What Sweden can teach us about primary care

Fulfilling every stereotype, I sat at my grandparents’ house in southern Sweden, sipping elderberry juice out of an IKEA glass and eating meatballs with lingonberry jam. It was Christmas Eve, and I was enjoying a getaway from the rigors of medical school. However, it wasn’t a complete escape, as my grandparents loved talking about medicine and the differences between health care in the United States and Sweden.

In this particular conversation, I was looking up physician density data to make a point about the enormity of the U.S. health care system. To my surprise, I found that Sweden has a substantially higher density of physicians (3.8 vs. 2.4 per 1000 population) as well as nurses and midwives (11.9 vs. 9.8 per 1000). Yet, Sweden spends less than 10 percent of its GDP on health care and achieves better outcomes than the United States. Despite fundamental differences in organization and payment structure, the U.S. can still learn great lessons about primary care and team-based health care delivery from the Swedish system.

As are the residents of many European countries, every Swede is covered by national health insurance. Primary care docs are salaried and work in team-based practices of 4-6 physicians alongside nurses, physiotherapists, psychologists, occupational therapists and social workers. Nurses serve as the first contact with patients and are empowered to do home visits. Patients are legally guaranteed access to immediate contact with the primary care system and an appointment with a doctor within seven days. Although primary care explicitly does not serve a “gatekeeper” role for access to specialty care, it is still considered the frontier of the health system and the main point of entry for patients.

Health care in the U.S. faces a number of challenges with which we are all familiar — high costs, relatively poor quality, and limited access for many. What can we learn from this relatively successful Scandinavian nation to incorporate into our own practice and advocacy efforts?

First, Sweden’s primary care physician density is high. The government is working towards a goal of one primary care physician per 1,000 citizens, and though they aren’t quite there yet, the expectation reflects a high social value placed on primary care. We must bring about a similar cultural attitude in the US. While there is widespread discussion about the U.S. shortage of primary care doctors, Dr. Stephen Schimpff and others have noted that our institutions have not made necessary changes to address the issue. Let’s generate excitement about primary care at our medical schools and advocate for policy changes that make primary care the most attractive career option for talented medical school graduates.

Second, Sweden has demonstrated what can be done with effective team-based care. Although more practices across the country are transitioning into patient-centered medical homes, there is still limited scope of practice for nurse practitioners, little reimbursement for population management, and almost no role for community health workers, despite their widespread achievements globally. We know that primary care physicians can’t do everything alone, and we need to work inter-professionally to advocate for the policies needed to support patients’ health at the highest level and to provide the best possible care.

As we work toward long-term policy change, we have to get creative in our practices immediately. I’m working with an academic primary care practice to investigate what medical student health coaches can do to help patients manage their diabetes. Student volunteers cost nothing, and the literature shows that they can make a significant impact on patients’ HbA1cs and long-term health outcomes. Elsewhere, “hot spotting” programs are taking off, highlighting that intensive team-based care can take care of the sickest patients more cheaply and more effectively than traditional health care.

In the face of great challenges, we can look around the world for inspiration. Sweden has figured out that the key to great health in a sustainable system is a strong, team-based primary care infrastructure. We can get there from here. We must advocate for policies that expand the primary care workforce — not just physicians but also nurses and health coaches and community health workers — so that we can protect the nation’s health without burning out our doctors. While we work on bringing that change to bear, we must pursue innovative ideas that bring team-based primary care to the next level.

Andreas Mitchell is a medical student who blogs at Primary Care Progress.

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