COLUMN. Henrik Sjövall is strongly involved in the supplemental training for doctors educated outside the EU – a commitment that has already resulted in several columns in Academy Life (links at the end of the column). Now, he has just finished the teaching in social orientation for course participants who came from Russia, Central Asia, Pakistan and the Middle East, among others. Many concepts to explain; here, he shares his thoughts after an eventful week.
I had Herman Nilsson-Ehle, a recently retired, particularly experienced and discerning clinician, at my side at the beginning of the week. We had four half-days to give an overall picture of the Swedish society that they will work in, and my goal was to try to explain why it looks the way it does with reference to our history. The power issues are always interesting, which is why we began on Monday by trying to explain how Sweden is governed.
I began with the question: “What is a prime minister and what can he or she decide?”. Nobody knew. “A kind of elected king?” “No, we don’t have a president, we don’t have a republic!” Now they began listening. I explained to the surprised students that the prime minister, after an election, is assigned by the speaker (the chairman of the Swedish Parliament) to form a government, then leads the government’s work and that he or she can ask the speaker to dissolve the government if he or she so desires. That’s it. The colleagues in the government in turn lead the various ministries that handle issues of national importance, such as foreign policy, roads, railways and the court system. So a kind of politically appointed civil servants.
What about the rest, who decides there? That question provided a natural transition to the division of power between the state, county councils and municipalities (each with their own coffer), which in political science terms is called multilevel governance. I spoke about the municipal autonomy that is nearly holy in Sweden and about the principle of subsidiarity (meaning that things are to be handled as far out in the periphery as possible as long as it works). About the important distinction between political governance (“the what”) and implementation (“the how”) that is often handled by civil servants. And that it is now common to have different political majorities in the state, county councils and municipalities. About the national state’s role as the overseers (the police are national!) and coordinators of the other levels (the county administrative boards!) and about the state’s responsibility for the universities (the Swedish Council for Higher Education – UHR). And clarified that the main task of the Swedish Parliament is to make laws and that some principles (like the equality of all people) are considered to be so important that they are in the constitution and thereby require a 2/3 majority and intervening elections to be changed.
They wrote and wrote and wrote; they had apparently never heard most of this before. They looked a bit proud when I said that the principle of equal treatment, meaning that they may not be discriminated against, is in the actual constitution!
Next level, the county councils. I said that we right now have 21 county councils, but that many are too small to be able to finance the increasingly expensive health care and therefore want to merge with each other to share the costs. I explained that we belong to the country’s most established county council merger, the Region Västra Götaland (VGR), with around two million residents in everything from pure countryside to the big city. About the difficulty in governing such a heterogeneous construction. About the political governance at virtually every level, about the client-implementer system, about the public healthcare services committees that have the possibility to take into account local conditions, about the large organization of civil servants that tries to handle and develop this sprawling colossus. I tried to explain all of this as simply as possible without a lot of unnecessary details. I also reminded them that VGR is not only responsible for health care, but also for commerce and culture, among other things; I mentioned that they pay for example for the Opera and the Botanical Gardens (picture). And that all of this is mainly financed by taxes. Their pens were getting warm.
Next level: the municipalities. I told about our own municipality – which oddly enough is called the City of Gothenburg – and is responsible for people’s daily lives: schools, social services, elderly care. About the system of city district councils, about the collaboration in the Göteborg Region Association of Local Authorities, about the Swedish Association of Local Authorities and Regions (SALAR), about municipal equalization grants. And about the difficulties for small poor municipalities with a weak tax base in financing their assignment, and how this is today handled through various redistribution systems. This too seemed to be completely new information.
I then went back to the county council world and began by emphasizing that medical care, primary care and care (which is handled by the municipalities) are organizationally distinguished. I began by discussing inpatient care, with Sahlgrenska as a model system (picture SS). I briefly told about the three main bodies, about the political governance, about the management group and its mission, about the area breakdown with a rough equivalence between the areas, about the system of information transfer through the operating areas and sections, about the workplace meetings (APT) as the meeting form closest to operations. About the chief medical officer system that handles when healthcare fails, about our quality assurance system. Deep breath, on to university healthcare. I explained “the three branches”, education, research, healthcare, the structure of the academic positions, the combination positions, mentioned something about the medical education and research (ALF) system, the possibilities of clinical research, the concept of university healthcare. They wondered what my job is; I explained how things were and received appreciative glances. Time for a break again.
Next module: the management system at an inpatient ward. I go through the titles, explain that a senior physician is only a title while a licensed physician and a medical specialist are qualifications. That certain things require qualification, not everyone may do everything. About the difference between nurses, assistant nurses, nurse’s assistants, medical secretaries. About the difference between line positions and medical responsibility, about nurses often being care unit managers, but not managers over the doctors and absolutely not having the medical responsibility. About the APT as an important meeting place to discuss operations. “Oh, I hadn’t even understood that.”
And the last important piece of the puzzle in the management system: primary care. I explained the distinction between primary care and inpatient care, the system of primary care areas and healthcare centers. I took up problems related to transitions in care. I mentioned the system of public and private healthcare centers, and tried to explain differences and similarities. I took up the problem of the handling of continuously increasing quality requirements, patients with multiple illnesses and a shortage of doctors. I spoke about the recruitment needs of primary care and the ambition to take a clearer holistic responsibility for the patient.
I then concluded the block about the management system by quickly repeating everything, from prime minister to healthcare center. “Did you get it?”. Yes, they felt that they had understood. Lastly, they got to practice on a few examples with discussion cases where patients had gotten stuck in transitions in care. I think they managed those cases pretty well.
We thereby left the management system to its fate and went over to ethics on the next day. We roughly used the same structure as in our own internal medicine course, with analysis of situations that the students experienced themselves. Hermann began by going through a patient case, where the patient was a Jehovah’s Witness and therefore could not take blood, which led to a very complicated and expensive course of care. We discussed the ethical principles and situations where autonomy, doing good, doing no harm and the justice principle are pitted against one another. They then had the chance of taking up ethical dilemmas they experienced themselves and I made the observation that many of the situations they had found to be difficult were about an exercise of authority: revoking a driving license, reporting an infectious disease against the patient’s will, using compulsory care for substance abusers, refusing to prescribe psychopharmacologic drugs. The next day, I mentioned that observation to the students and asked the question if their interest in the exercise of authority could be related to themselves having been subjected to arbitrary power. Some nodded in agreement.
On Wednesday, they were given a little adjustment time to digest all the information they had received, but we continued on Thursday, now with the topic of teamwork. They were very interested in this topic; those who had been out in the operations had noticed that the strictly hierarchical systems they were accustomed to did not exist here. I began by going through the various kinds of teams (role differentiated, role integrated or role supplementing), and emphasized that the choice of model depends on the situation. The keeper is as a rule role differentiated and the fullback should stay well back, but sometimes the fullback can be permitted to change roles and try to make a goal (picture?). We talked a little about this and they then had a chance to discuss half a dozen conflict situations where people with different roles had different perceptions and the students got to suggest how the disagreement could be handled. Many of them are very impulsive and answer almost before one is done asking the question. I tried to emphasize that one should reflect first, try to figure out what the problem is about before reacting emotionally! Try to divide the conflict up into subcomponents; try to understand the others’ map, think through how one’s own role is perceived. I comfortingly noted that if one does this, the solution is generally somewhat obvious. “And it’s a good idea to talk with people, ask for help if you don’t know what to do. But do it constructively, don’t just shout without showing that you’ve analyzed the situation and preferably provide a few alternative solutions when you call a tired on-call doctor! This inspires respect, and if you do that, you will almost always get the help you need.”
And lastly, they were given a few important warnings: Don’t guess, rather if you don’t know what to do, ask or back away! And if an experienced nurse says: “That’s not how we usually do it here!” Back away then, back away! And absolutely do not get aggressive; that’s always a very, very bad idea!
A smile here and there in the audience.
The last day, the most demanding of all, cultural issues. I began by saying that I would try to give them a simple model for why the Swedish society looks the way it does based on our history. I was clear in saying that this was my model, others can have other views in terms of emphasis on political factors or economics, for example. I began in any case by saying that mentally, most Swedes are still farmers. And then I told the history of the farming society, about the splintered small farms with a spot here and there, about the attempts to make the farms viable through land reform (picture), about how the soil was gradually sucked out, the attempts to break new ground, the stone fence farms as a monument from this time, about the lack of margins for bad years, about the difficulty in feeding large numbers of children on ever smaller and rockier patches of land. I told about the wave of emigration, and recommended reading Vilhelm Moberg as a good source if they wanted to know more about that time. I spoke about how poor people in the countryside were drawn into the cities, and here I referred to Per-Anders Fogelström’s city series. I spoke about the uniquely high literacy rate in Sweden created by a compulsory folk school and the system of catechetical meetings, spoke about the creation of a strong union movement that was gradually united with a dominating political party that governed Sweden for half a century. I told about the struggle between employers and the union movement, about the Ådalen riots, about the reconciliation, about the development of the spirit of the Saltsjöbad negotiations, that Sweden is one of few countries in the world where employer and employee representatives can get along well away from the negotiating table. About how in times of crisis one stops arguing about details and tries to reach agreement on what is good for Sweden. I told about the modern experiment, the high-tax society, the Million Homes Program, the entry of new liberalism. I spoke of the revivalist movement that is still an important social force, about study associations, adult education…
After a long break, it’s time for the next module, a practical example of how this journey can come to expression in a certain place and here I chose my own home island, Donsö. Here, I previously spoke about the very special community we have out there so I will keep it short. I told about the age of smuggling, the sailing period, the boozing, the revival, the arrival of motors, the daring stakes of the Donsö shippers on ever larger and more modern boats, the matriarchal society out there (the men were mostly at sea), told about the tradition of always taking care of the widows, the important role of the Missionary Church in giving children a clear ethical framework, about tolerance under responsibility and about the boundary where one must essentially choose between shaping up or leaving the island. I told about the Donsö spirit, how the shipping companies have survived and expanded on an increasingly tough market.
They seemed completely fascinated, “Can we come and visit you?” I promised to arrange it in the spring when they are done with their exams.
The finishing line, the annual question time (picture). “Now you can ask me about everything you find strange in Sweden.” After a slow start, it started coming: why don’t people talk with each other? Why do they sit so far apart from each other? Why don’t you take care of your elderly instead of sending them to the old folks’ home? Why are you always saying thank you? Why do you almost always eat the same food? Why do you like animals? Why do you think darkness (“lighting candles”) is nice? Why do you celebrate Christian holidays when you don’t believe in God? Many good questions, I did my best to answer, most often referred to the farming culture I had previously described. An appreciative nod here and there indicated that they had gotten most of it.
Exhausted, I then thanked them for a stimulating week. And received applause, it’s never happened before at the supplemental training. And do you know what they said? “We think you should learn Arabic!”
That’s what we Swedes call inviting back, isn’t it?
PS: I wonder if some of the ordinary students wouldn’t also benefit from participating in a review of how Sweden is governed..
A column by Henrik Sjövall
Here, you can read more columns from Henrik’s pen that concern the supplemental training for doctors educated outside the EU:
- Differences between individuals is an opportunity: http://130.241.135.136/2016/03/32189/
- We have to help educate doctors in Europe: http://130.241.135.136/2014/05/19139/
- Coming in from the cold – reflections on the Swedish physician’s role: http://130.241.135.136/2013/06/12618/
- With the PU express around the globe: http://130.241.135.136/2013/01/8318
