tioner or specialist of his own choice. This principle faces many practical obstacles, however. In many districts there is only one physician. If a patient 'wants to see a doctor employed by the county whether working in hospital or purely on an outpatient basis he is only allowed to choose among those residing within his own county. Since purely private practice only exists to a limited degree and in large cities, only a few patients can avail themselves of this, even if they are prepared to defray the higher costs that a visit to a private practitioner involves. To see a well known specialist in a teaching hospital is only possible through referral from a local specialist and will usually take a long time, even though no extra cost is involved. As long as the shortage of doctors exists, no really free choice will function. THE PATIENT'S VIEW What do patients feel about all this? It is difficult for a physician to get a balanced account from a patient regarding the entire system of medical care. On the whole I believe that the Swedish people are satisfied with the way things have been run. They complain about difficulties in seeing a special doctor, to get care without waiting, and similar items. On the other hand, they are proud of the high repu tation of Swedish medicine that they believe it has all over the world, and they are aware of the fact that they have a cheap at the time of illness and efficient medical-care organization that will provide service for anybody anytime. The relative indifference demonstrated by most people toward the recent changes in medical practice, as judged from what is written in newspapers or discussed on television, has always astonished me. The explanation I have arrived at is that the people rely upon the government and are confident that all is going to function as well tomorrow as it did yesterday. APPENDIX 6 Several chapters from the book "Health Services in Norway," by Dr. Karl Evang, Director General of Health Services in Norway, are appended. They provide an excellent description of specific aspects of the Norwegian Health Services system. (522) MEDICAL CARE IN GENERAL What happens to a person who falls sick or suffers an accident in Norway? No matter who he is-man or woman, adult or child, wealthy or wanting, self-supporting or dependent on others he has the legal and moral right to seek immediate medical aid. The normal thing is to call on the doctor in his office, but if necessary the physician will come to him by car, by boat or airplane, on skis or reindeer sled. The patient is not bound to a certain doctor; he can pick any general practitioner he pleases at least in theory. Out in the remote countryside, among those endless mountains, it usually happens that there is only one doctor to choose: the one who lives the nearest, and often he is a good distance away. The ordinary doctor's office is well equipped, especially with instruments which will enable him to make an accurate diagnosis. Most physicians have their own little laboratory, sometimes with a laboratory assistant, and carry out themselves the usual tests of blood, urine, faeces, etc. A country doctor, whose nearest colleague or hospital may be many miles and mountain ranges away, or who often has a young doctor and a public nurse as his only assistants, must be prepared to handle almost any health problem himself: accidents and injuries, difficult births, cases of poisoning or drowning, anything at all. His medical training (to be described later) was planned with this in mind. At times, however, every general practitioner needs help. He may lack a complicated bit of equipment needed for diagnosis, in which case he can send samples of blood, spittle, or whatever to larger laboratories, usually publicly owned ones, which mail or wire back a report. Or he can dispatch the sick person to a laboratory or the out-patient department of a hospital for further tests. Perhaps the patient needs examination and treatment by a medical specialist, or hospitalization for a longer or shorter time. Under the Norwegian system it is normally the family doctor who decides when this is the case. With some few exceptions, the sick person does not have the right to go to a specialist or seek admission to a hospital on his own. The general practitioner carries full medical responsibility at this stage, and he determines when to call in outside help. Of cource, if the patient does not agree, he is free to go to another general practitioner. Specialists are still too few in Norway, and unequally distributed at that, and hospitals far between; this rule is meant to save their services for those who really need them. In critical cases, the physician may send a patient to the hospital "for immediate treatment". With this phrase on the admittance form, the hospital will accept the person regardless of how overcrowded it may be. If the patient can wait, on the other hand, and the hospital has no room, then he is put on a waiting list and admitted when his turn comes. When he is discharged, the hospital sends a report on diagnosis and treatment to his personal doctor, who resumes responsi bility for his care. A specialist does the same when he finishes treatment, so that the general practitioner is informed about all that has been done to help his client. Sometimes the hospital continues to treat the patient for a time after discharge, through its ambulatory department; or on his doctor's recommendation he may be sent to a convalescent home to regain full strength. But in the great majority In the treacherous and stormful waters of the north and west coatst the "combined" general practitioner and local public health officer needs a reliable vessel. of cases, the care of the general practitioner through office or home calls is enough. If the patient is employed and must be absent from his job, his doctor makes out a sick-leave declaration which may be shown to the employer, and which is not recalled until the person has recovered enough to go back to work. On the basis of this declaration health insurance authorities will pay out whatever cash sick allowance is due. Follow-up treatment, stays in nursing homes* and physiotherapy, are also included under medical care, as well as all maternity cases *To the extent the patient is in need of "medical nursing". See chapter on |