A Tale of Two Systems

Ariëtte Sanders and Marianne Broers were students at Leiden University in the Netherlands when they met almost 40 years ago, joining the same sorority at the country’s oldest university. Both were drawn to studying medicine, attracted by the science and the prospect of working intimately with patients. Both went on to train as family physicians.

Then, their paths diverged. Sanders would take over a medical practice with her husband outside Utrecht, another Dutch university town about 35 miles from Leiden. Broers went farther afield, moving nearly 5,000 miles to the American Northwest, where she started a family practice outside Seattle.

Over the years they drifted out of touch, following news of one another mostly through mutual friends and acquaintances. Today, the two women, both in their mid-50s, are approaching the ends of their careers. Their children are mostly grown. Each has enjoyed being a physician, relishing the deep relationships they’ve built with patients. They’ve had frustrations. Neither has many regrets.

Their journeys have left them feeling very differently about medicine and health care, however. In many ways this reflects the contrasting professional experiences of primary care physicians in the U.S. and other high-income countries like the Netherlands.

Sanders, who remained in Europe, practiced in a country with one of the most robust, carefully planned primary care systems in the world, a place where family physicians can tap extensive community resources and support services to help their patients at all hours of the day. Sanders is upbeat about her job. She is confident that the Dutch system serves her patients well, with affordable medical care broadly available. “I am very happy that everyone can get health care. We have a lot of opportunity to offer care and cures for our patients.” 

Broers had to navigate more complex terrain. With less organized systems to coordinate care and support her patients, she learned to do a lot by herself before she closed her practice in 2018 and joined a larger group practice. Broers is still happy in her work. But she is far less sanguine about the health care system she sees around her. Too often, she said, she struggles to connect her patients with the services they need. Increasing numbers of patients are rationing their care, fearing medical bills they won’t be able to afford. “The system could be so much better,” she said.

Broers’ assessment is widely shared across the U.S., the latest international survey of primary care physicians by the Commonwealth Fund shows. Just four of 10 American primary care doctors rate the overall performance of their health care system as “good” or “very good.” That is the lowest among 11 wealthy countries surveyed. The U.S. is also the only nation where fewer than half of primary care physicians give their health care system high marks. By contrast, eight of 10 Dutch primary care doctors rate the overall performance of their health care system as “good” or “very good.” The Netherlands is second only to Norway in this regard.

In Driebergen, a suburb of about 20,000 people outside Utrecht, Sanders is quick to say that not everything is perfect. The Netherlands is one of the few countries in Western Europe that requires patients to pay a deductible before their insurance coverage kicks in. “That’s becoming more and more of a problem, especially for low-income patients,” Sanders said, though primary care visits in the Dutch system are exempt from cost-sharing. The standard annual deductible in the Netherlands is 385 euros, or roughly $431. (In the U.S., by contrast, the average deductible for a single-person job-based health policy was $1,846 in 2018, according to recent analysis by the Commonwealth Fund.) Sanders also is working on how to better address social and economic challenges that her patients face. “It should be more of a topic of our work,” she acknowledged. In general, Dutch physicians are less likely than their American counterparts to screen patients for housing, food insecurity, and other social determinants of health, the survey found.

Nevertheless, Sanders is able to offer her patients an extensive array of services, even in her small practice. In addition to herself and her husband, there are seven more people in the office providing clinical services, many funded by health insurers or by the local government. Patients with chronic medical conditions such as diabetes or chronic obstructive pulmonary disease, for example, are paired with a specially trained nurse to help them manage their diseases. Another nurse specializes in geriatric care. Additional case managers are assigned to help patients with dementia, offering educational programs, financial planning assistance, and frequent home visits.

Like the vast majority of Dutch primary care physicians, Sanders and her husband also frequently visit home-bound patients, seeing about 25 a week between the two of them. For patients who cannot make regular office hours, the practice helps support a regional after-hours clinic about nine miles away and staffed by primary care physicians in the area. Sanders works at that clinic one evening and one weekend day every month. She is also on-call for the clinic six or seven nights a year. Nine of 10 Dutch general practitioners report that their patients can be seen by a doctor or nurse after hours. In comparison, fewer than half of U.S. primary care physicians say their patients have similar after-hours access.

An electronic records system alerts Sanders when a patient goes to urgent care or is admitted to a local hospital. Similarly, she gets notifications from specialists who see her patients and from the local pharmacy when a patient fills a prescription. “We are very well informed about our patients,” she said. Coordination with local social services is more challenging. There are efforts underway to improve this, however, including bimonthly meetings between the regional government and local physicians to strengthen support services for dementia patients, at-risk youth, and other needy populations. “We are making progress,” Sanders said.

Broers has noted progress in her work, as well, though there have been trade-offs since she moved to the larger group practice. She misses the intimacy of her own practice, which she had for more than 15 years in Renton, an industrial suburb of Seattle where Boeing builds many of its commercial airliners. But the administrative burdens — first implementing an electronic record system and then preparing for new Medicare reporting mandates — ultimately proved too much for her. Last year, she joined Pacific Medical Centers, a group practice with about 175 primary care and specialty doctors scattered around the greater Seattle area. Broers now works out of an office with two other primary care physicians 30 miles south of Seattle in Puyallup, a working-class community of about 40,000 people.

In the larger group practice, Broers gained access to a robust electronic records system that allows better communication with local hospitals and specialists. When one of her patients is sent home from the hospital, a nurse in her office is notified and contacts the patient within 48 hours. The nurse makes arrangements if a patient needs follow-up with specialists or home health services. Most patients are scheduled for an appointment with Broers within seven days of discharge. “It’s very helpful,” Broers said. “That system actually works pretty well.” One day a week, a diabetes educator comes to the clinic and works with newly diagnosed patients and those who need to adjust their insulin. A registered nurse who is in the office three or four days a week helps coordinate social services for lower-income patients.

Other services are more fragmented. Broers has to refer diabetic patients who need wound care to a specialty clinic. Physicians in her office almost never do home visits. And if her patients need care after hours, they must go to an urgent-care clinic operated by a for-profit company or one of the large regional health systems. Even more frustrating for Broers are the challenges of finding some specialty care for her patients. Rheumatology and neurology are particularly tough. Most difficult is finding psychiatrists and other mental health professionals. “There is just no one available,” said Broers, noting patients can wait months to see someone. “Sometimes it feels like we as primary care providers are facing this alone. We can handle the bread-and-butter stuff, but now we have to treat bipolar disorder, schizophrenia, even serious personality disorders.”

This is a common complaint in this country. Nationally, just 45 percent of American primary care physicians say they are well prepared to care for patients with mental illness, compared to 84 percent of Dutch general practitioners. In contrast, there is considerably less disparity between the two countries in chronic disease care — 86 percent of U.S. primary care doctors and 96 percent of Dutch physicians say they feel well prepared to care for patients with chronic illness.

As Broers eyes retirement in a few years, she said she doesn’t regret having left the Netherlands. Despite the professional challenges, she’s enjoyed living in the Pacific Northwest. “I love hiking and skiing, and there are few better places to sail than Puget Sound,” she said. But neither Broers nor her husband, who is an anesthesiologist, were surprised that none of their children chose to be doctors. “I think we complained too much about the system,” she joked.

Back in the Netherlands, by contrast, Sanders’ eldest son has followed his parents into medicine. He is currently doing research on chronic pain.