Medical Practice

American Primary Care and My Soviet Era Class Trip: Sensing the Inevitable Collapse of a Top Down Bureaucracy

By HANS DUVEFELT, MD

Swedish Healthcare seemed competent but a bit uninspired and rigid to me but my medical school class trip to the Soviet Union showed me a healthcare system and a culture I could never have fully imagined in a country that had the brain power and resources to have already landed space probes on Mars and Venus by the time my classmates and I arrived in Moscow in the cold winter of 1977.

The first time we sat down for breakfast at two big tables in the restaurant of the big Россия hotel near the Red Square, our two male waiters asked if we wanted coffee or tea and people started stating their preferences. The waiters shook their heads and put their hands up in the air. No, they couldn’t split the beverage order, they explained. We had to all decide on one beverage with no substitutions.

The restaurant obviously had both coffee and tea, and as far as I know, they cost about the same. The only thing standing between the tea drinkers and their favorite morning beverage (the coffe crowd won the popular vote) was convention and attitude. I don’t know if this was a policy set by the hotel management or a complete lack of service-mindedness by he staff, but my classmates and I felt as if we, the customers, did not matter.

(Writing this piece, I came across the news item that the Hotel Rossiya, once the biggest hotel in the world, was demolished in 2006.)

From that first morning on, everything I encountered felt dim, dark and repressive. I saw with my own eyes that Sweden’s degree of uniformity was nothing compared to the Soviet Union’s, which some of my classmates, communists and former Viet Cong supporters, had spoken well of before we got there.

During our stay I saw dilapidated hospital wards and surgical suites with antiquated medical instruments in scarce supply, which we couldn’t even all see because of a lack of scrubs and booties. We saw bare-bones ambulances staffed with underpaid specialist physicians, neurologists for stroke victims, for example. I thought being a doctor in the Soviet Union seemed like one of the most depressing things you could end up doing for a living.

I yearned for the freedom and optimism I had seen back in 1971, when as an exchange student I fell in love with America and a girl I met in my high school sociology class.

During my high school year here, I got the impression that almost everybody in America had a personal ambition, like making music, writing a book or starting a business. I saw a service mindedness I had not seen in Sweden, where years later I saw the epitome of that in a restaurant near the Arctic Circle that closed for lunch (for the staff) from 12 to 1 pm every day.

In America I also got the impression that the rules of society were not exactly cut in stone the way there were in Sweden. Due dates seemed a little flexible, rules seemed to have countless exceptions; even spelling of the American language seemed to offer a few individual choices.

Doctors in America were mostly in private practice. I didn’t see much of American healthcare that year, except the afternoon reruns of Marcus Welby, MD that I devoured. It ran from 1969 to 1976 and it solidified my vision of being a primary care doctor in America.

Fast forward twenty years, to 1991, the year the Soviet Union collapsed. The Planned Economy proved itself to be an unsustainable daydream of the social engineers of communism.

That year I had lived in this country for a decade. My work in a Federally Qualified Health Center, part of a safety net that offered subsidized or free care to people without health insurance, had shown me the inequalities and health hazards of “the other half” of American society. I felt proud to be part of such a clinic, providing equal access to everyone.

During the ensuing two decades, the Federal agencies that paid our grants and provided our preferred reimbursement rates started to micromanage what we did and how we structured our work. My original liberated experience of American healthcare turned into a sense that the bureaucrats mistrusted doctors and administrators of FQHCs so deeply that they had to structure our work for us.

The crowning event was when we all more or less had to earn recognition as “Patient Centered Medical Homes”, which at first sounded like we needed to make our practices Marcus Welby-like. Instead, PCMH was not really about nimbly meeting your patients needs but about creating rigid protocols that in fact made it hard to improvise. This was followed by many other initiatives that to a small or larger degree lacked firm anchoring in the reality of front line medicine and became virtual shackles for medical practices.

This hampering of improvisation in how you meet individual patients needs felt strangely familiar, and brought back memories of that cold December morning in Moscow:

Tea or Coffee, but not both.

Save one same day slot and qualify for easy access recognition, double book freely and fail the access parameter (no “protocol”).

And then when Uncle Sam wanted our “data”, presumably for better central planning some day, we were given grants to computerize our patient records with numerous qualifiers about how to use these computers. “Meaningful Use” broadly sounded like a good idea, except the technology was immature.

One example: Patient information about their medical condition, if generated by the EMR software, often amateurish and rudimentary, gives us Meaningful Use brownie points, but high quality handouts from sources like Up to Date, Harvard or the Mayo Clinic don’t count.

Another Federal shackle: Uncle Sam wants us to deliver comprehensive care, which includes screening for a growing list of clinical and societal issues, like depression, alcohol use, domestic violence, sexual orientation, food insecurity and so forth. If we don’t do all this, we lose brownie points. Consequently, we hesitate fitting infrequent visitors into our clinic schedules, because you can’t possibly do all that in a single visit for a sore throat, so we look better if that patient goes to a walk-in clinic – one ding on the Access parameter instead of numerous dings for all the other ambitious comprehensiveness requirements

I am sorry to report that the well meaning bureaucrats of the Central Planning Office are making American Primary Care feel more and more like the Soviet Union of Lenin and Marx where people mattered as populations, perhaps, but not as individuals. That is not the way Americans think. They don’t want to be told what to drink with their breakfast and they don’t want to be told what the agenda is for their next doctor’s visit.

Collapse or profound disruption seems inevitable.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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8 replies »

  1. Even though I won’t vote for him, drug company profits are a big problem in this country. Class action lawsuit announced today about EpiPen price increases for example, racketeering is the American word for that. And don’t get me started again on insurance company profits, including managed Medicare which you have to think about when people say Medicare for all. Too many times I have fought for and written about people with probable pancreatic cancer I can’t get the CAT scan covered for because of for-profit Medicare advantage plans.

  2. After consulting with my Swedish friend and colleague, referenced in another comment here, he says the Swedes now go by biological and not chronological age, so I think Bernie would have gotten stented there, too.

  3. Hans, if Bernie Sanders had his recent heart attack in Sweden, would he have been considered too old to treat at age 78? If not, what’s the age threshold currently beyond which treatment will not be offered or considered?

  4. Hans, thanks very much. That’s very helpful. Your post suggests that Bernie Sanders is way off base regarding why healthcare is so much more expensive in the U.S. than elsewhere. It has little or nothing to do with insurance company profits, CEO salaries and relatively little to do with drug prices. If the U.S. paid European or Canadian prices for brand name and specialty drugs, we would save some money but I think there is a good chance that it would result in a significant adverse impact on medical innovation, especially the development of new cures or at least more effective treatments that would extend decent quality life.

  5. Briefly:

    Sweden has a no-fault compensation for patients who are harmed by the health care system. Compensation is independent of what the consequences are for implicated providers, who may be subject to warnings, practice restrictions/remedial measures or even loss of license.

    The current pre-tax monthly salary for Swedish primary care physicians is about $8,000.

    In prehistoric times, when I as an intern tried to get a healthy, vital 80 year old male patient with a myocardial infarction admitted to the CCU from the emergency room, I was plainly told he was too old. More recently, when my then 83 year old mother was diagnosed with pancreatic cancer, an oncological surgeon did not discuss the technical operability of her tumor or options for chemotherapy. She was simply told she was too old to be treated. She was introduced to hospice care, which she ended up needing six months later.

    I will ask my high school friend, now head of thoracic surgery anesthesia and a medevac physician to update me/us on Sweden’s current view on how age affects treatment choices.

  6. Hans — I’m very interested in the Swedish Lagom concept as it relates to controlling healthcare system costs. Perhaps you could address the inclination of patients in Sweden to sue their doctor in the event of a bad account or a failure to diagnose a disease like cancer as soon as it might have been diagnosed if certain tests like MRI’s were ordered sooner. Second, how does the Swedish attitude toward end of life care compare to America’s when it comes to the use of heroics even when the prognosis is dire and the care provided is marginally useful at best or even futile despite high costs? Finally, could you speak to the average compensation of doctors, nurses and other healthcare workers in Sweden compared to their American counterparts? I think these are the main issues that account for America’s highest in the world healthcare costs though high brand name and specialty drug prices also play a role as well. What say you?

  7. Yes, Peter, it really is pretty decent. We’re looking at nuances, degrees of intensity of workups and interventions. The Swedes have a unique and favorite word, Lagom, which means just enough. Swedes are more measured in their approach to many things. There is nothing wrong with that – especially compared with feast or famine, lack or excess of care the way we have ended up here. /Hans

  8. Always wonder why comparisons of U.S. system seem to go to the worst (other) system to somehow justify why capitalistic U.S. health care is the best, or at least the least worst. So Hans, does Sweden’s government health care do OK for most of the country in providing universal care?

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