Warning
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FRENCH REPUBLIC | ||
| Ministry of Health and Solidarity | Ministry of Tourism | ||
| Directorate General of Health | Tourism Department | ||
| Paris, 6th July 2005 | |||
STATEMENT
Aesthetic surgery offered by travel agencies during tourist stays abroad
Some travel agencies offer package tours on the Internet including aesthetic surgery services abroad. The Directorate General of Health is warning people who may resort to such services about the lack of guarantees offered by these agencies, relating in particular to qualification held by the doctors called upon to provide surgical care, conditions for the practice of anaesthesia, but also to compliance with the rules of hygiene and asepsis. The people must be fully aware of the risk they incur by buying this type of plan; the French authorities have no power to check the care and the levels of care and practice offered outside national territory.
Medical aesthetic surgery procedures are not covered by the legislation on travel agents, as set out in Articles 211-1 and following of the French Tourism Code which provides that travel agents must be concerned solely with tourism. Thus, a travel agent may not, on pain of a possible withdrawal of his/her licence, contribute in a direct or indirect way, by advertising or the provisions of information to the sale of plastic surgery services. Moreover, and as such, the insurance of the French travel agencies does not cover the liability for these aesthetic surgery services in the event of medical complications.
Press Contacts:
Ministry of Tourism
Office of the Minister Delegate for Tourism Marie PLASAIT Tél : +33 (0)1 44 49 80 53
Department of Tourism Carole LEBRUN NOLEN Tél : +33 (0)1 70 39 94 85
Directorate General of Health
Laurence Danand Tél. +33 (0)1 40 56 52 62
Medical Deontology on the Web
Recommendations of the National Council of the College of Physicians
The development of the Internet in the field of health care affects more widely, amongst other applications, to:
- users seeking information,
- and the doctors who provide it.
Regarding activities by doctors, we must remember that the rules of the Code of Professional Conduct (Deontology) apply to all information channels. But the Web poses specifics questions, because of the protean aspect of the information found there - the relevance and reliability of which is sometimes uncertain and uncontrollable - and the relative anonymity of the sources that this medium allows.
Therefore, the National Council of the College of Physicians wanted to update and clarify the reports that were devoted to this subject in 2000 and 2001.
The following report has been adopted for distribution by the National Council of the Medical Association to clarify the application of the Code of Professional Conduct for Doctors:
- intervening on health websites intended for the public,
- who wish to create their personal and professional website to present their activities,
- or when the structures in which they work or cooperate with have a website open to the public.
We are well aware that the Internet is universal, and that the sites can be housed outside French territory. Therefore, it would be desirable for more work to be undertaken on this subject, at least with the regulatory authorities of other member states of the European union, be established. These recommendations for French doctors might contribute.
We are also aware of the evolution of ICT in health. Accordingly, the following recommendations will be regularly updated.
- Participation of the doctor in a non-institutional health site intended for the public
- Professional website of the doctor
- Characteristics of the personal website (or personal page through portal)
- Les liens
- Formalités ordinales
Participation of the doctor in a non-institutional health site intended for the public
The health site.
Law n° 2004-810 of August 13, 2004 on a health insurance requires the High Authority for Health, an independent scientific public authority with moral personality to establish a procedure for certification of sites dedicated to health [...] this certification is implemented and delivered by an accredited agency certifying compliance with rules of practice enacted by the Health High Authority.
The law does not establish that any computer site dedicated to health should be subject to this certification. Therefore an application for this certification follows a voluntary request from the webmaster, if he wishes to comply with certification procedures and set this out expressly. The National Council of the College of Physicians can only recommend it.
The High Authority for Health has chosen to carry out its mission, its role of certifying French websites through the Health On the Net Foundation (HON). The experience of this foundation, its international renown, and the fact that the procedure is free to the applicant health website, and certification criteria used (HON-CODE) were amongst the deciding factors in determining the HAS’s choice of this organisation.
It is not the National Council of the College of Physicians who should comment on the choice of an independent public authority. But, seeing that doctors are involved in these sites, it is the National Council of the College, as part of its own tasks, that must specify the provisions of the Code of Professional Conduct applicable to this media and to inform doctors who are contributing to these health sites, whether or not they have sought certification.
Indeed, even though when you find happy convergences between the principles of medical ethics and principles that apply to HON certified sites them-selves, we cannot deduce that certification would be, ipso facto, a deontological label conferred by HON and HHA. In addition, as demand for certification is not a regulatory requirement for websites, its absence does not infer that physicians involved, have failed to comply with the rules of Professional Conduct.
It follows that no doctor may take advantage of the certification of the website he is involved in during the course of his professional activities, nor can a doctor be reproached for working with an uncertified website. A strict distinction must be made between: on the one hand, certification of the website, which falls within the regulatory responsibilities of the HAS and, on the other hand, the quality, competencies and qualifications of the doctors involved, which fall within the responsibilities of the Professional College of Medical Practitioners.
In any event, the relationship between the doctor and the health website providing information to the public must be the subject of a contract. This must reproduce the essential clauses of the standard contract established by the National Council of the Order. This contract must be communicated in accordance with the Public Health Code, to the Council for the Department where the doctor is registered.
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Nature of medical information intended for the public.
This is an activity involving popularisation of scientific and medical knowledge. This activity is useful and necessary for informing the public, in simplified terms, of the current state of medical science, its research methods and advances. This website activity is not likely to be different from similar activity in the press or audiovisual media. The information thus provided, therefore, remains subject to the requirements of Sections 13 and 14 of the Code of Professional Conduct (R.4127-13 and R4127-14 of the Public Health Code). It should, therefore, distinguish between which notes come from evidence-based science and which from research. As the boundary is moving, the doctor must bear in mind the implications his statement may have for the public and in particular, for patients in relation to whom information which is too hastily presented may give rise to false hope.
As the doctor is responsible, in ethical and deontological terms, for the relevance of the information he/she provides, he/she should allow the user to distinguish very clearly in the presentation that is made in the Website between information that constitutes a popularization of data acquired from medical science and that which is a popularization of data acquired from research. In the latter case, he/she must refer to the main sources for what is said and to what extent this may be promising in character but inadequately tested by technology, investigation or care. The user must be able to connect to the main source.
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Customized information provided by a doctor to a person searching the Web.
Seeking information on the Internet arises from concern on the part of the patient or someone in his/her circle about symptoms or a diagnosis, experience as a worry. It may be a general inquiry about a disease, symptoms or treatment. It may also be a precise search, personal and interrogative.
The information sought reflects a failure completely to satisfy the patient’s request during a consultation with the doctor but is not necessarily a challenge to the relationship itself.
The patient may be looking for anonymous additional advice in the wake of a poorly explained diagnosis. There may be a need for a personal, even intimate journey to be undertaken following announcement of the diagnosis, and this is regardless of its severity and its consequences. In all these circumstances, the patient is in a situation of instability and psychological vulnerability, regardless of the nature and severity of the illness.
For his part the doctor, called to give information on the web cannot know whether he is dealing with the patient himself or someone in his circle. He/she does not know either and cannot see the caller and cannot grasp his immediate reaction to the information provided. This is an exchange of correspondence and not a true dialogue. Also the doctor knows only what his/her correspondent reports on symptoms and the way he/she interprets them, without truly knowing the context in which they occur or or being able to include in them into a clinical examination.
Questions can be of two kinds:
- a query concerning well known pathologies,
A response on a pathology, a symptom or treatment should be made by sending a standardized response, including be in accordance with classification and structure recommended for information that a doctor would provide on a Website targeted only at the general public (A.2). In this regard, it would be helpful if the website includes a database to which the user could be directed.
- a specific query of the user either on his/her illness and its treatment, either on the professionals who can deal with it or on a symptom pointing to an illness.
The provision of information or advice onlin is not a medical consultation and should not exonerate the doctor or the patient from a real consultation with a medical history and physical examination that in themselves can lead to a diagnosis and prescription. This information should appear in the ad on the homepage of the website. The doctor should therefore advise a consultation based on what the person consulting the internet has said, he/she should not provide information on doctors or registered establishments and must focus on the use of the General Practitioner. The information supplied must be dated. The identity of the doctor who issued it must be kept in the archives of the email system and must be capable of being found, even though it would not be directly displayed.
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Open forums.
This is the offer given to users, the offer to users given on health Websites to allow for the on-line exchange of questions. The entry on the forum may be open to any member of the public or reserved for subscribers. This type of forum creates a virtual community for the exchange of information, the medical relevance of which may sometimes be doubtful but which is supported and associated in an case by research by the users involved. The presence of a moderator can eliminate incongruous exchanges. As for the Order, a recommendation of caution is necessary when the moderator is a doctor, whether or not his status is specified. Indeed, his presence has given a guarantee to the medical surveillance of exchanges and makes him partially liable for their content. Apart from the direct deletion of messages submitted when they violate laws and regulations in force, the intervention of the doctor moderator following a discussion of such forums must restate the discussion on-line in general, medically relevant terms without this intervention appearing to constitute medical advice where the discussion goes beyond the bounds of general suggestions and tends towards a solution in a particular case, the doctor/moderator must remind those concerned of the need for an appropriate medical consultation.
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Professional website of the doctor.
To present his professional activity, the physician may have a web site accessible through a shuttle portal or an institution. He/she can also create his/her own website, either alone or jointly with others. Whatever the choice made, the doctor must follow certain rules: The site is intended to inform the public about the doctor and his activities and may also provide health information in general. It does not hold itself out as a promotional or advertising medium. The address of this personal website can be on prescriptions and on the headers of professional letters.
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In some disciplines, portals have been placed at the disposal of doctors.
The directory of qualified doctors in the discipline is posted by the Society, the College or Professional organization, union or otherwise, to which they belong. This portal can provide direct access to the the doctor’s personal page. The structure of this page is left to the initiative or creativity of the doctor. As long as the doctor appears in a personal page, he/she is responsible and his liability is engaged by the content of the information contained on the portal. a usage agreement should therefore be concluded between the person legally responsible for the portal and the doctor who gives access to his personal page via this route. This agreement should explicitly refer to the Code of Professional Conduct and the recommendations of the National Council of the College of Physicians, in the matter. Such a portal should be open to all qualified doctors in the discipline, without any other distinction of belonging and the same conditions should apply to all.
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Where the Website is created directly by the doctor or his/her associates.
Individual creation.
The doctor takes personal responsibility and must ensure, if the tender involves a creator/designer, that the creator/designer does not use the work of the doctor in his trade promotions.
If the doctor works in association: the names of associated doctors from the same discipline may appear on the doctor’s site.
The creation within an association, a corporate practice or a medical centre.
A welcome site as a portal can be created by groups of doctors in different legal forms of association. An addendum to the contract of association or articles of the corporation should be concluded on this subject. In the case of a medical centre gathering physicians from different disciplines or even other health professionals, a host website may be created for the centre. The personal responsibility of each doctor is instituted in this page as in the personal pages that are attached. The home page is set out like that of a portal which provides links to each personal page but no links between the various personal pages involved.
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The site is created by the institution where the doctor practises.
According to the code of medical ethics, doctors should monitor the use made of their name, their status or their statements and should not allow public or private organizations where they are based or that they attend to use their name or occupation for advertising purposes. These comments apply, by extension, to the circumstances referred to above for collaborative or medical discipline portals.
Thus, the National Council of the College of Physicians recommends to physicians and institutions they are involved in, the inclusion under the title of the establishment, of the titles of its various services and that of the disciplines concerned. Members of the medical team shouldbe referred to by:
- their full name, business address, telephone, fax, email address, days and hours of consultation;
- their position in respect of health insurance agenciess;
- their recognized qualifications under the regulation of qualifications, and the DESC and capabilities.
The National Council will complement these recommendations on the subject of the existence of links between the website of the facility and the personal website of doctors.
Indeed, on one hand, each physician at the facility cannot be held responsible for the content of the site of the institution that is endowed with legal personality; and secondly, the establishment has no standing to interfere in or control the content of the personal professional websites of each staff physician.
Before making a specific recommendation on this point, the National Council will take the advice of public and private hospital associations. We recall that in the field of aesthetic surgery, article L. 6322-1 of the French Public Health Code imposes specific rules on the establishment. The interpretation of these must be analysed. « The authorization shall be withdrawn if there is any direct or indirect advertising in any form whatsoever in respect of the establishment ».
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Characteristics of the personal website (or personal page available via the portal).
WWW term.
This must match the identity of the doctor. Use of a pseudonym, a nickname or a geographical location is prohibited. It may refer to the qualification or discipline exercised so as to assist the public in the same way as is done when entering an authorised listing in the Directory. It will then take the form: www.discipline.nom
Any other form of referencing should be banned.
The same applies to personal pages linked in the various ways referred to above.
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Layout.
While it is natural for each doctor to seek to personalize his website, a certain degree of seriousness should be brought to bear. This layout should not appear to be promotional, commercial or to constitute advertising.
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Presentation of the doctor
The doctor must include aside from his professional identity (name, surname, date of birth, board registration number table and SDHP):
- His/her status under the Convention,
- Its main fees
- Its membership at an AGM
- The terms and condition for preparing estimates when required to do so by the regulations for the specialisation practised.
The following may also be included:
- A photo ID
- Titles and professional qualifications and membership of scientific societies
- Work and scientific publications with indication of the bodies having accepted them with references, if any, to conflicts of interest
- Spoken languages
- Honours recognized by the French Republic
Elective public offices held, of whatever kind, past or present are not permitted.
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Practice location.
- Can be mentioned: the address, phone, fax, email address (by a warning if not confidential).
- A map of the area, transport links for reaching the office, ease of access (for disabled, lifts, parking) may also be included.
- Facilities for dealing with emergencies and providing continuing care (duty doctor, local arrangements for providing cover, referral to the emergency medical service number) must be included
- Holiday dates; information on the availability of a replacement, a collaborator, referral or colleagues can be specified.
- If he practises in multiple locations, it is lawful for the doctor to show on his Website the other addresses where he is authorized to practise pursuant to Art. 85 MDC and the addresses of establishments where procedures or examination are carried out.
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Practise.
- The description of the nature of the procedures and technical advances the doctor performs may give rise to the displaying of information sheets which precede, accompany or to provide information delivered by the doctor during the consultation. They can be illustrated with diagrams. But such publication could lead to a drift into advertising style material if the public is not alert to such things. The National Council also considers that this release may contain fins like advertising for a lay audience. Similarly, the presentation of individual circumstances, under the appearance of clinical cases is strictly prohibited.
- The description of procedures and technical data files should include scientific references or sources from which these files are derived. These fields are regarded as providing health information to the public. This information must be clear, understandable, fair, appropriate and consistent with established science.
- Where computerised data processing is involved, this must be made clear, as provided in the Data Protection Act.
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Contact details.
A « contact us » icon often appears on websites.
In this case, the portal should be limited to providing the opportunity to book an appointment with the doctor, with the doctor using it to confirm that one has been made. An automated confirmation response must be provided if the patient registers itself on the free areas of an online agenda. Appointments already made by other Internet users must absolutely be hidden. For security reasons, the configuration of the agenda should be strictly limited to making appointments (name, phone number) and may not include an area for describing symptoms or for other purposes. An easily readable notice should provide a telephone contact number for use where the patient considers there is an an emergency or is confused. This agenda must not reveal the dates and times available. In the absence of the doctor, an out of office message should be sent to the patient as response, with a number to contact in case of emergency.
If a public email address for the doctor is listed on the site, a statement must appear showing how often emails are read.
For existing patients, email exchanges, where necessary, should take place via a public email address but a separate, reserved one. In case of absence, an automated response should be sent indicating that the message has not been read as should an acknowledgement of receipt once the email has been opened.
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Funding.
The doctor should pay for his website and cannot mention advertising links of any kind. The physician's personal website can not be hosted by companies having an industrial, commercial, pharmaceutical or other association because it would be likely to compromise the independence of the doctor.
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Links.
Where a link is created between the doctor’s website and sites he has referred to, any legal requirements (e.g. on copyright) must be complied with as must ethical ones (copyright, for example) and ethical (prohibition of business practices, advertising, sweetheart agreement).
Thus, the National Council recommends that the doctor:
- does not copy onto its website elements drawn from an external source, but creates a link to the source;
- ensures that the presentation of the link does not tend to cause the use to believe there is cooperation between the linking site and the linked resource;
- includes in any hyperlink references that allow the... to be identified (name of website the linked resource is on, reference to home page, name of author or the linked resource etc);
- informs the owner of the website or linked resource that a link has been established to it;
Links to the websites of commercial companies, including those making and distributing medicines, objects, devices and products described as being health related are prohibited.
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Registration formalities.
The County Council must be informed in advance of the online placement of the website, so that it can make any comments.
The County Council must be informed in advance of the online position of the website, so that it can make any necessary comments. Provided that the doctor has read the recommendations for doctors’ websites adopted by the National Council of the College of Physicians, and any comments made by the Departmental Council with which he is and he signs the conditions of use agreement which sets out the HON principles, the National Council may set up a link between the doctor’s personal website and the on-line Directory of Medical Practitioners issued by the National Council of the College of Physicians. In this way, the doctor’s website may claim that, in respect of the quality of information supplied to the public, the website is both HON_HAS certificated and registered on the College of Physicians Website.
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