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International audience; INTRODUCTION: Musculoskeletal disorders (MSD) were responsible for 9.7 million days of sick leave in 2010 in France. They are also a leading cause of occupational exclusion. The objective was to study the role of medical advisers (Mas) in the care of patients with MSD and their interactions with general practitioners (GPs) and occupational health physicians (OPs).METHODS: We performed a qualitative study with semi-structured interviews with medical advisers from the Brittany region. Semistructured interviews were double-coded and were submitted to thematic analysis.RESULTS: Nine interviews were conducted with MAs from the general regime, agricultural regime, and independent workers regime. MAs described an increase in MSD, especially with complex forms. They explained that their activity was not limited to control, but that they also had an important role in limiting occupational exclusion. It is important to anticipate difficulties related to return to work in this setting. They reported contrasted but necessary relations with GPs who are at the centre of care. Return to work may require negotiation with OPs.CONCLUSION: Relations between MAs and GPs are partly based on control of prescriptions, which can create a climate of suspicion. Emphasizing the fight against occupational exclusion can provide new light on the role of MAs. Improving relations between MAs and GPs can be achieved by a better understanding of their respective roles.; Introduction : Les troubles musculo-squelettiques (TMS) ont été à l’origine, en 2010, de 9,7 millions de journées d’arrêt de travail en France. Ils représentent également une cause importante de désinsertion professionnelle. L’objectif était d’étudier les rôles des médecins-conseils (MC) dans l’accompagnement des patients atteints de TMS et leurs relations avec les médecins généralistes (MG) et les médecins du travail (MT).Méthodes : Il s’agissait d’une étude qualitative par entretiens semi-dirigés auprès de médecins-conseils de Bretagne. Les entretiens étaient double-codés et ont fait l’objet d’une analyse thématique.Résultats : Neuf entretiens ont été menés auprès de MC du régime général, du régime agricole et du régime des indépendants. Les MC décrivaient une augmentation des TMS et notamment d’atteintes multiples. Ils ont expliqué que leur activité ne se limitait pas au contrôle et qu’ils avaient un rôle dans la lutte contre la désinsertion professionnelle, ce qui nécessitait d’anticiper les difficultés de reprise du travail. Ils ont évoqué des relations contrastées mais nécessaires avec les MG, au centre de la prise en charge. La reprise du travail pouvait nécessiter de négocier avec le médecin du travail.Conclusion : Les relations entre MC et MG sont en partie basées sur le contrôle des prescriptions ce qui peut engendrer un climat de méfiance. La mise en avant de la lutte contre la désinsertion professionnelle donne un éclairage nouveau sur leur pratique. L’amélioration des relations entre MC et MG pourrait passer par une meilleure compréhension de leurs rôles respectifs.

Contexte : l’Etude nationale nutrition sante a montre que les objectifs du programme national nutrition sante lance en 2001 pour promouvoir la sante des Francais n’avaient pas tous ete atteints, notamment dans la population adolescente. L’objectif de ce travail etait d’identifier les representations des adolescents sur l’alimentation pour mieux adapter les messages de prevention a cette population singuliere tres concernee par le « risque nutritionnel ».Methode : etude qualitative par entretiens semi-directifs aupres de 46 adolescents volontaires issus de 5 lycees de deux departements de l’ouest de la France. Une analyse de contenu a ete conduite de facon inductive apres retranscription integrale des entretiens.Resultats : l’alimentation est un moyen d’autonomisation et d’emancipation sous influence parentale. La nourriture industrielle entraine mefiance et anxiete pour des raisons de sante. Le fast-food est un « lieu pour adolescent » synonyme de plaisir et liberte. Le « bio » et le « fait-maison » sont valorises. Des representations sexuees des aliments sont relevees sur la norme minceur pour les filles et la virilite pour les garcons. Un rapport etroit entre l’aliment et le vivant est a l’origine de refus alimentaires. Les messages de prevention alimentaire, bien que diversement integres au sein de ces representations, etaient bien retenus.Conclusion : les representations alimentaires des adolescents, manifestement meconnues et parfois a contre-courant de l’imaginaire collectif devraient etre prises en compte dans l’elaboration des campagnes de prevention nutritionnelle.

International audience; BACKGROUND: Low back pain (LBP) is a major cause of sickness absence and disability in the working population, and the pre-employment examination should insure that worker's state of health is compatible with the requirements of proposed job. This paper summarizes the main recommendations of the good practice guidelines of the French Society of Occupational Medicine for pre-employment examination in workers exposed to manual handling of loads apart from pre-employment test.METHODS: The recommendations were developed according to the Clinical Practice Guidelines proposed by the French National Health Authority and based on a systematic search of the literature 1990-2012 in several databases. The guidelines were written and reviewed by two multidisciplinary committees. On the basis of the level of evidence in the literature, the proposed guidelines are classified as grade A, B, C or expert consensus.RESULTS: The main recommendations of these guidelines are as follows: (1) medical contraindications alone should not exclude employment in a job associated with a low back risk on the basis of a history of "simple" nonspecific LBP; (2) the relevance of examining a previous history of LBP, which is the best predictor of future LBP due to the recurrent nature of LBP.CONCLUSIONS: These guidelines correspond to a constant concern with prevention of occupational risk. Primarily intended for occupational physicians, they are also intended for general practitioners who carry out pre-employment examinations in many countries and are likely to be increasingly faced with this type of situation because of the combination of increasing work constraints with ageing of the workforce.

International audience; Background : Psychosocial factors at work (PFW) can be defined as all non-physicochemical occupational risks. Several epidemiological models have been proposed to measure PFW, but one of the most widely used is Karasek’s model.Aims : To determine whether psychosocial factors, evaluated by Karasek’s questionnaire, had increased in a cohort of workers.Methods : A random sample of workers in the Pays de la Loire region of France, who could be considered representative of the region’s population of salaried workers, filled in a self-administered questionnaire, including Karasek’s self-administered questionnaire, in 2002–05 and 2007–09. Karasek’s questionnaire can be used to study three psychosocial dimensions (psychological demand, decision latitude and social support in the workplace) in workers in order to define two high-risk situations for their health: ‘Job Strain’ and ‘Iso Strain’. Changes in job strain and iso strain among workers were studied according to the workers’ sociodemographic characteristics and their working conditions.Results : In this sample of 2049 workers, the proportion with iso strain increased between the two periods from 12 to 16%, P < 0.001, mainly among manual workers. Deterioration of Karasek indicators was mainly explained by an increase of the ‘low social support’ dimension (38 versus 49%, P < 0.001). Working conditions such as temporary employment of colleagues and high perceived physical exertion were associated with higher PFW.Conclusions : This study, based on a quantitative and collective model, showed deterioration of working team environments and increased risk for individual mental health in this cohort of French workers in recent years.

International audience; IntroductionL’activité de publication scientifique issue de la formation initiale est mal connue. Nous avons évalué la proportion des thèses et des mémoires de spécialité aboutissant à une publication, leur impact en termes de points SIGAPS et les principaux obstacles à la publication de ces travaux. Méthodes Les thèses de doctorat en médecine soutenues de 2002à 2008à la faculté de médecine d’Angers ont été recensées à partir du système universitaire de documentation (SUDOC), et les mémoires de spécialité directement auprès des diplômés. Les publications ont été recherchées dans Medline via Pubmed, ISI Web of Knowledge et dans les trois rapports SIGAPS de 2002à 2008. Une enquête cherchant à connaître les obstacles à la publication a été lancée auprès de tous les directeurs de thèses et responsables de discipline impliqués. Résultats Cinq cent quatre-vingt-dix-huit thèses ont été soutenues, 311 (52%) en médecine générale et 287 (48%) en spécialités. Cent soixante-cinq thèses ont donné lieu à publication (28%) dont 97 (16%) indexés dans Medline via Pubmed (soit 11% en médecine générale et 22% en spécialité). Trente-trois de ces 97articles (35%) ont été publiés dans des journaux de haute qualité classés A, B ou C de la classification SIGAPS. Ces articles issus des thèses ont représenté 4,17% du score SIGAPS du CHU calculé sur un total de 2088articles au cours de cette période. Deux cent quatre mémoires de spécialités ont donné lieu à 69articles (33,8%), dont 50 (24,5%) indexés dans Medline. Les taux de publication des mémoires de DES et de DESC ont été respectivement de 31% (45/145) et de 40,7% (24/59). Ils ont représenté 1,9% (432points) du score total SIGAPS. Les principaux obstacles ressentis pour la publication ont été le manque de temps des directeurs, l’éloignement des étudiants après la soutenance et le manque de moyens logistiques. Conclusion La production scientifique issue de la formation initiale à la faculté de médecine d’Angers a été de bonne qualité mais insuffisante quantitativement et peu contributive au financement du CHU malgré un nombre important de diplômés. Un soutien logistique mérite d’être envisagé afin de valoriser la production scientifique issue de la formation initiale.

Resume Cet article etudie un aspect psychologique implique dans certaines affections somatiques, ici les lombalgies chroniques. Plusieurs cas de patients lombalgiques recus en entretiens psychotherapiques montrent que le statut de la douleur evolue selon que le sujet lui accorde ou non une valeur de symptome, au sens psychanalytique. Le « choix » de ce statut est personnel, subjectif, inconscient, et impacte l’evolution de la lombalgie. Apres avoir defini le symptome au sens medical et au sens psychanalytique, et avoir rappele la distinction entre l’hysterie et la psychosomatique, les auteurs presentent leur conception des rapports corps et psyche selon le modele de la bande de Mobius utilisee par Lacan pour definir les rapports entre le conscient et l’inconscient. Il est cependant illusoire, en medecine generale, de pouvoir amener tous les patients a faire de leur lombalgie un symptome « psychanalytique ». Le contexte et le cadre ne sont pas les memes car le patient qui va consulter son medecin n’en attend pas la meme chose que celui qui va consulter un psychologue, un psychanalyste ou un psychiatre. Neanmoins, l’ouverture des uns et des autres a la possibilite d’une evolution du patient fondee sur un changement de sa position subjective peut etre un avantage important, car ce qui est en jeu dans le processus de la chronicisation n’est pas seulement la disparition pure et simple de la douleur, mais la modification prealable de sa fonction pour le sujet, c’est-a-dire le passage de la fonction premiere de la douleur comme signal de danger a celle qui favorise l’elaboration d’un sens subjectif. Et pour cela, faut-il encore que ce sujet, comme les praticiens concernes, lui reconnaissent cette seconde fonction.

Objectif : Les projets des medecins generalistes en exercice vont influencer la demographie medicale dans les annees a venir. Cette etude a pour but d’apprehender les evenements qui pourraient aggraver la demographie medicale en soins primaires a court terme. Methode : 455 medecins generalistes liberaux de plus de 55 ans de trois departements de l’Ouest de la France ont ete selectionnes afin de participer a cette enquete prospective. 258 questionnaires valides (56 %) ont ete recus. Une analyse globale, puis par sous-groupes geographiques, a ete effectuee a l’aide du logiciel SPSS version 1.5. Resultats : Sur l’ensemble des medecins ayant repondu, si 27 % voulaient poursuivre leur activite dans les memes conditions et 10 % etaient indecis, 63 % voulaient cesser ou adapter leur activite liberale avant 65 ans. Les principaux motifs de ces projets etaient les contraintes horaires, la charge de travail liee aux tâches administratives et a la permanence des soins mais aussi a l’exigence des patients, l’epuisement professionnel et la difficulte a concilier vie familiale et professionnelle. Discussion : Les medecins souhaitant cesser leur activite (30 %) sont les moins satisfaits de leur vie professionnelle et semblent avoir anticipe leur projet car ils travaillent moins en termes d’heures et de gardes. Ceux qui souhaitent adapter leur activite professionnelle (33 %) sont, eux, majoritairement satisfaits meme s’ils travaillent plus ; 70 % veulent cependant diminuer leur temps de travail. Conclusion : L’impact de ces projets risque d’etre lourd, d’autant plus que deux des departements concernes presentent une faible densite medicale et une forte activite des medecins en exercice. Les mesures gouvernementales actuellement proposees ne semblent pas repondre a l’evolution de l’exercice liberal attendu par les medecins generalistes de plus de 55 ans.

Cette etude a pour objectif de recenser et comprendre les cessations d’activite liberale de medecine generale en soins primaires, et d’apprehender leur role dans l’evolution de la demographie medicale actuelle. Elle concerne les cessations effectives dans trois departements de l’Ouest de la France de 2000 a 2005. Les donnees ont ete recueillies aupres des conseils departementaux de l’ordre des medecins, puis par questionnaire aupres de 75 medecins (taux de participation 60 %). Elle revele que seules 29 % des cessations sont des departs en retraite. Plus d’un medecin sur deux a poursuivi un exercice salarie, 18 % ont choisi une nouvelle installation liberale hors departement. Les deux tiers exercaient en zone rurale ou semi rurale. Moins de la moitie, 47 %, a eu un successeur. Les medecins ne cessent pas toute activite medicale : leur carriere est polymorphe et ils sont mobiles. Les raisons retrouvees sont majoritairement les contraintes de travail et la difficulte a concilier vie familiale et personnelle. Ils recherchent alors une activite liberale ou non, en soins primaires ou non, qui repondent a leur exigence de temps pour soi, de mobilite.

Objective: In order to develop primary care research by general practice university lecturers, it was necessary to evaluate the representativeness of this group of lecturers at the Angers Faculty of Medicine.Methods: Declarative study based on self-administered question-naires filled in by 216 university lecturers. The questionnaire was derived from that of the regional panel of the Research, studies, evaluation and statistics directorate of 2007, investigating the sociodemographic characteristics, professional organization, activities and certain professional practices of general practitio-ners. University lecturers were compared to the population of the panel by means of a Chi-square test of conformity.Results: A total of 181 university lecturers participated in the survey, comprising 65% of men. The proportion of women was higher among university lecturers and the 45-54 years age-group was underrepresented. The university lecturers group was signifi-cantly different from the panel in terms of predominantly group practice and shorter weekly working hours. No significant differ-ence was observed for the type of town of practice and the continuing medical education participation rate.Conclusion: University lecturers present certain specificities, partly related to the reference population used. The development of research based on such a network appears to be feasible in terms of representativeness, provided these specificities are clearly described., Objectif : Afin de développer des travaux de recherche en soins primaires à partir des médecins généralistes maîtres de stage universitaire (MSU), il a été nécessaire d’évaluer la représenta-tivité du groupe des MSU rattachés à la Faculté de médecine d’Angers.Méthodes : Étude déclarative par auto-questionnaire auprès de 216MSU. Le questionnaire a été inspiré de celui du panel régional de la Direction de la recherche, des études, de l’évaluation et des statistiques de 2007, explorant les caractéris-tiques sociodémographiques, l’organisation professionnelle, les activités et certaines pratiques professionnelles des généra-listes. La comparaison entre les MSU et la population du panel a été réalisée à l’aide du test de chi-deux de conformité.Résultats : Au total, 181MSU ont participé à l’enquête dont 65% d’hommes. La proportion de femmes était plus importante chez les MSU et la classe d’âge 45-54ans y était sous repré-sentée. Le groupe des MSU se différenciait significativement du panel par un exercice en cabinet de groupe majoritaire et un temps de travail hebdomadaire inférieur. Il n’y avait pas de diffé-rence pour le type de commune d’exercice et le taux de partici-pation à la formation médicale continue.Conclusion : Des spécificités existent chez les MSU en partie liées à la population de référence utilisée. La mise en place de travaux de recherche à partir d’un tel réseau semble envisa-geable sur le plan de la représentativité, sous réserve de bien décrire ces spécificités.

Introduction. Les aidants naturels de malades Alzheimer jouent un role preponderant dans la prise en charge de ces patients. La moitie des aidants naturels sont les conjoints, souvent âges. Ce role a une repercussion importante sur la sante des aidants. Depuis 2010, il est recommande aux medecins generalistes francais d’organiser un suivi medical annuel specifique. Les objectifs de cette etude etaient de comprendre le vecu de cette situation par le conjoint aidant et comment celui-ci percoit le role joue par son medecin generaliste dans ce contexte. Materiel et methode. Une etude qualitative a ete realisee par entretiens individuels semi-diriges aupres de 14 aidants conjoints recrutes via des structures d’accueil de jour d’Angers, France. Resultats. L’analyse des entretiens a montre que la maladie d’Alzheimer representait une crise existentielle pour les aidants-conjoints. L’engagement et le lien affectif pour la personne malade les impliquaient activement dans le soin. Cela n’avait pas modifie le rythme de leurs consultations medicales, mais pouvait les amener a retarder les soins non urgents. Leur reticence a se faire aider et une interaction avec l’equipe soignante de la personne malade genaient l’implication de leur propre medecin traitant. Conclusion. L’adaptation de l’aidant a la maladie du conjoint engendre des conduites a risque mais aussi des conduites benefiques. Plutot que de proposer une consultation annuelle centree sur la sante des aidants, l’amelioration de la communication entre tous les intervenants y compris le medecin generaliste de l’aidant pourrait permettre de mieux cibler et mieux repondre aux besoins de ce dernier.

The National Nutrition Health Study showed that the objectives of the National Nutrition Health Programme, launched in 2001 to promote the health of all French people, had not been achieved, especially in the adolescent population. The objective of this study was to identify teenagers' representations regarding food. It was carried out in order to more effectively tailor prevention messages to this particular population, which is particularly concerned by the "nutritional risk".Qualitative investigations by semi-directive interviews with 46 teenage volunteers,from 5 high schools in 2 departments in the west of France. A content analysis was conducted inductively after full transcript of the interviews.The study showed that nutrition was a means of autonomy and emancipation from the parental influence. Teenagers were suspicious and anxious about the health risks associated with processed food. Fast food restaurants were a "place for teenagers" synonymous with pleasure and freedom. They valued "organic" and "homemade" foods. The sexual representations of food consisted of a "slim" image for girls and a "virile" image for boys. A close relationship between food and living beings was responsible for refusal of certain types of food. Although prevention messages were integrated in various ways, they were effectively recalled by teenagers.The nutritional representations of teenagers are poorly known and sometimes contrary to commonly health beliefs and must be taken into account when preparing nutrition prevention programmes.

International audience; BACKGROUND: Low back pain (LBP) is a problem that is frequently encountered in primary care, and current guidelines encourage care providers to take into account psychosocial risk factors in order to avoid transition from acute to chronic LBP.OBJECTIVE: To review the effectiveness of interventions focusing on psychosocial risk factors for patients with non-chronic LBP in primary care.METHODS: A systematic search was undertaken for controlled trials focusing on psychosocial factors in adult patients with non-chronic, non-specific LBP in primary care by exploring Medline, Embase, PsycInfo, Francis, Web of Sciences and The Cochrane Library. The methodological quality of the studies included was assessed before analysing their findings.RESULTS: Thirteen studies were selected, seven being considered as having a low risk of bias. Information strategies were assessed by eight trials, with high-quality evidence of no effectiveness for pain, function, work issues and health care use, low-quality evidence of no effectiveness for self-rated overall improvement, satisfaction and pain beliefs and lack of evidence in terms of quality of life. Cognitive behavioural therapy was assessed by three trials, with very low-quality evidence of moderate effectiveness for pain, function, quality of life, work issues and health care use. There was lack of evidence concerning the effectiveness of individual and group education intervention or work coordination.CONCLUSION: Among the wide range of psychosocial risk factors, research has focused mainly on pain beliefs and coping skills, with disappointing results. Extended theoretical models integrating several psychosocial factors and multicomponent interventions are probably required to meet the challenge of LBP.

The activity of scientific publication after initial medical education is unclear. The purpose of this study was to evaluate the proportion of MD theses and Board certification manuscripts resulting in a publication, their impact in terms of SIGAPS points and the main difficulties in the publication of this work.MD theses sustained from 2002 to 2008 at the Faculty of Medicine of Angers have been identified from the "Système universitaire de documentation" (SUDOC), catalog, and specialty certification manuscripts (Board and Complementary Board) directly to diplomates. Publications were searched in Medline via Pubmed, ISI Web of Knowledge and in the three SIGAPS reports from 2002 to 2008. A survey aimed at determining the barriers to publication and the way to suppress them was launched to all MD directors and specialty mentors.Five hundred and ninety-eight theses were sustained, 311 (52%) in general medicine and 287 (48%) in specialties. One hundred and sixty-five theses have resulted in publication (28%) of which 97 (16%) indexed in Medline via Pubmed (11% in general medicine and 22% in specialty). Thirty-three of these 97 articles (35%) were published in journals of high quality classes A, B or C of SIGAPS classification. These articles from theses represented 4.17% of the SIGAPS scoring of the hospital calculated on a total of 2088 articles over this period. Two hundred and four specialty certification manuscripts resulted in 69 articles (33.8%), 50 (24.5%) indexed in Medline. The rate of publication of these specialty manuscripts, Board and Complementary Board, were respectively 31% (45/145) and 40.7% (24/59). They represented 1.9% (432 points) total SIGAPS score. The main barriers to publication were lack of time of directors, remote students after the promotion and the lack of logistic resources.Scientific publications issued from initial medical education at the Faculty of Medicine of Angers was of good quality but quantitatively insufficient, and contributed poorly to the University Hospital funding despite a significant number of diplomates. Logistical support should be considered in order to promote scientific production after initial medical education.

Medical demography and the practice of medicine will be influenced by the personal plans of GPs and their decisions to stop practicing in the coming years. This study aims to understand the events that could potentially worsen the medical demography in terms of shortages of GPs for primary care in the short term.455 GPs (all aged over 55 years) practicing in three districts of western France were selected to participate in this prospective study. 258 valid and complete questionnaires (56%) were received. With the use of a special programme, SPSS version 1.5, an overall comprehensive analysis and one by geographical sub-regional groups were performed.When queried about their plans or wishes for their practice between the present time and their age of 65, of the responding physicians, 27% wanted to continue working under the same conditions, 10% were undecided, and 63% wanted to stop or adjust their professional activity before age 65. The main reasons and factors motivating these plans were their current time constraints, the workload related to administrative tasks and the continuity of care; moreover, GPs noted the demands and expectations of patients, professional burnout and difficulties in obtaining a healthy work-life balance as factors contributing to these plans.Physicians who wanted to stop practicing (30%) were the least satisfied with their work and seem to have anticipated this plan of action given that they reduced their number of hours in the office and on-call. Those who wish to adapt their work time (33%) are for the most part satisfied even if they work more, but 70% want to reduce their work hours.The impact of these projects is a potentially heavy one, especially since two of the counties concerned have a low medical density and high rate of practicing physicians. Government measures currently proposed do not seem to respond to the evolution of private practice expected by GPs over 55 years.

The purpose of this study is to conduct a census of general practitioners in order to better understand their early withdrawal from primary care practice and to assess the impact of such withdrawal on current medical demography. The study covers the withdrawals from January 2000 to December 2005 in three western French counties. Data were collected through the district councils of the practitioners'guild, followed by a questionnaire filled in by 75 doctors. The participation rate was 60%. The study reveals that only 29% of these withdrawals are due to retirement. More than one in two doctors left to pursue another paid employment, and more than 25% chose to relocate their practice in a different area of the county. Two thirds of them were practicing in rural or semi-rural locations. Less than half, 47%, were replaced by a successor. General practitioners surveyed did not stop all professional medical care provision and service activities. Their careers are complex, and they are mobile professionals. The main reasons for suspending their activities in a given location were essentially related to the difficulties they had in dealing with their work loads and in maintaining a healthy work-life balance. They have noted that they will leave a range of possibilities open, either looking for private practice or not, exploring the possibility of primary care or not; the basis of their decision is whether a new position will correspond to their desire of mobility and meet their needs for more free.

To assess the taking charge of the patients requiring a follow-up with the long course by the trainees during the Saspas, to identify the obstacles to its setting up and to propose prospects of improvement are the main objectives of this work. The trainees of Angers carried out a collection concerning each patient seen three times or more during the semester of winter 2006-2007. At the end of semester, they answered a questionnaire and participated in a focus group. There were great inequalities between the trainees. They had seen between 13 and 51 patients three times or more (average=22). The proportion of chronic disease varied from 24 to 68%. Most frequently met were those of the 50 first results of consultation of the SFMG. Four of the 11 trainees made a follow-up of pregnancy, three a follow-up of infant. When the first consultation concerned a situation requiring a follow-up with the long course, the trainees had proposed a new appointment in 38.6% of the cases, 95% of the patient had it honoured. The obstacles identified were inherent in the organization of the training course, the secretariat, the Masters of training course, the trainees and the patients. These obstacles are perfectible by a work on the appointement management privileging the patients concerned with a follow-up to the long course, on the organization of the training courses, on the invesment of the trainees and the masters of training course.