Fanny Nilsson - Go to the ER

Transcript

The following transcript is AI generated and may contain errors.

Thank you.

So I just want to say ER.

That's the American version of the emergency room.

And the English or the British would be A and E, accidents and emergencies.

But you've seen the ER, so that's why I use the E-R.

Akiften, it is in Swedish.

This is my ER This a small hospital outside of Stockholm.

I go by train there every day, one hour, because I love trains.

and I also love small hospitals.

So I've been working there for quite some time, and I have been writing about healthcare politics.

And I kind of got stuck in the Swedish debate and also in my own arguments, because in Sweden, a lot of the debate about health care is about two things, privatisation and the patient's right to choose.

And there's so much bigger questions for us at hand about the aging population, about them medical possibilities that are always expanding.

There must be more cleverer persons, smarter people outside Sweden, I thought, because they have the same problem as us.

All of the healthcare system have same problems.

Not enough staff, not enough money, increasingly complex patient that is just getting older.

So I took six months off from my ER and my hospital and wards, and I bought an internal training ticket and went out to Europe and interviewed a lot of researchers, patients, healthcare staff.

And the first question I try to answer in my book is how.

How can we have a healthcare system?

How do we structure it?

Do other countries do better than we do in Sweden?

Are there other lessons to learn from how we can do this?

And there's no perfect healthcare system.

We all are looking at each other.

Everyone is thinking the grass is greener on the other side, just so you know.

And the second question is what?

Because we can't have a perfect health care system, it doesn't exist.

we also have to think about what is medicine and what are we gonna do.

So the first thing that I find out is this, and this is why I'm invited to speak here, because I am a hospital doctor, but everything is about this.

And the non-Swedish people, if you haven't picked up this word in these days, this the GP's home, the Vårdcentral, where the GPs reside.

This is one of the key findings in my book, primary care.

And we are so far behind on primary care in Sweden.

That was what I realized.

So this is compared to other countries.

This is OECD countries study that is presented by the Swedish authority.

We've asked the patient or the researchers have asked a patient, do you have an ordinary doctor?

Do you know your doctor by name, a doctor that takes care of you?

which is the same question that I asked my patients in my ER, who is your doctor?

And very often in Sweden, the answer, I don't know.

I never get to meet the thing.

And we're different every time.

But the average in the OECD countries is 80%. You feel like you have your own doctor.

To the right here, 97% is Netherlands.

Are there any Dutch people here?

So Netherlands is like the darling of healthcare politics right now because they're performing very well in very many parameters.

And people are very interested in Netherlands because we have a system not of tax but mandatory health insurance.

People are just looking at that system thinking maybe this is what we should do.

We should stop the tax thing and we start with mandatory insurance, but what they really have is this.

This is what they have.

97% know their doctor and have known their doctors for many, many years.

In Netherlands, it's the primary care doctors who rule the system.

And look at Sweden.

We're very far behind.

30% of the people say that they know their own doctor.

And in many regions that are sparsely populated, difficult to staff, it's much less than that.

Then it is just temp doctors going around from week to week.

It's zero.

Zero relationship continuity.

So, and why it's like this?

It's many historical reasons that I go through through my book and hospital doctors is a big problem because we've stopped these reforms for a long time.

But if you look at Norway, Norwegians here.

Yay!

So you know fast leg reform.

Yes, we look at fast-leg reform in Norway because you were like us some like 20 years ago with a primary care that was similar to us with low personal responsibility, fragmented, the patients didn't really know where to belong and you did this huge reform and invested a lot of money.

And you attracted hospital doctors to become primary care doctors, and you made a very clear list of these are your patients.

This is what you're going to do.

And it was a success.

I know it has problems, but as I said, no health care system is perfect.

But it's still better.

You're this is still considered a successful.

And then this study followed up the consequences 15 years later.

And they compared if you have the same doctor for 15 year compared to a patient who had had the doctor only for one year, there's a 30% lower risk of out of office care needing to go to the ER or be admitted to hospital.

There's also a 25% of lower mortality.

And this is not just Norway.

This has been shown in several studies about mortality and relationship continuity.

Why aren't we talking about this?

Why are we listening to the cardiologists saying that this new medication, we're gonna give it to 300 people and we are gonna prevent maybe one heart attack.

why are doing that?

why aren´t we doing this.

this the art of medicine, staying with your patients, this what we should do.

And this is the hardest number that we use in research.

It's mortality.

You have mortality data, so talk about it.

Sometimes I think, in Sweden, where are our patients?

Because we still have quite high life expectancy.

We are good in cancer survival.

we're good at cardiac care.

But it's perceived very difficult to get hold of your own GP.

And we have the lowest number of hospital beds in the OECD countries and lowest numbers of ICU beds.

So if the patient are not with a GP and they're not in a hospital, where are they?

Well, they are calling this number a lot.

The Swedish people are laughing.

This is a number for medical advice, which a nurse is answering.

It's not your nurse, it's a random nurse.

For a while, Stockholm had nurses sitting in Thailand, and then they realized it was not legal to do like that, so they stopped it.

People are calling here.

It's not video, it's just a call.

And what are the nurses saying?

Yeah, they're saying a lot, go to the ER.

They're seeing other stuff too, but they saying go the the E.R.

And we who work in the e.r.

receive these patients who come there, They have they are not really concerned themselves.

they just wanted to seek medical guidance.

and someone, the medical system answered and said, you have to go, to The E R.

When they come to, The ER the nurses and the doctors, are they not very impressed by these, patients.

Maybe they may be always treating them very well.

They have to wait because they're primary care patients.

Why is 1177 open during daytime?

Why aren't those nurses sitting in your GP's offices, sitting at your ward central, talking to their own patients that they know?

This doesn't happen in Holland.

It's nothing like 11 77. You just call your doctor's office.

So the ER gets tired of all these primary care patients, so then we invent the light ER, Narakut, in the big cities.

And where people can come with minor ailments, but it's not really...

It's a kind of in-between station.

But the people who work in a light E.R., it is often GPs.

So instead of the GP seeing their own patient, they're seeing someone else's patient.

And then we have a huge problem with this.

It's an app doctor on demand, and I'm not going to go into this, but it's a big controversy and problem.

Ask a Swedish person about it.

Very unserious businesses who take no responsibility for the patient, who takes as many patients as possible during an hour and receive extra money for how many they take.

And they do care that is very, very...

Yeah.

Unserious.

And the politicians have a big problem stopping this, and it's still today paid by tax money.

And then they call us in the hospital and they ask, are you my doctor?

Can you renew my prescription?

Are you taking care of me?

And they're on these waiting lists.

So we're having an election coming up in Sweden, so there's a lot of talk about waiting list, but actually our waiting is not that much worse compared to other countries.

Denmark is doing very well, other country also have these.

And although we have very few hospital beds in Sweden, we had very many nursing home beds internationally compared.

Which is good, I think.

But in the nursing homes, you can't do so much healthcare.

There's no oxygen, for example.

This is a big thing in...

in covid that we could not provide them oxygen and we banned them from coming to hospitals but maybe with oxygen only they would have survived in norway this is also different and it's very difficult for me i perceive to get a doctor or a nurse to go to a nursing home to assess a patient very often they're just sent to the er And when people don't feel cared for, they turn to alternative medicine and social media for guidance.

And this, all of these different places to seek healthcare is called in research organizational in-betweens or organisatoriska mellanrum.

And if you get a very severe diagnosis in Sweden, a cancer or a heart infarction, you would get really good care.

Karolinska Hospital in Stockholm is priding itself all the time of being one of the best hospitals in the world.

But there's not so many patients who need to go to Karolska.

Most of their patients need just now and then see their GP.

And being in all of these different areas or different sectors of the healthcare system makes you feel very insecure.

It makes feel that you don't really know where to turn.

And often you call maybe different sites at the same time trying to get help.

We can look at the healthcare system in Sweden and maybe your other countries in a way, a bit like an archipelago.

So the islands are the different clinics who say that we're dealing with this diagnosis.

This is what we are doing here, and this is we doing right here.

And the patient has to try to get up on one island swimming around.

Only one way where all the other patients can go with all of their ailments, and it's to you.

You will be the water.

you will have to help them swim.

But they're not supposed to swim around here feeling lonely.

They're supposed be with you supposed to be with you.

So this is a series that was aired in the Swedish public service called The Neighborhood Doctor before I started medical school.

And it follows Magnus and Lotte, who's GPs in Stockholm.

Magnuss is retired now.

I met him and he told me a story that one time he referred a patient to the ER and just wrote, patient I've known for a long time now suddenly looks very sick.

And I think that's a great referral.

I stand in the ER and I get this, I understand.

What he means.

Trust this colleague.

Take a lot of tests.

And have to do a broad workup.

But this you can only do if you know your patients.

So Swedish doctors and the SfAM organizing these committees is talking a lot about one doctor for 1,100 patients.

That's the goal.

But it doesn't matter if you keep changing the patients If you keep having your colleagues' patients, then you don't have this fantastic mortality data.

And you can't raise those good referrals.

That's minus two.

You have to go with your patients.

So the take-home point number one in my book is primary care, primary, and primary.

It's the solution to everything.

This is why I'm here.

But it lowers mortality.

It makes the population feel more secure.

It releases the stress of the system and it costs less money than hospital care.

This is what the Netherlands has realized and Norway and many other countries.

And it's time for us in Sweden to start realizing the same.

So this is illustrated on the cover of my book.

So, this the rod of Asclepios, the medicine symbol, and it's a very chaotic healthcare system, as it is perceived by many people, a chaotic health care system.

And right in the bottom, it says Vård Central on fire.

I'm sorry.

It's to be very, yeah, symbolism is a bit exaggerated.

Then on very top is the fancy university hospital clinic that gets all the attention and all of the money all at the time.

And now we're going to talk about the guy who goes into the elevator, surpasses all of the queues and lines and goes directly to specialist care.

That is to illustrate private paid care and I use UK in my book to show of how it looks when a system is going backwards.

Any people from the UK?

Are they too shy to say?

Yeah, but they're having a lot of problems at the moment, so to speak.

There's a decreasing life expectancy, increasing infant mortality rates, and it has to do with extreme poverty and NHS is under so much stress, a lots of factors.

So this is a man who 87-year-old who fell on his asphalt terrace and broke his rib cage and his pelvis.

His family called 911 to ambulance, and they said, we're coming.

Don't move him.

It's going to take some time.

The family built this around him because it started raining, so they built a little shelter and tried to keep him warm from the rain.

They called in the evening, the ambulance came the morning after.

And you all understand that this is a medical disaster.

But this actually quite common in the UK.

This is how big problems they have at the moment.

And what are you going to do then?

Well, there's a market opening.

So in the book, I interview this guy who called for ambulance for his parents, and they couldn't get help.

And he's an ambulance driver nurse himself.

He started this business where you can pay for an ambulance to come.

It told me, what you're going do?

Wait 20 hours and watch your husband die on the floor, or call us and pay One of six in the UK has a private health insurance.

It has increased a lot and it's not just the rich anymore.

All sorts of people have lost faith in NHS.

And this is growing a lots in Sweden too.

Maybe your other countries.

This is a problem.

I said initially that there's a lot of debate in Sweden only about privatization, but what is it?

What does it mean, private healthcare?

It's too unnuanced to debate.

We have to have more nuance when we're discussing private care.

A GP working in Norway or Holland or Denmark, having their own company with a contract with the state or the region, is a private actor, one would say, because it's not the State who runs the care, it is the private actors.

And Carpio, who owns a lot of healthcare in Sweden, In other countries, it's one of the big healthcare companies in many different countries.

It's owned by a French bank and a health insurance company.

That's also a private actor.

Two completely different private actors and different incentives.

We have to differentiate these two.

And we also have to discuss if we're talking about privately run or privately funded, because healthcare can be privately ran that the state buys the provider from a private company, but privately-funded that a patient pays themself, that is the problem.

But the privately run healthcare opens for the private funded.

You can't, from a state hospital, you can pay extra to skip the line.

But that you could do in a privately-run hospital.

And this is called, with a research term, it's Voluntary Health Insurance, VHI, which you call private care.

So privately ran, privately funded And if you look at the Netherlands again, I'm sorry, what they did some 20 years ago was that they do a huge reform and everything in the Netherlands is privately run and now the state doesn't run any healthcare.

So everything is private run, but they have no VHI.

They scrapped that, they had that before, But it's not possible anymore to pay extra to skip the line.

It's priority based only on medical need.

And what is interesting, especially when we talk to Swedish people about this, is that they're not allowed to make any profit.

The hospitals and the insurance companies are not allow to to profit The only ones who can make profit, really, are the GPs.

And that's, I think, probably because you are so important.

and you run the system.

So if you compare to Sweden and Spain and other countries where we have both private and state run with absolutely no regulation of voluntary health insurance, and we had huge and increasing possibilities to skip the line and pay extra for the other patients.

And at least in Sweden, there's absolutely for profit, even though there's 75% of the population who think that we should have limits on profit.

Copio can take as much as they want.

So, why is this a problem?

Well, so, if we have the public care, privately paid for healthcare will always exist.

But the problem is it's very, very many people who stop, who leave the pubic and go into the private.

Because the patients, they bring the healthcare staff.

And the patients who leave are often more rich and more healthy.

And that leaves the people in the public care, the poor and the multi-morbid, who can't afford the insurances that the insurance companies don't want.

The healthcare staff, I understand, go to the privately paid care because it's better working conditions.

There they have more money.

So often healthcare stuff feel that this is now I can do my profession in a way that I want, But if there's two big shifts of this, that is the problem.

Because staff shortage is a core problem in all of our countries.

Every country in the world wants more healthcare staff.

We cannot saturate the need for healthcare stuff.

I mean, we have to work with other stuff too.

Everybody can't be a nurse and work in healthcare systems.

They have we to have other jobs too, So if you have too much staff leaving the public care going to the private care, that's a problem for the system at home.

So take home message number two is we have to limit private-private care or we watch the systems go down.

Which is a little bit what they're doing in the UK at the moment.

Okay, so that was how.

How are we going to have a healthcare system?

Well, we have to a system based on primary care.

And we really have keep an eye on what the privately paid sector is doing and if it's pulling all of our good nurses and doctors.

But what?

We have also to talk about what.

I guess you've talked a lot about, what is healthcare in this conference?

So we're going do this with the help of Anne-Erin Bevan.

He was the founder of the NHS in the UK.

During World War II, Churchill was a prime minister, a very popular prime-minister and a conservative.

And then they were thinking, how are we going to rebuild the UK?

It was very bombed.

As you know, it was shattered.

How are you going get out of this?

And there was this economist called William Beveridge who wrote a report called The Beverage Report suggesting that what if we have a healthcare system for everyone and we base it on tax?

And Churchill was skeptical about this, but Labour, the Social Democrats, took this to their heart and said, this is what we're going to do.

If we win the election, we are going do this.

And even though Churchill is so popular, Labour won a landslide.

And Aaron Bevan, who was a miner's son from Wales, managed to put this into action and make this a reform.

And one asked him later, how did you do this?

How did he manage to get the doctors, the very conservative working, this very, conservative type of professionals, How do you get them on board on this socialist experiment, which it was?

And he said, I stuffed their mouth with gold.

And they did an investment in the healthcare system.

They invested two, three percent of the GDP, which is worth a lot of money.

And, they thought, this is going to decrease.

We just make this huge investment now, people are going get well, and it's going decrease, but that didn't happen.

Because what happens if people survive, well they just keep on living.

and they get old and then you have to change the knees and the hips and heart valves and lenses and you get cancer and cardiac disease and costs for healthcare has continued to rise.

And today we're at like 10 to 12% of the GDP in all of Western countries.

USA is the outlier, but the rest of us are around 10% to 11%, 12%. And it's not changing.

It's been the same in Sweden at least for the last 10 years.

But we can still do more and more to the patients.

And he said then, which I think is very thoughtful even today, we shall never have all we need.

Expectations will always exceed capacity.

The service must always be changing, growing, improving.

It must be always inadequate.

That is still true of today.

So you heard about this concept?

Yes, if you've been to Sweden, I hope you heard about this concept, because Mina Johansson and Victor Montori and their colleagues have studied how much guidelines take your time.

And as a GP, you have to work 27 hours in order to follow the guidelines that we hospital specialists so helpfully have created for you.

That's not possible.

And so hypertension, hot topic always, the case of hypertension guidelines.

This is a very famous study that you would need more GPs than there are Gps in Norway in order to just follow one guideline, which is the hypertension guideline.

And that would destabilize the whole health care systems, as the writers say.

But hypertension is number one risk factor.

in the world and in Sweden for heart disease, stroke, kidney disease dementia, all of it.

It's such an important risk factor.

We have to do something about it and I mean, if you're trying to be a guideline fundamentalist, you gotta be very stressed.

You're not gonna do so well to your patients.

Gonna force your patient to a lot of stuff if think that guidelines are the truth.

But you can't be a guideline nihilist either.

Because this is what we have guidelines for, in order for people to get the same kind of threshold basis equal care.

So what are you going to do?

Well, you have to find some kind middle ground here.

And the middle ground compares to what is it, what disease is, it what patient is.

And you have to learn from the evidence, What is high and low value care?

Because the guidelines, unfortunately, does not teach you that.

You have learn that also from a patient, because the patient will tell you what's high or low for them.

So for hypertension, for example, if it's a 25-year-old, Don't let that guy go.

You have to really keep an eye on him and walk with him through his life and make sure he takes his medication.

If he's an 85-year-old, doesn't matter.

Talk to him about other stuff, about his hobbies or something.

His hypertension doesn' matter, so, and the evidence, if you look at the evidences, it's very important to track the blood pressure of a young person with hypertension, but with an old person it is not as important.

So what has happened?

How did we end up here?

That we have so much guidelines that it's important for you to follow.

We have to go back and look at what is evidence-based medicine.

So when I talk to the public and I say that we invented evidence based medicine in the 90s, they're a bit horrified.

What did you do before?

Yeah, well, we had like expert- based medicines, which was mostly like male experts saying what they think.

But now, in 90's, There was a group of people who thought maybe we could structure this and organize this, and they started this concept and randomized controlled trials and meta-analysis and evidence hierarchy and everything like that comes from this era.

And evidence-based medicine, what people think mostly when they talk about it is they think it's the orange circle here.

What the literature says, that is the evidence.

But evidence-based medicine is also the doctor, the clinical expertise, knowledge, and the wisdom.

And it's the patient.

Who is the patients?

It's much more important who is a patient than what disease the if the patient is 85-year-old or 25- year- old with hypertension.

And the relationship between those two, the patients and the doctor, there's something magic going on there.

That's what we see in the mortality decrease is something happening in their relationship.

Evidence-based medicine is created in a middle of this.

It was early criticism of evidence- based medicine.

What is this type of cookbook medicine?

What about the art of medicine, And David Sackett, who is one of the founders, he warned already in 96 in an article in BMJ saying that, no, you have to consider the doctor and the patient and their relationship.

Otherwise, we're risking what he said, a tyranny of evidence.

And the tyrannies of evidences, I think what we are seeing is what were seeing today.

So we have impossible guidelines, impossible to follow.

We have very defensive medicine, keeping your back free.

We are very low patient influence, a lot of studies show this.

Very low continuity, especially in Sweden.

Patients don't know who their doctor is.

A low belief in our own generalist competence.

This is increasing the more subspecialists that we have.

So we're calling consulting subspecialists instead of thinking and examining ourselves.

And this is why I stopped working in a university hospital, because all I did as a junior doctor was just calling different consultants.

Because no one really could make a decision about anything.

We just have to call a lot of people to get their expertise and their expert knowledge on everything.

But the subspecialist on the other side of the phone doesn't see the patient, doesn´t talk to the patients, often just says that you can order this or you cannot do that, just to kind of be safe.

And then who has the responsibility for the patience if we're just fragmentizing everything like this?

And the generalist becomes very unsure how to make their own decision.

And as you've heard probably the different figures, but 20% OECD thinks that healthcare is of low value, is either harm or meaningless to the patients.

There's figures of like 30 or 20, 10%, something like that.

And I think it's quite obnoxious actually from us to always demand more money and more staff from the politicians if we're doing so many things that are completely meaningless.

And we have a very high workload, especially you in primary care.

And I'm thinking, aren't we creating our own crisis?

So us aside, how is it for the patients?

Well, you have many diagnoses, and you get to see a lot of specialists.

You get often conflicting advice, there's a sense of low responsibility in the system because there are very few generalists and people don't dare to make decisions.

People get a necessary diagnosis because the more we look, the incidental findings we find, and we do necessary controls and give them a lot of medications.

This is a study about patient responsibility for dealing with your medications, that is obviously very difficult.

And this is about Anita who is interviewed in this radio show that she dealt with her husband's 32 different medications I mean, you have to be like a pharmacist in order to do that.

That's very difficult.

But also, what?

What's going on?

There's no research on 32 medications in an old person's body.

We have no evidence for that, there's not research done on that combination of those cocktail effects.

And she says in this interview that sometimes she asked for help, she asks a doctor for some help.

but the doctors weren't really that interested.

You know, polypharmacy, ugh, it's boring.

So, in the end of life, the elderly have an extreme amount of healthcare contacts, and it is a lot about healthcare and receipts from the pharmacy.

And how good is our evidence?

for 32 medications.

So this is a study about studies.

It's a little bit complex.

I'm going to explain.

On the y-axis, we have percentage of patients in a clinical populations that are excluded from a trial.

For example, the clinical population heart failure.

We're going do a heart-failure study.

we're gonna exclude some of them that cannot partake in the study, and on the x- axis, every bar is study and this important studies who lay the foundations for the guidelines that you are to follow.

And as you can see, three quarters of the trials exclude more than half of patients.

And a quarter of trials include 90% of patient in the clinical populations.

The patients who are excluded are often those who're multi-morbid and already have a lot of medications, which is those that we use the most medications on.

It's completely reversed what we're supposed to do.

Sometimes I think that really the elderly, we can do a little bit whatever we want with them because they're not studied.

We don't have so much evidence for them.

You can just listen to them what they want.

Because this is what makes me most angry.

These are my most common patients.

The elderly elderly the frail.

What are we really doing with So this is a study that was an article of the year in the magazine for doctors in 2023. It's called Undignified Care at the End of Life, Real World Palliative Care.

And this a is study where they follow the patients the last months of their life through the journals and see what happened the months leading up to their death.

I'm just going to read one example.

A 99-year-old man with hypertension and suspected gastrointestinal cancer was referred to a mobile team in the region by the responsible GP.

During the initial consultation, the man stated clearly, I don't want anything that prolongs my life.

I want to come to my dead wife.

The doctor wrote, patient very negative towards investigation, extended care being transported.

Despite this, blood tests were drawn and the patient was persuaded to go to the ER for a blood transfusion, received four bags of blood, and was admitted to a ward for further blood transmissions before he died 24 hours later.

I see this all the time.

What are we doing to these people?

And these are the future, because the is a rise in elderly patients who are having more and more diseases.

But there is, as you know, an international uprising about this bad medicine.

It's called choosing wisely.

Comes from internal medicine in the US.

Everything that's good comes from international medicine, and it's spread out across the world.

And interestingly, there's also a philosophical reaction that I'd like to mention from Jonna Bornemarck, who's a philosopher who is interested in care and healthcare.

And she talks about Aristotelian knowledge frameworks.

And he talked about episteme, which we can translate to the studies, the evidence, and the tekne, practical know-how of what we're doing, how to be a doctor.

But what she thinks is missing, also what has fallen out of the Evidence-Based Medicine, is the froniasis, that practical wisdom of being a Doctor.

And this is why we'll never be replaced by AI.

So if we take this, if you take Magnus and Lotte, you guys, and we combine it with a little bit more of wisdom, we will get lower mortality, lower pressure on the system.

Patients will feel more safe and cared for.

We will have less meaningless care and lower costs.

So my last take-home message is that we have to stop low-value care.

And this is, I mean, if you're an economist, you can be happy that healthcare should cost less money, but I think this a huge ethical problem.

And many hospital doctors and probably also many GPs have completely just left the medical ethics at home when they are treating elderly patients as in the example.

I'm sorry.

So, of course we need specialists.

I mean, we have both specialists and generalists, We have to work together.

We need someone who knows everything about a special type of lymphoma because there's so much happening in that area at the moment.

But it's getting increasingly difficult to be a specialist means that it is also getting difficult for you to become a generalist.

We need more of the generalist perspective in order to take in all of different guidelines and all the different diseases and different medications that the patient has.

That is the future.

Because you are the solution.

And we have a strong weight on specialist care in most Western countries.

But how are we going to tackle the future is becoming having a more generalist perspective.

So I will stand in the ER and I would receive your very good referrals written in a way that Magnus had written them.

But I'm only a part of a patient's life for a very short time.

And I'll do my best.

You guys are going to save the patient lives.

We're going walk with the patients through their lives and that is the most important thing.

This is all I have to say.

Thank you.