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.