General Practice doctors as “Gatekeepers”

As I alluded to in my previous post, GPs in Norway are rock stars. The system is set up in such a way that they are the foundation of the system and the patient’s primary point of entry when seeking higher levels of care.

In the GP clinical setting, there are relatively few resources. They have the ability to draw basic labs (but they have to be sent to the hospital for analysis) and run point of care tests (rapid strep, blood glucose, instant flu, etc.). Beyond these things there is little to go on. X-rays, ultrasound, and other diagnostic modalities simply aren’t available in the primary care office. However, there was one thing in the GP office that caught me by surprise. Everybody had a point of care CRP machine (for the non-medical folks, C-reactive protein, which is a nonspecific marker of inflammation) which was used like a litmus test for “sick” vs. “not sick.” I found this to be somewhat remarkable, and both Dasha and I were shocked to see their heavy reliance on this test when we hardly every use it as a primary diagnostic modality in the US. We asked them about it and even went so far as to question its role. You would have thought we were speaking sacrilege – how could we question the “golden child,” CRP!?!

In the states, it is not a big deal that our PCP offices don’t have extensive diagnostic equipment. In most settings, when a doctor is concerned that a patient is sick or needs urgent evaluation, we can send them to the nearest Emergency Department for a nearly instant comprehensive workup. In Lexington, KY, we have at least 3 emergency departments within a 1 mile radius. No doctor’s office is more than a half hour from an ED. Nobody gives a second thought to send a patient for a workup. In the west of Norway, the situation can be quite different (and is reflective of many rural areas in the US). The small town of Larsnes is 1.5-2 hours from the nearest hospital. The decision to send a patient to the ED is a big one. It requires significant resource expenditure by the system to coordinate ambulance transfer and such. Perhaps this is why all the offices have a point of care CRP machine. It provides that extra bit of evidence that can sway a clinician’s decision making process.

There is a somewhat intermediate step in between the PCP office and the ED – the legevakt. These function as a sort of “urgent care” center and usually come with a few more diagnostic tools than the PCP office. Primarily, they serve as a place for patients to seek medical care after clinic hours are over (clinics close around 3 or 4 while the regional legevakt stays open until at least 10pm). Secondly, they are a slightly higher level of care than the PCP office and have more equipment for minor procedures, casting, imaging, etc. For instance, the one we visited was equipped with an x-ray machine as well as lab equipment for electrolytes and urinalysis. Legevakts are a place for sick patients who aren’t quite sick enough to be sent to the hospital.

By this point, you may be asking yourself “what the heck does he mean by this ‘gatekeepers’ nonsense?!?” Fear not!! The time has finally arrived. In the US we sometimes perceive healthcare as a consumer product. Because of this, we expect to be able to show up at an urgent care clinic, a “little clinic” in a grocery store, or any emergency department and be seen. There is an expectation that we, as healthcare consumers, get to choose how and when to use the healthcare system. The paradigm in Norway is completely different. In fact, it is inappropriate and unexpected for patients to just show up at an emergency department. In fact, one of the doctors at a hospital was telling us that they can turn patients away from the ED, if they weren’t referred by their PCP. The system is set up in such a way that when a patient is sick, they go to their PCP who then determines if they are appropriate for an ED or if they are able to go home. If they are sick enough for an ED, an ambulance is called for and will take them from the clinic to the ED (not always, but many times it happens like this). The PCP needs to fill out the appropriate paperwork and send a “triage” form of sorts along with the patient to the ED. Similarly, if a patient wants to see a specialist, have a surgery, imaging, or whatever other procedure, the PCP mediates and coordinates the exchange (somewhat similarly to the US).

As a future emergency medicine doctor, it absolutely blows my mind to think about a system set up this way. As things stand today with EMTALA (Emergency Medical Treatment and Active Labor Act – a law which states an emergency department must see and stabilize everyone who walks through the door) I can’t even wrap my head around a healthcare system that doesn’t see all comers in the ED. I suppose that this alone is a testament to the Norwegian system. Because every patient has a PCP assigned to them, the hospitals aren’t bogged down with hundreds of people using the ED for primary care. There is a clear societal expectation that healthcare starts with the PCP and that the ED is not to be used as a free clinic.  Still, I can’t even fathom what it would be like to not have to deal with the sniffles, med refills, and tiny cuts/scrapes while on shift in the ED. Many of the issues with overcrowding and long wait times would simply disappear, which is something that I think everyone – patients and doctors – can support.

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