A Global Family Doctor
who held leadership roles in Norwegian, Nordic, European, and world family medicine organizations. She is a Past President of the World Organization of Family Doctors (WONCA).
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…it was extremely important that we have a clear voice to differentiate when are we speaking about physicians working conditions, and when are we speaking about the content of practice. And we should do that in the right order. First, we should advise on what we consider good medicine. And then, only then, should we discuss the price. In many places in the world it’s mixed up and that is to the cost of our reputation.
We are familiar with your high profile through WONCA (World Organisation of Family Doctors), but I want to take you back to the beginning because you didn’t start off in medicine. Tell us about that journey.
Anna Stadval: That’s right. I was raised by parents with a broad academic scope. My father was a sociologist, the first sociologist in Norway in fact. I felt I was bound to follow that path so I started out studying sociology. I also had the idea that I could change to psychology and combine the two. However, the subject became a little bit too close because of family reasons and I wanted to do something which didn’t have to do with my upbringing, and also to challenge myself. Science in the more narrow sense was not my main field so I thought medicine would challenge me in that way. It would also give me broader opportunities in the job market. And I knew I wanted to work with people. So that was more or less how it started.
DMacA: And then your journey into family medicine…
AS: I would like to say a few words about a person who meant a lot, and who influenced that decision. He passed away last week. (Oct 13th ) at just over 100 years old. We are not mourning, we are celebrating his life, what he did, and what he contributed: Christian F Borchgrevink.
He was the first professor of general practice of family medicine in Norway and also a pioneer on the international arena. He did a lot to raise the profile of the discipline in Norway. He introduced longitudinal student’s groups from first year of medical school, so we were invited to join groups with mentors from his department, which was very small and not something that would be considered a department these days. We followed these groups through all six years at medical school, not especially under the heading of family medicine or general practice, but discussing topics which were not part of the formal curriculum, topics related to ethics and dilemmas clinicians encounter in their daily work. It resonated with my background in sociology and my upbringing, “make an effort always to understand the context”. Saying that sounds as if I am being politically correct, but it’s actually ingrained in my DNA. So, family medicine was a natural choice.
DMacA: And then you went into practice in Oslo. Tell us a little about general practice in Norway.
AS: We have a long tradition in primary care. If you look at the map, Norway is this long country where people live in remote areas way up north, but also in rural areas down south. People need healthcare to be able to live in these areas. We have traditionally had, for more than 200 years, what we could call district medical officers in Norway. Like most other Western countries where family medicine has status, the discipline was not recognized as an independent discipline in its own right until it became more formalised in the 70s. But due to geography and tradition, we used to have family doctors or general practitioners outside the cities, to the extent that we have big cities in Norway, who were also the public health officers in the community within in the municipality. We call that a combo doctor, which is more or less exactly the words we use in Norwegian. This gradually changed and from 2001, to make the story short, we introduced the ‘list’ system. By law, every citizen in Norway is entitled to be listed with a qualified family doctor, a system which has now existed for almost 25 years.
And that brings me to what I usually point out when I promote family medicine. I say that there are important principles, which were put in legislation 25 years ago in Norway, and they are the personal continuous relationship with the patient. These are, primarily, the marker of a GP. After the introduction of the list system, we had a predictable positive wave in the standing of general practice. But Norway is, of course, also subject to general international trends and that is why the discipline of family medicine is struggling, primary care is struggling. But, compared to most countries I have visited, including the UK at present and many other countries throughout the world, I would say that we have a very good primary care based health system. I hope we are able to make sure it prevails.
“… the endorsement of the strictest set of rules for collaboration between the pharmaceutical industry and doctors in Norway. I’m proud of that.”
DMacA: Let me ask you now about something different – your transition into a leadership role. What was the driving force for you to do that?
AS: I think I’ve always been a leader. Even as I taught folk dance it seemed natural for me to take leadership. The motivation to go into family medicine organisations, starting at the Norwegian level, was that I felt a need to encourage a higher level of reflection amongst my colleagues about our role. In Norway the ‘College’ is organized within the overall medical association. When I was chair of the Norwegian College, close to 25 years ago, this issue created a huge battle because I argued that we should be outside the medical association because it was extremely important that we have a clear voice to differentiate when are we speaking about physicians working conditions, and when are we speaking about the content of practice. And we should do that in the right order. First, we should advise on what we consider good medicine. And then, only then, should we discuss the price. Like many places in the world it’s mixed up and that is to the cost of our reputation. People, journalists, bureaucrats, politicians, they are not always sure about who they are talking to at any particular moment: Is it the highly professional person who gives their advice or, or is this part of a negotiation that coming up next month, ie money? That was one aspect- I wanted to refine that professional voice. But, I also wanted to raise awareness, again back to the context, the societal context, that family doctors are working as part of the community, they’re part of the first line. We’re not just service delivery providers, we are part of the community and we need to understand how things work in the community to play a good role and to utilize the potential of that role in a good way.
Maybe I am also motivated because it’s fun to say -let’s look how we can do this differently? Often my question will be – can we simplify? The general tendency is to create new turfs when we’re not satisfied with what’s existing. So, instead of building new turfs and making things more complex, as we do in healthcare all the time, let’s simplify. What are the basic needs? What’s our mandate? And the fourth thing, which is related, and which was an issue when I grew up as a doctor, is the mixing of interests between commercial actors and doctors, not least the pharmaceutical industry. That was one of the big issues I was working on and we actually managed, in my time to contribute to the endorsement of the strictest set of rules for collaboration between the pharmaceutical industry and doctors in Norway. I’m proud of that.
The world of global family medicine
“Gender counts. Simple as that. Maybe being a woman also has been an advantage? I am not sure. Women often say that when they are asked that question and I always wonder if they say this just to sweeten the pill?”
DMacA: While you were taking these leadership roles, you were bringing up a very young family. That was a huge challenge. Tell me about the challenges facing women in leadership.
AS: Yes, that’s a big one. I was fortunate. I’m still married to my children’s father and we have a balanced equal relationship. We are not too alike. And, his work situation was such that it made it possible for him to be at home when I was away. You must ask my children if it was an advantage or not, but I choose to see it as an advantage: they were very seldom in the care of other people. One of us was almost always there. But, the gender issue is a big one. Gender counts. Simple as that. Maybe being a woman also has been an advantage? I am not sure. Women often say that when they are asked that question and I always wonder if they say this just to sweeten the pill?
Born in 1959, I’m in-between, or at least after, a defining generation that established, invented, modern family medicine. There were good and bad aspects of the impact of the ‘68 generation and I was not always impressed. While I think there were a lot of good things, it may sound strange speaking as a leader who has led large organizations, that I am sometimes wary of large groups, the massive energy in a group, the power of the group. The 68-ers is an example. Maybe one of the things that has made me succeed when, if, I have succeeded, and something which has not been always welcome, especially coming from a woman, is that I ask: “Well, I’m not sure if this is true, even if it is defined by you, or by the majority, or the old buddies network”.
DMacA: You did something else which was quite unusual, and which I’m sure created some ripples in the medical profession, and that is you wrote a long term newspaper column.
AS: It was for the biggest tabloid in Norway, read by the general public. It started when the list system was introduced. I was invited to be ‘the GP’/ the “list doctor” of that paper, writing a weekly column. And I thought, wow, what an opportunity, I always liked to write. But this was special. And it also gave me a stage. I wrote a weekly column for seven years, and I chose the topics myself, and I was hardly edited. Not in content, I mean. So that was extremely rewarding for many reasons. The column format is short and you have to make the point at the start; this is what I want to say, elaborating a little bit on it, and then closing it so it`s not too provocative, but leaves the reader with food for thought. I raised many topics. Because I was in practice all the time I had daily input from patients- I was reminded of what’s happening out there. And by the way, I feel that the clinical corrective has given me legitimacy in all the work I’ve done outside practice; I have always stuck to practice. This work was very rewarding. My husband read the column almost every week before submission. He is not a doctor and he has quite a good sense of Norwegian grammar, punctuation etc. But, primarily, he reviewed the content, to see if it was understandable for ley people? Does the message come across? And I think this experience also help me when I switch to a foreign language and have to give short messages. That’s been part of the WONCA job, to give short messages in another language. It’s very good to have that vocational training in writing.
“I was elected WONCA World President Elect and the last six years have been, in one sense, a bit too much in relation to work-life balance. But it has definitely been worth it…”
DMacA: It’s fascinating to hear the background to the story of your life, but how do you get the balance? What do you do for relaxation?
AS: That’s something I’m reflecting a lot on now because I’m in transition. I have reduced practice. I have a younger colleague , she and I share my list. And, of course, I am stepping down from very hectic international activities. I know this sounds very doctor-ish, very healthy and very clever, but I do physical exercise every day. I think I can count on two hands the days during the year where I don’t do at least half an hour physical exercise. It’s mandatory for me. And when I have time, and that is something I can indulge in now; reading, theatre, cinema, but also making sure that I have some time for myself, even if it’s just a few hours. I’m not saying it’s easy. It’s six years yesterday since I was elected WONCA World President Elect and the last six years have been, in one sense, a bit too much in relation to work-life balance. But it has definitely been worth it. I am expected to say that, of course, but I do really mean it as well.
DMacA: Anna, Thank you very much. It’s been an absolute pleasure talking to you. And thank you very much for your huge contribution to our profession on a local, Norwegian, and on a world level. Thank you very much indeed.
