An idiotic compromise

The Finnish government was on the verge of being dismantled over the argument on the number of the Social and Healthcare Districts – 5, 12 or 18. They have now settled with a compromise, 15, that brings together the worst of all worlds.

I’d rather have seen a new election take place.

Healthcare professionals (including the National Institute for Health and Welfare, Finnish Medical Association and independent expert groups) recommended either 5 districts (based on the 5 university hospitals in Finland) or 12, tops (corresponding with the minimum population base needed to deliver good care 24/7).

However, the Centre Party wanted 18, from a purely political perspective – their backing is the strongest in the rural areas, and keeping the districts small will help them cement their power in the periphery of Finland.

15 districts means some of them will be too frail to provide high-quality emergency care. It also means the administration costs will remain as bloated as they are, with no hope of cutting them down significantly.

Why appoint so many expert groups and order so many reports if you’re going to rule against them anyway?



Dumpster diving

Today's catch.

Today’s catch.

Up to 300 kg of food per person per year is being thrown in the trash. The figures, as you’d expect, are much lower in the global south but even where the households are thriftier, significant loss occurs in the production and retail stages. In Finland, it has been estimated that maybe 10-15 % of all food produced goes to waste.

My first personal attempt to lessen the retail stage losses by dumpster diving was around the time I moved from my parents’ home 8 years ago. My only negative experience was a scary pig carcass in one of the dumpsters that once took me by surprise. At some point, the shopkeeper locked up their dumpsters and I had to quit my hobby for a while. Where I now live, they tend to leave the door open, which I much appreciate.

And just look what I found two weeks ago:

Dumpster diving does not solve the root problems of food wasting but it’s a rational and sustainable thing to do all the same – both ecologically and economically. I seriously doubt there are any significant adverse health effects – the store guidelines on when to trash foodstuffs are needlessly cautious, and assessing the freshness of food is one of the reasons our senses have evolved to be so sharp long before the time of cold chains and best before dates. Since most of the loot is vegetables, there might even be a net health benefit;).

It is illegal in some countries (I would consider dumpster diving a victimless crime, though, unless you consider the possible losses of the shopkeeper who failed to sell you something you got for free). Keeping that in mind, I would encourage anyone to try it out.

Private healthcare reimbursements

State subsidies for private sector services have long been a curious part of the Finnish healthcare system.

The public healthcare sector is tax-financed save for moderate user fees – but the clients of private clinics also get reimbursements from the tax-financed Social Insurance Institution (Kela). The refund is calculated based on a schedule set by the SII – there’s a fixed rate for every medical procedure – but generally amounts to some 20 % of the total costs to the consumer.

The subsidy has sustained an unending argument.

One side says that supporting the (generally better-off) clients of private clinics out of the taxpayers’ pockets is both costly and unfair and serves to deepen the healthcare gap between the rich and the poor.

Others say the reimbursement creates a big enough incentive to use private services instead of overburdening the under-resourced public healthcare system. Thus it would protect the public sector from collapse and even generate savings for the state since the clients still pay 80 % of the costs out-of-pocket.

Which side is right depends on the price elasticity of demand for private healthcare and a number of other things, but as the new government has recently decided to cut the reimbursements considerably, I’m sure we’ll find out soon enough.

(See also: Effects of the national health insurance reimbursement system on private medical services / Finnish Medical Journal 12th June 2015)

Food of the future

nightmarketCrickets @ Helsinki Night Market / The Night of the Arts.

A Summer in Psychiatry

Since the beginning of July, I’ve been working on a psychiatric ward. The experience is in so many ways unlike my previous work in primary care.

First, the pace is different. As a GP, I would see around 10 to 25 patients each day (depending on whether they came for some minor acute illness or for more extensive checkups). In this ward, I sometimes only meet 3. But I have time. Sometimes a consultation will last up to 1,5 hours, and I have no doubt they could last more. It’s far from the assembly line tempo of the rush hour ER (“state your complaint… no, just one please… ok, here’s your prescription, get outta here”). And I like it. It suits my way of working. It’s a more comprehensive take on the biopsychosocial whole.

The overall working method is different. “Multidisciplinary” is such a buzzword in medicine these days but for me, the psychatric wards are the first place where I have really been part of a multidisciplinary team and witnessed how much it can accomplish. A psychologist, a social worker and an occupational therapist (plus sometimes a physiotherapist) are all there and can help tackle problems from anxiety and depression to not having enough money for a bus trip back home.

The results of the treatment, too, are different from what I thought. I came to the psychosis ward half expecting to meet people with so grave and chronic illnesses they would be beyond any help I could possibly offer. I’m happy to find I was wrong. True, I have received patients whose schitzophrenia or drug problem has worn out their cognitive capacity and left them quite crippled and ostracized, plenty of tragic life stories. But somehow, we could help each one of them one way or the other. At least we could take out the meanest edge of the voices inside their heads or offer some consolation for longstanding feelings of shame and self-loathing. The majority return to their homes in better shape than they arrived in.

There is some existential anxiety out there that reaches to the very core of one’s soul and concerns one’s perception of reality itself. Even when there is no cure, being able to alleviate at least some of that somehow feels every bit as important as treating an aching knee or a swollen eye.

Prescribing cheap

A while ago, I received a letter from the Social Insurance Institution (the government agency responsible for the Finnish social security programs including subsidizing drug prices) that summarizes some key figures regarding my prescriptions from year 2014. (It’s the very first such letter by the way: I’ve been practicing medicine for a little more than a year now!)


I was surprised to find that my average prescription cost was only around half of the Finnish average. Why might that be?

The most obvious explanation is that I work in primary care, not in, say, oncology or rheumatology where some useful drugs just happen to be quite expensive. But that’s unlikely to be the whole story: when compared to other non-specialized doctors my figure was still 42 % lower.

I believe one reason is that my basic toolkit of drugs includes molecules such as metformin, ibuprofen, ramipril, omeprazole, escitalopram and paracetamol – tried-and-true medications whose patents have expired. The market is flooding with “me-too drugs”: slight modifications of existing molecules that are heavily advertised and expensive but offer few benefits over the originals they are trying to replace. In these cases, going for the cheaper alternative will not hurt the patient a bit: they (and the national economy) will get the same benefit without wasting any money.

In the case of equally safe and effective medications where the more expensive one has some minor edge over the cheaper one – such as the newer oral anticoagulants which, unlike the older warfarin, do not require as extensive laboratory monitoring – I lay out the facts, and often the patient opts for the more affordable option.