Who is the best doctor in Oslo
Comparison of the German with the Norwegian primary doctor system from a medical point of view
Summary: At the moment, many issues in the German healthcare system, such as brief doctor-patient contacts, are increasingly being discussed critically. A comparison with the strengths and weaknesses of the systems of other countries could help to better identify positive aspects of our system and a possible improvement potential. Based on the experience reports of two German general practitioners who worked in Norway as general practitioners and in an acute outpatient clinic, various areas of the state primary doctor system in Norway are compared with the corresponding structures in Germany and their positive and negative aspects are analyzed. Due to the state-regulated system, the care structures in Norway are also clearly defined for the patients, so that the use behavior can be better understood and controlled. The decades-long tradition of a primary care system in Norway has resulted in a high status for general practitioners. A disadvantage is the often long waiting time for the patient, since many appointments with specialists and polyclinics and elective interventions are regulated via waiting lists.
Keywords: Norway, health care, primary care system
The German primary doctor system differs in essential respects from the systems of other countries. For example, only in Germany, the USA, Switzerland and Belgium do specialists practice in primary care . Although the care tasks are shared with us, the German general practitioners have a far above average number of patient contacts of 243 / week in an international comparison . According to the Barmer-GEK doctor report from January 2010 , the total number of doctor contacts in 2008 was 18.1 per capita. This means that German doctors only have eight minutes on average for a patient consultation. Nevertheless, per capita health expenditure in Germany is the most stable in an international comparison with the other OECD countries. There is a very low growth rate of only 1.9% here. In terms of per capita spending, Germany ranks tenth behind France, Belgium, the Netherlands and Norway . Since the work is therefore quite cost-effective, it follows that the services are provided in the so-called hamster wheel effect. Accordingly, a high proportion of general practitioners (96%) would like fundamental changes in the German health care system . By looking at other health systems, insights could be gained about which changes would be necessary in order to achieve greater professional satisfaction among general practitioners, possibly even accompanied by an increase in the quality of care. With a special focus on the general medical area, the Norwegian health system is to be described and compared with the German system. A detailed description of the German health care system is dispensed with here, as knowledge of our system is assumed by the readers of the ZFA.
Around 4.8 million people live in Norway, around a quarter of them in the greater Oslo region . Norway is a long country (2532 km ): If you were to drive south from Oslo instead of to the northern tip of the country, you would reach Istanbul. 100 years ago Norway was a very poor country with small-scale farmers and fishermen. Industrialization that began at the beginning of the 20th century, initially made possible by using water power, and finally by enormous oil and natural gas discoveries off the coast, have made Norway one of the richest countries on earth. The per capita income of a Norwegian is now about twice as high (about 322,500 NOK = 40,258 euros ) than that of a German (about 20,004 euros ). The health system in Norway is planned by the municipalities and the state . The health insurance is financed by taxes and organized together with the social welfare office and employment office. This means that Norwegian citizens do not have to pay any health insurance contributions on top of taxes. In the outpatient sector, part of the costs (around 15%) is financed through personal contributions .
According to the 2009 OECD report, Norway has the second highest per capita health care expenditure after the US, although overall health expenditure is dampened by a relatively small number of inpatient health services. The number of hospital beds per 1000 inhabitants is 2.9, well below the corresponding number of 5.7 in Germany . The elective inpatient treatments are controlled via waiting lists . Norwegians are surprisingly relaxed and wait months for an appointment for an elective procedure . A waiting period of 2–3 weeks for an appointment with the general practitioner for a non-acute problem is also generally accepted. The high costs in the health care system can be explained, among other things, by the fact that 20% of all workers in Norway work in the health sector, in contrast to 11.6% in Germany . This leads to high personnel costs, but presumably also significantly less workload for the individual. Health policy and population statistics for both countries are shown in Table 1.
Education and training
Three universities in the country (Tromsø, Trondheim, Oslo) offer medical studies with early doctor-patient contact and learning in small groups in module-based years of training . Only at the University of Bergen is there still a traditional course with a physics course. The state examination is followed by a year and a half of training until the license to practice medicine: one year in hospital (divided into surgery and internal medicine, or divided into three with a third elective) and six months for all prospective doctors in general medicine, divided according to a lottery. During this training period, the doctor receives a state-funded salary and the general practitioner training a free employee.
The specialist training takes place under the direction of the Medical Association . A five-year training period is required for general practitioners, one year of which can be spent in hospital and at least three years of work in a general practitioner's practice. The core of the training is a training group of a maximum of 10 training candidates, moderated by an experienced family doctor, trained as a moderator. This group meets 40 times over the course of two years. The advanced training is supplemented by four basic courses (4 x 40 hours). The specialist must be recertified every five years - with specific requirements for general medical topics from different clinical areas. For decades there has been an institute for general medicine at all four Norwegian universities, which is comparable in size to the other main subjects of the course. The general medical society awards grants that enable practicing physicians to scientifically deepen a topic for 1–3 months and to pay a representative in the practice.
Primary doctor system
The historical development and the geography with a very low population density make the general practitioner as the primary care provider the rule, the specialist the exception. General practitioners usually have contracts with the municipalities . Every Norwegian is required to register with a general practitioner, whom he should then primarily consult in the event of illness. The enrollment system for general practitioners was used by 99.5% of Norwegians. It has been evaluated, is also valued in rural areas and has further improved the continuity of care there . The income of the general practitioners consists of the billing of individual services, the patient's own contribution and a fixed rate for each patient enrolled on his list and amounts to approx. 125,000 euros per year . If the family doctor does not have an appointment free in the event of acute illness or is not accessible outside of office hours, an outpatient center (Legevakt) is available in all large and medium-sized cities and towns, where patients receive medical care outside of normal business hours and often around the clock can be . Table 2 lists data on the working conditions and income of Norwegian general practitioners compared to German general practitioners.
In the following field reports from two German doctors who worked in Norway, Harald Kamps, general practitioner from Berlin, describes his twenty years of family doctor activity in the country and in a Norwegian university town and Dr. Marlies Karsch-Völk, general practitioner from Munich, reports on her one and a half year work at a general medical acute outpatient clinic in Oslo.
Experience report by Harald Kamps
I worked as a general practitioner in Norway for about 20 years - as a state-employed district doctor, as a community doctor with a fixed salary in a municipality with 5000 inhabitants on a peninsula and as a doctor (fastlege) in the central Norwegian university city of Trondheim. I have always worked in group practices - the norm in Norway. A patient consultation usually lasted 20 minutes, on a day there were usually 15-20 patients in my consulting room - both in the country and in the city. They expected a lot from me: I treated young children with asthma, prescribed birth control pills to young girls, performed gynecological checkups, prescribed physiotherapy to people with persistent back pain, and accompanied people to their deaths - in our community only a few people died in hospitals .
Many competent people were employed in the municipal health service: pregnant women were looked after together with a midwife, child check-ups were organized by the health nurse - a nurse with one year of additional training - the doctor only came in for defined examinations. For problematic children, we were occasionally visited by a child neurologist or discussed solutions in the social medical team (social worker, school psychologist). Every day I experienced good cooperation with municipal home nursing or the municipal nursing home. Competent and motivated nurses work here, not on the instructions of the doctor, but with their own quality goals and commissioned directly by the people. They saved us many house calls, recognized the time of an urgent house call or saved patients the long way to the hospital. The operator of the local funeral home was also involved in the community's palliative care team. House doctor work was often experienced as good teamwork.
It was unusual to get money from patients in many situations: In 1978 it was ten kroner for each doctor's visit (at that time the equivalent of around 2 euros), but in 2002 they had to pay 130 kroner (around 15 euros) for a home visit at a late hour double that. The health insurance only reimbursed the cost of medication if it was used to treat chronic illnesses (longer than 3 months a year) - the penicillin for acute strep throat was always paid for out of pocket. Even today, appointments with a specialist are almost twice as expensive as with a family doctor. This personal contribution is limited to around 160 euros per year, and nothing has to be paid for children under 7 years of age . I also like to remember everyday life: in summer the practice closed at 3 p.m., in winter they worked an hour longer - 8 doctors shared the on-call duty in the country; So everyone was on it about once a week, responsible for 10,000 people, controlled by the acute medical emergency center. Nurses trained in intensive care were employed there, who sometimes ordered the helicopter on their own or advised the patient to go to the doctor the next day. The health nurse had already answered many questions about the diseases of the young children; she usually knew better when chickenpox was rampant somewhere. The on-call services were usually only exhausting because of the uncertainty as to what would happen next - the cruel traffic accident of drunk young people in constant memory.
Experience report Marlies Karsch-Völk
From 2002-2004 I was employed in the general medicine department of Legevakt Oslo for 18 months. Layevakt in Oslo is accessible to all acutely ill patients throughout the city. There are departments for general medicine, surgery, psychiatry, a social service and an emergency care service. As a result, the patients are cared for during and outside the opening hours of the general practitioners' practice by an outpatient facility in which doctors and nursing staff can be reached around the clock. These facilities, which can be found in all larger and medium-sized cities and towns in Norway, are mostly operated by the local general practitioners. Doctors are specially employed in Oslo for this task. Almost all emergencies come to Layevakt, all patients outside of office hours, patients who cannot get an appointment with the family doctor due to insufficient capacity, tourists or patients without a family doctor. Some also find that it is more convenient to go to Layevakt, as you can go there outside of regular business hours and then do not have to take time off from work. The co-payment for a daytime consultation is around 16 euros. Most of the doctors working there are permanently employed in shifts. During my activity there, the sentence circulated among the doctors working there: working on the laying vact is like "Chicago Hope" without "Hope". The reasons for this pessimism are certainly the very high patient throughput, many patients, mainly from Africa, with some serious problems, many homeless and many addicted and / or psychiatric patients. In addition, the General Practice Department is responsible for the forensic examination of all sexual assaults and rape in Oslo. The spectrum of illnesses ranges from simple sick leave due to a cold to life-threatening emergencies. On some days, patients wait many hours, even with sick children. The patients are sometimes very dissatisfied, especially with the "service" and vent their displeasure with the doctors.
But despite the often high workload, I was able to find that the laying process works very well for most patients. As a rule, medical help is quickly and easily available. A pragmatic solution is sought for all problems. The classification and acceptance of the patients is carried out by very well trained nursing staff, who assign the patients to different departments with different degrees of urgency. Superfluous examinations should be strictly avoided, but avoidable dangerous processes should be recognized. A wait-and-see attitude is often adopted. Compared to the usual medical procedure in Germany, there is a relatively relaxed approach to diagnostic uncertainty. There are numerous information brochures on various diagnoses for patients that are sent home to "wait and see". You should recognize a possible deterioration yourself and then introduce yourself again. The medication prescription strictly follows the relevant guidelines. In particular, the use of broad spectrum antibiotics is handled restrictively , which is certainly one of the reasons why there are very few antibiotic resistances in Norway .
Every country comparison has a problem: Countries are difficult to compare with one another, as they have a specific history and culture and often a special geography. Away from the larger cities and towns, roads in Norway are often cut off by fjords and can only be crossed by ferry, behind every bend you can see an inhabited homestead off the road or along the coast. This poses major logistical challenges for the healthcare sector. The basic prerequisites of the Norwegian health system differ significantly from the German one, and many aspects can certainly not simply be transferred to the German system. Nevertheless, a comparison could be useful in order to work out suggestions for improving work in Germany.
Like Denmark or the Netherlands, Norway has a primary medicine health system. In Germany, primary care is also covered by resident specialists. However, this specialist-based care is not reflected in important quality indicators: life expectancy is slightly higher in Norway, child mortality is significantly lower in Norway than in Germany (see Table 1). Nonetheless, the sometimes months-long waiting times in Norway for appointments to clarify unclear findings with specialists or for the start of psychotherapy can be very stressful for the patient. In any case, the reasons for the better outcome with regard to survival and child mortality are not only to be found in the health care system.Wilkinson and Picket documented that a major reason for the good performance of the Scandinavian countries (and Japan) lies in the relative income equality in these countries .
Despite the political and geographical differences in Norwegian health policy, there are many very good solutions or approaches to problems that also dominate the health policy discussion in Germany, such as the necessary cost savings or the impending shortage of doctors. By permanently enrolling sick and healthy people with a family doctor, the workload of the individual doctor could also be regulated in this country and multiple consultations with different doctors could be avoided. The contracts for family doctor-centered care of the AOK in some countries of the FRG come close to the Norwegian list system - they allow the doctor to see "healthy sick" less often and "sick sick"  more often and to care for them more intensively without painful loss of fees.
The quality of primary medicine is also guaranteed by highly qualified nurses and physiotherapists. Since the nursing staff in Norway takes on many tasks that are reserved for doctors in Germany, such as B. blood sampling or IV injections, time and money are saved. Responsibilities in the Norwegian health system are also clearly defined by the laying evakt system in the area of acute care. This enables a particularly easy access to general medical, acute psychiatric and crisis intervention help for the Norwegian citizens. Due to the low access threshold, medical help is easily accessible, especially for socially disadvantaged groups, for whom the social welfare office pays their own contribution.
Evidence-based medicine is practiced in most general practices in Norway - they have online access to a doctor information system that provides references to the level of evidence, provides patient-specific information sheets and suggests criteria for referral to the specialist. In Norway, as in the rest of Scandinavia, general medicine is a respected academic discipline. The consistent promotion of general medical research over many decades is now bearing fruit - the self-confidence of general practitioners in dialogue with other specialists is correspondingly high.
Our impression is that general practitioners in Norway are satisfied with their working conditions: their workload can be planned through the enrollment system, the responsibility for undercapacity lies with the health insurance company, and family and leisure are well compatible with work, even in the country. Working conditions and a status that the general practitioners in Norway have had for years would certainly also lead to greater satisfaction among your German colleagues. However, it should not be forgotten that health care costs have also increased in Norway. With regard to the organization in the health care system, which allows waiting lists and is very family doctor-based, this is surprising, but can certainly be explained in part by the more complex staffing .
Conflicts of Interest: none specified
Dr. med. Marlies C. Karsch-Völk
Institute for general medicine at the Klinikum rechts der Isar
Technical University of Munich
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Table 1 Comparison of health policy facts in Germany and Norway (based on data from the OECD health report 2009  and the GEK Barmer doctor report 2010 ).
Table 2 Comparison of the working conditions of Norwegian and German general practitioners.
1 Institute for General Medicine, Klinikum rechts der Isar, Technical University of Munich, Wolfgangstr. 8, 81667 Munich
2 Möllendorffstr. 45, 10367 Berlin
Peer reviewed article submitted: February 25, 2010, accepted June 20, 2010
DOI 10.3238 / zfa.2010.0468
(Status: December 27, 2010)
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