Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Norwegian MDs Confront Paradoxes of Egalitarianism To cite this article: (1977) Norwegian MDs Confront Paradoxes of Egalitarianism, Hospital Practice, 12:1, 155-177, DOI: 10.1080/21548331.1977.11707068 To link to this article: https://doi.org/10.1080/21548331.1977.11707068
Published online: 06 Jul 2016.
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Medicine Around the World
Norwegian MDs Confront Paradoxes of Egalitarianism The University of Tromsl(/l Medical School, set on an island some 130 miles north of the Arctic Circle, provides an unorthodox initiation into a medical career. The freshman class is not introduced to medicine with a catalogue of bones and organs. Instead, on opening day of the school year, the primary exhibit is a patient who is presented not as a walking compendium of symptoms but as a person. It may be a woman with rheumatism. She will talk about her various aches, the difficulties she encounters in wor~ing at her job or her housework, and the effect of her disorder on her family and on her social life. Her physician will talk about her. A social worker will discuss the resources that may or may not be available to aid her. A psychologist may sketch the interlocking relationships between physical disease and mental outlook. In short, she will exhibit not only her physical symptoms but her life. That first day is designed to guard students against an impression that a body is merely an arrangement of parts like an automobile engine. Later in the first term, the students go out in groups of three or four to spend a week with a country CP. In this way, the school attempts to demonstrate the concept of "people-oriented medicine" that Professor Peter F. Hjort, a typical Norwegian amalgam of athletic vigor and academic sophistication, used to persuade Parliament to build the medical school as part of the world's only full university above the Arctic Circle. Tromsr/1 Medical School was not conceived primarily to fill a need for medical training in a community that was clamoring for it. It was developed to create or at least preserve a community. In the late Ht}os, when the project was proposed, this remote re-
gion of 450,000 population was losing 6,ooo people a year to migration. Many of those leaving the north were of university age, fleeing not because of the climate but because of the lack of stimulating jobs. The north of Norway had long held a semicolonial status, yielding up mineral resources and fish for the people of the south. If necessary, some Oslo politicians felt, Norway could do what is usually done by countries with a finger in the Arctic: keep people up there by the lure of fat salaries and bonuses. Bribery, however, seemed to many to violate the rectilinear Scandinavian conscience and to offer poor motiva•
tion to the people who, after all, would be manning a crucial frontier. Though Norway enjoys harmonious relations with all its neighbors - Sweden, Finland, and the Soviet Unionto leave a frontier region primarily and thinly peopled by settlers with mercenary motivations might in some future crisis invite disaster. The government set about devising inducements to keep people in the north and to draw back those who had fled. What was needed was not the conventional slow process of attracting industries and building towns and services but a dramatic move that would stanch the flow. The government therefore decided to begin with the crowning glory of an established community- a university. "The medical school was to be a flagship of the whole effort," says Dr. Hjort. He saw the new university not so much in geopolitical terms but as an opportunity to train doctors for community service and to open up the curriculum accordingly, with more psychology and sociology and a much earlier exposure to clinical work. He summed up his ideas in a book that
Reindeer provide Norwegian Lapps with meat and skins, but custom of tying children to their sides during migrations causes a peculiar form of hip displacement. Lapps also suffer a rare disorder of glycoprotein catabolism called aspartylglycosaminuria. Hospital Practice January 1977
15 5
Far above the Arctic Circle, University of Trams; Medical School has classrooms in this psychiatric hospital. The university was recently founded in an effort to stem the outmigration of 6,lX)() a year- mainly young people -lacking stimulating jobs.
came out in a white-and-red jacket: white for all that was good in the old way, red for the new. "This was the flag we needed," he recalls. After the scheme was approved unanimously by Parliament, Dr. Hjort and his colleagues advocated opening the school as soon as possible, using whatever facilities existed -particularly the local hospital, for example- and erecting temporary structures where necessary until a permanent physical plant could be built. He granted that in the long run his proposal might cost more· money, but the university would be fu.nctioning while politicians still argued over appropriations. The proponents of the plan went down to Oslo for a one-hour meeting with the Cabinet. They knew they had won when the Minister of Finance, Ole Myrvoll, who had been a professor of economics, said: "As a minister of finance I can sec this as a catastrophe, but as a professor I'm sure it is the only way to do it." The University of Troms4J Medical School welcomed its first freshman class of 40 in 1973. They will be graduated in 1979. There is no firm dividing line in this six-year course between premedical and mediL.Jl subjects. The subjects tend to merge, points out a professor of internal medicine, Dr. Arne Nord4Jy, because the student sees "a social problem in every.bed." The first four semesters (one and a 1 56
Hospital Practice January 1977
third years) include basic chemistry and biology, cell structure and a general review of organ biology, interspersed with sociology, philosophy, and an introduction to the routine of primary care. Then come two and two thirds years of "organ" courses. Each organ is studied in turn, combining class work, lab, and clinical work, along with the social, epidemiologic, neurologic, and psychologic factors related to the organ under study. Then follow two semesters in local hospitals and primary care facilities and four more semesters of hospital clinical training that constitute an internship. The student is then eligible for residency training of four to six years, depending on the specialty. The school's curriculum and management are predicated on the notion that the students, although generally under 20 when they come in, are in fact mature, working adults. Only three examinations are given in the six years of training: one after the fourth semester, another at the end of clinical training, and the last one after the internship program. In all these, students are given no grades but only a pass or fail. The test at the end of each organ course is optional; and if a student does take it, he need not put his name to it. It is meant only to help the student evaluate his own progress and give the teacher a clue as to how well
he is making himself understood. The notion of anonymous tests originated with the student representatives on the study committee. Students function on every committee of the school, including budget, curriculum, and admissions. After the initial excitement of participatory democracy the students' enthusiasm tends to fade, Dr. Nordoy says, so that faculty members have to prod student representatives to attend committee meetings. Nevertheless, even those who are relatively nonpolitical exhibit a proprietary affection for the school. Take, for example, the second-year student Ingrid Melheim, one of 19 women in the class of 40. "You can't say I'm representative," she warns emphatically. "In the first place I like my instructors and that's not the way most students say they feel. And secondly I'm not a political activist." Despite her lack of enthusiasm for the political life, she relishes the democracy of Troms~: "When we see something we think is wrong in the school we can get together on a collective letter to the faculty and ask, 'What are you people doing up there?'" What are the prospects facing a student like lngrid Melheim in a country with an unwavering resolve to make medical care available to all as an essential ingredient of a welfare state? One possible career might follow the model of Dr. Kaare Torp, a veteran of the Norwegian public health service from the days when it had a touch of pioneering heroics to it. He likes to recall the time about 15 years ago when he was the only pediatrician in the north, and often made his rounds of the villages and rural clinics of Lapland on a dog sled. Dr. Torp is in his sixties now. One finds him at the end of his day clad in a sweat suit, for he has performed the Norwegian evening ritual of a run through the woods and a sauna bath. He is standing in front of his house, playing "My Old Kentucky Home" on an accordion in honor of his American guests. Dr. Torp points to his neighbor's house, which is somewhat bigger and has more garden space than his own huge, rambling, gadget-filled home. "He lives like I do and he's not a doc(continued on page 161)
NORWEGIAN
MD (from page 156)
tor. He works in a factory," he says. Actually, the prime difference between those who are well off and those who are poor in Norway is that the poor family may need two breadwinners to live almost as well as the nearrich. who can manage it on one income. The steeply graduated income tax (up to 90%) is a mighty leveler. For example, a moderately prosperous doctor who earns the equivalent of $30,000 a year might net after taxes some $12,000. A skilled construction worker who is paid $12,000 a year is left with about $9,000. When Dr. Torp is not teaching at the medical school in Tromsf/l or in.: dulging in the strenuous recreations favored by most Norwegians of advanced middle age, he is out in the tundra and taiga of Lapland examining children or studying unique disorders, the origins of which are lost in La pp history and culture. The Lapps themselves are a puzzle to anthropologists, who have so far found it difficult to trace the origins or relationships of these light-skinned, blue-eyed aborigines. Formerly, they lived throughout Finland, Sweden, and Norway but, pushed by missionaries, kings, pirates, and, later, industrialists and homesteaders, they eventually retreated peaceably to the north. They hunted, trapped, herded reindeer, farmed, fished. Intermarriage occurred with relatively few problems, since their fair skin and light eyes made them rather hard to distinguish from the invaders. Despite all the facility with which they could blend into the population around them, they have survived as a distinct ethHic entity. Though their language, Lappish, was downgraded for years and allowed in a few country schools only as a reluctant concession, it has persisted. In recent years, with the cultivation of the Norwegian conscience in regard to minority rights throughout the world, Lappish has been taught in all of the northern schools. Organizations have sprung up to defend the rights of Lapps and to preserve their culture. A policy of affirmative action has been adopted at most universities, including the medical school at Tromsr/>,
which has admitted several Lapps in every class. Dr. Torp denies that this occasions any resentment. "Two of my own kids tried to get into medical school and failed, but two Lapps got in with lower scores. My children don't resent it. I don't resent it." There are about 20,000 Lapps in Norway and another 10,000 in the rest of Scandinavia and the Soviet Union. Some 3,000 of them in the remote regions of Norway speak only Lappish, pursue a seminomadic life, and follow their reindeer herds. In general, though, tent life has given way to village life. Dr. Torp has seen the Lapp villages where they still sing ancient Lappish songs. He has treated children for the peculiar form of hip displacement that is attributed to the custom of tying children to the sides of reindeer during migrations. He has also studied the phenomenon of aspartylglycosaminuria, a disorder of glycoprotein catabolism that is found only among Lapps and Finns and that can have devastating effects. A child with such an inherited fault is born normal and yet becomes severely retarded mentally by the age of 14 or 15. Of every 250 cases of mental retardation among the Lapps, nine exhibit signs of aspartylglycosaminuria. Dr. Torp began studying the uncommon malfunction years ago, when he himself was a rare phenomenon. When he turned up at an isolated district health office, people would come
for miles to see "a real live pediatrician in the north." Now that there are 13 pediatricians in the region and he can go out with pediatric teams, he can more accurately measure the prevalence of the strange disorder. He estimates that one child out of every four is at risk. By a curious and compensatory good fortune, among people who exhibit a high incidence of aspartylglycosaminuria, phenylketonuria is unknown. Whatever harm may have been done to Lapp traditions by acculturation, medically the results have been good. Dr. Torp recalls that 10 or 12 years ago one out of every four children in remote pure-Lapp communities was born in a tent without medical aid. Infant mortality was abnormally high. Now, he says, 90% arc born in maternity centers, attended by trained midwives. Lapp infant mortality is now down to about 13.7 per 1,000 births, the rate in Norway as a whole. Dr. Torp, with his interest in research and his teaching, seems to lead a satisfying medical life in the north. But if a student seeks an easier model to follow he or she might consider Dr. Ove Sejerven, the district doctor responsible for primary health care in Tromsr/>. Dr. Sejerven is not an altogether happy man. In his early thirties, he is somewhat disenchanted with his life as a district doctor. He finds he is working too many hours, seeing too many patients, doing too much paper-
A veteran of the public health service, Dr. Kaare Torp used to make rounds by dog sled when he was the only pediatrician in northern Norway. Now a faculty member at Trams-. he returns to Lapland to study unique disorders of the people.
Hospital Practice January 1977
161
District doctor responsible for primary health care in Troms(l, Ove Sejerven, sees about 100 patients a week, finds the workload oppressive, but does not complain about his income, $11,000 after taxes.
work. Yet his workweek does not sound oppressive. He sees patients at the health center four days out of the week. In winter he works from 8:30 in the morning until 4:30 in the afternoon, and in summer until 3:30. He may meet clinic appointments one or two evenings a week as well. One day a week he travels some 40 miles to a health outpost over the mountains and up a winding fjord. Another day he allots to an old folks' home. In all, he sees perhaps 100 patients a week and thinks he could give far better care if he saw half as many. When Dr. Sejerven came out of medical school in the south, he went to work for a year and a half in microbiologic research, then applied for a post as district doctor. If the government doesn't do something to give him more time, he'd just as soon go back to research. If he does, it will not be because he is uninterested in the problems of the north. He finds the 162
Hospital Practice January
1977
clinical picture fascinating and hopeful. He expects that as Tromsl/l settles down after the boom stimulated by the coming of the university, the relatively high incidence of alcoholism and venereal disease in the north will subside. But he wants better facilities, though the ones he has seem more than adequate by any standards other than Norwegian. It is not easy to comprehend Dr. Sejerven's dissatisfaction because the patient load, the hours of work, and the well-equipped clinics and hospital facilities at Trams(/) would seem to add up to a rather pleasant situation for a doctor a few years out of medical school. Yet the same mood is encountered at the health center at Lakselvbukt (Salmon River Bay), a small town on a fjord hemmed in by green velvety hills. In the low, neat clinic a group of old men sit waiting with the patience of people for whom this is not so much an ordeal but a way of passing time. They are typical of this community. Many are pensioners who can no longer work their farms or go out with their fishing boats but will not leave their homes. Some young people take over the farm chores, but many others have answered the· lure of Troms(/)'s building boom and now commute the 50 miles or so of winding mountain road. Off the waiting room in the clinic, an assembly hall has been built that is used for weddings, for meetings, and for screening examinations by the public health nurse who makes periodic visits. Space has been set aside for a government representative who every week comes to enlighten the villagers on what they are entitled to receive from the government in the form of medical care, pensions, allowances, or travel pay for visits -to the doctor. Many of life's problems, it seems, can be solved by filling out the proper form. The clinic also has a nurse and a clerk-receptionist who keeps a meticulous file on the health status of everyone in the area. Presiding over the well-equipped, pleasant center is a young woman, Dr. Astrid Stranden, mother of two children and with a third on the way. She echoes the expressions of discontent voiced by her superior, Dr. Sejerven. She finds the seven-hour day exces-
sive. "There is too much stress," she says. She would like to find a half-day doctor's job. Her husband, who is also a doctor, is looking for a similar schedule so that both might practice and still have time for each other and their children. Only in Scandinavia could two young doctors hope for such a life-style. There is no temptation to work harder for more money because a higher gross income brings higher taxes and little improvement in takehome pay. There is no pressure to save for a rainy day because Norwegians are shielded against adversity by the umbrella of the welfare state. Although these doctors find many grounds for complaint, their incomes, even after their high taxes, are rarely mentioned as a grievance. Dr. Sejerven, for example, grosses about $24,000 a year and ends up with a net of about $11 ,ooo. He is paid a straight salary of about $7,500 for his work with the elderly, and the rest he collects in strictly regulated fees from his patients, or rather from their insurance funds, for virtually everyone in Norway must carry medical insurance. This covers everything from a casual visit to a GP to the most catastrophic illness, longterm hospital stays, and rehabilitation. For this total family coverage the insured Norwegian pays roughly 4% of his income. With scarcely any additional cost, he is entitled to every medical service available, plus cash benefits in case illness keeps him from work. He chooses his own family doctor and pays out of his pocket only the equivalent of $2 for each of the first two visits. Whatever happens after that, all expenses are paid by the insurance fund. Both employers and the government contribute to that fund. All medical fees are set in annual negotiations with the Norwegian Medical Association. A GP may charge $8 for an office visit, $10 for a house call. A specialist gets $10 for an office visit and $15 for a house visit. Bills to insurance funds are paid within a month. Insurance fund officials claim that the top income for a GP in Oslo, attained by very few, is $1oo,ooo a year, of which taxes might consume as much as 75%. Most gross closer to $35,000 but emerge with after-tax incomes almost equaling those of their (continued on page 167)
NoRWEGIAN MD (from page 162) more affluent and busier colleagues. A full-time doctor on salary in a hospital gets a starter's minimum of $18,000. On the whole, a big-city doctor has an income second only to that of a prosperous company executive. In the countryside, he is likely to be in the top bracket. Although Dr. Sejerven has no complaints about his income, he feels strongly that a district doctor should be paid a flat salary with no fee-for-service arrangement. He finds that the present system is clumsy, adds to his paperwork, and tempts a doctor to take on more patients than he should and perhaps administer unnecessary tests, which are paid for by the insurance fund. In this he is at odds with the Norwegian Medical Association, which is devoted passionately to feefor-service. It has always fully endorsed the program of universal insurance and fixed fees but resists every proposal to increase the numbers of doctors on salary. The NMA, says Dr. Sejerven, is "too eager to keep medical practice a business. It fights change." To which Dr. Jon Skortun, Secretary-General of the Norwegian Medical Association, replies, "The man who would say a thing like that just doesn't know his stuff." Dr. Skortun is a medical politician of impressive dignity. Seated beneath a gilt-frame portrait of an imposing predecessor in the gracious Oslo mansion that houses NMA headquarters, he takes on a ministerial air. This, however, is relieved of any stuffiness by a disarming directness. "I would not describe the NMA as conservative," he says. "But. we don't throw overboard a system [fee-for-service] just for the fun of throwing it overboard." Describing NMA membership, which includes just about all of Norway's 7,000 doctors, he points out that "we have radicals and conservatives and every color of party and politics." He likens the organization more to the British Medical Association than to the American Medical Association. As for young doctors, he says, "I don't see much difference between young and old. We take them right into the council."
When asked whether he would characterize the relationship between the NMA and the Norwegian government as "reasonably friendly," Dr. Skortun says, "Take out the word 'reasonably.' It is just plain friendly." Although the government does indeed work closely with the NMA not only on fee schedules but on a host of other problems from recruiting specialists for the north to hospital construction, there are nevertheless some discernible differences in approach. The government is not wedded to fee-for-service and is beginning to be concerned about an eventual oversupply of doctors. Dr. Skortun admits that discussions are taking place on these points and is willing to concede that in exceptional circumstances, perhaps in the Arctic, a salaried system may be justified. As for the doctor surplus predicted for the 198os, Dr. Skortun says, "I am not afraid today." He would not limit admissions to medical schools (which nobody in the government is suggesting for the moment) because, as he points out, some Norwegians still go abroad to study. The GP situation, he says, is better in the north than it is in Oslo, where there is an actual doctor shortage. This is aggravated by the fact that a doctor can't find an office in which to set up practice. This is due not to lack of housing, he points out, but to government regulations that require every vacant apartment to be used exclusively for living purposes,
not for business, in which category the government places medical practice. Although income policy is not really in contention, Dr. Skortun notes that the average GP in Oslo earns about $35,000 a year, which, he says, the government would like to see reduced to approximately $25,000. Dr. Skortun is also not impressed by the government program for health centers in urban areas. "The trouble is," he says, "that nobody knows what a health center is." He is critical of current trends to incorporate social workers and doctors into a team. A patient wants to see his doctor, he maintains, and if there is a need for a social worker the doctor can refer the patient to the proper agency. (This runs counter to the doctrine taught at Troms!/l, where sociologists, theoretically at least, work in close and equal partnership with doctors.) The type of center that wins the complete approbation of Dr. Skortun is one set up for group practice, currently making its first appearance in Norway. An example is the group at Hokksund, 90 minutes by train from Oslo. Hokksund is a town of some 15,000 population set in an industrial valley. It does not have the seamy look of industrial towns elsewhere, but neither can it boast any charm. The structure of the Legehuset (doctors' building) is low and undistinguished. One is all the more surprised, therefore, by the sleek, almost elegant modernity that confronts one inside. The
Health cent er at Lakselvbukt provides not only medical care but screening examinations by a visiting public health nurse, space for weddings and meetings, and weekly get· togethers with a govemment representative on pensions and other benefits.
angularity of modern Scandinavian furniture and decor is softened by comfort, soft lighting, and flourishing green plants. The Legehuset at Hokksund is the collective enterprise of five doctors, all between the ages of 35 and 40. Three of them arc CPs, one is a surgeon, and the other an internist. They function together in a modern, small-town, round-the-clock primary care facility. They have their own x-ray department and a lab that can run urine tests and do basic serology. They have an electrocardiograph. They employ one nurse, two lab technicians, two secretary-receptionists, and three telephone operators, so that their switchboard is covered 24 hours a day. In 1
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Norwegian MDs Confront Paradoxes of Egalitarianism To cite this article: (1977) Norwegian MDs Confront Paradoxes of Egalitarianism, Hospital Practice, 12:1, 155-177, DOI: 10.1080/21548331.1977.11707068 To link to this article: https://doi.org/10.1080/21548331.1977.11707068
Published online: 06 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20
Medicine Around the World
Norwegian MDs Confront Paradoxes of Egalitarianism The University of Tromsl(/l Medical School, set on an island some 130 miles north of the Arctic Circle, provides an unorthodox initiation into a medical career. The freshman class is not introduced to medicine with a catalogue of bones and organs. Instead, on opening day of the school year, the primary exhibit is a patient who is presented not as a walking compendium of symptoms but as a person. It may be a woman with rheumatism. She will talk about her various aches, the difficulties she encounters in wor~ing at her job or her housework, and the effect of her disorder on her family and on her social life. Her physician will talk about her. A social worker will discuss the resources that may or may not be available to aid her. A psychologist may sketch the interlocking relationships between physical disease and mental outlook. In short, she will exhibit not only her physical symptoms but her life. That first day is designed to guard students against an impression that a body is merely an arrangement of parts like an automobile engine. Later in the first term, the students go out in groups of three or four to spend a week with a country CP. In this way, the school attempts to demonstrate the concept of "people-oriented medicine" that Professor Peter F. Hjort, a typical Norwegian amalgam of athletic vigor and academic sophistication, used to persuade Parliament to build the medical school as part of the world's only full university above the Arctic Circle. Tromsr/1 Medical School was not conceived primarily to fill a need for medical training in a community that was clamoring for it. It was developed to create or at least preserve a community. In the late Ht}os, when the project was proposed, this remote re-
gion of 450,000 population was losing 6,ooo people a year to migration. Many of those leaving the north were of university age, fleeing not because of the climate but because of the lack of stimulating jobs. The north of Norway had long held a semicolonial status, yielding up mineral resources and fish for the people of the south. If necessary, some Oslo politicians felt, Norway could do what is usually done by countries with a finger in the Arctic: keep people up there by the lure of fat salaries and bonuses. Bribery, however, seemed to many to violate the rectilinear Scandinavian conscience and to offer poor motiva•
tion to the people who, after all, would be manning a crucial frontier. Though Norway enjoys harmonious relations with all its neighbors - Sweden, Finland, and the Soviet Unionto leave a frontier region primarily and thinly peopled by settlers with mercenary motivations might in some future crisis invite disaster. The government set about devising inducements to keep people in the north and to draw back those who had fled. What was needed was not the conventional slow process of attracting industries and building towns and services but a dramatic move that would stanch the flow. The government therefore decided to begin with the crowning glory of an established community- a university. "The medical school was to be a flagship of the whole effort," says Dr. Hjort. He saw the new university not so much in geopolitical terms but as an opportunity to train doctors for community service and to open up the curriculum accordingly, with more psychology and sociology and a much earlier exposure to clinical work. He summed up his ideas in a book that
Reindeer provide Norwegian Lapps with meat and skins, but custom of tying children to their sides during migrations causes a peculiar form of hip displacement. Lapps also suffer a rare disorder of glycoprotein catabolism called aspartylglycosaminuria. Hospital Practice January 1977
15 5
Far above the Arctic Circle, University of Trams; Medical School has classrooms in this psychiatric hospital. The university was recently founded in an effort to stem the outmigration of 6,lX)() a year- mainly young people -lacking stimulating jobs.
came out in a white-and-red jacket: white for all that was good in the old way, red for the new. "This was the flag we needed," he recalls. After the scheme was approved unanimously by Parliament, Dr. Hjort and his colleagues advocated opening the school as soon as possible, using whatever facilities existed -particularly the local hospital, for example- and erecting temporary structures where necessary until a permanent physical plant could be built. He granted that in the long run his proposal might cost more· money, but the university would be fu.nctioning while politicians still argued over appropriations. The proponents of the plan went down to Oslo for a one-hour meeting with the Cabinet. They knew they had won when the Minister of Finance, Ole Myrvoll, who had been a professor of economics, said: "As a minister of finance I can sec this as a catastrophe, but as a professor I'm sure it is the only way to do it." The University of Troms4J Medical School welcomed its first freshman class of 40 in 1973. They will be graduated in 1979. There is no firm dividing line in this six-year course between premedical and mediL.Jl subjects. The subjects tend to merge, points out a professor of internal medicine, Dr. Arne Nord4Jy, because the student sees "a social problem in every.bed." The first four semesters (one and a 1 56
Hospital Practice January 1977
third years) include basic chemistry and biology, cell structure and a general review of organ biology, interspersed with sociology, philosophy, and an introduction to the routine of primary care. Then come two and two thirds years of "organ" courses. Each organ is studied in turn, combining class work, lab, and clinical work, along with the social, epidemiologic, neurologic, and psychologic factors related to the organ under study. Then follow two semesters in local hospitals and primary care facilities and four more semesters of hospital clinical training that constitute an internship. The student is then eligible for residency training of four to six years, depending on the specialty. The school's curriculum and management are predicated on the notion that the students, although generally under 20 when they come in, are in fact mature, working adults. Only three examinations are given in the six years of training: one after the fourth semester, another at the end of clinical training, and the last one after the internship program. In all these, students are given no grades but only a pass or fail. The test at the end of each organ course is optional; and if a student does take it, he need not put his name to it. It is meant only to help the student evaluate his own progress and give the teacher a clue as to how well
he is making himself understood. The notion of anonymous tests originated with the student representatives on the study committee. Students function on every committee of the school, including budget, curriculum, and admissions. After the initial excitement of participatory democracy the students' enthusiasm tends to fade, Dr. Nordoy says, so that faculty members have to prod student representatives to attend committee meetings. Nevertheless, even those who are relatively nonpolitical exhibit a proprietary affection for the school. Take, for example, the second-year student Ingrid Melheim, one of 19 women in the class of 40. "You can't say I'm representative," she warns emphatically. "In the first place I like my instructors and that's not the way most students say they feel. And secondly I'm not a political activist." Despite her lack of enthusiasm for the political life, she relishes the democracy of Troms~: "When we see something we think is wrong in the school we can get together on a collective letter to the faculty and ask, 'What are you people doing up there?'" What are the prospects facing a student like lngrid Melheim in a country with an unwavering resolve to make medical care available to all as an essential ingredient of a welfare state? One possible career might follow the model of Dr. Kaare Torp, a veteran of the Norwegian public health service from the days when it had a touch of pioneering heroics to it. He likes to recall the time about 15 years ago when he was the only pediatrician in the north, and often made his rounds of the villages and rural clinics of Lapland on a dog sled. Dr. Torp is in his sixties now. One finds him at the end of his day clad in a sweat suit, for he has performed the Norwegian evening ritual of a run through the woods and a sauna bath. He is standing in front of his house, playing "My Old Kentucky Home" on an accordion in honor of his American guests. Dr. Torp points to his neighbor's house, which is somewhat bigger and has more garden space than his own huge, rambling, gadget-filled home. "He lives like I do and he's not a doc(continued on page 161)
NORWEGIAN
MD (from page 156)
tor. He works in a factory," he says. Actually, the prime difference between those who are well off and those who are poor in Norway is that the poor family may need two breadwinners to live almost as well as the nearrich. who can manage it on one income. The steeply graduated income tax (up to 90%) is a mighty leveler. For example, a moderately prosperous doctor who earns the equivalent of $30,000 a year might net after taxes some $12,000. A skilled construction worker who is paid $12,000 a year is left with about $9,000. When Dr. Torp is not teaching at the medical school in Tromsf/l or in.: dulging in the strenuous recreations favored by most Norwegians of advanced middle age, he is out in the tundra and taiga of Lapland examining children or studying unique disorders, the origins of which are lost in La pp history and culture. The Lapps themselves are a puzzle to anthropologists, who have so far found it difficult to trace the origins or relationships of these light-skinned, blue-eyed aborigines. Formerly, they lived throughout Finland, Sweden, and Norway but, pushed by missionaries, kings, pirates, and, later, industrialists and homesteaders, they eventually retreated peaceably to the north. They hunted, trapped, herded reindeer, farmed, fished. Intermarriage occurred with relatively few problems, since their fair skin and light eyes made them rather hard to distinguish from the invaders. Despite all the facility with which they could blend into the population around them, they have survived as a distinct ethHic entity. Though their language, Lappish, was downgraded for years and allowed in a few country schools only as a reluctant concession, it has persisted. In recent years, with the cultivation of the Norwegian conscience in regard to minority rights throughout the world, Lappish has been taught in all of the northern schools. Organizations have sprung up to defend the rights of Lapps and to preserve their culture. A policy of affirmative action has been adopted at most universities, including the medical school at Tromsr/>,
which has admitted several Lapps in every class. Dr. Torp denies that this occasions any resentment. "Two of my own kids tried to get into medical school and failed, but two Lapps got in with lower scores. My children don't resent it. I don't resent it." There are about 20,000 Lapps in Norway and another 10,000 in the rest of Scandinavia and the Soviet Union. Some 3,000 of them in the remote regions of Norway speak only Lappish, pursue a seminomadic life, and follow their reindeer herds. In general, though, tent life has given way to village life. Dr. Torp has seen the Lapp villages where they still sing ancient Lappish songs. He has treated children for the peculiar form of hip displacement that is attributed to the custom of tying children to the sides of reindeer during migrations. He has also studied the phenomenon of aspartylglycosaminuria, a disorder of glycoprotein catabolism that is found only among Lapps and Finns and that can have devastating effects. A child with such an inherited fault is born normal and yet becomes severely retarded mentally by the age of 14 or 15. Of every 250 cases of mental retardation among the Lapps, nine exhibit signs of aspartylglycosaminuria. Dr. Torp began studying the uncommon malfunction years ago, when he himself was a rare phenomenon. When he turned up at an isolated district health office, people would come
for miles to see "a real live pediatrician in the north." Now that there are 13 pediatricians in the region and he can go out with pediatric teams, he can more accurately measure the prevalence of the strange disorder. He estimates that one child out of every four is at risk. By a curious and compensatory good fortune, among people who exhibit a high incidence of aspartylglycosaminuria, phenylketonuria is unknown. Whatever harm may have been done to Lapp traditions by acculturation, medically the results have been good. Dr. Torp recalls that 10 or 12 years ago one out of every four children in remote pure-Lapp communities was born in a tent without medical aid. Infant mortality was abnormally high. Now, he says, 90% arc born in maternity centers, attended by trained midwives. Lapp infant mortality is now down to about 13.7 per 1,000 births, the rate in Norway as a whole. Dr. Torp, with his interest in research and his teaching, seems to lead a satisfying medical life in the north. But if a student seeks an easier model to follow he or she might consider Dr. Ove Sejerven, the district doctor responsible for primary health care in Tromsr/>. Dr. Sejerven is not an altogether happy man. In his early thirties, he is somewhat disenchanted with his life as a district doctor. He finds he is working too many hours, seeing too many patients, doing too much paper-
A veteran of the public health service, Dr. Kaare Torp used to make rounds by dog sled when he was the only pediatrician in northern Norway. Now a faculty member at Trams-. he returns to Lapland to study unique disorders of the people.
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District doctor responsible for primary health care in Troms(l, Ove Sejerven, sees about 100 patients a week, finds the workload oppressive, but does not complain about his income, $11,000 after taxes.
work. Yet his workweek does not sound oppressive. He sees patients at the health center four days out of the week. In winter he works from 8:30 in the morning until 4:30 in the afternoon, and in summer until 3:30. He may meet clinic appointments one or two evenings a week as well. One day a week he travels some 40 miles to a health outpost over the mountains and up a winding fjord. Another day he allots to an old folks' home. In all, he sees perhaps 100 patients a week and thinks he could give far better care if he saw half as many. When Dr. Sejerven came out of medical school in the south, he went to work for a year and a half in microbiologic research, then applied for a post as district doctor. If the government doesn't do something to give him more time, he'd just as soon go back to research. If he does, it will not be because he is uninterested in the problems of the north. He finds the 162
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clinical picture fascinating and hopeful. He expects that as Tromsl/l settles down after the boom stimulated by the coming of the university, the relatively high incidence of alcoholism and venereal disease in the north will subside. But he wants better facilities, though the ones he has seem more than adequate by any standards other than Norwegian. It is not easy to comprehend Dr. Sejerven's dissatisfaction because the patient load, the hours of work, and the well-equipped clinics and hospital facilities at Trams(/) would seem to add up to a rather pleasant situation for a doctor a few years out of medical school. Yet the same mood is encountered at the health center at Lakselvbukt (Salmon River Bay), a small town on a fjord hemmed in by green velvety hills. In the low, neat clinic a group of old men sit waiting with the patience of people for whom this is not so much an ordeal but a way of passing time. They are typical of this community. Many are pensioners who can no longer work their farms or go out with their fishing boats but will not leave their homes. Some young people take over the farm chores, but many others have answered the· lure of Troms(/)'s building boom and now commute the 50 miles or so of winding mountain road. Off the waiting room in the clinic, an assembly hall has been built that is used for weddings, for meetings, and for screening examinations by the public health nurse who makes periodic visits. Space has been set aside for a government representative who every week comes to enlighten the villagers on what they are entitled to receive from the government in the form of medical care, pensions, allowances, or travel pay for visits -to the doctor. Many of life's problems, it seems, can be solved by filling out the proper form. The clinic also has a nurse and a clerk-receptionist who keeps a meticulous file on the health status of everyone in the area. Presiding over the well-equipped, pleasant center is a young woman, Dr. Astrid Stranden, mother of two children and with a third on the way. She echoes the expressions of discontent voiced by her superior, Dr. Sejerven. She finds the seven-hour day exces-
sive. "There is too much stress," she says. She would like to find a half-day doctor's job. Her husband, who is also a doctor, is looking for a similar schedule so that both might practice and still have time for each other and their children. Only in Scandinavia could two young doctors hope for such a life-style. There is no temptation to work harder for more money because a higher gross income brings higher taxes and little improvement in takehome pay. There is no pressure to save for a rainy day because Norwegians are shielded against adversity by the umbrella of the welfare state. Although these doctors find many grounds for complaint, their incomes, even after their high taxes, are rarely mentioned as a grievance. Dr. Sejerven, for example, grosses about $24,000 a year and ends up with a net of about $11 ,ooo. He is paid a straight salary of about $7,500 for his work with the elderly, and the rest he collects in strictly regulated fees from his patients, or rather from their insurance funds, for virtually everyone in Norway must carry medical insurance. This covers everything from a casual visit to a GP to the most catastrophic illness, longterm hospital stays, and rehabilitation. For this total family coverage the insured Norwegian pays roughly 4% of his income. With scarcely any additional cost, he is entitled to every medical service available, plus cash benefits in case illness keeps him from work. He chooses his own family doctor and pays out of his pocket only the equivalent of $2 for each of the first two visits. Whatever happens after that, all expenses are paid by the insurance fund. Both employers and the government contribute to that fund. All medical fees are set in annual negotiations with the Norwegian Medical Association. A GP may charge $8 for an office visit, $10 for a house call. A specialist gets $10 for an office visit and $15 for a house visit. Bills to insurance funds are paid within a month. Insurance fund officials claim that the top income for a GP in Oslo, attained by very few, is $1oo,ooo a year, of which taxes might consume as much as 75%. Most gross closer to $35,000 but emerge with after-tax incomes almost equaling those of their (continued on page 167)
NoRWEGIAN MD (from page 162) more affluent and busier colleagues. A full-time doctor on salary in a hospital gets a starter's minimum of $18,000. On the whole, a big-city doctor has an income second only to that of a prosperous company executive. In the countryside, he is likely to be in the top bracket. Although Dr. Sejerven has no complaints about his income, he feels strongly that a district doctor should be paid a flat salary with no fee-for-service arrangement. He finds that the present system is clumsy, adds to his paperwork, and tempts a doctor to take on more patients than he should and perhaps administer unnecessary tests, which are paid for by the insurance fund. In this he is at odds with the Norwegian Medical Association, which is devoted passionately to feefor-service. It has always fully endorsed the program of universal insurance and fixed fees but resists every proposal to increase the numbers of doctors on salary. The NMA, says Dr. Sejerven, is "too eager to keep medical practice a business. It fights change." To which Dr. Jon Skortun, Secretary-General of the Norwegian Medical Association, replies, "The man who would say a thing like that just doesn't know his stuff." Dr. Skortun is a medical politician of impressive dignity. Seated beneath a gilt-frame portrait of an imposing predecessor in the gracious Oslo mansion that houses NMA headquarters, he takes on a ministerial air. This, however, is relieved of any stuffiness by a disarming directness. "I would not describe the NMA as conservative," he says. "But. we don't throw overboard a system [fee-for-service] just for the fun of throwing it overboard." Describing NMA membership, which includes just about all of Norway's 7,000 doctors, he points out that "we have radicals and conservatives and every color of party and politics." He likens the organization more to the British Medical Association than to the American Medical Association. As for young doctors, he says, "I don't see much difference between young and old. We take them right into the council."
When asked whether he would characterize the relationship between the NMA and the Norwegian government as "reasonably friendly," Dr. Skortun says, "Take out the word 'reasonably.' It is just plain friendly." Although the government does indeed work closely with the NMA not only on fee schedules but on a host of other problems from recruiting specialists for the north to hospital construction, there are nevertheless some discernible differences in approach. The government is not wedded to fee-for-service and is beginning to be concerned about an eventual oversupply of doctors. Dr. Skortun admits that discussions are taking place on these points and is willing to concede that in exceptional circumstances, perhaps in the Arctic, a salaried system may be justified. As for the doctor surplus predicted for the 198os, Dr. Skortun says, "I am not afraid today." He would not limit admissions to medical schools (which nobody in the government is suggesting for the moment) because, as he points out, some Norwegians still go abroad to study. The GP situation, he says, is better in the north than it is in Oslo, where there is an actual doctor shortage. This is aggravated by the fact that a doctor can't find an office in which to set up practice. This is due not to lack of housing, he points out, but to government regulations that require every vacant apartment to be used exclusively for living purposes,
not for business, in which category the government places medical practice. Although income policy is not really in contention, Dr. Skortun notes that the average GP in Oslo earns about $35,000 a year, which, he says, the government would like to see reduced to approximately $25,000. Dr. Skortun is also not impressed by the government program for health centers in urban areas. "The trouble is," he says, "that nobody knows what a health center is." He is critical of current trends to incorporate social workers and doctors into a team. A patient wants to see his doctor, he maintains, and if there is a need for a social worker the doctor can refer the patient to the proper agency. (This runs counter to the doctrine taught at Troms!/l, where sociologists, theoretically at least, work in close and equal partnership with doctors.) The type of center that wins the complete approbation of Dr. Skortun is one set up for group practice, currently making its first appearance in Norway. An example is the group at Hokksund, 90 minutes by train from Oslo. Hokksund is a town of some 15,000 population set in an industrial valley. It does not have the seamy look of industrial towns elsewhere, but neither can it boast any charm. The structure of the Legehuset (doctors' building) is low and undistinguished. One is all the more surprised, therefore, by the sleek, almost elegant modernity that confronts one inside. The
Health cent er at Lakselvbukt provides not only medical care but screening examinations by a visiting public health nurse, space for weddings and meetings, and weekly get· togethers with a govemment representative on pensions and other benefits.
angularity of modern Scandinavian furniture and decor is softened by comfort, soft lighting, and flourishing green plants. The Legehuset at Hokksund is the collective enterprise of five doctors, all between the ages of 35 and 40. Three of them arc CPs, one is a surgeon, and the other an internist. They function together in a modern, small-town, round-the-clock primary care facility. They have their own x-ray department and a lab that can run urine tests and do basic serology. They have an electrocardiograph. They employ one nurse, two lab technicians, two secretary-receptionists, and three telephone operators, so that their switchboard is covered 24 hours a day. In 1
