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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  • Dr. Drake Ramoray

    Well normally I would point out that Sweden has a small homogeneous population, relatively closed borders, paid physician education, the right of collectively bargaining for physicans, and probably comparable but not superior outcomes than the US system when you look at actual health outcomes as opposed to life expectancy (you know something influenced by a culture of guns and cars.), but today I’m gonna take a different take since none of the authors listen to my other posts.

    Unless you plan on going into direct pay care get out of the US to practice medicine. We are moving to a crony capitalist nightmare of big business healthcare in the US that can’t be stopped any time soon. You will become some middle management drone focused on initiatives, mandates, and community outcomes all while the NPs and PAs take your job.

    Use your contacts and move to Sweden. I’m keeping my international contacts in my back pocket should my plans for a direct pay practice fail.

    • Deceased MD

      See you on the other side of the pond Drake. LOL. seriously as always you have hit the nail on the head. This is not only NOT a place to practice, it is certainly not a place to get sick.
      How does one get a medical license overseas in Europe? It looks a bit hellish, but then the alternatives here as you say are not sustainable.

      • Dr. Drake Ramoray

        Canada is pretty straightforward. As buzz has pointed out they actually recruit in the Pacific Northwest. American doctors are the most unhappy and there is actually a net migration to Canada.

        http://www.washingtonpost.com/blogs/wonkblog/post/meme-busting-doctors-are-all-leaving-canada-to-practice-in-the-us/2011/06/03/AGVdAuHH_blog.html

        Australia and New Zealand were fairly accommodating when I looked a decade ago. I didn’t go because of the primary care requirement.

        It is difficult to get into the NHS system, and the credentialing to do so is difficult.

        • Deceased MD

          Thanks! Interesting article. And from what I see, just about anything sounds better than here. We should develop maybe a zagat’s guide or Rick Steve’s Europe equivalent of where to practice medicine.

      • SarahJ89

        As I’ve mentioned before, we’re moving to Europe this year, where I have citizenship. I’d happily move to Canada (I love Canada, live only a couple of hundred miles from the border) but they really need to heat the place, plus they aren’t offering me citizenship.

  • goonerdoc

    Bravo. Well put.

  • ninguem

    The docs I know that are Swedish nationals, from Sweden and trained in Sweden, do tell me that their families back in the old country also maintain private insurance for specialty care when they want services not covered in the basic system there.

    They tell me that’s not unusual, but I wouldn’t know.

    • Bill Viner

      Here in NZ about 30% of the population have private insurance which is actually relatively cheap. It covers non-emergent surgery so that you dont have to wait as long, or things not covered in the public system. For example a hip replacement, or botox injections of the bladder.

      • ninguem

        And I don’t have a problem with that, don’t get me wrong.

        Just that I strongly suspect that in any “socialized” system contemplated for the USA, say we adopted a Canadian model, or the NHS, or the OZ/NZ or French or German or Swedish system, the American public would be outraged over such a thing.

        Unrealistic expectations.

  • Bill Viner

    Thanks for the article Andreas, but you are not telling us anything new here. The powers that be in the US aren’t trying to implement high quality, universal health care coverage. They are trying to divide the money pie into large slices for their respective financial supporters: hospital corporations, pharma, trial lawyers, insurance companies… As you know, most doctors didn’t enter medicine for the money. However, after accruing massive debt, a mortgage, start up business costs, family expenses and the like, we are forced to care more about productivity and overheads and reimbursements. I now work in a foreign country and I will tell you that medicine is a great career if you take the emphasis of profit away. Don’t get me wrong, I like money, but I really like knowing what my income is going to be and that as long as I live within my means, then I don’t have to worry about it. I also like the option of doing private work and actually getting a very fair reimbursement that I set with the insurance carrier.
    As others have said already, medical training in other countries is less expensive, they get paid better in residency training, & their patients may be more fit (due to less sugar consumption, less tobacco use, helmet use…). GPs also have a great work/life balance, and few or no NP/PAs to compete with.

    I could go on, but I’m boring myself already. The key is first to fix Congress, then create a similar system to whatever country seems to be doing it right. If you create a simple system, pay the doctors what they deserve (Not less than what a good plumber earns), protect them from bogus lawsuits, and encourage patients to reduce their health risks, then I can’t see many people fighting against that. Except for the above mentioned pie eaters.

    • guest

      I agree entirely. Thank you!

    • SarahJ89

      Eek. In other words, totally reconfigure our culture.

  • ninguem

    What Malcolm Gladwell-Lincoln-Richard Branson’s horses playing basketball with airline industry nurses in Sweden at the McDonald’s Cheesecake Factory and Apple Store can teach us about primary care.

    I don’t know why I bothered with medical school, internship and residency.

  • SarahJ89

    US nationalized health care would never be as effective as it could be. The special interests are already too entrenched and the politicians on both sides of the aisle too corrupted.

    I have watched the national health care in the European country in which I once lived degrade over time due to the incursion of private health insurance. It caused the same kind of middle class abandonment of their previously excellent system that many people fear will happen with school vouchers. Basically, once the newly minted middle class got private health insurance they no longer cared about the national system. Now that their economy has collapsed, they are left with an impaired system and less access to health insurance.

    • SarahJ89

      Sorry to sound so gloomy. It’s early in the day.

      • Eric Thompson

        Not gloomy. Just thought provoking. I don’t think Americans would accept the limitations. The patients I deal with, particularly the poorer ones, don’t want to even hear about lifestyle changes. Just want a pill or surgery. The ’400 pound man’ with bad knees just wants the replacement joints and won’t even consider weight loss. Americans demand ‘spare no expense’ and ‘I don’t have to do anything, just fix it’. When I lived in Europe people were taught to live with various conditions. They seemed to accept limits. A lot cheaper that way.

        • querywoman

          Isn’t that what Jahi McMath’s mother wanted for her, a quick fix, major surgery?

        • SarahJ89

          There is a certain arrogance in our culture that causes us to believe, on a very deep level, that somehow the rules of nature can be transcended. By us.

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