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and treatment rooms closer to each other. Equipment incorporating the latest technological developments is used in every field. A central dictation system, which saves doctors from having to write their chart notes, improves staff efficiency.

HOSPITAL CARE

What is it like to be a patient in a Swedish hospital? A person admitted to the Sahlgrenska Hospital, typical of a large modern Swedish hospital, would most likely be admitted to a four bed room. There are no private or semi-private rooms, only several isolation rooms on each ward. All expenses of his hospitalization, including his room, food, doctor's salary, X-ray and lab expenses and drugs will be paid by the County Council, which operates the hospital. The County Council pays for this hospital care by local taxation, about 70%, reimbursal from the National Health Insurance, 7%, from the Central Government about 13%, and from other sources about 10%. While in the hospital the patient will also receive Sickness Insurance, proportional to his salary level, to compensate for his lost wages. Therefore, all Swedes are entitled to as much hospitalization as their doctors judge necessary, without having to worry about paying hospital and professional costs, which are fully covered by compulsory insurance and government subsidy, payed indirectly by taxes.

The hospital is a large one, having sixteen stories and containing beds for 2011 in-patients. The wards are divided according to specialty. Surgical wards are further separated according to subspecialty, such as orthopedics and neurosurgical wards. Most medical patients are taken care of on general medical wards, exceptions being a separate cardiology ward, coronary care unit and renal dialysis ward. (Chronic pulmonary patients are cared for at another hospital, the Renstromska Sanatorium). Most wards contain 28 beds, and are

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divided into four-bed rooms. Often wards are overcrowded and sometimes, patients beds are placed in corridors. The beds have wheels and can double as movable stretchers. Usually there are no partitions or curtains between the beds. The rooms are quiet: TV is not allowed. Smoking is prohibited. The medical staff of the ward consists of a chief doctor (Overläkare) and one or two junior staff doctors (Underläkare), roughly equivalent to an American resident, and perhaps several medical students. The patient never has choice of his doctor, but is assigned the doctor on his ward, often a specialist in his type of condition. The hospital doctors are all full time salaried government employees; many doctors in the Regional Hospitals also hold university teaching appointments. The patient's private doctor, if he has one, is not allowed to have hospital privileges and, hence, cannot treat his patient when he is in the hospital.

On the nursing staff are a head nurse, an assistant nurse and three to four aides for the ward. There are no private nurses.

One big difference in the ward routine from an American hospital is that the nursing staff is given more responsibility. There is no doctors' order book. Rather, the head nurse follows the chief doctor on rounds and takes notes as to his wishes for treatments and drugs. These she can change on her own initiative in an emergency or if the doctor is not available, when the patient's needs change. Many tasks done by American interns, such as drawing bloods, changing IV's and dressings, and removing sutures are often done by well-trained Swedish nurses. Trained aides take an active part in

patient care.

Swedish surgery is very advanced, especially at the Regional Hospitals.

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on patients with renal failure. Much basic research on the hemodynamics and immunology of transplant and on the best methods of organ preservation has been done in the Rheology Laboratory there by Dr. Lars Erik Gelin, Chief of Surgery, and Dr. David Lewis, an internist investigating measurement of blood flow by means of radioactive isotopes. Results of this research are ple directly in the Operating Room, in the form of a rapid technique to assess whether there is adequate blood flow to the freshly transplanted kidney.

DISCUSSION

The best features of Swedish hospitals are their new buildings, planned for efficiency and the best use of new equipment and well-trained staff. Also praiseworthy is the financing, which makes access to hospitals available to all Swedes equally, dependent only on their medical needs. The carefully planned distribution of different levels of hospitals in every region of the country makes for an even quality to hospital care throughout the whole country, unmatched in the U.S.

Problems in Swedish hospitals stem from long waits for patients to be admitted, some times as long as one to two years for elective surgery. Often new wards remain un-used, because of a shortage of nurses. Sometimes there are equipment shortages, when the County Council will not appropriate enough funds. For example, the Coronary Care Unit, which is responsible for treating acute heart attacks from the whole city of Goteborg, only has five heart monitors, fare less than the minimum number needed and requested repeatedly by the staff.

Do Swedish patients get "impersonal" health care in their hospitals as some Swedes and others charge? The answer must be tempered by another question: when compared to what? A well-off suburban American might well miss the personal doctor of his choice, his semi-private room with TV set

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and the chance to hire a private nurse after his surgery. On the other hand, a middle class American in the city, a small town dweller, or a ghetto dweller would find the efficiency and cleanliness of a Swedish hospital, the abundance of its special resources, the friendliness of its staff and the absence of financial catastrophe following a serious illness a distinct improvement compared to the care in the old city hospital or small country hospital he is used to.

IV DOCTORS

It is generally acknowledged there is a shortage of doctors in Sweden. There are plans to increase the number of doctors by more than 50% in the next ten years, from about 10,000 physicians now to over 20,000 in 1960 30 by increasing the number of medical students. This would decrease the

population per physician ratio from 860:1 to 450:1 as shown in Figure VI. There are three different career patterns for Swedish doctors. All doctors now spend five and a half years in medical school. After passing their medical school examination they must perform 21 months of General Service, roughly equivalent to an American rotating internship, with six months of hospital medicine, three of psychiatry and six months of out-patient care. After this physicians chosing general practice will have three more years of training in medicine, pediatrics and psychiatry. After this they can work as general practitioners, either in private practice or as District Medical Officers.

Doctors who wish careers as specialists will spend four to six years in specialty training as underlakare, equivalent to American residents, in either "country hospitals" or in the large university Regional Hospitals, such as the

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Most specialists will eventually work in "country hospitals" and might aspire to being Assistant Chief and finally Chief of his hospital service after many years.

Those specialists who aspire to academic careers, that is practicing, teaching and doing research in a university hospital setting, will return to the university hospital and spend three to six years doing intensive original research and writing a thesis in one specific area of medicine. For example, in Goteborg some surgeons will investigate specific methods for preservation of organs in tissue transplantation and several intemists are doing research on the causes of heart attacks. This makes the academic doctor a man with great depth of knowledge in his specific field, truly a "student of his disease." If he defends his thesis successfully he acquires the title "Docent," and will probably aspire to continue his teaching and research, working his way up the academic ladder to become Professor and Chief of his specialty department.

A particular doctor's motivation for giving good medical care to patients is dependent on many factors, among them his personality, the stage of his training, the quality of the medical facility where he practices, and numerous personal and financial factors. The Seven Crown Reform in 1970 drastically changed the doctors' salary structure. What effect has it had on Swedish doctors' motivation to provide good medical care?

Before 1970 all hospital doctors were salaried, but there was financial incentive to treat out-patients to earn money on a fee for service basis. The effect of the Seven Crown Reform in 1970 was to give all doctors at the same level of training the same salary, independent of what specialty they practice or how many patients they care for and to abolish fee for service for seeing out-patients. Doctors are paid solely by the number of hours they work. The effect of this has been to decrease the salaries of doctors who see many