General Practice - Europe PMC

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than Inuvik, the fjord never freezes and temperatures of -20°C are un- usual. The snowfall is light and storms rarely interfere with transportation. The one big ...
General Practice In Northern Norway D.P.BLACK,MD SUMMARY A study was made of general practice in northern Norway where conditions are similar to parts of rural Canada. The Norwegian general practitioner has developed expertise in the preventive and psychosocial aspects of practice and the team concept is highly developed. Since the general practitioner is separated from the hospital, his facilities for procedures and diagnostic workups are primitive. Involvement of general practitioners in medical education is not yet well developed although all new graduates spend a compulsory period in rural practice.

Dr. Black is a clinical assistant professor in the Department of Family Practice at Memorial University and practices family medicine in Baie Verte, Nfid.

SINCE I PRACTICE family medicine in a relatively isolated practice on the north-east coast of Newfoundland, I was asked by the Department of General Practice at Memorial University to make a study of medical services in northern Norway. We felt that this area had many of the same problems as Newfoundland, with a scattered population and severe weather conditions. The trip was planned for December when the problems of isolation would be at their worst.

a number of points for emergency work.

Hospitals

A system of district hospitals in Norway is staffed exclusively by salaried specialists and house staff. Even in the most remote parts of Norway the general practitioner does not have hospital privileges. The system has resulted in considerable centralization of all hospitals and diagnostic services, with complete separation of general practice from hospital practice. There seemed to be little real consultation between hospital doctors Geography and Weather and general practitioners. The general in Northern Norway While the areas I visited were well practitioner had no choice of his connorth of the Arctic Circle, the climate sultant, and outpatient consultations seemed more hospitable than ours. seemed to have a low priority. Even in Alta, which is farther north than Inuvik, the fjord never freezes Economics of General Practice and temperatures of -20°C are unGeneral practice in Norway is done usual. The snowfall is light and storms on a fee for service basis. For each rarely interfere with transportation. consultation a doctor collects ten The one big problem is the darkness; kroner (approx. $2), from the patient there are only two to three hours of and 17 kroner (approx. $3.50), from half light each day in December. the government insurance scheme. While the population is scattered, Special procedures such as office laboGovernment services are more highly ratory tests are paid for as extras at a developed than in our part of Canada. relatively high scale. A doctor can The Norwegian Government has been greatly increase his income by doing a making a real effort to keep the people lot of these extras. in the small villages. Transportation is In each district there are some also better developed than in Canada. physicians appointed as district docEven small communities have regular tors. They receive a partial salary and air service and flights are seldom can- subsidized housing in return for procelled by weather conditions. Planes viding medical services in rural areas and helicopters are kept on standby at and overseeing public health services.

CANADIAN FAMILY PHYSICIAN/APRIL, 1975

They also receive fees for patients seen and hourly remuneration for public health work. In Norway, as in Canada, there is considerable discussion about the merits of fee for service as opposed to other forms of remuneration. As yet, no general practitioners in Norway work on a salary but one group in Tromso expects to go on a government salary shortly. It was my impression that doctors in Norway receive incomes comparable to their Canadian counterparts. However, both the cost of living and the taxes are higher. There is no financial incentive other than the district doctor's stipend to attract doctors to the rural areas. The basic medical education in Norway is six years - students enter directly from high school. All graduates must serve an internship which includes six months surgery, six months medicine and six months in a rural general practice. Trainees are usually placed with a district doctor but are sometimes used to fill solo practices. During this rural practice experience the trainee is paid a fee for service, at a rate of 15 percent below the regular schedule. He must also turn over a considerable part of his earnings to the supervising doctor to cover office expenses. An Institute for General Practice has recently been established in Oslo. This institute appears to be having a hard time getting accepted as part of 95

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The First Year of Life What to Look For in The First Year of Life A. Hacker, MD Neonatal Emergencies in an Outpost Setting W. G. Goldthorpe, MD Immunization in the First Year of Life R. L. Ozere, MD Psychosocial Aspects in the First Year Peter Rosenbaum, MD Looking Over Infants' Overlooked Eye Problems Maria Arstikaitis, MD Resuscitation of the Newborn C. J. Kilduff, MD Besides a varied selection of material on the monthly theme, CFP's May issue will also feature a special supplement on venereal disease, covering legal, ethical, clinical and social aspects of this urgent and current problem. This issue will also include the Self Evaluation Program, which will now be free of charge to all students and residents in family medicine who are members of the College of Family Physicians of Canada (see page 137). 96

the medical school and obtaining teaching time. Their involvement is limited to giving the student some exposure to patients and interviewing techniques during their preclinical years. Students also have an opportunity to do a short elective in general practice during their clinical years. At Tromso, a small city in the Arctic, a new medical school has been established. Here, in contrast to Oslo, the Department of General Practice is an integral part of the medical school. A general practitioner is even chairman of the curriculum committee. Here students observe general practitioners in their offices and interview patients under the direction of general practitioners during their basic sciences year. General practitioners will also be involved in the teaching of the clinical subjects. All students will have a six month period away from the teaching hospitals at the beginning of their clerkship. Two months of this period will be spent in rural general practices. Norway has recently established a qualification for 'semi-specialists' in general practice. They have no plans to establish residency training and there is no examination. To achieve this standing a doctor must have two years experience in general practice, attend six courses selected from a list of ten approved courses and spend three months in a hospital rotating through the services. To maintain his status, a doctor must repeat these qualifications every five years. The program is new and few doctors have qualified. There has been considerable trouble getting hospitals to accept general practitioners for this training. There is a financial incentive in the form of increased fees for those who qualify.

Practices One practice I visited was at Vaeroy, a small island about 80 km from the mainland. Here a single doctor served 1200 people on this island and 800 on another island 16 km away. He had been placed there as a trainee but had stayed on as district doctor after his compulsory period was finished. On the island there was a 17 bed institution, the Norwegian name for which translates as "sick house". It had only one qualified nurse on staff and was primarily an old folks home. It did not have facilities for obstetrics or even the most minor surgery. There were no X-ray or laboratory facilities. Attached to it was an office where the

doctor worked without assistance. In the community there was also a part time public health nurse and a full time dentist. The practice was heavy for one man but did not generate enough income for two. The doctor was entitled to holidays and study leave but had to find and bear the cost of his replacement. There appeared to be no prospect of finding a locum. Support or encouragement from the hospital doctors or other general practitioners was not evident, and in spite of good transportation the island doctor was completely isolated. If the strains of practice and isolation continue to be as great as they were while I was visiting him, it is unlikely that he will be able to stay long, even though both he and his wife like the community. Another practice I visited was at Alta, not far from the most northerly point in Norway. Here there was a town of 7,000 people with 3,000 more in the surrounding villages. It was served by four district doctors and two trainees. They worked as a group in a doctor-owned health centre and occasionally went to other villages for clinics. In Alta there was a 'sick house' with 27 beds. It was staffed by nine nurses and patients were admitted for observation and medical treatment. There was an obstetrical suite where three midwives, with only occasional help from the doctors, delivered 200 babies per year. The surgery was suited only for the repair of minor lacerations. The laboratory was limited to hemoglobin and urinalysis and the X-ray machine could X-ray only extremities. They were not prepared to give local or general anesthetics, or to give blood transfusions. Any patient requiring more specialized services had to be transferred to the district hospital located at Hammerfest. This was a trip of 2% hours by road or 40 minutes by air. The cost of transportation for patients must have been phenomenal. Even a person requiring a chest X-ray had to be sent to Hammerfest at government expense. In contrast to this rather primitive situation, other aspects of medical services were very well looked after. The four district doctors were expected to spend half of their time at public health duties. The list of workers in the community who were considered part of the health team included:

CANADIAN FAMILY PHYSICIAN/APRIL, 1975

Three public health nurses. Seven home visitors, of whom three were registered nurses. One family therapist, a professional social worker, who dealt with psychological and social problems referred by the doctors. Two psychologists and one social worker who worked primarily with psychological and social problems amongst school children. Three social workers who did the customary welfare work. Five dentists, of whom three did full time public health work. Four physiotherapists, who where in private practice but did some public health work. There was no unified administration for all these workers. There was, however, a real effort to work as a team and a great deal of time was spent in team conferences. A new health centre was under construction which would bring all of these workers under one roof. It will also replace the "sick house' with a new unit but will not apparently improve the surgical, laboratory or X-ray facilities.

Recruitment of Doctors Throughout northern Norway there

seemed to be little problem in recruiting doctors. This is partly due to the fact that Norway is well supplied with doctors and it is difficult for new graduates to get a position in the south. Also, the professionals seemed to have greater appreciation for life in the rural areas than the typical Canadian professional. All of the doctors and wives I talked to were happy with life in the north. The country was beautiful, there was ample opportunity for outdoor recreation, the schools were good and there was quite a bit of cultural activity. The disadvantage mentioned was the long period of darkness, but one soon became accustomed to this.

Impressions and Conclusions The Norwegian general practitioner has developed a greater interest and expertise in the preventive and psychosocial aspects of practice than his Canadian counterpart. On the other hand he has little interest in somatic medicine, particularly the more technical aspects. This orientation is undoubtedly largely due to the fact that he has been shut out of the hospitals. We have much to learn from the Norwegians in the use of paramedical

personnel. On the other hand I was large team

not convinced that such a

necessary, or that it resulted in efficient medical practice. Norway appears to have made little progress in providing good medical services to the small isolated community. The rural solo practitioner is just as badly off there as he is in Canada. The compulsory period of rural general practice for new graduates is an interesting feature. It did increase the number of doctors available and it provided them, particularly the future specialists, with good experience. It may have increased the number of doctors who chose to work permanently in rural areas. was

Acknowledgement

I wish to thank Dr. Keith Hodgkin of the Department of Family Practice, Memorial University, who made this study possible and Professor Christian Borchgrevink of the Institute of General Practice in Oslo, who made most of the arrangements.