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Swedish physicians' perspectives on work and the medical care system: The case of district general practitioners
Sot. SCI. .Hed. Vol. 23. So. 8. pp. Pnnted in Great Britain. .A11rights
763-771. resened
1986 Copyright
0277-9536g86 93.00 + 0.00 C 1986 Pergamon Journals Ltd
SWEDISH PHYSICIANS’ PERSPECTIVES ON WORK AND THE MEDICAL CARE SYSTEM: THE CASE OF DISTRICT GENERAL PRACTITIONERS ASDREW C. TWADDLE Department of Sociology and Department of Family and Community Medicine, University of Missouri,
Columbia,
MO 6521 I, U.S.4.
Abstract--Interviews
with district general practitioners in a large Swedish city in 1978-1979 solicited their perspectives on the frustrations and satisfactions they felt in their work, and on the successes and failures of the Swedish medical care system. With respect to work, four themes emerged: medical routine, patient centered care, overwork and isolation. Five themes emerged with respect to the system: financing,
relationships with hospitals and specialists, involvement in political decision making, the size of districts and care centers. These themes are discussed with relation to the influence of the social situation of practice to the influence of the social situation of practice and the conditions for physician satisfaction. Key words-ambulatory
care, Sweden,
physicians,
health
care systems
This paper reports findings on the perspectives of
THE DISTRICT
district-based general practitioners (disrriktsliikare) toward [l] their work situations and [2] the medical
PHYSICIAN
Responsibilities
Ambulatory medical care in Sweden was delivered by design in specialty clinics and by district general practitioners. In practice, a considerable amount of ambulatory care is also delivered by hospital emergency rooms [12]. By design, the patient was intended to initiate all medical care with the general practitioner, who will then make referrals, if needed, to appropriate specialty or hospital care. The general practitioner, who was assigned to serve a defined geographic district, was intended to be the front line of medical care, the dispenser of general services, and the screen for specialty services. In addition to individually focused primary care, (s)he was officially responsible for the health of the population of the district: monitoring the environment for health hazards and engaging in activities similar to those of a public health officer.
care system within which they served. Datz come from interviews with district physicians in Goteborg, Sweden during the 1978-1979 academic year. Previous work on the Swedish medical care system has fallen into one of several categories, none of which have taken the perspectives of the direct providers of care as problematic: epidemiological and utilization characteristics [e.g. I], organization of the Swedish medical care system [e.g. 2, 31 and planning of health services [4-6]. While some degree of diversity is recognized in the general population with respect to social class and among different interest groups in the society at large, the tendency has been to treat the participants in the Swedish medical care system as homogeneous, sharing the same general interests and the same general social circumstances. Studies in other societies, however, have documented important attitudinal and behavioral differences among health workers, and even among physicians, that are related to location in the structure of medical care [e.g. 7-101. The study on which this report is based was an exploration of the perspectives on the ambulatory medical care system held by physicians and others. An attempt was made to identify the kinds of occupations and settings that compose the system on the assumption that different social circumstances will produce different perspectives [ 1I]. In this report, we focus on one group of medical care providers, the general practitioners, that have a particularly critical role in the system of ambulatory care in Sweden. It is expected that this will be the first of several reports dealing with different occupational groups. It represents a partial set of perspectives, but one important to an analysis of the larger system.
Training
Medical training in Sweden at the time of this study [13] consisted of a 6 year program entered after a 4 year natural science ‘line’ in the gymnasium with content virtually identical to that of the United States and Western European societies. Specialty training was entered at the close of medical school and took from 2 to 5 years. General medicine was treated as a specialty with a residency program nominally geared to ambulatory care but carried out, for the most part, by specialty rotations in the hospitals. It bears analogy with family practice in the U.S. Practice structure
General medicine in Sweden developed as an ambulatory care focused, solo practice [14] entirely outside the hospital system, as in the U.K. At the 763
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time of the study almost all district physicians were in solo practice. As in the rest of the Western world where medical care organization has been dominated by physicians [15] general practice was a shrinking segment of medical care in Sweden from 40% of all public physicians in 1920, 18% by 1970 and less than 10% by 1978. Swedish medicine, more than any other place known to this writer, was dominated by hospitals and specialists. General practice was low in glamour and prestige within medicine, a feature not without notice among physicians in our interviews. Two developments in the decade preceding this study were important to understanding some of the concerns we will address below. First, in 1972 the boundaries between public and private practice had been sharpened. Physicians were forced to choose one sector or the other, and were no longer allowed ‘part time’ private practices while on the public payroll. All of the general practitioners in this study were in the public sector. Second, both national and local decisions had been taken to convert solo general practice offices into ‘care centers’ (V&dcentra[er). Districts were to be made larger and several district physicians were to combine practices along with other primary care providers such as community nurses, social workers, pediatricians, maternal health physicians and dentists. Both of these developments, one implemented and the other in process, were important in the thinking of respondents in this report. In 1968, general practice patients in Gijteborg were disproportionately female (60%) and aged [16]. In 1978, the percentage of young patients had declined and the aged had sharply increased. Diseases treated had shifted from the acute and infectious to the chronic and degenerative-this according to a respondent who kept statistical records on his practice in a working class district. These changes reflected both the general aging of the population, more than 17% of whom were over 65, and a shift of acute medical problems toward care in the hospital sector [cf. 51. As the front line of medical care, the district general practitioner had a strategic position in the overall system as provider of primary services and the screen and referral agent for other services. The actual performance of the district system of general practice was not as comprehensive as its official role, as we will show below. METHODS
AND DATA COLLECTION
This paper reports on a portion of a larger study that focused more comprehensively on the ambulatory medical care system of a large city, Giiteborg. The goal was to describe and evaluate that system from the perspectives of a variety of participants: general practitioners, pediatricians, maternal health physicians, social physicians, industrial physicians, nurses, social workers, pharmacists and the general public. Focused interviews [18] were tape recorded in the physicians’ receptions with a snowball sample selected by theoretical saturation criteria [19]. The design was exploratory, intended to discover the persepctives of the respondents rather than to test hypotheses [cf. 201. A focused interview guide was
C.
TWADDLE to cover a description of the practice (including its organization and the character of the clientelle), sources of satisfaction and frustration in work, an assessment of the respondents’ views of the medical care system at large, and changes the respondent would like to see in the system. Interviews were conducted in English, which all respondents handled with remarkable facility: English was a prerequisite to university training. The sample was constructed with a snowball design from a key informant, who was well placed in the medical care system and knew its political arrangements intimately. An effort was made to identify all types of practitioners who delivered primary care and within each type the kinds of settings (with respect to practice organization and characteristics of the client population) that might result in different perspectives. Each respondent was asked to identify other practitioners of the same type who might provide a different perspective on work and the system. This continued until interviews produced no new information or the referrals seemed to have come full circle and practitioners identified had already been contacted. In general, there w-as remarkable uniformity within categories of respondents making small samples seemingly representative of that group [21]. Goteborg was not ‘representative’ of Sweden. It was the second largest city in the country. It was more industrial, more leftist in its politics and had an older population than the nation as a whole. It also had a larger percentage of immigrants and a higher level of unemployment resulting from the collapse of shipbuilding in the previous decade. All of these factors may have had an unmeasured impact on our results. Most of the respondents were in solo practice serving districts ranging from just over 2000 population to over 23,000 and from upper class to ‘skid row’ conditions. A few were in care centers (ccirdcentruler) where two or more district general practitioners practiced alongside several other kinds of medical, dental and nursing practitioners. TWO worked in an ‘acute primary care center,’ which was a clinic attached to a telephone bank where people could call with health problems. In all, eight district general practitioners were interviewed [22]. A content analysis of responses to interviews showed the district general practitioners divided into two groups. On the one hand were those in true general practice, either in solo offices or in care centers. On the other were physicians in the acute primary care center, who differed in almost every particular as we report below. There were no evident differences in the responses of general practitioners based on the characteristics of their client populations or the districts, with the possible exception of size.
constructed
PERSPECTIVES
ON WORK
Among the district general practitioners practicing in solo offices and care centers four themes emerged regarding their perspectives on work: it was medically routine, patient centered, had inadequate resources and was isolated from the rest of medicine.
Swedish physicians’ perspectives on work Medical routine
Technical aspects of medical work were seen as quite routine. Emergent problems were often taken to the hospital emergency rooms or the acute primary care center. Complicated problems in diagnosis and treatment were referred to specialty clinics or hospitals. The general practitioner was left with the surveilante of chronic conditions, health screening and follow-up care. One physician, who found more intellectual challenge in his job than was the case for other respondents, expressed his orientation to work in the following manner. “There is not so much technical facilities for health care, and most is pen and paper work and a small fund of knowledge and a fund of common sense, I hope. That’s primary in this. . . . My education for this job is not what it had to be, because I had a profession that is very technical [23]. . I find today that very much of the technical work 1 have no time to do. I want to do it, but I have no time. So I have to take care of the whole human being, and minor technicalities I have to refer to the specialists, to the young doctors that are interested in science and who have more training than I have today to solve these problems.. This is a kind of center for sorting out people. . the first primary station for screening. I have two things to do: the first is to screen people in need. . When I refer people to hospitals and specialists in this first screening I put them into three groups because of the implications for referring. The first group is for people who are very ill; there is a life threat and danger, or I suspect there could be. There are vital indications for referring them, and I have not to waste time. Among three hundred patients in half a year, I referred three to the hospital. The second group are people who need more resources, maybe more skill from a doctor in this special field or maybe special resources-operating theatres, anesthesiologists, and other kinds. (For the third group) I have an indication which I call social, or maybe convenient, reasons to refer them. (These are) mostly old people. There is not technical objection to treating them at home, but I have to do investigations and observations. For the patients it is more convenient to do this in the hospital. That means.. . that there is a chance in a hundred that there is a very ill patient that is here in this place, and that is not very much. What about the other 99%? They live tomorrow and I can always think of them then. But this one that is urgent, whom I have to find. . I don’t express this very well, but I hope you understand. They are not very ill patients that I see here.”
While this physician regarded the identification of the one patient in 100 with a significant medical problem as a challenge, and seemed to take satisfaction in finding that case, several other district general practitioners seemed to find the routine nature of their work boring. Another respondent described his activities as “certification of illness (for social insurance), certification for driver’s licenses,
and documentation of injury, mostly for insurance purposes.” He claimed to do no therapy and described his work as “simple drudgery.” These respondents all noted that their training took place mostly in hospitals where complicated diagnosis and treatment provided intellectual challenges. Most felt that to be placed then in a situation where the work was “simple and monotonous” meant that their skills were underutilized and there
165
was insufficient challenge to make the job very interesting. Others, while acknowledging that the medical skills required for their work were minimal and the work was routine, took satisfaction from other aspects of their jobs, which brings us to the second major theme in the interviews. Patient centered care
The routine nature of the medical work in district general practice was regarded as stultifying by two of the respondents, who found their jobs bonng and alienating. The others reported satisfaction in interaction with sick people. This was expressed as an emphasis on ‘patient care’ which was contrasted with ‘illness centered care.’ The perspective was well summarized by one respondent. “I mostly describe the health care in two sections. One is what I call illness centered care: there is a technical problem that has a solution and the human who has the problem has no significance. Appendicitis is no problem. It is a case of operation. If it were a king or a kid it’s the same treatment. But in other cases it’s not the illness or sickness but the person that has the illness that is the most important. You should not treat the disease but the patient. This is the second section: the patient centered care and, oi course, in this kind of work, in general practice, there is more patient centered care than illness centered.. That is what I am really interested in. I must take the time. If I need half an hour for one person he gets it. And they sit crowded in the waiting room-1 don’t care. I think it is my greatest problem and takes more time than anything when I have a patient and I say this and this investigation show nothing. And the patient says, “But why do I feel so bad?’ Just that kind of people that I don’t have to treat, that should not have treatment-that takes the most time. I have to get them to understand. I have to explain to people why I want them to do this or that or why I don’t want them to do anything at all. I have to take time to explain this, because if I don’t they do as they like and the result might be disastrous if I’m unlucky. So that is the vital point of the care here. I have to explain to people and they have to get a good explanation . . . and that is the difference between health care today and twenty years ago. People are more educated; they ask more questions and they are more critical. We have to accept this. . .
I don’t ,call these people sick people; they are disturbed people, and the disturbances have two poles. The first pole is that they tell me “I don’t feel well,” “I feel dizzy,” “I have some kind of ache.” This disturbance of the subjective feeling of well being, I have no measurements for that; I couldn’t tell. I think that the man who has to have help to get up from bed has to have more ache than the man who can get up by himself, but I don’t know. . . The second pole is those who say “I don’t function well.” “I can’t climb a ladder,” “ I can’t do my job,” or whatever. And that is better, because the functional disturbances I can measure and quantify. I could measure the sedimentation rate, and how they bend to the floor, and so on. I could also, if I want, get information on how much they have in salary last year or the year before, and measure the ability to work and quantify that, too . . . then I have to put this together and make some sense about it.. Now I come to a point here, because people who have learned to say “I don’t feel well,” or “I have a functional disturbance, I must be ill,” also say “I must go to the doctor and see him.” And that is quite right, and that we have to accept. But all these people who are disturbed are not sick. It is my task to clarify whether this disturbance is an illness, an abnormality in life, or whether it is a normal reac-
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ASDREW
tion to the mi@. That is the point I see. Sometimes it’s easy to see that is not a medical problem, but most cases are both kinds, and some cases I can’t figure out” [Z-I].
One physician who expressed dissatisfaction with his job noted that activities other than diagnosis and treatment were the most satisfying aspects of work. He said his greatest satisfaction was in the “use of training and experience to teach people to avoid illness, but this comes seldom.” These physicians, while focussed on interaction with patients, saw that interaction in terms of problem solving that included significant non-medical dimensions. Others expressed more interest in nonproblem-solving relationships with patients. One said she especially enjoyed working with elderly patients. “They are so open and direct and they have lived through so much and have such wonderful stories about the way things used to be.” Another said that he had the best district in Sweden. Not only was it small, but “the people out here are so rugged and healthy.” Most shared interests of the physician in boating and fishing, providing a basis for discourse outside of medical problems. They also made small demands on service, which made it possible to see everyone on the same day they called and to take time to get to know each patient. This physician knew everyone in the district and took satisfaction in his integration into a real community. These two orientations, toward routine medical work and patient centered care, tended to divide the district general practitioners. Those interested in technical medicine focussed on diagnosis and cure and tended to be more negative about their jobs; those oriented toward patient care were more positive, provided they saw opportunities to realize that interest in their practices. The remaining two themes describing perspectives toward work were more universal. Ot’erwork
In spite of the fact that their receptions were open for regular hours and the work pace seemed fairly relaxed to this observer, all but one of the district general practitioners complained of being overworked. This theme had two related dimensions: a demand for services in excess of their capacities, and insufficient time to provide services they thought should be central to their practices. With respect to the first dimension, the average district served some 18,000 people while the ideal, stated as a political goal, was 3000. Relatively few people could be seen in a given year. Most of these had chronic conditions or non-urgent acute conditions. The volume of telephone calls to the reception was reported to be such that the physician felt it necessary to limit her or himself to one hour each day for telephone consultations. Only in the care centers and in the smallest districts was the telephone answered throughout the working day. One physician noted that there were plans to increase the number of district physicians and to reduce the size of the districts. “There are political intentions for the next decade. What are they? Nearness, availability and. continuity.. . But I’m not available, not today,”
C. TWADDLE The duties of the district general practitioner included, as noted above. overseeing the health of the district. Instead, the demand of symptomatic people was reported to be such that all of the physician’s time was spent responding to symptoms and performing routine chores, such as screening for drivers’ licenses. “I’m sorry to say, but primary prevention is unthinkable here. I have not the resources. and I have to be defensive. Secondary has what I think are unique opportunities. and I try to put in all efforts I can in secondary prevention. But that means that I have the patient here and something has happened (to him or her). He has no motivation to do as I want him.” Another physician noted that to engage in patient centered care requires ‘L.
time to build up confidence. Many have worn out lives. Good care means changing the way they live, but it is difficult to change abilities, their situation, their job demands, etc. I have much uncertainty about their lives, even their economic situation.”
Most of the district general practitioners reported frustration in carrying out what they thought would be good primary care and said a reduced work load would allow more time to do a better job. Isolation
Almost all of the district general practitioners interviewed reported a problem with isolation. Most complained that their isolation from colleagues in other specialties and from the hospitals not only reduced their satisfactions, but resulted in their being unable to keep up with developments in medicine. Some reported little contact with other district general practitioners. In sum, they reported poor colleague support. In addition, they reported feeling powerless with respect to the administration of the health plan for the city. Respondents reported that the move from the hospitals, where they had trained, to community practice involved an hiatus, not only with respect to the use of technology and the complexity of disease treated, but also with respect to colleagueship and intellectual stimulation. Several reported feeling it would be better for them and for their patients if they could rotate back to the hospital periodically to update their knowledge and to “recharge our intellectual batteries.” They also felt it would improve communication and understanding if hospital physicians were rotated periodically to the district receptions. All but one mentioned that there was little contact with other district physicians [El. While relatively autonomous in the running of their practices, respondents reported feeling that they had little impact on health policy in the city. As expressed by one respondent 6‘
. I think it is very interesting that you come all the way from America to ask my opinion. Nobody from Sweden has ever asked my opinion about our health system. I think Socialstyrelsen or Sjukcdrdsfb’rcalmingen [26] should be doing this kind of thing.” Respondents
reported
feeling that changes
should
Swedish physicians’ perspectives on work
be made to integrate them into the mainstream of medicine and provide them better input into policy questions. The acute primary care center
Physicians
at the acute primary care center shared few of the concerns voiced by other district general practitioners. As a clinic serving the entire city, seeing relatively more interesting acute problems, and acting as triage for the specialist and hospital components of the system, their social situation was quite different. They reported their work as less routine, the pace more variable, and the people as in more urgent need of attention. They were more occupied with medical, as opposed to patient, care. They reported their role as diagnosing, treating and referring diseases. Their contacts with patients were generally of short duration. While they reported heavy demand on the center, it was better staffed and the work could be shared. Respondents reported working hard, but not being overwhelmed by demand. They reported that their role in providing an interface between district general practice and the more specialized and technologically developed sectors integrated them with the whole medical care system in a way not possible for other district physicians. Acute primary care center physicians did not complain of isolation. At the same time, their contact with other district general practitioners made them aware of their problems, which they reported in detail along with the judgement that their complaints were legitimate. (Jourcentral)
PERSPECTWES
ON THE SYSTEM
Respondents were asked general questions about things they saw as (a) functioning well and (b) in need of change with respect to the medical care systems in Goteborg and Sweden. In addition, they were asked specifically about the ongoing shift to care centers as the basic unit of organization for the city. Five topics were mentioned by almost all respondents: the financing of medical care, relationships with hospitals and specialists, involvement in political decision making, the size of districts and (by definition) the care centers. Financing
The system by which patients paid a small sum at the first contact for each disease episode and physicians were on salary was regarded favorably by all but one of the district general practitioners interviewed. They reported the system provided equitable access. “Before the reforms [27] many people could not pay for care. Many who needed to see a doctor could not. Now we have built a system where all who need can be seen. You must see that that is a very great accomplishment.” The administrative system for reporting service delivery was simple and no respondent thought it a burden.
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While general practitioner salaries were lower than for specialists, no respondent complained about this discrepancy. The only dissent came from a respondent who had been in a private practice that had been ‘taken over’ by the public system in 1972. He thought the financing system led to abuse because the patient did not know what medical care costs. From his point of view, a system where a national health insurance system reimbursed the patient (the system before 1968) would be better because “the patient should know the price of consultation.” He also said a direct financial tie with the patient would increase the responsibility
of the physician.
Hospitals and specialists
Almost all the respondents reported problems in the relationship between the district general practitioner and the hospital sector. These were mostly problems in referrals. Most reported that when they referred to specialty clinics or hospitals they lost control over the patient. On one hand, there was no opportunity to follow the patient, to observe what was happening with reference to diagnosis and treatment. The referring physician reported feeling isolated from the decisionmaking process and unable to provide proper follow-up care. On the other hand, they said patients were often returned to them with inadequate information about diagnosis and treatment. Several complained that it was not infrequent for patients to come in for follow-up care with no information at all about events in the hospital or clinic. Often it was not possible to gain this information, even with repeated telephone calls. This was reported as a breach of colleagueship and as dangerous for the patient. More often a limited amount of information was returned to the district general practitioner, often only the diagnosis and the prescriptions ordered. This was thought to be often inadequate for planning proper follow-up care. One physician, who had served as a hospital specialist before becoming a district general practitioner, observed that by developing personal contacts a better flow of information could be obtained. He was also critical of his district colleagues for deficiencies in their referral patterns. He still had some problems. . . you have too large hospitals. . . and you have no good personal connections. That is a great disadvantage. Often I am angry with doctors in the hospitals.. because they are interested in research and such, and to care for people is of minor importance. They’re more interested in technical uroblems. O.K.. I know that.. . I know how it is. But if ihey have a patient referred from me I should have an answer, and I should have it before I have the patient. That doesn’t function all the time these patients are very often asking for a referral. I always tell them that a-hen I refer them to another doctor or a hospital I always have a question or a request to the person who gets the referral. When I ask silly questions I always get silly answers, and I’m not interested. I don’t want silly answers. If my questions are adequate and are based on common sense. I get answers that I, and the patients, get the benefit of. I tell them that I might not have the right question to ask the specialist, but when I’ve got the right question you don’t have to ask me for a referral, you get it automatically.. . In
ANDREW C.
768
that way I get the right answers, but it takes too much time to get them. That is the problem for me.”
Another theme sounded by a few respondents involved relationships with other primary care specialties. One respondent, after noting that the development of the child health programs had sharply reduced the number of children seen by district general practitioners, complained that pediatricians should either function as specialists taking referrals or convert to general practice. Political
decision
making
Major changes in the medical care system, such as the shift from solo practice to care centers, were reported to have taken place without the input of the district general practitioners. While few raised any objections to the decisions taken, they felt they should be consulted more. As one physician expressed it, decisions were ‘imposed from above’ in ways that did not build on existing strengths. He felt that there should be more attention to the ‘natural development’ of the system and less to radical change. But, he added “Nobody cares about the opinion of the physician. It is hard to develop interest in such things. Our opinions are of no practical value. District physicians are regarded as support workers. Our opinions are discounted.” District
size
All respondents saw the average district size as too large, adversely affecting the patient mix, limiting the range of conditions seen and their ability to respond to community health needs. “In a rural community the same doctor may have the pregnant mothers; he has the small children; and he has the old people, and all that. But in this town all the pediatrics, school health care, and even geriatrics-there are specialists who deal with that.. so my profile is very small compared with doctors in the rural districts.” District boundaries, because of size, were rigidly adhered to. Most said this was a disadvantage that could be eliminated with smaller districts, as a lighter work load would result in greater flexibility and choice by patients. But given the heavy demand, the rigidity of district boundaries was seen by some as an advantage. .. . we get some very high consumers of health care,-people who are seeking around town.. There are investigations done and they don’t tell the next doctor . and he makes them again and again. Among a thousand people who had some money from the social sick insurance in a year there were 67% who stayed home less than a week per year.. and there were three persons who had sick pay for more than 90 days a year. These large groups.. got 10% of the totally paid sick insurance money, but these three that get 50% of the money, they are a very expensive group. In a great town, we’ve quite a few hospital doctors and private doctors and district doctors. They could keep on going for quite a time before the authorities try to say what is really wrong with them. But we can say that most of the people are very loyal to the system. With this load, we have no chance to have what they call preventive medicine.. I have no resources to go out to people.”
TWADDLE Care centers
All respondents reported important advantages in the change to care centers and all but one stated a preference for working in one. Care centers were thought to provide greater flexibility in use of time and colleague support. There was no consensus on the potential impact on efficency or productivity. Several of these themes were sounded by one respondent who said of the care center “ . we have so short time of experience that our knowledge is not complete. My colleagues in the rdrdcenrralen say that they have the same problems that I have: they have too much to do and too little time. As I know yet, they have not that experience that could make us know that there is a solution of this problem. We have to see what happens in the future. But.. it is probably more convenient for the doctors and the personnel who works. They could be free. I can take an example from this week. I felt very bad and I had an infectious illness. On Monday, I called to be home because I didn’t feel fit for work. But I’m the doctor. so I have to work. In ucirdcenrral they have more doctors. and you could stay at home and cure your illness. But I don’t think these centers are more effective.. It means a lot of personnel.”
Another respondent practicing noted other ,personal advantages.
in a care center
“I am divorced and have two children. And I want to be with them when they are not in school. Here I can work part time in the mornings and another doctor works part time in the afternoon. It is very nice for both of us. If I had a district alone or a private practice there would be no possibility (to make such arrangements). It is the udrdcentralen that allows me to continue working as a physician.”
Most felt that the care centers would increase colleagiality and the quality of care. There would be opportunities for informal consultation that could improve diagnosis and treatment as well as the quality of referrals. They could reduce the sense of isolation. The one dissenter was a physician with a small district who had his office in his home. Plans for a care center in another part of his district were well advanced. Given the size of the district, no physicians were to be added to the center. ‘I . I will have a waiting room, reception, and examining rooms for adults, another set for infectious diseases, and yet another for children. I am one physician and will have three receptions in the same place. The dentist will also have a reception. I can meet the needs of this district now without full time effort. I see everybody the same day. The center will not make me more efficient. All this is so the dentist and I should have lunch together. I think it is ridiculous.” SUMMARY
AND PROPOSITIOSS
In this paper we have identified some themes that seem to be important to district genera1 practitioners in Sweden when they were asked to describe their satisfactions and frustrations with their work and their opinions regarding the successes and problems of the larger medical care system. In 1983, these themes were reviewed with several of the physicians
Swedish physicians’ perspectives on work
who were respondents in 1978-1979 [28]. There is to be confident that these themes existed as important concerns. Given the nature and size of the sample, we make no firm assertions about the distribution of perspectives in the population of general practitioners at that time. To recapitulate themes with reference to work in this sample, district general practitioners working in solo offices and care centers-reported the work as routine and complained of isolation (from hospitals and colleagues) and overwork. Those who enjoyed their work did so because they valued patient centered care over technical challenge; dissatisfied practitioners had the reverse priority. Those working in the acute primary care center expressed none of these concerns. They reported their work as varied and interesting, technically oriented and variably paced. They said they worked hard, but were not overworked. They felt well integrated into the ambulatory care and hospital systems by virtue of their focus on acute care and medical triage. With reference to the system, there were no differences between general practitioners working in solo offices, care centers and the acute primary care center. Respondents reported that hospitals and specialists did not provide for adequate communication with community based physicians. General practitioners felt alienated from the political decision making process. Districts were too large on the average. Care centers could cut down on isolation from colleagues but were not thought to be an answer to other work problems. With one exception, the financing of the system was seen as a positive achievement rather than a problem. Nevertheless, it was impressive that district general practitioners, when asked about satisfactions and frustrations with work and with the medical care system, focused mostly on problems. In this they were distinct from other categories of physicians. It is possible that changes since this study have mitigated these problems and changed the perceptions of these respondents. Given the issues in the United States, it is also impressive that pubhc financing was not seen as a problem, but an achievement [29]. The themes related to apparent satisfaction of district general practitioners might be reducible to three: (1) isolation from colleagues, facilities and political decision making; (2) overwork as a result of too large districts and heavy demand relative to resources; and (3) patient care, which, if valued, made the medically routine aspects of work interesting. The overwork theme is supported in some of the Swedish literature. In a review article on psychosocial stress in medical practice (which drew mostly on non-Swedish studies) Arnetz [30] noted that in 1979 30% of all Swedish physicians worked more than 47 hr a week and a substantial minority worked as much as 65 hr per week. Real work time had increased since 1977. These figures did not distinguish the small minority of physicians in general practice from the overwhelming majority working in hospitals, however [cf. 311. Swedish physicians had higher death rates than others with equivalent academic training [cf. 321 and general practitioners had higher death rates than specialists, especially from heart disease [cf. 331. Extrapolating from data collected reason
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outside Sweden. .4metz presented a case that work tempo, sleep problems, psychological problems, substance abuse and other difficulties might be associated with overwork and stress. The themes identified in this paper sug_gest that general practice might be a more satistying occupation if some way were found to reduce isolation, provide more colleague support and increase the supply of generalist physicians relative to population. To the extent that Arnetz is on target, such changes may also have a positive effect on the health of general practitioners. Indeed, events in Sweden [e.g. 6, 341 should allow a test of these propositions as the city and country convert number
from
solo offices to care centers.
.I\ larger
of general practitioners now practice in group settings and a repeat of this study could show improvement in the perspectives of district general practitioners as a result. The hiatus between the ambulatory sector and the hospital would still be a problem. It would be interesting to experiment with a system where general practitioners rotate back to the hospitals periodically and/or where specialists attend as consultants in general practice receptions. The identification of satisfaction in practice with a patient-care rather than a disease orientation suggests that some modification in medical education could be beneficial. As in other Western nations. medical students are recruited through a competitive process focused on the laboratory sciences. Their predisposition toward a disease orientation is reinforced in the medical education process. A rigorous focus on illness and sickness [35] in the medical curriculum could tap the scientific interest of students while cultivating an interest in the problems of patients. It would be interesting to study whether such an approach might yield a larger proportion of district physicians with more positive perpectives on their work. It seems equally likely, however, that there are inherent problems in the position of the general practitioner that transcend the situation of the Swedish case. Mechanic a decade earlier found many similar patterns among British general practitioners, [36-44] whose social circumstances were in many ways dissimilar [36-44]. They were the least satisfied of British physicians and could be distinguished by their scientific versus patient orientations, with the latter expressing greater satisfaction with work. Their perspectives also contained themes of overwork, isolation, underutilization of skills and so forth [38,41]. British GPs had smaller practices, had moved earlier into group practices [45], and had a formal tie to the hospital sector as gatekeepers [7,40,41,42.45] their Swedish counterparts lacked. Clearly, what is needed is a systematic comparison of general practice in different countries. Only then might it become possible to dissect the elements that separate the cultural from the structural and the meaningful from the ephemeral structural aspects of practice. To make even the Swedish case convincing, it will be necessary to have a larger data base. This paper, hopefully, has provided insights into features than need to be measured. Their better measurement is left to another study. It will also require a series of comparisons with other physician groups in Sweden.
770 That
ASDREW
task
is left to other
papers
based
C.
on this study.
Acknowledgement-The research on which this paper is based was supported by the Svenska Institut, Sociologiska Institutionen of Goteborg University and the Graduate School of the University of Missouri. REFERENCES I. Anderson 0. Health Care: Can There be Equity? Wiley, New York, 1972. 2. Anderson 0. and Bjiirkman J. Equity and health care: Sweden, Britain and the United States. In The Shaping of the Swedish Health Svstem, pp. 223-237. St Martin. New York, 1980. . __ 3. Flora P. and Heidenheimer A. The Deeelopmenr of Welfare States in Europe and America. Transaction, New Brunswick, 1981. _ 4. Navarro V. National and Regional Health Planning in Sweden, USDHEW-NIH Publication NO. 74-240. Washington, D. C., 1974. 5. Hessler R. and Twaddle A. Sweden’s crisis in medical care. J. Hlth Policy Polit. Law 7, 44&459, 1982. 6 Twaddle A. and Hessler R. Power and change: the case of the Swedish commission of inquiry on health and sickness care. J. Hlth Policv Poh’t. Law. 11, 1. 19-40, 1986. 7. Cartwright A. and Anderson R. General Practice Recisired: A Second Study of Patients and Their Doctors. Tavistock, London, 198 I. 8. Gill D. The British National Health Semite, A Sociologist’s Perspectitie, USDHHS-NIH Publication No. 80-2054. Washington, D.C., 1980. T. The Division in British .Medicine. St 9. Honigsbaum Martin, New York, 1979. IO. Starr P. The Social Transformation of American Medicine. Basic, New York, 1982. Il. This assertion is sufficiently commonplace in sociology to make extensive documentation superfluous. It is central to the work of Marx, Merton’s [46] conception of role sets, Goode’s [47] conception of role strain, and the seminal work of Berger and Luckman [48]. Within the traditions of medical sociology, Duff and Hollinghead [49] have used this approach most effectively in documenting differences among health workers. 12. Twaddle .4. and Hessler R. Scandanavian medical care: lessons for the U.S.? Unpublished paper. of general practice is in the past tense, 13. Description referring to the study period, 1978-1979. While we have not heard of changes in medial education since that period, the data at our disposal are not current on this point. Unless otherwise noted, all characterizations of Swedish medical care are specific to the study period. 14. SOU (Statens Offentliga Uttredningar) Husliikare, p. 74. Socialstyrelsen, S&kholm, 1978. 15. While more politically accountable than in some other societies, such as the U.S.A., it is inarguably true that policy decisions with respect to medical care have been dominated by the Swedish Medical Association (Lakarfiirbundet). There is not space to document this assertion here. The reader is referred to [5. 34 and 121. 16. Bratthall B., Molstedt B. and Ogrelius Y. Vad Gjorde en Distriksllkare i Maj 1968? Liikartidningen 66, 2902-2904, 1969. 17. Carder M. and Klingeberg B. Towards a salaried medical profession: how Swedish was the Seven Crowns Reform..In The Shaping of the Swedish Health System, DD. 143-172. St Martin, New York, 1980. 18. ‘Merton R., Fiske M. and Kendall P. The Focused Inrerrierv. Free Press, Glencoe, Ill., 1956. 19. Glaser B. and Strauss A. The Discovery of Grounded Theory. Aldine, Chicago, 1967. 20. Kaplan A. The Conduct of Inquiry. Chandler, San Francisco, 1964.
TWADDLE
21. There were. however, major differences between groups. Discussion of these will have to be deferred to another paper, as they cannot be summarized briefly. 22. At the time of the study. there were 36 districts in Giiteborg. Because of the difficulty in attracting physicians into urban general practice. almost one third of those positions were vacant. Vacancies seemed not to be associated with characteristics of the districts on superficial inspection. The physicians in the sample were over one fourth of all district positions in the city or one third of the district physicians in the city. Representativeness, however, is not at issue as we are not trying to present a distributive picture of practices. Rather, we are trying to capture a range of types of responses. This sample seems adequate to that task. 23. This respondent had worked as a hospital specialist and part time primary care physician. When forced to a choice between hospital medicine and district general practice, he chose the latter. it is remarkable 24. While not using the same vocabularies. that this statement shows close parallels with Baumann’s [50] classification of symptoms, especially feeling states and capacities. It also parallels Twaddle’s [35] distinction between disease and illness. It leaves out Baumann’s category of ‘other’ symptoms that involve neither capacities nor feeling states and Twaddle’s ‘sickness’ category which is the social dimension of poor health. 25. It was not until the last interview that it was discovered that there was a regularly scheduled weekly meeting for district physicians held in the city. In light of this, the assumption that the nature of the practice kept physicians atomized becomes more problematic. Either these meetings were not well attended or they were not serving some felt need of the practitioners. This was not explored in the interviews and must be left to a subsequent study. Board and the Medical Care 26. The Social Welfare Administration, respectively. 27. Referring to the ‘Seven Crowns Reform’ of 1968 [cf. 171. 28. The author returned to Sweden in the Summer of 1983 to document changes in the medical care system since the earlier study. As part of that effort, several respondents from 1978-79 were reinterviewed on .the effects of changes on their practices. Findings from this study were reviewed and commentary solicited. groups will be presented in 29. Data on other physician other papers. Respondents from the earlier study were presented with a summary of findings in 1983. While all agreed that the themes were accurately portrayed, some felt that the overall picture of the district physician was too negative. While they focused on problems, they were at the same time personally satisfied with their work. Some data collected at a meeting of district physicians supported this view [51]. B. Stark Psykosocial Stress i LZkaryrket: Stort 30. Aietz Behiiv av Forbattringer i Arbetsmiljiin. fikartidningen 79, 4807-4809, 1982. 31. Statistika Centralbyrin. Teknisk Rapport Avseende 1977 OCH 1978Ars Undersdkningar au hna&firhaUanden. Liber, Stockholm, 1980. 32. MellstrBm D. Pdcarkas Aldrandet of Olika Omgicningsfaktorer? Liikardagarna i orebro. SPRI (SPRI Rapport No. 92/1982), Stockholm 1982. L. and Theorell T. Psycosocial Arbetsmiljij 33. Alfredsson och Hjlrtinfarktrisk. Ltikartidningen 79, 4658-4661, 1982. 34. Twaddle A. and Hessler R. Restructuring Swedish medical care: the new health and sickness care law. Paper presented at the Annual Meeting of the Midwest Sociological Society, April 11, 1985. A. Sickness Behacior and the Sick Role. 35. Twaddle Schenkman, Cambridge, Mass., 1979.
Swedish physicians’ perspectives on work 36. !&chanic D. General practice in England and Wales. .Wed. Care 6, 245-260. 1968a. 37 Mechanic D. General medical practice in Engiand and Wales: it’s organisation and future. X=w Engl. J. Med. 279, 680-689, 1968b. 38. Mechanic D. Practice organisation among general practitioners in England and Wales. Med. Cure 8, 15-25, 1970a. 39. Mechanic D. Private practice among general practitioners in the English Natianal Health Service. Med. Care 8, 32&332, 1970b. 40. Mechanic D. Doctors in revolt: the crisis in the English National health Service. Med. Care 8, 442-455, l97Oc. 41. Mechanic D. Correlates and frustration among British general practitioners. J. Hlth sot. Behav. 11, 87-107, 1970d. 42. Mechanic D. The English National Health Service: some comparisons with the United States. J. Hlrh sot. Behav. 12, 18-29, 1971.
43. Mechanic D. General medical practice: some comparisons between the work of primary care physicians
44.
45. 46. 47. 48. 49. 50. 51. 52.
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in the United States and England and Wales. Med. Care 10, 402120. 1972. Mechanic D. Ideology, medical technoloav. and health care organization in-modern nations. Amy-J. publ. Hlth 65, 241-247. 1975. Jeffreys M. and Sachs H. Rethinking General Practice. Tavistock, London, 1983. Merton R. Social Theory and Social Structure. Free Press, Glencoe, Ill., 1949. Goode M. A theory of role strain. .4m. Social. Rev. 12, 483-496, 1960. Berger P. and Luckmann T. The Social Consrruction of Reality. Doubleday-Anchor, Garden City, N.Y.. 1967. Duff R. and Hollingshead A. Sickness and Society. Harper & Row. New York. 1968. Baumann B. Diversities in conceptions of health and physical fitness. J. Hlrh Hum. Behar. 2, 39-46, 1961. Brunei1 U. Vad gor vi pa vlrdcentralen. Styrsii, Gar det att Mata? Mimeo, 1983. Heidenhiemer A. and Elvander N. The Shaping of the Swedish Healrh System. St Martin, New York, 1980.
763-771. resened
1986 Copyright
0277-9536g86 93.00 + 0.00 C 1986 Pergamon Journals Ltd
SWEDISH PHYSICIANS’ PERSPECTIVES ON WORK AND THE MEDICAL CARE SYSTEM: THE CASE OF DISTRICT GENERAL PRACTITIONERS ASDREW C. TWADDLE Department of Sociology and Department of Family and Community Medicine, University of Missouri,
Columbia,
MO 6521 I, U.S.4.
Abstract--Interviews
with district general practitioners in a large Swedish city in 1978-1979 solicited their perspectives on the frustrations and satisfactions they felt in their work, and on the successes and failures of the Swedish medical care system. With respect to work, four themes emerged: medical routine, patient centered care, overwork and isolation. Five themes emerged with respect to the system: financing,
relationships with hospitals and specialists, involvement in political decision making, the size of districts and care centers. These themes are discussed with relation to the influence of the social situation of practice to the influence of the social situation of practice and the conditions for physician satisfaction. Key words-ambulatory
care, Sweden,
physicians,
health
care systems
This paper reports findings on the perspectives of
THE DISTRICT
district-based general practitioners (disrriktsliikare) toward [l] their work situations and [2] the medical
PHYSICIAN
Responsibilities
Ambulatory medical care in Sweden was delivered by design in specialty clinics and by district general practitioners. In practice, a considerable amount of ambulatory care is also delivered by hospital emergency rooms [12]. By design, the patient was intended to initiate all medical care with the general practitioner, who will then make referrals, if needed, to appropriate specialty or hospital care. The general practitioner, who was assigned to serve a defined geographic district, was intended to be the front line of medical care, the dispenser of general services, and the screen for specialty services. In addition to individually focused primary care, (s)he was officially responsible for the health of the population of the district: monitoring the environment for health hazards and engaging in activities similar to those of a public health officer.
care system within which they served. Datz come from interviews with district physicians in Goteborg, Sweden during the 1978-1979 academic year. Previous work on the Swedish medical care system has fallen into one of several categories, none of which have taken the perspectives of the direct providers of care as problematic: epidemiological and utilization characteristics [e.g. I], organization of the Swedish medical care system [e.g. 2, 31 and planning of health services [4-6]. While some degree of diversity is recognized in the general population with respect to social class and among different interest groups in the society at large, the tendency has been to treat the participants in the Swedish medical care system as homogeneous, sharing the same general interests and the same general social circumstances. Studies in other societies, however, have documented important attitudinal and behavioral differences among health workers, and even among physicians, that are related to location in the structure of medical care [e.g. 7-101. The study on which this report is based was an exploration of the perspectives on the ambulatory medical care system held by physicians and others. An attempt was made to identify the kinds of occupations and settings that compose the system on the assumption that different social circumstances will produce different perspectives [ 1I]. In this report, we focus on one group of medical care providers, the general practitioners, that have a particularly critical role in the system of ambulatory care in Sweden. It is expected that this will be the first of several reports dealing with different occupational groups. It represents a partial set of perspectives, but one important to an analysis of the larger system.
Training
Medical training in Sweden at the time of this study [13] consisted of a 6 year program entered after a 4 year natural science ‘line’ in the gymnasium with content virtually identical to that of the United States and Western European societies. Specialty training was entered at the close of medical school and took from 2 to 5 years. General medicine was treated as a specialty with a residency program nominally geared to ambulatory care but carried out, for the most part, by specialty rotations in the hospitals. It bears analogy with family practice in the U.S. Practice structure
General medicine in Sweden developed as an ambulatory care focused, solo practice [14] entirely outside the hospital system, as in the U.K. At the 763
AmaEw
764
time of the study almost all district physicians were in solo practice. As in the rest of the Western world where medical care organization has been dominated by physicians [15] general practice was a shrinking segment of medical care in Sweden from 40% of all public physicians in 1920, 18% by 1970 and less than 10% by 1978. Swedish medicine, more than any other place known to this writer, was dominated by hospitals and specialists. General practice was low in glamour and prestige within medicine, a feature not without notice among physicians in our interviews. Two developments in the decade preceding this study were important to understanding some of the concerns we will address below. First, in 1972 the boundaries between public and private practice had been sharpened. Physicians were forced to choose one sector or the other, and were no longer allowed ‘part time’ private practices while on the public payroll. All of the general practitioners in this study were in the public sector. Second, both national and local decisions had been taken to convert solo general practice offices into ‘care centers’ (V&dcentra[er). Districts were to be made larger and several district physicians were to combine practices along with other primary care providers such as community nurses, social workers, pediatricians, maternal health physicians and dentists. Both of these developments, one implemented and the other in process, were important in the thinking of respondents in this report. In 1968, general practice patients in Gijteborg were disproportionately female (60%) and aged [16]. In 1978, the percentage of young patients had declined and the aged had sharply increased. Diseases treated had shifted from the acute and infectious to the chronic and degenerative-this according to a respondent who kept statistical records on his practice in a working class district. These changes reflected both the general aging of the population, more than 17% of whom were over 65, and a shift of acute medical problems toward care in the hospital sector [cf. 51. As the front line of medical care, the district general practitioner had a strategic position in the overall system as provider of primary services and the screen and referral agent for other services. The actual performance of the district system of general practice was not as comprehensive as its official role, as we will show below. METHODS
AND DATA COLLECTION
This paper reports on a portion of a larger study that focused more comprehensively on the ambulatory medical care system of a large city, Giiteborg. The goal was to describe and evaluate that system from the perspectives of a variety of participants: general practitioners, pediatricians, maternal health physicians, social physicians, industrial physicians, nurses, social workers, pharmacists and the general public. Focused interviews [18] were tape recorded in the physicians’ receptions with a snowball sample selected by theoretical saturation criteria [19]. The design was exploratory, intended to discover the persepctives of the respondents rather than to test hypotheses [cf. 201. A focused interview guide was
C.
TWADDLE to cover a description of the practice (including its organization and the character of the clientelle), sources of satisfaction and frustration in work, an assessment of the respondents’ views of the medical care system at large, and changes the respondent would like to see in the system. Interviews were conducted in English, which all respondents handled with remarkable facility: English was a prerequisite to university training. The sample was constructed with a snowball design from a key informant, who was well placed in the medical care system and knew its political arrangements intimately. An effort was made to identify all types of practitioners who delivered primary care and within each type the kinds of settings (with respect to practice organization and characteristics of the client population) that might result in different perspectives. Each respondent was asked to identify other practitioners of the same type who might provide a different perspective on work and the system. This continued until interviews produced no new information or the referrals seemed to have come full circle and practitioners identified had already been contacted. In general, there w-as remarkable uniformity within categories of respondents making small samples seemingly representative of that group [21]. Goteborg was not ‘representative’ of Sweden. It was the second largest city in the country. It was more industrial, more leftist in its politics and had an older population than the nation as a whole. It also had a larger percentage of immigrants and a higher level of unemployment resulting from the collapse of shipbuilding in the previous decade. All of these factors may have had an unmeasured impact on our results. Most of the respondents were in solo practice serving districts ranging from just over 2000 population to over 23,000 and from upper class to ‘skid row’ conditions. A few were in care centers (ccirdcentruler) where two or more district general practitioners practiced alongside several other kinds of medical, dental and nursing practitioners. TWO worked in an ‘acute primary care center,’ which was a clinic attached to a telephone bank where people could call with health problems. In all, eight district general practitioners were interviewed [22]. A content analysis of responses to interviews showed the district general practitioners divided into two groups. On the one hand were those in true general practice, either in solo offices or in care centers. On the other were physicians in the acute primary care center, who differed in almost every particular as we report below. There were no evident differences in the responses of general practitioners based on the characteristics of their client populations or the districts, with the possible exception of size.
constructed
PERSPECTIVES
ON WORK
Among the district general practitioners practicing in solo offices and care centers four themes emerged regarding their perspectives on work: it was medically routine, patient centered, had inadequate resources and was isolated from the rest of medicine.
Swedish physicians’ perspectives on work Medical routine
Technical aspects of medical work were seen as quite routine. Emergent problems were often taken to the hospital emergency rooms or the acute primary care center. Complicated problems in diagnosis and treatment were referred to specialty clinics or hospitals. The general practitioner was left with the surveilante of chronic conditions, health screening and follow-up care. One physician, who found more intellectual challenge in his job than was the case for other respondents, expressed his orientation to work in the following manner. “There is not so much technical facilities for health care, and most is pen and paper work and a small fund of knowledge and a fund of common sense, I hope. That’s primary in this. . . . My education for this job is not what it had to be, because I had a profession that is very technical [23]. . I find today that very much of the technical work 1 have no time to do. I want to do it, but I have no time. So I have to take care of the whole human being, and minor technicalities I have to refer to the specialists, to the young doctors that are interested in science and who have more training than I have today to solve these problems.. This is a kind of center for sorting out people. . the first primary station for screening. I have two things to do: the first is to screen people in need. . When I refer people to hospitals and specialists in this first screening I put them into three groups because of the implications for referring. The first group is for people who are very ill; there is a life threat and danger, or I suspect there could be. There are vital indications for referring them, and I have not to waste time. Among three hundred patients in half a year, I referred three to the hospital. The second group are people who need more resources, maybe more skill from a doctor in this special field or maybe special resources-operating theatres, anesthesiologists, and other kinds. (For the third group) I have an indication which I call social, or maybe convenient, reasons to refer them. (These are) mostly old people. There is not technical objection to treating them at home, but I have to do investigations and observations. For the patients it is more convenient to do this in the hospital. That means.. . that there is a chance in a hundred that there is a very ill patient that is here in this place, and that is not very much. What about the other 99%? They live tomorrow and I can always think of them then. But this one that is urgent, whom I have to find. . I don’t express this very well, but I hope you understand. They are not very ill patients that I see here.”
While this physician regarded the identification of the one patient in 100 with a significant medical problem as a challenge, and seemed to take satisfaction in finding that case, several other district general practitioners seemed to find the routine nature of their work boring. Another respondent described his activities as “certification of illness (for social insurance), certification for driver’s licenses,
and documentation of injury, mostly for insurance purposes.” He claimed to do no therapy and described his work as “simple drudgery.” These respondents all noted that their training took place mostly in hospitals where complicated diagnosis and treatment provided intellectual challenges. Most felt that to be placed then in a situation where the work was “simple and monotonous” meant that their skills were underutilized and there
165
was insufficient challenge to make the job very interesting. Others, while acknowledging that the medical skills required for their work were minimal and the work was routine, took satisfaction from other aspects of their jobs, which brings us to the second major theme in the interviews. Patient centered care
The routine nature of the medical work in district general practice was regarded as stultifying by two of the respondents, who found their jobs bonng and alienating. The others reported satisfaction in interaction with sick people. This was expressed as an emphasis on ‘patient care’ which was contrasted with ‘illness centered care.’ The perspective was well summarized by one respondent. “I mostly describe the health care in two sections. One is what I call illness centered care: there is a technical problem that has a solution and the human who has the problem has no significance. Appendicitis is no problem. It is a case of operation. If it were a king or a kid it’s the same treatment. But in other cases it’s not the illness or sickness but the person that has the illness that is the most important. You should not treat the disease but the patient. This is the second section: the patient centered care and, oi course, in this kind of work, in general practice, there is more patient centered care than illness centered.. That is what I am really interested in. I must take the time. If I need half an hour for one person he gets it. And they sit crowded in the waiting room-1 don’t care. I think it is my greatest problem and takes more time than anything when I have a patient and I say this and this investigation show nothing. And the patient says, “But why do I feel so bad?’ Just that kind of people that I don’t have to treat, that should not have treatment-that takes the most time. I have to get them to understand. I have to explain to people why I want them to do this or that or why I don’t want them to do anything at all. I have to take time to explain this, because if I don’t they do as they like and the result might be disastrous if I’m unlucky. So that is the vital point of the care here. I have to explain to people and they have to get a good explanation . . . and that is the difference between health care today and twenty years ago. People are more educated; they ask more questions and they are more critical. We have to accept this. . .
I don’t ,call these people sick people; they are disturbed people, and the disturbances have two poles. The first pole is that they tell me “I don’t feel well,” “I feel dizzy,” “I have some kind of ache.” This disturbance of the subjective feeling of well being, I have no measurements for that; I couldn’t tell. I think that the man who has to have help to get up from bed has to have more ache than the man who can get up by himself, but I don’t know. . . The second pole is those who say “I don’t function well.” “I can’t climb a ladder,” “ I can’t do my job,” or whatever. And that is better, because the functional disturbances I can measure and quantify. I could measure the sedimentation rate, and how they bend to the floor, and so on. I could also, if I want, get information on how much they have in salary last year or the year before, and measure the ability to work and quantify that, too . . . then I have to put this together and make some sense about it.. Now I come to a point here, because people who have learned to say “I don’t feel well,” or “I have a functional disturbance, I must be ill,” also say “I must go to the doctor and see him.” And that is quite right, and that we have to accept. But all these people who are disturbed are not sick. It is my task to clarify whether this disturbance is an illness, an abnormality in life, or whether it is a normal reac-
766
ASDREW
tion to the mi@. That is the point I see. Sometimes it’s easy to see that is not a medical problem, but most cases are both kinds, and some cases I can’t figure out” [Z-I].
One physician who expressed dissatisfaction with his job noted that activities other than diagnosis and treatment were the most satisfying aspects of work. He said his greatest satisfaction was in the “use of training and experience to teach people to avoid illness, but this comes seldom.” These physicians, while focussed on interaction with patients, saw that interaction in terms of problem solving that included significant non-medical dimensions. Others expressed more interest in nonproblem-solving relationships with patients. One said she especially enjoyed working with elderly patients. “They are so open and direct and they have lived through so much and have such wonderful stories about the way things used to be.” Another said that he had the best district in Sweden. Not only was it small, but “the people out here are so rugged and healthy.” Most shared interests of the physician in boating and fishing, providing a basis for discourse outside of medical problems. They also made small demands on service, which made it possible to see everyone on the same day they called and to take time to get to know each patient. This physician knew everyone in the district and took satisfaction in his integration into a real community. These two orientations, toward routine medical work and patient centered care, tended to divide the district general practitioners. Those interested in technical medicine focussed on diagnosis and cure and tended to be more negative about their jobs; those oriented toward patient care were more positive, provided they saw opportunities to realize that interest in their practices. The remaining two themes describing perspectives toward work were more universal. Ot’erwork
In spite of the fact that their receptions were open for regular hours and the work pace seemed fairly relaxed to this observer, all but one of the district general practitioners complained of being overworked. This theme had two related dimensions: a demand for services in excess of their capacities, and insufficient time to provide services they thought should be central to their practices. With respect to the first dimension, the average district served some 18,000 people while the ideal, stated as a political goal, was 3000. Relatively few people could be seen in a given year. Most of these had chronic conditions or non-urgent acute conditions. The volume of telephone calls to the reception was reported to be such that the physician felt it necessary to limit her or himself to one hour each day for telephone consultations. Only in the care centers and in the smallest districts was the telephone answered throughout the working day. One physician noted that there were plans to increase the number of district physicians and to reduce the size of the districts. “There are political intentions for the next decade. What are they? Nearness, availability and. continuity.. . But I’m not available, not today,”
C. TWADDLE The duties of the district general practitioner included, as noted above. overseeing the health of the district. Instead, the demand of symptomatic people was reported to be such that all of the physician’s time was spent responding to symptoms and performing routine chores, such as screening for drivers’ licenses. “I’m sorry to say, but primary prevention is unthinkable here. I have not the resources. and I have to be defensive. Secondary has what I think are unique opportunities. and I try to put in all efforts I can in secondary prevention. But that means that I have the patient here and something has happened (to him or her). He has no motivation to do as I want him.” Another physician noted that to engage in patient centered care requires ‘L.
time to build up confidence. Many have worn out lives. Good care means changing the way they live, but it is difficult to change abilities, their situation, their job demands, etc. I have much uncertainty about their lives, even their economic situation.”
Most of the district general practitioners reported frustration in carrying out what they thought would be good primary care and said a reduced work load would allow more time to do a better job. Isolation
Almost all of the district general practitioners interviewed reported a problem with isolation. Most complained that their isolation from colleagues in other specialties and from the hospitals not only reduced their satisfactions, but resulted in their being unable to keep up with developments in medicine. Some reported little contact with other district general practitioners. In sum, they reported poor colleague support. In addition, they reported feeling powerless with respect to the administration of the health plan for the city. Respondents reported that the move from the hospitals, where they had trained, to community practice involved an hiatus, not only with respect to the use of technology and the complexity of disease treated, but also with respect to colleagueship and intellectual stimulation. Several reported feeling it would be better for them and for their patients if they could rotate back to the hospital periodically to update their knowledge and to “recharge our intellectual batteries.” They also felt it would improve communication and understanding if hospital physicians were rotated periodically to the district receptions. All but one mentioned that there was little contact with other district physicians [El. While relatively autonomous in the running of their practices, respondents reported feeling that they had little impact on health policy in the city. As expressed by one respondent 6‘
. I think it is very interesting that you come all the way from America to ask my opinion. Nobody from Sweden has ever asked my opinion about our health system. I think Socialstyrelsen or Sjukcdrdsfb’rcalmingen [26] should be doing this kind of thing.” Respondents
reported
feeling that changes
should
Swedish physicians’ perspectives on work
be made to integrate them into the mainstream of medicine and provide them better input into policy questions. The acute primary care center
Physicians
at the acute primary care center shared few of the concerns voiced by other district general practitioners. As a clinic serving the entire city, seeing relatively more interesting acute problems, and acting as triage for the specialist and hospital components of the system, their social situation was quite different. They reported their work as less routine, the pace more variable, and the people as in more urgent need of attention. They were more occupied with medical, as opposed to patient, care. They reported their role as diagnosing, treating and referring diseases. Their contacts with patients were generally of short duration. While they reported heavy demand on the center, it was better staffed and the work could be shared. Respondents reported working hard, but not being overwhelmed by demand. They reported that their role in providing an interface between district general practice and the more specialized and technologically developed sectors integrated them with the whole medical care system in a way not possible for other district physicians. Acute primary care center physicians did not complain of isolation. At the same time, their contact with other district general practitioners made them aware of their problems, which they reported in detail along with the judgement that their complaints were legitimate. (Jourcentral)
PERSPECTWES
ON THE SYSTEM
Respondents were asked general questions about things they saw as (a) functioning well and (b) in need of change with respect to the medical care systems in Goteborg and Sweden. In addition, they were asked specifically about the ongoing shift to care centers as the basic unit of organization for the city. Five topics were mentioned by almost all respondents: the financing of medical care, relationships with hospitals and specialists, involvement in political decision making, the size of districts and (by definition) the care centers. Financing
The system by which patients paid a small sum at the first contact for each disease episode and physicians were on salary was regarded favorably by all but one of the district general practitioners interviewed. They reported the system provided equitable access. “Before the reforms [27] many people could not pay for care. Many who needed to see a doctor could not. Now we have built a system where all who need can be seen. You must see that that is a very great accomplishment.” The administrative system for reporting service delivery was simple and no respondent thought it a burden.
767
While general practitioner salaries were lower than for specialists, no respondent complained about this discrepancy. The only dissent came from a respondent who had been in a private practice that had been ‘taken over’ by the public system in 1972. He thought the financing system led to abuse because the patient did not know what medical care costs. From his point of view, a system where a national health insurance system reimbursed the patient (the system before 1968) would be better because “the patient should know the price of consultation.” He also said a direct financial tie with the patient would increase the responsibility
of the physician.
Hospitals and specialists
Almost all the respondents reported problems in the relationship between the district general practitioner and the hospital sector. These were mostly problems in referrals. Most reported that when they referred to specialty clinics or hospitals they lost control over the patient. On one hand, there was no opportunity to follow the patient, to observe what was happening with reference to diagnosis and treatment. The referring physician reported feeling isolated from the decisionmaking process and unable to provide proper follow-up care. On the other hand, they said patients were often returned to them with inadequate information about diagnosis and treatment. Several complained that it was not infrequent for patients to come in for follow-up care with no information at all about events in the hospital or clinic. Often it was not possible to gain this information, even with repeated telephone calls. This was reported as a breach of colleagueship and as dangerous for the patient. More often a limited amount of information was returned to the district general practitioner, often only the diagnosis and the prescriptions ordered. This was thought to be often inadequate for planning proper follow-up care. One physician, who had served as a hospital specialist before becoming a district general practitioner, observed that by developing personal contacts a better flow of information could be obtained. He was also critical of his district colleagues for deficiencies in their referral patterns. He still had some problems. . . you have too large hospitals. . . and you have no good personal connections. That is a great disadvantage. Often I am angry with doctors in the hospitals.. because they are interested in research and such, and to care for people is of minor importance. They’re more interested in technical uroblems. O.K.. I know that.. . I know how it is. But if ihey have a patient referred from me I should have an answer, and I should have it before I have the patient. That doesn’t function all the time these patients are very often asking for a referral. I always tell them that a-hen I refer them to another doctor or a hospital I always have a question or a request to the person who gets the referral. When I ask silly questions I always get silly answers, and I’m not interested. I don’t want silly answers. If my questions are adequate and are based on common sense. I get answers that I, and the patients, get the benefit of. I tell them that I might not have the right question to ask the specialist, but when I’ve got the right question you don’t have to ask me for a referral, you get it automatically.. . In
ANDREW C.
768
that way I get the right answers, but it takes too much time to get them. That is the problem for me.”
Another theme sounded by a few respondents involved relationships with other primary care specialties. One respondent, after noting that the development of the child health programs had sharply reduced the number of children seen by district general practitioners, complained that pediatricians should either function as specialists taking referrals or convert to general practice. Political
decision
making
Major changes in the medical care system, such as the shift from solo practice to care centers, were reported to have taken place without the input of the district general practitioners. While few raised any objections to the decisions taken, they felt they should be consulted more. As one physician expressed it, decisions were ‘imposed from above’ in ways that did not build on existing strengths. He felt that there should be more attention to the ‘natural development’ of the system and less to radical change. But, he added “Nobody cares about the opinion of the physician. It is hard to develop interest in such things. Our opinions are of no practical value. District physicians are regarded as support workers. Our opinions are discounted.” District
size
All respondents saw the average district size as too large, adversely affecting the patient mix, limiting the range of conditions seen and their ability to respond to community health needs. “In a rural community the same doctor may have the pregnant mothers; he has the small children; and he has the old people, and all that. But in this town all the pediatrics, school health care, and even geriatrics-there are specialists who deal with that.. so my profile is very small compared with doctors in the rural districts.” District boundaries, because of size, were rigidly adhered to. Most said this was a disadvantage that could be eliminated with smaller districts, as a lighter work load would result in greater flexibility and choice by patients. But given the heavy demand, the rigidity of district boundaries was seen by some as an advantage. .. . we get some very high consumers of health care,-people who are seeking around town.. There are investigations done and they don’t tell the next doctor . and he makes them again and again. Among a thousand people who had some money from the social sick insurance in a year there were 67% who stayed home less than a week per year.. and there were three persons who had sick pay for more than 90 days a year. These large groups.. got 10% of the totally paid sick insurance money, but these three that get 50% of the money, they are a very expensive group. In a great town, we’ve quite a few hospital doctors and private doctors and district doctors. They could keep on going for quite a time before the authorities try to say what is really wrong with them. But we can say that most of the people are very loyal to the system. With this load, we have no chance to have what they call preventive medicine.. I have no resources to go out to people.”
TWADDLE Care centers
All respondents reported important advantages in the change to care centers and all but one stated a preference for working in one. Care centers were thought to provide greater flexibility in use of time and colleague support. There was no consensus on the potential impact on efficency or productivity. Several of these themes were sounded by one respondent who said of the care center “ . we have so short time of experience that our knowledge is not complete. My colleagues in the rdrdcenrralen say that they have the same problems that I have: they have too much to do and too little time. As I know yet, they have not that experience that could make us know that there is a solution of this problem. We have to see what happens in the future. But.. it is probably more convenient for the doctors and the personnel who works. They could be free. I can take an example from this week. I felt very bad and I had an infectious illness. On Monday, I called to be home because I didn’t feel fit for work. But I’m the doctor. so I have to work. In ucirdcenrral they have more doctors. and you could stay at home and cure your illness. But I don’t think these centers are more effective.. It means a lot of personnel.”
Another respondent practicing noted other ,personal advantages.
in a care center
“I am divorced and have two children. And I want to be with them when they are not in school. Here I can work part time in the mornings and another doctor works part time in the afternoon. It is very nice for both of us. If I had a district alone or a private practice there would be no possibility (to make such arrangements). It is the udrdcentralen that allows me to continue working as a physician.”
Most felt that the care centers would increase colleagiality and the quality of care. There would be opportunities for informal consultation that could improve diagnosis and treatment as well as the quality of referrals. They could reduce the sense of isolation. The one dissenter was a physician with a small district who had his office in his home. Plans for a care center in another part of his district were well advanced. Given the size of the district, no physicians were to be added to the center. ‘I . I will have a waiting room, reception, and examining rooms for adults, another set for infectious diseases, and yet another for children. I am one physician and will have three receptions in the same place. The dentist will also have a reception. I can meet the needs of this district now without full time effort. I see everybody the same day. The center will not make me more efficient. All this is so the dentist and I should have lunch together. I think it is ridiculous.” SUMMARY
AND PROPOSITIOSS
In this paper we have identified some themes that seem to be important to district genera1 practitioners in Sweden when they were asked to describe their satisfactions and frustrations with their work and their opinions regarding the successes and problems of the larger medical care system. In 1983, these themes were reviewed with several of the physicians
Swedish physicians’ perspectives on work
who were respondents in 1978-1979 [28]. There is to be confident that these themes existed as important concerns. Given the nature and size of the sample, we make no firm assertions about the distribution of perspectives in the population of general practitioners at that time. To recapitulate themes with reference to work in this sample, district general practitioners working in solo offices and care centers-reported the work as routine and complained of isolation (from hospitals and colleagues) and overwork. Those who enjoyed their work did so because they valued patient centered care over technical challenge; dissatisfied practitioners had the reverse priority. Those working in the acute primary care center expressed none of these concerns. They reported their work as varied and interesting, technically oriented and variably paced. They said they worked hard, but were not overworked. They felt well integrated into the ambulatory care and hospital systems by virtue of their focus on acute care and medical triage. With reference to the system, there were no differences between general practitioners working in solo offices, care centers and the acute primary care center. Respondents reported that hospitals and specialists did not provide for adequate communication with community based physicians. General practitioners felt alienated from the political decision making process. Districts were too large on the average. Care centers could cut down on isolation from colleagues but were not thought to be an answer to other work problems. With one exception, the financing of the system was seen as a positive achievement rather than a problem. Nevertheless, it was impressive that district general practitioners, when asked about satisfactions and frustrations with work and with the medical care system, focused mostly on problems. In this they were distinct from other categories of physicians. It is possible that changes since this study have mitigated these problems and changed the perceptions of these respondents. Given the issues in the United States, it is also impressive that pubhc financing was not seen as a problem, but an achievement [29]. The themes related to apparent satisfaction of district general practitioners might be reducible to three: (1) isolation from colleagues, facilities and political decision making; (2) overwork as a result of too large districts and heavy demand relative to resources; and (3) patient care, which, if valued, made the medically routine aspects of work interesting. The overwork theme is supported in some of the Swedish literature. In a review article on psychosocial stress in medical practice (which drew mostly on non-Swedish studies) Arnetz [30] noted that in 1979 30% of all Swedish physicians worked more than 47 hr a week and a substantial minority worked as much as 65 hr per week. Real work time had increased since 1977. These figures did not distinguish the small minority of physicians in general practice from the overwhelming majority working in hospitals, however [cf. 311. Swedish physicians had higher death rates than others with equivalent academic training [cf. 321 and general practitioners had higher death rates than specialists, especially from heart disease [cf. 331. Extrapolating from data collected reason
769
outside Sweden. .4metz presented a case that work tempo, sleep problems, psychological problems, substance abuse and other difficulties might be associated with overwork and stress. The themes identified in this paper sug_gest that general practice might be a more satistying occupation if some way were found to reduce isolation, provide more colleague support and increase the supply of generalist physicians relative to population. To the extent that Arnetz is on target, such changes may also have a positive effect on the health of general practitioners. Indeed, events in Sweden [e.g. 6, 341 should allow a test of these propositions as the city and country convert number
from
solo offices to care centers.
.I\ larger
of general practitioners now practice in group settings and a repeat of this study could show improvement in the perspectives of district general practitioners as a result. The hiatus between the ambulatory sector and the hospital would still be a problem. It would be interesting to experiment with a system where general practitioners rotate back to the hospitals periodically and/or where specialists attend as consultants in general practice receptions. The identification of satisfaction in practice with a patient-care rather than a disease orientation suggests that some modification in medical education could be beneficial. As in other Western nations. medical students are recruited through a competitive process focused on the laboratory sciences. Their predisposition toward a disease orientation is reinforced in the medical education process. A rigorous focus on illness and sickness [35] in the medical curriculum could tap the scientific interest of students while cultivating an interest in the problems of patients. It would be interesting to study whether such an approach might yield a larger proportion of district physicians with more positive perpectives on their work. It seems equally likely, however, that there are inherent problems in the position of the general practitioner that transcend the situation of the Swedish case. Mechanic a decade earlier found many similar patterns among British general practitioners, [36-44] whose social circumstances were in many ways dissimilar [36-44]. They were the least satisfied of British physicians and could be distinguished by their scientific versus patient orientations, with the latter expressing greater satisfaction with work. Their perspectives also contained themes of overwork, isolation, underutilization of skills and so forth [38,41]. British GPs had smaller practices, had moved earlier into group practices [45], and had a formal tie to the hospital sector as gatekeepers [7,40,41,42.45] their Swedish counterparts lacked. Clearly, what is needed is a systematic comparison of general practice in different countries. Only then might it become possible to dissect the elements that separate the cultural from the structural and the meaningful from the ephemeral structural aspects of practice. To make even the Swedish case convincing, it will be necessary to have a larger data base. This paper, hopefully, has provided insights into features than need to be measured. Their better measurement is left to another study. It will also require a series of comparisons with other physician groups in Sweden.
770 That
ASDREW
task
is left to other
papers
based
C.
on this study.
Acknowledgement-The research on which this paper is based was supported by the Svenska Institut, Sociologiska Institutionen of Goteborg University and the Graduate School of the University of Missouri. REFERENCES I. Anderson 0. Health Care: Can There be Equity? Wiley, New York, 1972. 2. Anderson 0. and Bjiirkman J. Equity and health care: Sweden, Britain and the United States. In The Shaping of the Swedish Health Svstem, pp. 223-237. St Martin. New York, 1980. . __ 3. Flora P. and Heidenheimer A. The Deeelopmenr of Welfare States in Europe and America. Transaction, New Brunswick, 1981. _ 4. Navarro V. National and Regional Health Planning in Sweden, USDHEW-NIH Publication NO. 74-240. Washington, D. C., 1974. 5. Hessler R. and Twaddle A. Sweden’s crisis in medical care. J. Hlth Policy Polit. Law 7, 44&459, 1982. 6 Twaddle A. and Hessler R. Power and change: the case of the Swedish commission of inquiry on health and sickness care. J. Hlth Policv Poh’t. Law. 11, 1. 19-40, 1986. 7. Cartwright A. and Anderson R. General Practice Recisired: A Second Study of Patients and Their Doctors. Tavistock, London, 198 I. 8. Gill D. The British National Health Semite, A Sociologist’s Perspectitie, USDHHS-NIH Publication No. 80-2054. Washington, D.C., 1980. T. The Division in British .Medicine. St 9. Honigsbaum Martin, New York, 1979. IO. Starr P. The Social Transformation of American Medicine. Basic, New York, 1982. Il. This assertion is sufficiently commonplace in sociology to make extensive documentation superfluous. It is central to the work of Marx, Merton’s [46] conception of role sets, Goode’s [47] conception of role strain, and the seminal work of Berger and Luckman [48]. Within the traditions of medical sociology, Duff and Hollinghead [49] have used this approach most effectively in documenting differences among health workers. 12. Twaddle .4. and Hessler R. Scandanavian medical care: lessons for the U.S.? Unpublished paper. of general practice is in the past tense, 13. Description referring to the study period, 1978-1979. While we have not heard of changes in medial education since that period, the data at our disposal are not current on this point. Unless otherwise noted, all characterizations of Swedish medical care are specific to the study period. 14. SOU (Statens Offentliga Uttredningar) Husliikare, p. 74. Socialstyrelsen, S&kholm, 1978. 15. While more politically accountable than in some other societies, such as the U.S.A., it is inarguably true that policy decisions with respect to medical care have been dominated by the Swedish Medical Association (Lakarfiirbundet). There is not space to document this assertion here. The reader is referred to [5. 34 and 121. 16. Bratthall B., Molstedt B. and Ogrelius Y. Vad Gjorde en Distriksllkare i Maj 1968? Liikartidningen 66, 2902-2904, 1969. 17. Carder M. and Klingeberg B. Towards a salaried medical profession: how Swedish was the Seven Crowns Reform..In The Shaping of the Swedish Health System, DD. 143-172. St Martin, New York, 1980. 18. ‘Merton R., Fiske M. and Kendall P. The Focused Inrerrierv. Free Press, Glencoe, Ill., 1956. 19. Glaser B. and Strauss A. The Discovery of Grounded Theory. Aldine, Chicago, 1967. 20. Kaplan A. The Conduct of Inquiry. Chandler, San Francisco, 1964.
TWADDLE
21. There were. however, major differences between groups. Discussion of these will have to be deferred to another paper, as they cannot be summarized briefly. 22. At the time of the study. there were 36 districts in Giiteborg. Because of the difficulty in attracting physicians into urban general practice. almost one third of those positions were vacant. Vacancies seemed not to be associated with characteristics of the districts on superficial inspection. The physicians in the sample were over one fourth of all district positions in the city or one third of the district physicians in the city. Representativeness, however, is not at issue as we are not trying to present a distributive picture of practices. Rather, we are trying to capture a range of types of responses. This sample seems adequate to that task. 23. This respondent had worked as a hospital specialist and part time primary care physician. When forced to a choice between hospital medicine and district general practice, he chose the latter. it is remarkable 24. While not using the same vocabularies. that this statement shows close parallels with Baumann’s [50] classification of symptoms, especially feeling states and capacities. It also parallels Twaddle’s [35] distinction between disease and illness. It leaves out Baumann’s category of ‘other’ symptoms that involve neither capacities nor feeling states and Twaddle’s ‘sickness’ category which is the social dimension of poor health. 25. It was not until the last interview that it was discovered that there was a regularly scheduled weekly meeting for district physicians held in the city. In light of this, the assumption that the nature of the practice kept physicians atomized becomes more problematic. Either these meetings were not well attended or they were not serving some felt need of the practitioners. This was not explored in the interviews and must be left to a subsequent study. Board and the Medical Care 26. The Social Welfare Administration, respectively. 27. Referring to the ‘Seven Crowns Reform’ of 1968 [cf. 171. 28. The author returned to Sweden in the Summer of 1983 to document changes in the medical care system since the earlier study. As part of that effort, several respondents from 1978-79 were reinterviewed on .the effects of changes on their practices. Findings from this study were reviewed and commentary solicited. groups will be presented in 29. Data on other physician other papers. Respondents from the earlier study were presented with a summary of findings in 1983. While all agreed that the themes were accurately portrayed, some felt that the overall picture of the district physician was too negative. While they focused on problems, they were at the same time personally satisfied with their work. Some data collected at a meeting of district physicians supported this view [51]. B. Stark Psykosocial Stress i LZkaryrket: Stort 30. Aietz Behiiv av Forbattringer i Arbetsmiljiin. fikartidningen 79, 4807-4809, 1982. 31. Statistika Centralbyrin. Teknisk Rapport Avseende 1977 OCH 1978Ars Undersdkningar au hna&firhaUanden. Liber, Stockholm, 1980. 32. MellstrBm D. Pdcarkas Aldrandet of Olika Omgicningsfaktorer? Liikardagarna i orebro. SPRI (SPRI Rapport No. 92/1982), Stockholm 1982. L. and Theorell T. Psycosocial Arbetsmiljij 33. Alfredsson och Hjlrtinfarktrisk. Ltikartidningen 79, 4658-4661, 1982. 34. Twaddle A. and Hessler R. Restructuring Swedish medical care: the new health and sickness care law. Paper presented at the Annual Meeting of the Midwest Sociological Society, April 11, 1985. A. Sickness Behacior and the Sick Role. 35. Twaddle Schenkman, Cambridge, Mass., 1979.
Swedish physicians’ perspectives on work 36. !&chanic D. General practice in England and Wales. .Wed. Care 6, 245-260. 1968a. 37 Mechanic D. General medical practice in Engiand and Wales: it’s organisation and future. X=w Engl. J. Med. 279, 680-689, 1968b. 38. Mechanic D. Practice organisation among general practitioners in England and Wales. Med. Cure 8, 15-25, 1970a. 39. Mechanic D. Private practice among general practitioners in the English Natianal Health Service. Med. Care 8, 32&332, 1970b. 40. Mechanic D. Doctors in revolt: the crisis in the English National health Service. Med. Care 8, 442-455, l97Oc. 41. Mechanic D. Correlates and frustration among British general practitioners. J. Hlth sot. Behav. 11, 87-107, 1970d. 42. Mechanic D. The English National Health Service: some comparisons with the United States. J. Hlrh sot. Behav. 12, 18-29, 1971.
43. Mechanic D. General medical practice: some comparisons between the work of primary care physicians
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45. 46. 47. 48. 49. 50. 51. 52.
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in the United States and England and Wales. Med. Care 10, 402120. 1972. Mechanic D. Ideology, medical technoloav. and health care organization in-modern nations. Amy-J. publ. Hlth 65, 241-247. 1975. Jeffreys M. and Sachs H. Rethinking General Practice. Tavistock, London, 1983. Merton R. Social Theory and Social Structure. Free Press, Glencoe, Ill., 1949. Goode M. A theory of role strain. .4m. Social. Rev. 12, 483-496, 1960. Berger P. and Luckmann T. The Social Consrruction of Reality. Doubleday-Anchor, Garden City, N.Y.. 1967. Duff R. and Hollingshead A. Sickness and Society. Harper & Row. New York. 1968. Baumann B. Diversities in conceptions of health and physical fitness. J. Hlrh Hum. Behar. 2, 39-46, 1961. Brunei1 U. Vad gor vi pa vlrdcentralen. Styrsii, Gar det att Mata? Mimeo, 1983. Heidenhiemer A. and Elvander N. The Shaping of the Swedish Healrh System. St Martin, New York, 1980.