a national "elite", while in Canada the goals of "equity" and the guarantee of a level of "minimum competence" under pin a very different system. In conclusion, we highlight the important of taking into consideration these factors before undertaking reform of educational systems or transferring methods from one country to another.

World conference on medical education: a window on the globalizing world of medical education?

The Association for Medical Education in Europe (AMEE) is a worldwide association for all interested in medical and health professions education (http://www.amee.org). AMEE organizes an annual meeting, the most recent of which (2005) was held in Amsterdam. At this meeting certain countries and regions were better represented than others, while some countries with large populations or a significant role in the history of medical education were almost completely absent from the international scene. At the same time, the themes addressed at the AMEE conference concern issues of international interest, and appear to be leading to internationalization of pedagogical and research methods and policies for educational standards. It is therefore crucial that all parts of the medical education world be well represented. This paper illustrates both the strengths and imbalances of AMEE as a forum for the elaboration of international activities and standards in medical education. Finally, the authors wonder why a tendency to assume international generalizability of concepts and perspectives in medical education is not accompanied by studies that compare and contrast medical education methods, research and values between countries and cultures.

[Selection of medical students: a process influenced by history and culture]. / Sélection des étudiants en médecine: une procédure influencée par la liberté d'accès aux études et l'égalité des chances.

OBJECTIVES: Every medical school in the world has a procedure for selecting students for medical studies, intended to identify those who are capable of becoming doctors, according to specific expectations. The means of selection, however, vary significantly from one school to another and from one country to another. France has chosen to undertake this selection at the end of the first year of university studies. This method is costly in that it requires medical schools to organize a whole year of curriculum for thousands of students, fewer than 30% of whom will be chosen for further medical studies. It is also counterproductive for students, a significant proportion of whom are not admitted despite above-average results on their examinations. METHODS: This article examines the historical and cultural factors that have led to the current organization. Our study is based on an analysis of government archives dealing with medical education reforms from 1905-1970. RESULTS: We argue that the format of the current selection process is linked to ideas of freedom of access for students and of equal opportunity for admission to medical studies. CONCLUSION: We conclude that for any reform to be acceptable it must take into account the historical and cultural elements (for the most part stemming from the French Revolution) that form the basis of the current system.

[Anonymous and free screenings: population comparison between those conducted on-site in a testing centre and those done off-site]. / Dépistages anonymes et gratuits: comparaison de la population rencontrée en centre et en dehors des locaux.

The free and anonymous HIV testing centre of Fernand Widal Hospital (CDAG) regularly organises off-site visits to distribute information and provide screening for people at high risk in the community. To demonstrate the benefits of this action, this at-risk targeted population in the community was compared with that which comes to the centre. The individuals screened during the community off-site visits in 2005 were recorded. An equivalent number of patients coming spontaneously to the centre for screening were used as a reference point for comparison. The socio-demographic characteristics, the delay in time between the screening and return to the CDAG for the results and the screening results of the number of people infected were analysed. In total, 427 persons out of 443 were screened in 14 visits: 7,7% of persons tested off-site were infected versus 5,4% of those screened at the centre. Those who were tested off-site were in most cases infected with Hepatitis C, whereas HIV was more prevalent in those who had come to the CDAG centre. The African population (53,6%) was more significantly affected. Even when their results were positive (83,3%), 34,2% of patients tested off-site did not come to get their results versus only 8,2% of those who had come to the hospital centre for testing. The off-site community visits strengthen the role and the capacity of the CDAG to fulfil its mission because high-risk individuals are much less likely to come to the centre for screening. However measures must be taken and procedures established to improve the process and opportunity for results to be returned to the individuals, as well as follow-up and management of those who test positive for infection.

Duty hours reforms in the United States, France, and Canada: is it time to refocus our attention on education?

Resident duty hours restrictions have now been instituted in many countries worldwide. Such policies have resulted in a broad-based discussion in the medical literature concerning their effects on patient care, resident education, and resident well-being. To better understand the impetuses behind these changes, the authors examine not only the duty hours mandates currently in effect in the United States, Canada, and France, but also the events influencing their independent development in these three countries. In the United States, an 80-hour resident workweek was mandated by the Accreditation Council for Graduate Medical Education out of concern for patient safety. In France, a 52.5-hour workweek was decreed by the government, reflecting the broader European Working Time Directive initiated out of concern for the negative impact of extended work hours on its population. In Canada, resident unions, whose primary interest has been one of resident well-being, have negotiated a series of reduced resident duty hours that approach those mandated in the United States. At the core of these changes are unique differences in these countries' health care and medical education systems. The resulting diversity in the origin and nature of such regulations serves to highlight the lack of evidence that has guided their development and the need to refocus on the educational elements of postgraduate training.