Primary care for all: Lessons from Denmark
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When a body is discovered 10 miles out to sea, it sparks a mind-blowing police investigation. There's a man living in this address in the name of deceased. He's one of the most wanted men in the world. This isn't really happening. Officers finding large sums of money. It's a tale of murder, skullduggery and international intrigue. So who really is he?

I'm Sam Mullins, and this is Sea of Lies from CBC's Uncover. Available now. This is a CBC Podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. One in five Canadians don't have a family doctor or nurse practitioner providing primary care. Those who do often can't get a timely appointment.

On this special episode, we're off to Denmark because they don't seem to have that problem. The differences from Canada are startling. More than 98% of the people who live in Denmark have a GP. That's what they call primary care providers in that country. And Danes have little difficulty getting quick and even same-day appointments.

Like us, Denmark's health care system is publicly funded, which makes me wonder how they managed to do it. Who better to talk to first than two Canadians who have seen both health care systems up close? Emily Ritchie is 34 and comes from Vancouver, where she was a realtor. She moved to Copenhagen with her husband and young son almost a year ago. Carolyn Berard is 24 and comes from Montreal.

She's doing her master's in security risk management at the University of Copenhagen. Carolyn, let's start with you. How would you describe living here?

It's amazing. I love living in Copenhagen and the Danish way of life, I really appreciate it because it's a lot slower but a lot more meaningful than I find it is in Montreal. In what way? There's no rushing from one place to another. It's really taking the time to enjoy moments like with friends, with family or even just like moments in solitude. What Caroline is talking about is called hygge.

It's a Danish word that means to take time away from the daily rush to relax and feel content. You can do it alone or with friends and family. For instance, I saw lots of moms and babies in cafes, people on bikes, students hanging out with one another outdoors.

Emily says that aspect of Danish culture and way of life are a big part of why your family moved to Copenhagen. That and the good health care. How much did the health care system here in Denmark affect your family's choice to move? Knowing that we were moving somewhere that had a safety net was a huge peace of mind for us.

Just a peace of mind or was it, did it affect the choice? It did affect the choice, yes, yes. It made it all the more appealing. Unlike a lot of Canadians, Emily and Caroline had family doctors in Canada. For Caroline, access was difficult. Recently, when she tried to make an appointment, the soonest one she could get was in four months.

Emily says she could usually see her Canadian family doctor within two weeks and even faster for her young son. How nervous were you about finding a family doctor here in Denmark?

I was not nervous at all because I knew moving here, as soon as we were given our CPR numbers, we would be assigned a doctor. So it was a matter of days from us landing in Copenhagen to us being given our CPR numbers and therefore having a family doctor. So can you explain what a CPR number is to most people living in Canada? Certainly to health professionals living in Canada, that sounds like cardiopulmonary resuscitation, but I know it's something very different to Denmark.

It is a civil registration number. So everyone that's a resident in Denmark has a CPR number and that's attached to everything you do here. Most importantly for us, it was attached and is attached to our family doctor. And when you got that card, how did you know you had a family doctor?

It is on the card. It's on the card. Yeah. Can you show it to me? Yes, yes I can. Emily pulls out her CPR card and there is the name of her family doctor right near the top. It is right there. Wow.

You're not left looking for a number. You're not left searching for who to contact. It's on your health card. In Canada, the onus is on you to find a family doctor who will take you on. In Denmark, you don't have to do that. As soon as you register for health benefits, you're assigned a family doctor near where you live. What does it mean to you to see that there? Especially knowing that you come from Canada where you have to scrap and scrounge to try to find one.

Like I said, peace of mind. It's comfort. It's gold in a card. We'll get to the gold in just a moment. Caroline, how about you?

Having a CPR number and having the doctor assigned to me literally the moment I got to Copenhagen and got to Denmark made me think, yes, peace of mind, but also that it's something that's possible. Like, it is very possible for Western countries to have a certain amount of doctors to accommodate a population living in a country. It's not some far-fetched idea. It's something that is real, and I'm very grateful. Very grateful for a health care system that puts patients first.

Everyone who is eligible for health care in Denmark gets a GP without having to search for one. As I'm finding out, in Denmark you need a GP because they play a critical role in making Denmark's health care system work. As for GPs, in return for the right to set up a general practice, they must agree to take on a minimum number of patients. And how did you get that particular physician? It was assigned to us because of the community that we live in.

So that means that this physician is actually close to where you live? Yes. How far? From our first apartment, we were in half a kilometer. And now where we live, they're a little further away. And they gave us the option if we wanted to change doctors, you pay a small fee to do that. Otherwise, you are welcome to keep your doctor. And we were happy, so we kept our doctor. It's probably...

They're probably a kilometer and a half away. Think about it. Canada's public education system where your kids go to school is based on where you live. In Denmark, both your kids' school and your GP are based on where you live. It's called mandatory enrolment. And some experts would like to see the same kind of system in Canada.

As I'm finding out, their primary care system isn't inflexible. Patients do have a choice. So people listening to this might think that there's no choice, but in fact, there is a choice. And you actually made a choice to go to a different family doctor. How difficult was it to find another family doctor in this system?

It was extremely easy. I changed family doctors partly because I had a little bit of a bad experience with my original doctor that I was assigned to, but also I had moved outside of my original municipality, so I had the opportunity to change my doctor without a fee attached to it.

And it was super easy. I went online, I ordered my new CPR because I needed to get a new one because it's attached to your address and I immediately had the option to choose another family doctor based on my move. So far we've learned how people in Denmark get their GP. I wanted to ask Emily what happens next.

And how soon after you got your card and realized that this is your family doctor, were you able to make an appointment? I would say within the first month that we were here, I was in seeing the doctor. Denmark is very efficient in that they send you everything that they expect from you upon landing. So we were sent letters asking for our son's vaccination history. So I made sure to take that to our doctor.

I was sent a letter saying, you are due for a cervical exam. So I made sure to book that. And you've had experiences with your child where your child has had infections, I gather. So can you tell me about that and how easy it was to book an appointment and how quickly you were able to?

Yeah, so my little guy has issues with ear infections. I had the same as a child, so poor guy. But when he's showing symptoms of it, I will call. I have called our doctor, and they have a call period in the morning between 8 and 9. With children, it's similar to in Canada where they hear, oh, child sick, yes, we will get you in. So that very same day, we've always gone in. Yeah, always.

Carolyn, you had an interesting experience with that first doctor. What can you tell us about that complaint? Yeah, after my first appointment with my doctor, a few months later, I started having some digestive issues. And I went to my doctor, told her all of my symptoms, and her response was to Google it.

That must have been frustrating. It was frustrating. I did not feel heard. I think there's a reluctance really to prescribe here. It's just like treat it with paracetamol. That's kind of, yeah, Tylenol. That's the motto here for treatment in Denmark.

Once your symptoms are worse, then they look at it a little bit more closer. But that cultural difference, I think, definitely colored the experience I had at my first family doctor here in Copenhagen. What did you do as a result? I was going home that summer a few weeks after that initial appointment. So I called my family doctor in Canada. And that's when I was told that I had to wait three to four months to get in a checkup with her. So...

So I did embellish my symptoms ever so slightly just so that I could get a chance to see her and I managed to get an appointment with her. I told her you know the story of how the doctor told me to google things in Denmark and she sent me right away for some blood tests. Caroline got the blood test done but didn't hear back from her family doctor in Quebec. Meanwhile she returned to Denmark where she connected with a different GP than the one to which she was first assigned.

She showed her new GP the blood work done in Quebec. That doctor took Caroline's symptoms more seriously and quickly got her the help she needed. Compared to Canada, people in Denmark have extraordinary access to GPs. Wait till you hear about how they access specialists.

It's something Emily discovered recently when her son needed treatment for an ear infection. So we saw our family doctor who was fantastic. He'd had a really bad ear infection and she wanted to make sure that he was seen by an ENT to confirm that his tympanic membrane had healed properly.

And so I was immediately nervous because I thought, well, if we're being referred to a specialist, it's going to be six, eight, nine, 12 months before we see one. Was that your experience in Canada? Yeah.

Oh yeah, so I was nervous and I asked my doctor about it and she said, what do you mean? It's easy. You just look on, you go online, you choose the ENT you want to see, you can see their wait times, choose whoever you'd like to contact. And so I took a few recommendations from friends around here, called one and we were seen within two weeks.

This feels like an alternate reality. I know it does. I was completely shocked and my mom was actually visiting when we saw that ENT and so she got to come for that experience. So as I understand it, the family doctor, your family doctor puts in the request for the referral and that referral is not designated to any particular ENT specialist. It's whichever one you choose and they can't say no. No. Wow.

What a system. What did you think of all that? I thought it was amazing. I went from being completely nervous, thinking, well, this is pointless. We're going to wait forever, to, wow, this system truly works. To Emily, the system truly works because it seems designed to meet the needs of patients in ways that might make Canadians feel envious. We'll be right back.

I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.

You're listening to White Coat Blackheart. This week, we're in Copenhagen to find out what makes Denmark's primary care system one of the most celebrated in the industrialized world. So far, we've looked at the Danish model through the eyes and ears of health consumers. Next, we're going to hear from a GP who works on the front lines. Her name is Dr. Maria Kruger.

Dr. Kruger, I presume. Hello, I'm Brian. Thank you so much for doing this. It's very kind of you. I'm always glad to show the clinic and to tell about the healthcare system in Denmark because I think we have a wonderful system and I think it's important to tell about it. Dr. Kruger shows me around the clinic she bought 10 years ago.

She and two other GPs who also work here take care of just under 5,000 patients. The clinic is located in Friedrichsburg, a tony enclave in the capital region of Copenhagen known for low crime, good schools and upscale shops.

Kruger is vice president of the Danish College of General Practitioners, which is dedicated to enhancing general practice in Denmark. Out here it's the secretary. We have two secretaries because that's the way into the clinic. You call the clinic. Of course, we also have online. You can write the clinic. You can write email consultations. You can write and book appointments.

And every door is through us. Because you're the gatekeepers of the system. Yes, exactly. And everybody can come here. You have 1,600 patients, more or less. On your average day, how many patients do you see? I see around 20. I have consultations, of course. I have also telephone consultations. I have video consultations. I have email consultations. I supervise my staff. I supervise the younger doctors.

And I go to visit with the elder patients who cannot come here. And also we are doctors for nursing home for elder patients.

So how manageable is that for you? Yeah, all the time you have to go to right, go to left. Juggle. Yes. You're juggling. You have, yes. How much time are you spending with each patient? Between 10 minutes and 30 minutes, I think, when they come here. Because if they come with an acute condition, they can come every day between 11 and 12. People can come every day with an acute condition.

And for those who are not acute problems, how long does it take for them to get an appointment? Well, within...

five days or so. Dr. Kruger confirms what Caroline and Emily said about access to GPs. They offer same-day appointments to patients with acute problems like pneumonia. She says other patients can usually be seen within five days in person, by phone or email and virtually. She sounds busy though not stressed out like family doctors I know in Canada. Kruger and I compare notes. A lot of them are quitting and retiring early.

That is a very, very big concern also in Denmark. It is. We really, really have a big debate about that because we are also not enough family physicians.

We are 3,500 family physicians in Denmark and the government has estimated that we need 5,000. Wow. Yes, because we treat our patients so good so that they live longer now. We have so much preventive medication, so we have more and more elder population in Denmark. They get more and more diseases that we have to take care of. And also the big problem is that society has seen that

general practice as a big deep ocean where they can put everything in you know so why do you only have why are you short 1500 uh family doctors in this country so you you do an estimate as a politician and you decide this is uh how how much we're going to have but it takes 10 years to educate a doctor so you did the math wrong 10 years ago and that is what we're paying for now

We had that in Canada. We had a very influential report in Canada that restricted the number of medical students in schools, and then later we didn't have enough doctors. And as in Denmark, in Canada, they're asking doctors to do more things than they used to do before. So that means that you need more of them. Exactly. But what the government then did is that they turned on...

For university, we have to have more medical students. And now you can ask Monica after because she's an intern. Okay. She really wants to be a general practitioner. But now there are no jobs. They turned all up for medical students, but they did not give any more residents. Residency positions. Yes.

So it's a big problem. So you're telling me about problems. There's a lot of problems, but I'm also here to learn about what's good about the system. Oh, sorry. No, that's okay. No, that's okay. But tell me about what you think the benefits are for patients who, you know, they look at their CPR card and there's the name of a doctor. They have been assigned a doctor. Yes. They don't have to go looking for one like we do in Canada. How is that beneficial for patients? That is beneficial because...

then you get a more personalized relationship to your doctor. And when you have that, you will confide more in your doctor. So if they need to see a cardiologist, you put in a referral to a cardiologist, but the patient chooses which cardiologist they want to see. In this case, they can choose both. I can ask them, do you want to go to the hospital or do you want to go to a private hospital?

And they don't have access to hospitals on their own, only through you. Yes, yes, only through me. So there are pressures on family doctors here in Denmark. This is a bit of a different subject, but what goes through your mind when you hear, when I tell you that one in five Canadians, roughly 6.5 million Canadians, do not have a family doctor because they can't find one? I think that's, well, that's scary. I think it's

because there's a risk that you won't find out in time if you have a disease that can be cured.

Instead of here, if you just know who to call, you can write an e-consultation. I have experienced this. It's very easy. I can say, yes, this I should see. No, this I should see. So I think you are in a big risk, the society, for then you get more sick people because you did not find out in time. We are. What you're telling me is that there are challenges here. There are things that you could do better. But it's not as bad as Canada.

I think we have to focus on the good thing and why it's important that everybody have a primary doctor and that you know where to go. It's important. And I think that we have to take care of that institution. And I think the government has to acknowledge it more. And instead of there has been this fighting between the government and our organization because they want us to do more and more. I think now they have to see now we take care of you.

Because the worst thing would be that everybody is leaving this. Denmark's primary care system may be better than Canada's, but both nations are dealing with similar challenges. Dr. Kruger mentioned that Denmark has 3,500 GPs and needs another 1,500 to meet current and future primary care needs.

Denmark has opened up more places in medical school and it needs to train more GP residents. So, Monika.

Dr. Monika Muehlingaert is 28. She just graduated from medical school in Denmark. As part of her postgraduate training, she's learning the ropes from Dr. Kruger. Tell me about what you're doing here, the kinds of patients you're seeing and the kind of practice that you're starting to learn about. So at a GP like this one, we have babies and kids and they come in and they're

often healthy and they go through these regular checkups. And then obviously we have large group of patients that are adults and a lot of older patients. And when it comes to older patients, it's patients with chronic diseases that are important to see on a regular basis. And now that you're having the opportunity to learn what it's like to be a family physician, do you still want to be one? Yeah, this place has just confirmed that that's what I want to do. What is it about this place that has confirmed that for you?

a little cheesy, but the colleagues and the way that they have organized their clinic and how I can see that when it comes to work-life balance, this is a way I want to do it as well if I were to open my own practice someday. I'm getting at the sense that this kind of a practice works for you. How does it work well for patients? Have you thought about that? It seems like from the patients I meet, they're very satisfied.

And they also know that depending on what kind of problem they're coming with, we have different people who are great in that area. If you're pregnant, you come with someone who is specialized in pregnancy, the midwife. And then if you have a more chronic disease than having your regular doctor like Maria or Veruna who own the practice, then you can have that consistency. And the patients are really satisfied with that.

Do patients complain about anything about the system, about how the system works? That would mostly be the wait for when they need to go to the hospital or there is a referral we're making and they can't get this or that or a new appointment with a gynecologist because they're more specialized. They have a longer waiting time and so on. Besides that, I'm all in all seeing happy patients.

Thank you for speaking with me. You're welcome. Thank you. I have a patient I need to call. As Monica said, people in Denmark have their grumbles about the system. One of the biggest complaints is that GPs, being the gatekeepers of the system, sometimes stand in the way of patients getting the test or specialist appointment they want.

But overall, patients and GPs in Denmark are pretty satisfied with primary care. As we set off the top, Whitecoat traveled to Denmark to find out why primary care is a success there and most importantly, some lessons for Canada.

Also keen on learning from Denmark is Dr. Tara Kieran. Dr. Kieran is a family physician at St. Michael's Hospital in Toronto. She's also the Fidani Chair in Improvement and Innovation at the University of Toronto and Researchers Primary Care here in Canada and around the world.

Like me, Dr. Kieran has also visited Denmark. I wanted to compare notes. What stood out to you about its healthcare system? You know, there was one thing that really stood out to me. It was just how customer-oriented their healthcare system was.

Everything was really designed to be easy for the people who are using this system. I mean, one example, I think, is even how people are able to choose a family doctor and the government's goals around that. So the government has set a goal for everyone to have not just a family doctor, but to have a choice of a family doctor, what they call GPs there. But they want you to be able to, within...

sort of a certain radius of where you live, have a choice of two GPs at minimum who are accepting new patients. To me, like that is an example of how customer oriented their healthcare system is. One thing that struck me was just how quickly people can get in to see their GP. Of course, this is a major lament in Canada among patients. So what did you think about the speed with which they can see patients? I mean, yeah, it's a system that works. And I think actually it's tied to

the accountability GPs have built into their contracts. To get what they call, I think, a supplier number to actually start a practice in a region, you have to commit to a few things. Taking on a minimum of 1,600 patients, you have to commit to being open Monday to Friday, 8 to 4. You also have to commit to seeing urgent issues on the same day,

And GPs have accordingly figured out in their practice how to make that work. You know, you mentioned that patients have a choice in the family doctor that they want to have as their family physician. And that's also true for specialists. What do you think that that transparency does for patients?

I mean, I will say, Brian, I loved that system for how they refer to specialists. It was a revelation for me. So simple and so customer oriented. And like I was like, why don't we have that here? I think that kind of customer orientation and transparency is what we are desperately lacking here in Canada. You also went to the Netherlands. Why don't you give us a teensy preview of something that we're going to learn from your trip there? In my dreams,

readings about other health systems. You know, it was a few years ago that actually I came across the reforms in the Netherlands around how they handle after-hours care. We know it's a big pain point. You know, outside 9 to 5, Monday to Friday, it's very hard to get the care that you need. But in the Netherlands, it's easy. And so, yeah, I'm excited to share what after-hours care in the Netherlands looks like to everyone listening.

Next week, we'll have one of our favorite past shows. Then in two weeks, Dr. Tara Kieran brings us highlights of her look at primary care in the Netherlands, including that country's second to none after hours primary care system and what she plans on doing with the lessons learned. Don't miss it.

White Coat Black Art was produced this week by Stephanie Dubois, with help from Jennifer Warren and Samir Chhabra. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. That's medicine from my side of the gurney. I'm Brian Goldman. See you next week. For more CBC Podcasts, go to cbc.ca slash podcasts.