The approximately 180 neurosurgeons in Sweden serve a population of 9.2 million people, a ratio of 1 neurosurgeon to 50,000 people. One fourth of the neurosurgeons are retired and one tenth are female. The approximately 100 individuals active in neurosurgery typically work in one of six university centers.
These university centers are distributed throughout the country and cover a designated catchment area that serves between 800,000 and 1.8 million inhabitants. The catchment areas are overseen by county councils that organize and supply healthcare. Hospital and outpatient care is thus primarily financed through taxes, and the patients themselves only pay a minor fee per hospital day or for outpatient consultation. By law all citizens are guaranteed access to equal and good healthcare.
A large part of the population is satisfied with the Swedish healthcare system, and there is a general feeling that it is reliable, accessible and of high quality. Although private insurance is becoming increasingly popular, it is still rare and expensive. Private insurance is not valid in the general hospitals and, because difficult neurosurgical cases are sometimes handled outside of Sweden, private insurance would need to cover this care.
With the general availability of neurosurgical care, private facilities cannot provide competitive alternatives for cranial surgery. However, four or five private hospitals offer spinal surgery and some of the neurosurgeons work there full- or part-time. The development of spinal surgery outside of university neurosurgery is fairly recent. The patients utilizing private facilities may be covered by private insurance or pay out of their own pockets. County councils also may cover patient expenses in private facilities if they have decided to purchase care from external producers or if their own hospitals are unable to provide care within a reasonable time frame. By law, patients should not have to wait more than three months for surgery, but in practice waiting lists for nonurgent tumor surgery, pain, cervical stenosis and vascular problems may extend well beyond this limit. Still, trauma, stroke and tumor patients are admitted to neurosurgical wards as urgently as needed.
For most people, contact with neurosurgery is provided via their general hospitals; usually their treating physicians consult with the physicians at a regional neurosurgery center to recommend further workup or treatments. The patients are then admitted to neurosurgery centers, treated, and returned to the local hospitals as soon as possible. The number of neurosurgical beds is limited (Sweden has the fewest in Europe). It therefore is often very difficult for neurosurgeons, and for all hospital specialists, to admit patients.
Naturally, treatment traditions may vary among different regions. For example, metastases may be treated very aggressively or not treated at all, radiosurgery is not readily offered for acoustic tumors at all centers, and follow-up and radicality of meningioma treatment varies. Additionally, it is comparatively easy to terminate or withhold treatment in Sweden.
While patients theoretically have the freedom to choose their caregivers, it is frequently difficult to exercise this freedom because many regions refuse to send patients elsewhere for treatment. Patients usually do not ask for second opinions or to be transferred, and they typically are satisfied with their treatment. However, an increasing number of educated patients seek information via external sources or personal contacts, and the demand for choice appears to be slowly increasing.
The public system, which frequently provides very high quality care to the taxpayers, increasingly is encountering problems with accessibility. There is a general feeling that the society cannot support all demanded healthcare and that priorities must be established. All medically indicated treatments cannot be covered by the county councils, but whether the public will accept the concept of out-of-pocket payment for care that is not provided free is uncertain.
As I see it, access to neurosurgical care, to outpatient care, to be able to choose one’s own surgeon and the feasibility of obtaining a second opinion are the major problems of neurosurgical care in Sweden. The practice of neurosurgery may be at risk of becoming too depersonalized and aimed at treating patients expeditiously rather than at optimizing and individualizing treatment. Possible developments are a higher degree of private insurance to decrease delays in treatment, acceptance of private insurance coverage in public hospitals, or maybe even increased practice of in- and outpatient neurosurgery outside of the large university centers.
Neurosurgery is a very demanding speciality also in Sweden. The hours are comparatively long, work is difficult and salaries are similar across all specialities: An experienced neurosurgeon has a basic salary that is similar to that of a newly qualified general practitioner. While work hours per day are long, the total hours at work per week are restricted to 48. Neurosurgeons also are free on the days before and after a night-duty shift. Further, Swedish vacations are comparatively long: Most neurosurgeons are on summer holiday for four to five weeks, and they also need to take several weeks off to compensate for overtime.
Neurosurgery seems to attract students who are ready to invest time and who can handle the difficult issues and rapid decisions associated with the specialty. Medical students who enter neurosurgery cannot be compared easily with those in other specialities because Swedish medical schools grade students on a pass/fail basis. Neurosurgical trainees typically work 40 hours per week, excluding emergency call (averaged over the course of a year, call duties can add up to eight hours to a trainee’s workweek), and the training program lasts for a minimum of five years.
In case of unexpected complications and bad outcomes, all patients are covered by insurance without having to prove malpractice, but it is quite difficult to get compensation and the levels are low. Even so, medical malpractice cases are extremely rare. It is generally felt that this system functions well, but critics say that without such a pressure on both hospitals and individuals to always provide the best quality care, medical practice may sometimes deteriorate.
As in every system, being a neurosurgeon in Sweden has its pros and cons. It is a fascinating speciality, it can be practiced at a high level, the population has general access to excellent neurosurgery and the working hours allow for the practitioner’s good quality of life.
Tiit Mathiesen, MD, is professor in the Department of Neurosurgery, Karolinska Hospital, Stockholm, Sweden. The author reported no conflicts for disclosure.