Week 2: The TakeCare Takeover

Pool - Eriksdalsbadet

Preface: I have been a terrible photo-documentarian this week and only have one photo so far to share for the entire week 2. Also, I have quickly gotten into a routine and as such don't feel like much of a tourist which means that I haven't really done much exploring. There is one more day in the weekend so I hope to have actually done something Swedish before the start of week 3.


Alright, friends. This was my second week at Södersjukhuset and I spent it on the acute surgical ward in general surgery. I was pretty excited about this placement because there was sure to be a lot of surgery and I was looking forward to spending some time in the OR actually doing something. HA! That was definitely far from the experience that I had this week. Something that many of my medical school friends would be quite familiar with happened throughout the hospital on November 1 - a complete change of the electronic medical record system to one called TakeCare. This system change is part of an effort to get all of Stockholm on the same electronic medical record system to enhance sharing of patient information between providers and hopefully lead to providing better care for patients. I have been doing some research for my Flexible MD project on the health care system in Sweden and it is primarily funded by local county governments or municipalities. The hope is that eventually all of Sweden will be using the same system. This would likely cut down some on costs of health care as the system would provide the means for sharing medical information between hospitals, clinics, and providers. The downside to this happening this week in Sweden is that the hospital actually shut down half of the operating rooms and would not allow the acute surgery department to plan any surgeries in advance - they could only operate on acute cases that came in that week and absolutely needed to get done. This meant that instead of having an awesome week in the OR, I had a mediocre week on the surgery ward which basically functioned like a medicine ward in the US and spent a lot of time on rounds and took insanely long coffee breaks. HUGE bummer. Now, for those of you not familiar with the EMR system world, in the US, I have been through several updates of existing systems as well as the establishment of new systems. It is always a pain and it always takes forever to figure out how to use the new system and how to find things in the new system (some take longer than others to figure this out), but the hospital doesn't lessen the productivity to make it easier to transition. No way would operating rooms be shut down for this purpose. 


Unfortunately because I didn't actually get to see much surgery, I don't have much information to go on in making my evaluation of how things are done here in Sweden. But I did my best to observe the differences and similarities and find them to be quite interesting. First off, office hours. Yes, even surgeons have office hours here in Sweden and these hours are from 730-4 daily. Every once in a while a surgeon may stay until 430/5 if something is happening and they can't leave on time, but pretty much the hospital is emptied by 430 in the afternoon. Weekends are off unless you have one of the weekend shifts which are shared between the providers. Coverage for after 4 pm is done with an "evening shift" where one person stays until 8 pm followed by a "night shift" from 8 pm - 8 am. If you are on your "night shift" week, you work 3 of these shifts in a 7-day period. In addition, for taking night shifts or weekend shifts (Saturday and Sunday are split into 12-hour shifts), for every hour that you work, you get two hours of vacation time in return meaning that most surgeons and physicians in general that take call end up with about 12 weeks of paid vacation per year. Work hour restrictions in Sweden are much more strict than in the US - no one is allowed to work longer than 13 hours in a row and works a maximum of 40 hours per week with the ability to take I think one extra evening/night/weekend shift. I, trained in my American medical student ways, stayed one night for the evening and most of a night shift (until about 2 am) then showed up the following morning at 730 for the regular workday. My residents founds that to be really funny that I came in at all the next day and suggested that I put up a fuss and demand to go home immediately. They asked about a million times if I was feeling tired and suggested that I should go home early since that is what medical students in Sweden do. I did leave a little early, but I assured them that this was not unusual to stay all day, all night, and leave partway through the following day so really, I was fine.


Interestingly, I found out from two of the attending surgeons that there is a physician shortage in Sweden and in fact a shortage all over Europe, especially in specialty fields (anything other than a general practitioner). It is very difficult to get into medical school in Sweden - you must score within less than the top one percent on some exam after high school to be able to attend medical school. The nice things is that after you complete your one licensing exam after intern year, you don't take any more tests. After residency which is arranged by the resident with a particular hospital - not a standardized process or training by any means - the resident meets with his/her advisors/mentors/staff to evaluate whether or not the resident is ready to work without supervision. If they decide yes, then the paperwork is signed and the resident can start work as an overläkare (senior physician). During their training residents are allowed to do many surgeries and procedures on their own without a staff surgeon present in the operating room or even in the hospital. 


There is definitely a downside to this system that I discovered early on this week. This downside may have been partially due to the TakeCare switch and the shutting down of operating rooms, but I think it is a problem of the system in general. Every morning we gathered for a meeting with all the surgeons from each department and had a sign-out from the night shift and then went over what is called the "Acute List." The acute list is a list of patients that need surgery for any number of reasons. Every morning, the list is evaluated and it is decided which of those patients who need surgery would get surgery that day. If a surgery is not done during office hours, it likely won't get done as the evening and night shift are primarily there for emergent or highly urgent cases and so don't do things from the acute list for the most part because they don't have any support present in the hospital in case the surgery becomes more difficult. The result of this acute list is that many people wait for surgery and in some cases, this is actually harmful to the patient. There were two cases this week of patients that presented with acute appendicitis and because of being on the acute list, one waited about a day and the other a day and a half to be operated on. The end result being that the appendices in both patients were perforated and so the patients had to stay a few extra days in the hospital to get IV antibiotics. Not only do they have to stay longer in the hospital, but the risk of having post-op sepsis or an abscess increases when the appendix has perforated. We had one patient on the service who unfortunately had this as well. 


Some of the other ways I have noticed that the hospitals cut down costs is by keeping the hospital rooms extremely basic. There are a few private rooms, but most rooms hold 4 patients. There are no TVs in any of the rooms except the private rooms. There is really no waiting or lounge area for families. There are no private bathrooms in any of the rooms. If a patient is receiving IV fluids and is not in the intensive care unit, they don't have a monitor or machine to regulate the fluid flow - it is calculated by the nurses based on how fast to set the drip. I think patients probably are glad to leave as soon as they can since the hospital is really quite boring to sit in. 


One last comment on the hospital for this week. Sweden has one of the lowest infection rates in the world, and you would not guess it based on the method of surgical scrubbing. If I scrubbed for a surgical case in the US the way I did this week in Sweden, I would not have been allowed in the OR. They don't use surgical brushes but instead wash their hands well with soap, dry them with paper towels, then use a boat-load of some kind of waterless sanitizer. It was really odd and felt very wrong to scrub in especially when I walked into the OR and half the people don't have masks on (which I think I mentioned last week in my blog). Well, I guess there is not just one way to do things.


Okay, on a non-hospital related note. I didn't do much this week outside of the hospital except work out everyday and finish reading The Girl with the Dragon Tattoo by Steig Larsson (this is the most I've read for fun in the last 3 years...) I found the large swimming hall in Söder - Eriksdalsbadet - and paid for 10-time swimming pass. It was rather expensive, but I always feel better when I can do some swimming. The natatorium is beautiful with both a large 25m and 50m pool. I have enjoyed getting back in the water a few times this week and am glad that I will be able to return home in good physical shape and being better read. I just started a new book today, the second in Steig Larsson's series, The Girl who Played with Fire. Hopefully I'll do something more interesting tomorrow and can write a more exciting blog on life in Sweden outside of the hospital :) Tack så mycket för läsning!