France’s foreign doctors suffer insecurity as understaffed hospitals struggle to function

Karima*’s last visit to the prefecture was a complete nightmare, as her residence permit was not renewed. “All I have is a receipt”, she says. This is despite the fact that she has been working as a paediatric orthopaedic surgeon – including in the emergency department, where she is on call at least four nights a month – for the past two years in a hospital in the Parisian suburbs. “My colleagues in general surgery asked me to come help out,” says the surgeon, who is originally from a country in North Africa*. “I’m not going to let them down,” she says, although she doesn’t know how much longer she will be able to practise.

Even though the hospital has agreed to let her work, Karima is concerned that her contract, which is renewed every six months, will be allowed to expire. She is one of some 4,000 medical practitioners with qualifications from outside the European Union known as “Padhue” (for the acronym of praticiens diplômés en dehors de l’Union européenne) who have been working in French hospitals for years in precarious positions such as “acting intern”.

“The work I do is real work, the work of a practitioner, even though I’m on an intern contract for which I get paid 1,400 euros net and which has to be renewed every six months. The prefecture refused to renew my residence permit because of these breaches of contract,” says the doctor, who is constantly going back and forth with the authorities to try and stabilise her situation. “This time, the prefecture is asking me for a work permit provided by the regional health agency, which no longer wants to provide it, as the law has changed.” 

On December 31, 2023, the exemption scheme that allowed establishments to employ Padhue staff under a variety of precarious arrangements expired, making it impossible for them to continue working. As of January 1, these doctors must sit highly selective and competitive examinations known as “knowledge verification tests” (épreuves de vérification des connaissances, or EVC) before they can be reinstated. Posts under the scheme are hard to come by, with 2,700 available for over 8,000 applicants in 2023, some of whom try their luck from abroad. As a result, the majority of the Padhue doctors found themselves out of the running this year.

After an outcry from French unions, the government finally promised to “regularise a number of foreign doctors” and renewed their temporary work permits another year so that they can sit the 2024 EVC.

‘I don’t understand why I’m not being judged on my experience here’

However, Karima’s problems are far from over, as she tried to sit the EVC in paediatric orthopaedic surgery in 2023 but her application was rejected. “They tell me that I don’t have the right diploma, that I need one in paediatric orthopaedics, but my country doesn’t offer this type of diploma! I don’t understand why I’m not being judged on my experience here. I operate on my own, I consult, I have my own patients,” she says. 

When she arrived in France in 2020, she did not have long-term plans to live on this side of the Mediterranean. “I had been sent to France for further training in orthopaedic surgery because I had noticed shortcomings in the department where I was working in North Africa,” she says. But after almost two years as an associate trainee at a university hospital in Nice, Karima found herself stuck in France because of the Covid-19 pandemic and the closure of her country’s borders. She also lost her job in North Africa. 

While in Nice, she worked on the front lines during the Covid-19 pandemic alongside French medical staff, lending a hand in intensive care. “We saved lives. And we’ll continue to do so. It’s what we do. Sometimes in the emergency department, I find myself in a situation where I have to react in a split second, do the right thing and make the right decision to save someone.”

‘I regularly pack my bags’

Sometimes Karima thinks about returning to North Africa. “I ask myself the question if I can go on in this situation. But I have a job that I love, especially the children. I’m attached to my patients. When I see in their eyes that they’re satisfied, I feel useful.” However, she is thinking more and more about leaving, as she wants a life where she can plan beyond a day-to-day basis. “I regularly find myself packing my bags. I hesitate to order new furniture.” Those close to her have suggested that she apply for a job in Germany “Some of my colleagues have gone there. They were accepted on the basis of their applications and took German language courses,” she says.

Against the backdrop of its overwhelmed healthcare system, France is in desperate need of additional medical staff, but risks losing thousands of these doctors to other European countries.  

Watch moreA country short of doctors: Exploring France’s ‘medical deserts’

 

Dr Aristide Yayi is originally from Burkina Faso and qualified in forensic medicine in Dakar, Senegal. He has been working for three years as a general practitioner at the only residential care home for senior citizens (“Ehpads”, in France) in Commercy, a small town in the northeastern Meuse department. France’s elder care sector is in desperate need of doctors. “My contract runs until July 2024. After that, I don’t know what’s going to happen,” says Yayi. He wants to develop a pain management service for the Ehpad residents, but this project may never see the light of day if his situation does not become more stable. “I’ve been on one training course after another, with six-month contracts as an ‘acting intern’. It’s always uncertain and precarious. I feel like I’m being treated like a junior doctor,” he says.

Hospital services under threat without foreign doctors

Several hospital department heads, particularly in the Paris region, have warned that they will be “forced to close” if no more foreign doctors are hired. At his January 16 press conference, President Emmanuel Macron admitted that France needed these practitioners, saying he wanted to “regularise a number of foreign doctors, who help to hold our system together”. This promise was reiterated by newly-appointed Prime Minister Gabriel Attal in his general policy speech at the end of January. 

French unions are now demanding that this rhetoric be followed by action. At a meeting with the health ministry on February 15, they welcomed the previous day’s publication of the decree renewing temporary work permits for foreign doctors who undertake to sit the 2024 EVC. However, Olivier Varnet, general secretary of the National Union of Hospital Doctors FO, criticised the decree, saying it was “a first step” that “merely postpones the problem for a year”.

Meanwhile, foreign doctors are suffering, as almost 1,900 of them are unable to work at the moment. “My old department is desperately looking for someone to replace me. They’re really struggling. I was in charge of two units with 20 patients each. It’s absurd,” says Mostapha, who worked in a follow-up care and rehabilitation unit in Normandy. His contract as an “associate practitioner” was suspended on January 1, as he was not permitted to sit the knowledge verification tests. “The hospital wanted to keep me, but the regional health authority didn’t authorise it,” he says.

‘Some candidates failed, even with top marks’

A graduate of the Faculty of Physical Medicine and Rehabilitation in Algiers, he followed his wife, a French national, to France three years ago. “I don’t have any problems with my papers – I have a 10-year residence permit,” he says.

Mostapha hopes that his case will be examined more closely and that the new decree will enable him to return to work. However, he doesn’t really believe that taking the exam will help him get his career back on track: “I’m planning to take it again because for the moment there’s no other solution, although the chances of passing it are getting smaller and smaller because of the number of posts. It’s worse than selective.”

Many unions believe that the exam is more reflective of a quota system than an actual “verification of knowledge”. “Some candidates failed with an average of more than 15 [out of 20, a highly competitive result],” says Laurent Laporte, general secretary of the CGT’s Federal Union of Doctors, Engineers, Managers and Technicians. The unions say the test is “too academic”, “random”, “opaque” and “discriminatory for doctors working more than 60 hours a week”. The health ministry promised on February 15 to “reformulate the EVC” by making it more practical. 

*This person wishes to remain anonymous

This article has been translated from the original in French.