-17

best treated by an emergency service. There is no provision made for continuity of care. Under no circumstances will the same doctor who saw the patient at night provide subsequent followup care himself.

Thus, the Emergency Medical Service or Larmtjänst, although it does suffer from limited resources and lack of continuity of treatment, does fill a huge gap by providing rapid home medical evaluations for those who cannot come to the hospital at night.

AMBULANCE SERVICE

One excellent aspect of emergency medical services in Goteborg is a well staffed City Ambulance Service, equipped with twenty-five modern ambulances, assigned by a central dispatcher. The ambulance attendents are city firemen, who have received a minimum of three months of hospital training, two months of which are spent in the operating room, assisting an anesthetist and learning resuscitation techniques by first hand experience. This background serves them well when they must attempt to resuscitate patients in homes or in the ambulance.

INDUSTRIAL MEDICINE

One other important area of non-governmental primary medical care in Sweden is in the field of industrial medicine. The largest Swedish companies operate and finance their own clinics near their factories, and they stress preventive medicine as well as care for accident victims and workers with minor illnesses.

I visited SKF, the Swedish Ball Bearing Factory, which employs 6000 workers in Goteborg. There I talked to Chief of the SKF Clinic, Dr. Gunnar Edeus. He emphasized that the Clinic, one of the first and most complete in the country, with a staff of four doctors and nine nurses, has prevention as its first

-18

priority. Audiograms to detect early hearing deficit are compulsory for all workers on noisy machines; posters and seminars stress the use of ear plugs. Workers are encouraged to avoid skin contact with machine oils that might cause eczema. Men who are exposed to lead and silica have periodic checks to detect possible toxicity before symptoms occur.

The Clinic staff treats several hundred workers each day. Minor surgical procedures, such as suturing lacerations, can be performed. Over half the patients seen in the daily "sick call" are treated without the workers leaving his own factory area, since nurses from the Clinic make daily rounds to most 17 production areas to screen and treat sick workmen.

Clinic doctors perform pre-employment exams on all employees; biannual physical checkups on men over forty are performed only on company executives. The doctors try to perform periodic checkups on workers with chronic illness, such as diabetes or hypertension, but find they do not have enough time to do this as much as they would like.

When a Swedish worker is ill, he may stay home for a week on his own and draw pay from his compulsory government Sickness Insurance. If he is out of work for more than a week, he will require a doctor's certificate of sickness, which SKF Clinic doctors are often asked to provide. In cases where an employee becomes physically disabled, the Clinic doctors are often asked to give their medical opinion, before the worker goes before the Insurance Board which decides whether the man can be trained for another job or should receive a lifetime government disability pension.

II. INTERMEDIATE MEDICAL CARE

If an ambulatory patient needs more specialized diagnostic testing or treatment than is available at the primary (or first contact) medical facilities that we have just discussed, then he is referred to an intermediate medical

-19

Polyclinic or to one of the ambulatory facilities at a hospital: the Emergency Room, a Polyclinic (general clinic) or a Specialty Clinic. All of these are government run.

DISTRICT CENTRAL POLYCLINIC

In Goteborg, as we have seen, there are twenty-four District Medical Officers, who are general practitioners. When a patient needs an evaluation by a specialist, this doctor can refer him either to one of the six District Central Polyclinics or to the Hospital. In the district of Vasta Frölunda, for example, the Central Polyclinic has doctors in eleven different specialties, including internal medicine, neurology, pediatrics, gynecology, psychiatry and five surgical specialties. There are operating rooms for minor surgery and laboratory and X-ray facilities. Also there are public health nurses and midwives, who are responsible for pre-natal and post-natal "mother's care" and for a comprehensive program of infant care. These Central Polyclinics are busy and there is a two to six week waiting period for appointments. Some of the Central Polyclinics function as small (30 bed) hospitals as well as referral centers.

HOSPITAL EMERGENCY ROOM

The Hospital Emergency Room serves both to evaluate patients who come on their own or by ambulance, and patients referred for evaluation by primary doctors. Göteborg with only one large general hospital, the Sahlgrenska, is unique among large Swedish cities, because almost all emergencies in the city are sent to this one Emergency Room.

According to the Chief of the Emergency Room at the Sahlgrenska,

Dr. Bengt Zederfeldt, of the 150 cases seen there daily, about 16 (or 111) are admitted to the hospital. Unless a patient obviously needs immediate

-20

admission or can be sent home, he is kept on a 23 bed Overnight Ward for further observation and evaluation. A decision must be made the next morning whether the patient should be admitted to the wards or sent home. Since the number of available hospital beds is so limited (a patient for elective surgery must wai one to two years to be admitted to the hospital), observation on the Overnight Ward helps the doctors decide whether the patient really requires hospital admission.

Both Dr. Zederfeldt and the many patients I talked to are dissatisfied with the current set-up in the Emergency Room. Its rooms are few and cramped, In such a modern and spacious hospital, it is hard to understand how such an important area can be so poorly designed. There are also no waiting rooms for the patients or their families, who must spend their waiting hours standing or leaning in the corridors. The Emergency Room, which serves the whole city, is staffed only by two junior staff doctors (underläkare), who are doctors in training equivalent to American residents. This staffing is not sufficient to keep pace with the steady in-flow of emergency patients, who must wait from two to six hours, between the time they enter and the time a decision is made whether they go home or stay. This delay causes much dissatisfaction by both the waiting patient and harried doctor. It requires heroic Scandanavian patience to be a patient--and a doctor--in Sweden.

HOSPITAL OUT-PATIENT CLINICS

Swedish medical planners are placing increasing importance on outpatient clinics to relieve the pressures for beds that the hospitals face.18 An estimated fifty per cent of the 18.4 million ambulatory patient visits seen in Sweden in 1966 were patients referred to hospital out-patient departments, which are becoming increasingly busy each year. (Of the rest approximately 25% are seen by District Medical Officers and 25% by private

19

-21

Before the Seven Crown Reform in January 1970 both hospital service chiefs and junior staff doctors had been permitted to see private patients in the clinics run by each of the hospital's services, as well as see "service patients." After the Seven Crown Reform, no doctors are now permitted to see private patients in the Clinics. Patients no longer may choose which doctor they will see but are assigned a Clinic doctor randomly by the secretary, and see a different doctor on every visit.

How do patients and doctors like the change? Patients I talked to all complained about the long waiting time to get an appointment. At the General Medical Clinic (or Intake) this time ranges from three weeks for a "semiemergency" to six months for a non-emergency in Göteborg. (In this clinic two internists see 15 to 20 patients each daily, but only 3 new patients, for a total of six new patients daily). Most patients dislike not being able to request the doctor of their choice and having to see a different doctor each visit. This was expressed by one girl, a diabetic lab technician, as regret that she did not have one doctor to relate to, as she had when she worked in the States. Now she was forced to repeat her medical history to a different doctor on each visit. Another complaint was that all patients were told to report at one time (such as 9:00 a.m.), then might have to wait several hours for their time to see the doctor. For patients, a Clinic visit was a very impersonal "production line" experience.

The good result of the Reform for patients was on the financial side. Now patients pay only seven crowns ($1.40), which covers doctors services, X-ray and laboratory costs. (The Hospital is reimbursed an additional six dollars by National Health Insurance).

Most of the staff doctors I talked to in the Medical Clinics were not happy with the effects of the Seven Crown Reform. Several admitted frankly

that the total shift from private patients to randomly assigned "service