A Swedish EP on an observership in New York City reflects on the differences in care between the two developed nations.
Thanks to the Swedish Society of Emergency Medicine (SWESEM) and EMED EX I had the opportunity to spend two weeks at SUNY Downstate and Kings County Hospital in Brooklyn, New York. I am one of the first specialists in emergency medicine in Sweden, where EM has been a supra speciality since 2006. I am the resident program director at Södersjukhuset, the largest emergency room in Scandinavia, which is in the process of starting up a residency program in emergency medicine.
On visiting New York, I was first struck by the setting. I have been to New York City a couple of times before – even to Brooklyn in the 90s – but the taxi ride from Newark Airport to Flatbush in Brooklyn left me with mixed feelings. We drove over giant bridges, saw the Manhattan skyline, got lost in Brooklyn, had a malfunctioning GPS, and then I was finally dropped off at the residents halls at SUNY Downstate. All in all, it felt less like the world’s monetary center and more like, “Is it safe to go outside?” The few people I saw on the streets looked like gang members from some film. When I walked the neighborhood that first night, I walked quickly, found some fried chicken, and went straight back to my room. Phew! Later I realized the neighborhood was friendly but quite poor. I walked home in the middle of the night several timeswith no incident.
The next day I met Mert, one of the attendings and a member of EMED EX. He managed to get me an ID, a small, very pink piece ofpaper that helped me to get passed the guards watching every entrance. This is quite different than in Sweden, where access to the hospital is free. You never need an ID to get in; everybody comes and goes, for better or worse. In Brooklyn, many men and women in uniforms stood at checkpoints all over the hospital. Most of the time they seemed uninterested in my badge, but now and then someone really stopped me to make sure that the pink piece of paper was valid. I had to wonder at the value. Was this a way to keep people employed?
There were a lot of handshakes the first days. Everybody was very friendly and eager to help out. The United States is great in this aspect; people are largely easy going, talkative and open-minded. This came as a stark contrast to my visit to India a few years ago. On that trip, most doctors I met were very suspicious and not so keen on helping out.
My two week visit went by fast. I attended meetings, lectures and spent some time at the ER. Patients are more or less the same in NewYork as they are in Sweden. Some diagnoses are more common here, but there are no major differences in how we treat the patients. The large difference is that in the United States, emergency physicians are responsible for everything that is happening in the emergency department.
In Sweden, cardiologists are responsible for hearts, surgeons for surgery, and so on. The problem with this, of course, is that patients in the emergency department often don’t have a proper diagnosis when they present, or even after the workup, resulting in no speciality taking responsibility.
It was also striking that in the United States an attending has to sign for every patient. I observed that the residents in the later years are very good at what they are doing. Much better than most of the doctors staffing my emergency department back home, and yet they are still not allowed to work independently. In Sweden it is common that doctors fresh out of medical school work alone in emergency departments. Ofcourse, there is someone to call, but most patients are treated without consulting.
Another thing I found interesting was the fear of malpractice, and the health insurance situation, which makes everything a little bit more complicated. A large portion of the population in the United States don’t have health insurance, and they are very reluctant to seek medical help because it is very expensive. I met a man who lost the distal part of a fingertip last winter in an accident. He went to the ER to get help. No operation, just some revision and wound dressing. The invoice was $8,000 dollars. An uninsured American friend asked me for advise regarding his heart. When I suggested he see a doctor and check his ECG, he said that it would be too expensive for him. He would rather wait and hope for the best.
It would seem that in the United States, a lot of people don’t seek R Transatlantic medical help at all, or at least wait until the very last minute. On the other hand, those who seek medical help get every possible test and are signed off by a specialist to make sure that all the standards of medical care have been met. Right across the street from the hospital was a law office specializing in malpractice cases, further driving home that malpractice is something American doctors have to take into consideration every time they treat a patient.
Back home I sometimes get tired of all patients seeking help for very insignificant problems. But at least I don’t have to send all of them through the CT or MRI scan and do an extensive work up. Medical care in Sweden is easy to access and cheap for the population. It’s true that we do provide a little less care – maybe sometimes too little. However, I think that some of the workup and follow up in New York is too much, at least when you consider the number of people who aren’t getting any medical care at all.
For Swedish emergency medicine, I think the future looks bright. If we can get as skilled as the American specialists and practice in our environment without insurance companies, or fear of malpractice suits, I am confident we can bring the highest quality emergency care to our patients.