Am I A Socialist?

Am I a socialist? I don’t think so, but I did inch in that direction during the four days I spent in northern Norway last week, visiting the local hospital in Bodø and speaking to about 20 of the nation’s hospital CEOs. Here’s what I learned.

First, a word on visiting northern Norway – above the Arctic Circle – in summertime. I’d rank experiencing the midnight sun (your wristwatch says midnight, but the sky looks more like late afternoon) as among the most awe-inspiring things I’ve seen in my travels, up there with Xian’s terra cotta warriors, Scotland’s Isle of Skye, Masada at sunrise, and the 8th hole at Pebble Beach. And the people are a delight – unpretentious, outdoorsy types who were far less reserved than I’d been led to expect. It is well worth a visit.

But the medical piece was what fascinated me – particularly as it reflected the country’s broader societal values. Norway is a wealthy country, owing both to the miracle of oil reserves and to an industrious and well-educated population. Belying the notion that capitalism is the only way to achieve prosperity, the country is unabashedly socialist. Although the tax rate is high (about 50 percent for top earners), this level of taxation is an accepted part of life, the subject of absolutely no political debate. When the economy dipped a couple of years ago – a mere blip by world standards – it was a given that the government would pump in money to rebuild roads and improve the infrastructure.

The Norwegian healthcare system is organized into five regional trusts, whose underlying philosophy is similarly communal. Each runs on tax revenues, which are allocated to the hospitals based on the size of their catchment area, with adjustments based on the population’s age and socioeconomics. Hospitals that are able to manage their affairs on less than their budget are able to invest the surplus in research or new programs. But the CEOs I spoke to were all about population health: how to use their resources to promote the best health for their communities. Nobody seemed concerned about profits, bonuses, or the other accoutrements of market-driven healthcare. They see their mission as providing a social good.

Norway’s healthcare system is known as one of Europe’s most centralized, and the government’s touch is not light. Just recently, for example, the health ministry adopted new standards to ensure that patients newly diagnosed with cancer begin receiving therapy within about two weeks. I mentioned to my hosts that many U.S. healthcare organizations (hospitals, health plans) have internal standards that address such things (waiting time to get a clinic appointment, for example), but that – aside from the acute care measures like door-to-balloon time – there were no comparable national standards guiding patient flow. The CEOs were surprised.

The Norwegian government’s engagement and reach are such that I doubt it wouldn’t think twice before launching a secret shopper program to assess waiting times for primary care. In contrast, when The New York Times revealed Medicare’s plans to do just that last week, one day later the Obama Administration found itself mimicking Saturday Night Live’s Emily Litella (“Never mind”).

Egalitarianism governs many of Norway’s decisions, and this is as true in healthcare as the rest of the economy. “We want every hospital to be equally good,” one of the CEOs told me. I got the sense that there would be real discomfort with a hospital, university, or any other public institution, that appeared to be head and shoulders above its peers. While Americans accept such things as a natural outgrowth of competition, the Norwegians, it seemed to me, might well see this as a threat to the common good, and take steps – overt or subtle – to elevate the laggards and maybe even to add a little lead to the snowshoes of the lead dog.

I heard many examples of this egalitarianism, but the starkest was in Norway’s approach to residency admissions. After completing medical school (at no cost to the student, by the way), all Norwegian students enter a lottery. The person who draws number 1 can choose among any training position in the country, while the one who draws the last number (475 this past year) has to take any open position remaining. When I heard about this, my jaw dropped. I asked one of my hosts how both hospitals and trainees felt about this lottery system. She repeated the shared desire for all hospitals to be equally good, adding,  “It would seem unfair for all the best students to go to only a few places.”

Can you imagine someone proposing such a thing in the States? The top grad at Harvard Med School draws a number to determine where she will train? Will it be Mississippi? Iowa? UCSF and Hopkins fill their residencies with a random assortment of lucky medical students? Just when I am convinced that the world is indeed flat, tales like this convince me that some pretty lumpy contours remain.

The lottery system will soon become a thing of the past, but not because of any internal backlash from Norwegian training programs or students. Rather, it is yet another victim of the semi-permeable borders created by the European Union. While Norway did not enter the EU (a decision they’re feeling pretty good about these days, as the number of Euros required for the Greek bailout takes on additional commas), it did agree to abide by most of the EU’s border-related guidelines. This has meant that young doctors from other EU countries who can pass a Norwegian language test (not a small feat) can enter the lottery on an equal footing with Norwegian med students and, after completing training, be guaranteed a physician job in Norway. According to a recent article in the BMJ, there was a 50 percent annual growth in non-Norwegian applicants to Norwegian residencies between 2006 and 2009, and such applicants now make up more than half of all trainees entering the lottery. The displacement of Norwegian students from the country’s residencies is what is finally pushing the health ministry to abandon the lottery system for a less egalitarian system of formal applications. Absent this external pressure, I’m confident that the lottery system would have remained in place, relatively unquestioned.

After hearing about all of these manifestations of boundless egalitarianism, I was asked what I thought about them. Such questions are loaded, obviously – we are our upbringing, and who among us can jettison the worldview that we have inherited?

That said, I came away from my time in Bodø convinced that Norway’s system of delivering health care is better than ours in many respects. The system enjoys widespread public support, life expectancy exceeds ours by two full years, and their healthcare expenditures are 9.6 percent of GDP, compared with 17 percent for the U.S.

Of course, all choices have consequences, including Norway’s. Queues for elective surgery are common. (The well-off can go to private hospitals for things like plastic surgery, but even the wealthy wait their turn – several months – for their total hips. When a region’s queues grow too long, that region can purchase services from other regions, or even from other EU countries. But the queues are a fact of life.) Patients must see GPs for their initial contacts, who act as gatekeepers for specialty and hospital access. Such gatekeeping systems invariably produce tradeoffs, and some dissatisfaction. And, from what I witnessed, the U.S. is about 5 years ahead of Norway in approaching patient safety and quality in a systematic way.

But the bottom line is that every Norwegian citizen receives high-quality care in very good hospitals and clinics, staffed by very good doctors and nurses, all at an affordable cost. And the average Norwegian hospital is able to focus on providing care to its community – the hospital CEOs told me that they have no billing departments to speak of.

I guess I’m violating that old maxim that people get more conservative as they age. When it comes to the organization of medical care, I’ve moved leftward. (After seeing Don Berwick get pilloried for once professing his love for
the UK’s National Health Service
, God help me if I ever have to survive a Congressional hearing.) Medical care is a social good, and it should be allocated as equally as possible – at least with respect to the provision of a basic set of health care services. Sure, let the wealthy have plasma screens in their hospital rooms and concierge-type access by spending their own non-tax deductable dollars. But a basic package of preventive, chronic and acute care services should be standardized, robust, and guaranteed. Geez, you’d think we could do that for 17 percent of GDP.

Such sentiments notwithstanding, Norway’s residency lottery system demonstrates that even a good thing can be taken too far. Forcing the most gifted student to attend a mediocre training program nearly guarantees that he won’t reach his full potential. And, as I am privileged to experience at UCSF every day, allowing very accomplished, smart people to co-mingle tends to foment ideas and projects that would not have emerged if such folks were spread thinly, like margarine, throughout the system.

The worst of America – healthcare or otherwise – is awfully bad. On the other hand, I’m typing this blog on my Macintosh computer, checking my email on my iPhone, and searching the web on Google – all from a terrace outside my adopted flat in London (I’m on sabbatical here through December). This reminds me that Silicon Valley could never have happened if Stanford was prevented from accumulating a disproportionate share of really smart, ambitious geeks. Meritocracies have their value, even when the cost is a hierarchy and a little elitism.

8 Responses to “Am I A Socialist?”

  1. Menoalittle July 7, 2011 at 2:42 am #

    Bob,

    Only you know for sure.

    Make note of the fact that EMR and CPOE devices are regulated in Norway by the Medical Products Agency as Norway is one of the 25 EU-countries that has adopted the European Community Medical Devices Directives based on the Swedish Medical Devices Act (1993) and the Medical Devices Ordinance (1993).

    I understand that HIT systems in Norway work well, unlike in the USA where device manufacturers have lobbied Congress to spend $ billions without any assessment of the devices’ safety, efficacy. and usability by the FDA or any other safety body; and they are bereft of said qualities.

    If there is anything you bring back with you and promote (not socialism), I hope it is the firm concept that HIT devices that are proven (to the MPA) to achieve their intended purpose as designated by the vendor and involve no unacceptable risk to patients, staff, and other parties and undergo after market surveillance, have a much greater likelihood of being embraced by the doctors (rather than having them be rammed down their throats under threat of sham peer review).

    Best regards,

    Menoalittle

  2. SimeoonSaid July 7, 2011 at 9:17 am #

    Norway is not actually socialist, though. In socialist countries, the government owns all the businesses. Like Cuba and North Korea. Norway has lower corporate taxes than the USA, and a ferociously competitive economy, even without the oil. And that effcient capitalist wealth-creation engine drives the social programs you saw a bit of.

    Norway has universal health care, free university education, 5 weeks vacation, a year of maternity/paternity leave and a host of other social benefits. From the US point of view, this is pretty socialist.

    It seems to be a uniquely American error to believe social benefits equals socialism. From the American viewpoint, social policies and capitalism become points on the same line, and more of one must necessarily mean less of the other.

    To other countries, social benefits are political settings, socialism and capitalism are economic systems. You can in fact have the dials of both capitalism and social policies turned up high.

  3. Kheng Hock Lee July 8, 2011 at 7:34 am #

    Very interesting to learn of such unusual practices as a residents’ lottery and other unique features in Norway’s health system. Bob, you should travel more often and bring us more tales of exotic health policies and practices :-)

  4. ricardomann36 July 9, 2011 at 12:09 am #

    very interesting and so educational..

  5. wright30kevin July 18, 2011 at 12:24 am #

    a very interesting article you have done.

  6. K.Jensen, fresh m.d. July 20, 2011 at 4:19 pm #

    Bob,

    Thank you for a very interesting (and not the usual superficial) analysis of our health care system. As with any other system it has it’s flaws. Intriguing to hear that you consider it to lag behind some five years in what concerns patient safety. I believe this is one of the biggest topics of discussion today in Norway, both politically and medically, when it comes to delivering good health care today (along with centralizing facilities).

    Just a small comment regarding the lottery. It is true that all medical students get a random number and pick their first position based on this, but this position is strictly an intern year/transitional year, and not equivalent to a full residency in the US. It is only after completing this year that you are allowed to work as a doctor without more or less constant supervision. After 18 months (6 months of surgery, internal medicine and family medicine) the interns apply for a residency much the same way medical students do in the US, to continue their training and specialization. This system ensures a steady flow of students to all part of the country, regardless of qualifications, and is essential in providing rural districts with adequate numbers of family physicians (who can make themselves understood in Norwegian and not being a threat to the patient’s well being). It is also politically driven to promote the recruitment of doctors to the same rural districts and especially into family medicine, where there is a constant shortage of qualified physicians. It has scientifically been proven to do so (have similar actions been made in Canada?). It is in no way an “obstruction” for very career driven students, but it somewhat delays the time it takes to finish your specialization. Given our geographical challenges and tendency to centralize medical facilities it is regarded as very useful to ensure a broader basis of knowledge and skills in the biggest subjects, before allowing young doctors to start their residency, which are often quickly become very subspecialized. It is also embraced among most medical students.

    As you have correctly identified this system is completely collapsing due to a very high number of foreing students (and Norwegian students educated abroad) enrolling in the draw. A first year intern typically earns about $65 000 and the quality of life is good, and it is easy to get a decent position afterwards. The hordes of foreing applicants have surpassed the number of intern positions and created waiting lists for everyone, and it is now typical having to wait 6 months before starting your internship, which is a disgraceful way to treat fresh graduates. You can imagine the reaction you would get if suddenly 70% of the graduating class from UCSF were told they’d have to wait for 6months before they could start their residency. And yes, they’d have to start paying their student loans. So even Norwegians oppose egalitarianism (?) when it is pushed too far! Our intern system is currently being scrutinized and in the future we will probably see a more formal application systems where you apply for a residency that include working in family medicine for 6months in a rural district, regardless of what hospital you else will work at.

    Again, thank you for an interesting approach!

  7. Ole Jacob Nilsen August 8, 2011 at 2:47 pm #

    Thank you for an interesting observation of our health care system.

    I would like to point out one fact: It is the internship (18 months of compulsory practice with 12 months in a hospital and six months as a GP) that is lottery based. Recidency is as any other job, after application.

    I think most Norwegian doctors have fond memories from their internship in (usually) remote areas of Norway, and many are sad that this system is to be changed.

  8. Sydney August 15, 2011 at 6:40 pm #

    Such a good read, i enjoyed reading this post….

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