“Not on Banker’s Hours”: How Primary Care Differs in the Netherlands and the U.S.

NOAM LEVEY: And then at the end of the exam, I asked, you know, all the patients I saw that day there were 15, 20 patients or so, were you worried about how much this was going to cost? And I joked with people that I might as well have asked them, you know, how is your pet penguin?

SHANOOR SEERVAI: Hi everyone, welcome to The Dose. On this episode, we’re returning to a topic from some of our very first episodes of the podcast, how health care is different in the U.S. and other high-income countries. My guest today is Noam Levey. Noam writes about health care policy for the LA Times. And we’re going to talk about a story he wrote for the Commonwealth Fund in which he speaks to two primary care doctors — one in the Netherlands and the other in Seattle — to learn how they work, how their primary care practices are different. Noam, welcome to the show.

NOAM LEVEY: Thank you for having me.

SHANOOR SEERVAI: Let’s start by just talking a little bit about your story. What’s it about?

NOAM LEVEY: So I wanted to compare the experiences of physicians in the U.S. and the Netherlands, in part because I think their experiences provide a window into the way primary care works or doesn’t work in the U.S. and in other high-income countries. So, as many of your listeners no doubt know, primary care in this country has historically been underfunded and sort of viewed as the forgotten stepchild of the American health care system. And that’s a big contrast with a lot of other high-income countries. The Netherlands is interesting point of comparison, I think, for the United States because it has very deliberately built a health care system on the foundation of a very strong primary care system.

And of course it’s one thing to talk about that in generalities, but we thought it would be interesting to actually get into the nitty gritty of how primary care doctors go about their days and interact with their patients in these two systems to sort of see what the experience is like, not only for the physicians, but for patients who receive care.

SHANOOR SEERVAI: I’m curious about maybe time that you spent at a clinic or maybe a primary care practice in the Netherlands, and how that might be different from the ones you’ve reported in the U.S.

NOAM LEVEY: So there are a few things. One which is quite remarkable, I think, and deceptively important, I think, is that the physician whom I was visiting with in the Netherlands meets his patients in his office, not in an exam room. So his patients come into the office and they sit down with him at his desk in the same way that, you know, you might meet with a teacher of your kids or you might meet with a banker or any other kind of professional relationship.

SHANOOR SEERVAI: Right. But it’s not a medical setting. You don’t start out there.

NOAM LEVEY: You don’t start out in the medical setting. That’s right. And it creates an interesting dynamic that’s different from this country where most of these kinds of interactions happen in a much more clinical kind of setting where the patient is sort of oftentimes kind of sitting uncomfortably on an exam table or wedged onto a little chair while the physician is sitting kind of on a stool or something. I’m sure this would be familiar to anybody who’s gone to the doctor recently.

SHANOOR SEERVAI: I mean, I’m just thinking about my issue is always what do I do with my stuff? Where do I put my stuff? (laughs)

NOAM LEVEY: Exactly. And the doctor has the same kind of oftentimes cramped kind of experience. Where does he or she put her laptop, and how does she or he position herself for the conversation? And a lot of times people come with a spouse or they come with a child or a parent and you know, it’s tough to fit this other person into the little exam room. It creates sort of the physical space itself is sort of uncomfortable in this country a lot of times. By doing it in a more traditional office setting, and I should say this setting was quite nice, it sort of had a glass door that opened up to a garden in the back, it creates a sort of a more of an equal kind of an interaction and people are sort of more comfortable. The doctor is sitting across the desk from the patient, the two are facing one another. And I just noticed that the conversation seemed more natural than it does a lot of times in an exam room in this country. And so the doctor could also begin all the interactions with a conversation.

And sometimes I think the sort of art of conversation, like that interaction between the clinician and the patient, can get overwhelmed by sort of all the clinical demands of doing a routine exam with a patient. So much more seems to be often learned by just having that conversation.

The other thing that’s interesting about the interaction between the doctor and the patient in the Netherlands is that you can see a much more conservative medical culture at work. And so one of the features of the Dutch primary care system is that it is, and I use this term cautiously, but it is a gatekeeper kind of a system where patients are assigned to a primary care physician. And the expectation is that they go to their primary care physician first before seeking more specialized care. And this is not done primarily as a way to prevent patients from getting care, but rather with the recognition that if the primary care doctor is doing his or her job well, he is best positioned, he or she is best-positioned to manage a patient’s care.

And so one thing you see is that the Dutch primary care doctor is empowered to do a lot more, and the expectation is that a lot more could get done in the primary care office before the patient is sort of sent off to cardiology or sent off to get an MRI or sent to the hospital or what have you. And so —

SHANOOR SEERVAI: And it sounds like —

NOAM LEVEY: So, go ahead.

SHANOOR SEERVAI: Sorry. It sounds like that takes a degree of trust as well, where you’re going to see your primary care doctor not asking for the slip of paper that says, I want to see a cardiologist, I want an MRI, but you actually trust that your primary care doctor could tell you what’s going on.

NOAM LEVEY: I think that’s a really good point. Yes, I think that’s true. And obviously that level of trust is going to vary based on who the physician is. I’m sure there are some Dutch doctors who are not, don’t seem particularly trustworthy to patients. But there is this, because I think the system emphasizes the relationship between the patient and the primary care physician, maybe there’s an expectation that there can be a more trustworthy relationship.

SHANOOR SEERVAI: I was struck when we first started talking a couple of weeks ago, and you mentioned this very stark difference in the way that patients in the Dutch practice feel about their health care costs compared with patients you’ve interviewed here in the U.S.

NOAM LEVEY: It is really striking. And I should say this is not just in the Netherlands, but in other high-income countries I’ve visited, including Germany and the U.K. The very profound difference between how patients think about or talk about costs is really, really striking compared to the United States. So, you know, if you go into any doctor’s office or hospital in this country you wouldn’t necessarily hear doctors talking with their patients about cost. But if you talk to patients, you can be pretty darn well sure that they’re worried about how much it’s gonna cost. And so one of the things which I did when I was in this physician’s practice in the Netherlands was ask the patients, you know, what were you most worried about when you came to the doctor’s office today?

And people would say things like, you know, I’m worried about this pain in my back or my abdomen or I’m taking a new medication and I want to make sure there’s not the side effects, etc., and nobody would mention costs. And then at the end of the exam, I asked, you know, all the patients I saw that day, they were, you know, 15, 20 patients or so, were you worried about how much this was going to cost? And I joked with people that I might as well have asked them, you know, how is your pet penguin? Because they looked at me like I was crazy. Like this was not in the realm of possibility. “Well, of course, I didn’t think about cost.”

And in fact, one of the patients who was a sort of middle-aged man who had to leave his job, he had been overwhelmed by stress and had kind of a breakdown at work and was talking with his family physician about kind of getting back on his feet and so forth. When I asked him this question, he looked at me and he said, “I don’t understand. How would that be helpful for me to get better if I had to also worry about cost?” Which was sort of this, you know, blazingly obvious kind of issue, but sort of lost, of course, in our system.

SHANOOR SEERVAI: Right. That’s pretty much the most important point. When you’re dealing with a physical health condition, the last thing you need is compounded stress of financials.

NOAM LEVEY: One would think, one would think.

SHANOOR SEERVAI: Yeah. I mean if you’re the single earner in a family of four and you have two young kids and you have a $5,000 deductible, that’s a lot of money you have to spend every year before the insurance kicks in.

NOAM LEVEY: Absolutely. And clearly it’s having a huge impact on patients in this country. One of the things that sort of, I found interesting about talking to the primary care physicians in the United States and in Netherlands for the piece I did for the Fund was, you know, the Fund does obviously a survey every three years of primary care physicians in the U.S. and in other wealthy countries. And U.S. primary care physicians are notably much more downbeat about the health care system in which they work. There’s less of a difference in sort of their own professional satisfaction, but they feel very pessimistic about the American health care system in general.

And I think it’s speaking again from experience of talking to a lot of physicians in the U.S. over the years, they see the struggles that their patients are going through paying bills and, you know, Dr. Brewers, who is the American physician originally from the Netherlands who I interviewed for this piece, said she sees her own patients rationing their own care, not getting the tests that she recommends or not filling prescriptions because of the cost. And I mean, that’s very demoralizing from her. She cares about her patients and obviously if her patients can’t get the care they need, that’s pretty dispiriting.

And you know, by contrast, Dr. Sanders, who’s the Dutch physician who I profiled in this piece, you know, one of the things she said was that she felt very confident that her patients could get the care that they need and that the Dutch system protects people and, you know, that makes her feel better about being a physician. I thought that was pretty, pretty striking.

SHANOOR SEERVAI: Yeah. And I’m actually glad you brought that up. So let’s get into the story a little bit. The point you make about home visits and being able to go see a primary care doctor after hours in the U.S., of course, it’s much more common to go to the emergency room at night or on the weekend. So can you talk more about the different approaches to these two issues, home visits and after-hours care?

NOAM LEVEY: So again, I think one thing that’s striking about the Dutch system is the degree to which it has been sort of very deliberately planned, which is a contrast to, sort of, I think the much more haphazard way that our health care system has evolved over the years. And one of the things that the Dutch did in building a system with primary care as its foundation was to assure that patients would have a place to go after hours. And you know, anybody who has kids or has a medical condition or elderly parents knows that, you know, the time of the day when you’re assured that, you know, something bad is gonna go wrong with your kid and they’re gonna have an ear infection is, you know, at 7:30 at night when the doctor’s office is closed. I mean that it doesn’t happen on banker’s hours.

And you know, one of the things which we struggle with in this country is that it’s a pain to try to get after-hours medical care and we end up going to urgent care centers or, you know, in some cases going to the emergency room. Nobody thinks that’s the best way to deliver care. It’s not only more expensive, but it disrupts continuity between the place where you’re getting care. So the Dutch say we are going to create after hours and infrastructure for patients to get care after hours. And so Dr. Sanders, who I wrote about in this piece, has to staff an after-hours clinic a couple of days a month with other primary care physicians in the general area where she works so that her patients can go there after hours.

You know, it’s just this level of convenience and thinking about how patients actually interact with the system that, you know, unfortunately is so often missing in our own system. Home visits I think reflect that a little bit as well, although I think they’re also something of a product of the residential patterns in the Netherlands, which are different than they are in the U.S. Of course, home visiting used to be considerably more common in this country, you know, half a century ago and it sort of fell out of favor as people’s living patterns changed. But I think it also has a value beyond sort of being kind of a throwback to, you know, another age.

One thing I remember chatting with a doctor up in Boston named Robert Masters who pioneered a lot of thinking about better ways to deliver care to frail, elderly, older patients in Boston. He said, you know, it changes the dynamic with the patient, that when you are a clinician and you’re visiting a patient in their home, you know, you the clinician are the visitor. And so you are sort of —

SHANOOR SEERVAI: Right.

NOAM LEVEY: You are in some ways deferring to what the patient is telling you and you also as a clinician see the totality of a patient’s circumstances and you can see how they’re living and see what’s on the kitchen table and, you know, see whether the air conditioner is working. And that’s much more kind of constructive way of interacting with a patient, particularly one that has a whole constellation of challenges beyond just, you know, their medical care. And so I think it is —

SHANOOR SEERVAI: Right.

NOAM LEVEY: All a piece of a system that’s a lot more thoughtful about how primary care can be sort of leveraged to best address the needs of patients. And, unfortunately we sort of lost that a lot in this country, although, you know, ironically there are now efforts to reenergize home visiting, if not by physicians themselves, by nurses and others who work with physicians for precisely these reasons.

SHANOOR SEERVAI: Mm-hmm. It’s actually making me go back to something you said a little bit earlier: the idea of going to a patient’s house for example, if someone is complaining of back pain and you’re like, okay, well, let’s take a look at your mattress, and there is a problem there. That’s a very different fix than, okay, let’s order an MRI, right? But, obviously something is going on for the patient and the patient might not even know that the bed they’re sleeping on might not be great for their back.

NOAM LEVEY: Exactly. Exactly right. And I mean there are financing challenges to making home visits work in the U.S., in no small part because the costs of, you know, traveling and you can see four patients in an hour easily as a clinician in your office. Going to visit somebody at home probably takes an hour when you figure everything out and there are issues involved with how we pay for health care that make it challenging to do home visiting in this country. But you know, clearly the Dutch system puts a premium on this, and I think that’s a reason why it persists in the Dutch system to a degree that it doesn’t in the U.S.

SHANOOR SEERVAI: Right. Well, this has been great, Noam. Is there anything else that you observed or have observed in your decade of reporting that you’d like to talk about at this point?

NOAM LEVEY: I don’t think so. I think we covered it.

SHANOOR SEERVAI: All right. Well, thanks so much for joining me on the show.

NOAM LEVEY: Thanks for having me. It was a pleasure talking with you.