Sunday, February 8, 2009


[If you enjoyed my post below "It's not just health care", you might be interested in this essay written in March 2005. For the record, my local clinic abolished telephone time in January 2008. (You can now call any time of day to make an appointment.) According to staff, the atmosphere in the waiting room occasionally got ugly as doctors got backlogged and the room filled up with patients who had dropped in during the two-hour "open clinic" each morning (no appointment necessary) thereby avoiding telephone time. The clinic has also abolished its open clinic hours.]

I was explaining a fine point of English grammar to two of my adult students when one of them suddenly jumped up and ran out the door. Stunned, I turned to her colleague to see if she knew what was going on. “She has to call her doctor,” she explained. “It’s telephone time.” "Oh," I nodded, and resumed the lesson.

You can’t claim to know anything about Sweden until you’ve experienced telephone time. It is the one (and only) hour of the day when you’re allowed to call and schedule a doctor’s appointment at your local health care center. Telephone time is usually in the morning (at my clinic, between 8 and 9 a.m.), about the time you’re leaving for work. On the given hour, with a deep sigh, you grab your phone and frantically dial your doctor’s number (they schedule their own appointments) as fast (and often) as you can to try and get into your doctor’s answering queue.

If you’re lucky (and your doctor is at the office on time), you’ll get into the queue on your first try. If you’re very lucky, your call will be answered within a couple minutes. If you’re unlucky, you could be on hold for twenty or thirty minutes, or more. And if you’re really unlucky, you could get stuck in a queue for ages only to learn from an answering machine that your doctor is on vacation (yes, this happened to me), and that you’ll have to start the whole process again after scrambling to find the name and number of another doctor with only ten minutes left until the end of telephone time. For mobility’s sake, I’ve learned to call my doctor on my cordless phone if I’m calling from home or on my cell phone if I'm in transit. (“Hello, Doctor?” I holler above the traffic as I push through crowds on my way to the office. “I have a terrible yeast infection!”)

If you think your problem doesn’t need a doctor, you can take your chances and try the district nurse (same procedure), who will promptly ask for your naitonal identity number upon taking the call. (Patients in Sweden do not have names, only national identity numbers.) With a little pleading and a lot of lying (my district nurse is appointment aversive), you can get an appointment; but more often than not, you’ll be asked to come during "open clinic" (9-11 a.m. at my clinic) and spend your morning waiting in a room filled with white-haired retirees.

If you don’t know your assigned doctor’s name and telephone number, or the clinic’s designated telephone time, you’ll have to waste a day getting that information. (Because you usually find it out after telephone time.)

Scheduling a doctor’s appointment can take days.

But at least the health care system makes no bones about its disdain for patients (aka taxpayers) unlike SJ (svenska järnverket), the administrative arm of the Swedish state railway, which is running a poster campaign harrumphing its on-time service. The poster caught my eye because the train from which I read it was late. (I commute twice a week between Mälardalen, one of Sweden’s fastest growing regions, and Stockholm.) In fact, my morning train was cancelled or delayed three times in February and two times in March. As was last night’s train, which was delayed then cancelled due to brake trouble. As I waited last night, I decided to have a chat with the conductor.

Why, I asked, have I been having so much trouble with trains lately? I thought SJ had fixed the problems with its Regina trains, a batch of trains purchased three or four years ago that had not been designed for cold weather. The fiasco led to massive delays such as the January evening three years ago when my husband’s train stalled in the middle of nowhere. A new train was called to rescue the stranded passengers, but even this train had technical problems and could travel no faster than 40 km per hour. In the end, the passengers waited in dark, chilly carriages (the train’s reserve battery eventually ran out) for the next scheduled train, which arrived an hour later.

(My favorite SJ story is the time a Regina train stalled and the passengers got out and PUSHED THE TRAIN to help it regain power. There was a photo of the incident, taken by one of the passengers with a cell phone, on the front page of our local newspaper Västmanlands läns tidning. But I digress...)

They’ve fixed them, she reassured me, but now there’s a shortage of carriages and drivers. Oh, yes. I’d read about that in the paper. SJ has ordered some new, nifty double-decker trains that are so overdue – more than a year – that SJ has stopped promising when they’ll arrive. In the meantime, SJ has refurbished and put back in action some old, rundown carriages (apparently with none to spare for unexpected problems) to make up the shortfall until the new trains arrive. [Author's update: Once they arrived, there were chronic mechanical problems with the double-deckers, which caused major delays and cancellations.]

Hmmmm, I mused. But why is there a shortage of drivers? (There has been some very nasty flu going round…) The drivers, she explained, are off getting training for the new double-deckers, and there aren’t enough other drivers to cover for them.

The Social Democratic party, which has been in power for all but nine of the last 73 years, is gearing up for elections a year from this fall. On cue, Prime Minister Göran Persson is talking about raising taxes to meet future demand for public services such as health care and rail transport. (Only in Sweden can you win an election by raising taxes.) But surprisingly enough, support for Persson (and the Social Democrats) is slipping. Call me a skeptic, but I think the Social Democrats are missing the big picture.

Monday, February 2, 2009

It's not just health care (Also: The mammogram chronicles - part 1: Moscow School of Customer Care)

It’s about time for a mammogram. Not remembering what to do, I called my local clinic and asked how to get one. “I don’t think you need a referral [She doesn't know?],” answered the nurse? clerk?. (I've never been sure of the medical qualifications of the person who answers the phone.) Pleasantly surprised, I asked if she had the number for the main breast clinic where I needed to go. “No,” she said. (Why, of course, would she?) I had to look it up.

After rummaging around for the health care catalog, I found it, and the number for the breast clinic. But to my horror, listed under breast clinic was the dreaded “telephone time.” I could only call between 8 and 9:30 am on Monday-Friday and between 3 and 4 pm on Monday-Thursday to make an appointment. It was now 10:25 am. I’d probably have to wait until tomorrow. But not completely discouraged, I called the number anyway and got some kind of automated call system. The voice said there was a callback time today at 3:20 pm. If I left my phone number, someone would call me back. Okay, I thought, I’ll bite.

At 3:30 pm the breast clinic called. “I want to schedule a mammogram,” I said. “Do you have any symptoms? Would you like a consultation?” a voice asked. Tricky question. If I said no, I'd be put at the end of the queue. Hmmm…I haven’t had a mammogram for several years or a breast exam in more than ten. Better to say yes, and I described thickening tissue under my arm and soreness. (I have lumpy breasts and these symptoms are chronic but the voice didn’t need to know that.) “I’ll talk to the doctor and call you back,” said the voice, which also noted that it was late in the day.

I kept my ears open for a phone call all the next day. No call. So the day after that, Friday, I decided to call, skip the consultation and just schedule a mammogram. But alas, I missed telephone time again. (I called around 10:00 am.) I also got a message that there were no callback times available. End of recording. I started wondering about this callback system. Does it work on a day-by-day basis only? Or can I call on a Monday and schedule a callback for Tuesday or Wednesday? Only the breast clinic knows for sure, and they're not telling.

So this morning, Monday, I made sure to call during telephone time. I got a recorded message saying there was a callback time available at 9:25. (It was now 9:30.) I took it and thought if they don’t call, at least I can call again later in the morning.

About five minutes later the phone rang. “I want to schedule a mammogram,” I said. “Do you have any symptoms?” asked the voice. Oh, no, I thought! I’m not getting trapped into this again! But I couldn't resist completely. “Yes,” I answered, “but it’s not worth discussing since I talked to someone last week who promised to call back, but never did. I just want to schedule a mammogram.” “Just a minute,” said the voice, which could figure out who I was through my national identification number, which I had to provide when I scheduled the callback. Pause. “I see it here. You’re ‘wait.’ You need a referral.”

REFFERAL?! My heart started pounding! “My clinic said I didn’t need a referral and that I could call you direct!” “Yes,” the voice explained, “but you need a referral from one of our doctors here before we can schedule a time.” “But all I want is a mammogram,” I said. “Can’t I just schedule a time for that?” “No,” said the voice. Feeling my blood pressure rising and afraid that I had outsmarted myself, I took a deep breath and said, “Let’s pretend that I’m calling you for the first time and that I just want a mammogram. Can’t I schedule one?” “No. All mammograms require referrals.” (I still want to know how a doctor who has never seen me can make an informed referral. But never mind; some things are beyond the comprehension of mere mortals.)

Realizing it was hopeless, I asked how long the wait would be. “I don’t know,” said the voice. “Just give me an idea,” I pressed. “I don’t know,” the voice repeated. “Weeks?... Months?...A year?” I prompted. (Notice that I didn’t say days. THAT much I know.) The voice snorted softly when I said a year, as if the idea was preposterous. “Just give me SOME idea,” I insisted. The voice hesitated…“Maybe four weeks. Perhaps six. I don’t know.” (Mind you, this is six weeks until I’m notified of an appointment. The appointment itself can be any time up to three months AFTER notification. It’s possible I won’t get the mammogram until mid-June. And Swedish health care rules being what they are, I can’t go anywhere else for the mammogram unless I pay for it myself.) “By the way,” I added, “You shouldn’t promise to call someone back if you’re not going to do it.” Silence. We ended the call.

So, you may say, what a great argument against national health care! Not so. In all fairness, my county was rated dead last (or was it second to last?) in a recent national survey on health care quality. (Incidentally, even though it's only February 2, my health care catalog dated 2009 is already out of date. Apparently there is no “telephone time” anymore for the breast clinic.)

I’m convinced it’s how you design and administer the system, not who pays for it. There's no reason why a universal or national system has to be rigid or impersonal. That's simply a reflection of the person you're dealing with. A few years ago I received emergency obstetrical care in Canada. The service was reasonably prompt, and very friendly and courteous, with better equipment that I had experienced in Sweden.

There’s been a lot of talk about revamping health care here. But you would first have to redesign Swedish mentality. Sweden is not a service-minded culture; institutional services and many private businesses are designed for administrative ease, not customer convenience. (I’ve had endless discussions with friends and family about why.) You see it over and over again in many public services and private enterprises. It’s not just health care. (My other favorite example is the Swedish railway – a textbook example in every respect of how NOT to run a business.)

I don’t know what it will take for a paradigm shift here, but for starters, I’d stop sending employees to The Moscow School of Customer Care.