CONTEXT: Rural medical practice in Norway has an honourable 400 year history, but this has diminished since the end of World War II. Despite official intention to support a decentralised population, rural and remote populations have continuously reduced in Norway over the last 10 years. A consequence of the accompanying reduction in rural and remote GP services has been a distinct reduction in opportunities for medical student and intern placements. In 1999 the University of Tromso implemented some projects to stimulate rural medical practice, funded by the government. This culminated in the 2007 foundation of the Norwegian National Centre of Rural Medicine (NCRM) in Tromso.ISSUE: A key challenge of the NCRM is to identify factors that influence young doctors to choose rural careers. This is reflected in the three concurrent aims or perspectives of the NCRM: (1) to bridge the gap between the academy and rural medical practice (the principal perspective); (2) to promote research, education and networking among rural health professionals (the operational perspective); and (3) to contribute to the recruitment, stability and quality of rural health care (the political perspective).LESSONS LEARNED: The NCRM has had a number of achievements that include a publication that provides a narrative perspective on rural practice, the role of the rural doctor, and how rural culture and context influence proper clinical decision-making. Another achievement is a professional development and research program that has been successful in fostering a number of major studies, and led to the formation of a supportive PhD research group. The NCRM has also facilitated networking between rural practitioners and academics, at conferences and via its rural doctor website, and promoted cooperative international activities. In these ways the NCRM has fostered the transformation of rural doctors' experience into theory to enhance medical knowledge, begun to redress the balance between community- and hospital-based services, and so made a favourable start to building a bridge between rural practice and the medical academy in Norway.
INTRODUCTION: A patient's needs and the seriousness of the disease are not the only factors that determine referral to hospital. The objective of this study was to analyse whether locum doctors (LDs) have a different pattern of referral to hospital from regular GPs (RGPs).METHODS: All hospital referrals for one year (n = 5566 patients) from two Norwegian rural primary health care (PHC) centres to the nearby district hospital were analysed with regard to ICD-10 diagnosis groups. A major difference between the PHCs was that one had a continuous supply of LDs while the other had a stable group of RGPs. The equal-sized communities were demographically and socio-culturally similar.RESULTS: The PHC centre mainly operated by short-term LDs referred a relatively high number of patients to the district hospital within the diagnosis groups of chapter VI 'Diseases of the nervous system' (proportionate referral rate 210%; p = 0.010), and chapter IX 'Diseases of the circulatory system' (proportionate referral rate 130%; p = 0.048), and a comparatively low number of patients for the diagnostic groups in chapter X 'Diseases of the respiratory system' (p = 0.018), and chapter XIV 'Diseases of the genitourinary system' (p = 0.039), compared with the norm of the district hospital's total population. The number and proportion of the total number of referrals, adjusted for population size, did not differ between the two rural communities. The LD-run PHC centre differed significantly from the total norm in 5 out of 19 ICD chapters, equal to 41% of the patients.CONCLUSIONS: Only one significant difference in hospital referrals related to ICD-diagnoses groups were found between the studied rural PHC centres, but the LD-run PHC differed from the total norm. These differences could neither be explained from the district's consumption of somatic hospital care nor the demographical differences, but were related to staffing at the PHC, that is LDs or RGPs. The analysis also revealed that possible under- and/or over-diagnosing of certain diseases occurred, both having potential medical consequences for the patient, as well as increasing healthcare expenditure.
CONTEXT: The recruitment of sufficient health workers in rural and remote areas has been a constant challenge in many countries for decades. This article describes how medical internship (18 months of mandatory practical training, including 6 months in primary care, after graduation but before granted full license as a doctor) is used in Norway as one method of recruiting young doctors. Finnmark, the most northern and remote county, offers the most challenging medical practice and is also the area most dependent on interns as medical workforce, and later as licensed doctors.ISSUE: Providing adequate professional and social support for the interns during this challenging service is regarded as a prerequisite to retaining them for further service after internship. To accomplish this, a special tutorial program has been implemented since 1997. The scope of this study is to examine whether internship in Finnmark, accompanied by the group tutelage, enhances recruitment and, if so, what are the main predictors for taking their first voluntary job in the north.LESSONS LEARNED: Twice as many interns as were expected from their background chose their first job in the north. Those brought up in the region and the graduates from the (northern) University of Tromsø, were most likely to make this choice. However, graduates from Oslo were also much more likely to choose a job in the north after internship in Finnmark than had been predicted in their last term in medical school. Internship in Finnmark also increased the probability of choosing primary care, which is a political priority in Norway. This indicates that internship in remote areas, given the appropriate professional and social support, contributes to improved recruitment of doctors to underserved areas.
INTRODUCTION: The recruitment and retention of health workers, crucial to health service delivery, is a major challenge in many rural and remote areas. Finnmark, the most remote and northern county in Norway, has faced recurrent shortages during the last 5 decades, especially of primary care physicians.METHODS: This article describes a postgraduate training model for family physicians and public health/community medicine physicians, based on group tutorial and in-service training in rural areas. The effect of the training programs on physician retention in Finnmark is evaluated by a longitudinal cohort study.RESULTS: In total, 65-67% of the physicians from the programs are still working in the county 5 years after completion of the group tutorial. Rural practice provides good learning conditions when accompanied by appropriate tutelage, and in-service training allows the trainees and their families to 'grow roots' in the remote area while in training. The group tutorial develops peer support and professional networks to alleviate professional isolation.CONCLUSION: On the basis of these findings, traditional centralistic training models are challenged. Postgraduate (vocational) training (residency) for primary care physicians can be successfully carried out in-service in remote areas, in a manner that enhances retention without compromising the quality of the training.
INTRODUCTION: For many years political and professional concerns have centred on the health service access of Norway's modern Indigenous Sami people. Thirty years ago, a study determined that a low rate of health expenditure on Sami patients had lead to inferior health services for the Sami people, with their average consultation rate 6 times lower than the Norwegian national average. Since 1980, there have been few studies of differences in the utilization of medical services between the Sami people and the rest of the Norwegian population. There are few official statistics relating to the ethnic category Sami. This study explored the present utilization of healthcare services among the Sami people by investigating Sami municipalities' current expenditure on somatic hospital and specialist service.METHODS: To assess the use of health care in Sami municipalities, data on expenditure of somatic hospitals and specialist services were retrieved from the Norwegian Patient Registry, and age- and sex-adjusted expenditure rates were calculated. Predominantly Sami and non-Sami municipalities were compared, as well as a comparison with the national average. Factors considered to be explanatory variables for expenditure rates were distance to care, the supply and characteristics of the healthcare system, and the stability of GPs.RESULTS: The overall public hospital expenditure in Sami municipalities was above the national average and equivalent to corresponding municipalities in the same geographical area. However, there was considerable variation among the Sami municipalities. The age groups 35-49 and 50-64 years in all Sami municipalities had higher expenditure rates than the national average regarding out-patient contacts and hospitalizations, while the expenditure on the elderly (&#8805;80 years) was below the national average in most Sami municipalities. In addition to the public sector, there was a considerable volume of private practice specialist health care, mostly public funded and in urban parts of Norway. If the use of specialists in private practice is included, there is less variation in total out-patient expenditure rates in the Sami municipalities, with one exception. The municipalities with the lowest rate of public expenditure have the highest rate of private expenditure.CONCLUSION: No marked differences in healthcare expenditure was observed between the Sami and other municipalities. Overall healthcare use in Sami municipalities is above the national average and similar to corresponding municipalities in the same geographic area. However, a considerable variation in expenditure was observed among the Sami municipalities. These results do not indicate that ethnic barriers prevent Sami inhabitants from utilization of somatic hospital and specialist services. Disregarding the magnitude of expenditure, however, it is not possible to exclude that Sami patients experience a patient-physician relationship of lower quality.
AIMS: To investigate how cancer survivors (CSs) experience the cancer-related support they get at the workplace, the proportion of CSs who change work due to cancer and the sociodemographic and work-related factors associated with CSs' work changes.
METHODS: CSs of the 10 most common invasive types of cancer for men and women in Norway completed a mailed questionnaire 15-39 months after primary treatment. All CSs who were working when diagnosed were included in the analyses (n = 1115). Leaving the workforce and making other important changes in paid work were regarded as work changes.
RESULTS: When diagnosed with cancer, 84% of the CSs experienced their supervisor as caring vs. 90% for colleagues. At the time of the survey, 84% were still working; 24% had made changes in work due to the cancer. Work changes due to cancer were most common among CSs who reported low supervisor support related to the cancer (odds ratio (OR) 0.78) and high physical (OR 2.48) and psychological job demands (OR 1.39) at the time of diagnosis. Work changes were more common among self-employed CSs than among employees (OR 2.03). CSs with high education (OR 0.59) and medium income (OR 0.66) made fewer work changes than other CSs, but these differences were not significant when controlled for the work factors.
CONCLUSIONS: Close follow-up by supervisors should be a key element in workplace health promotion programs for CSs. Further, the programs should target both physical and psychosocial work factors.
AIMS: To explore whether and how immigrant general practitioners (GPs) in two major cities in Norway think that their own ethnic background affects their practices and their work.
METHODS: Qualitative focus group and individual interviews with seven immigrant GPs, five men and two women, age 36-65 years. Their clinical experience in Norwegian primary health care ranged from four to 30 years. Analysis was conducted by systematic text condensation.
RESULTS: First, immigrant GPs described a gradual process of becoming bicultural: the GPs communicate with immigrant patients on their own terms and draw upon their special knowledge from abroad to help selected patients, while also adapting to Norwegian cultural expectations of the GP's role. Second, the GPs described being aware of cultural issues in consultations with immigrant and Norwegian patients, but rarely making these issues explicit. The GPs ventured that cultural awareness, together with their personal experience in their own countries and as immigrants in Norway, made them able to sometimes help immigrant patients better than Norwegian GPs. Third, immigrant GPs experienced a big workload related to immigrant patients, but they accepted this as a natural part of their work. Fourth, immigrant GPs felt that they had to work harder and be more careful than their Norwegian colleagues in order to avoid complaints from patients, and to be accepted by colleagues.
CONCLUSIONS: Immigrant GPs express broad cultural competence and keen cultural awareness in their consultations. The immigrant background of these GPs could be considered as a special resource for clinical practice.
AIMS: In March and April 2009, the Norwegian Institute of Public Health was notified about two groups of schoolchildren with gastroenteritis following a stay at a Norwegian wildlife reserve. Although at first considered a typical norovirus outbreak, an investigation that considered other possibilities was initiated.
METHODS: A retrospective cohort study was conducted among schoolchildren visiting the reserve in the relevant weeks. A web-based questionnaire was distributed by email. Fecal samples of visitors and employees were analyzed. The premises were inspected, and water samples and animal feces analyzed.
RESULTS: We received 141 replies (response rate 84%); 74 cases were identified. Cryptosporidium oocysts were detected in fecal samples from 9/12 (75%) visitors and 2/15 (13%) employees. One employee diagnosed with Cryptosporidium infection helped in the kitchen. Additionally, one pupil was diagnosed with norovirus infection. No food item was identified as a source of the outbreak. Pathogens were not detected in water samples taken in week 12, one week from the start of the outbreak. Escherichia coli, but not Cryptosporidium oocysts, were detected in water samples taken one month later.
CONCLUSIONS: Although Cryptosporidium is seldom considered as an etiological agent of gastrointestinal illness in Norway, this outbreak indicates that it should not be excluded. In this cryptosporidiosis outbreak, the largest in Norway to date, the transmission vehicle was not definitively identified, but a food handler, water, and animal contact could not be excluded. We recommend improving hand hygiene routines, boiling drinking water, and emphasize that people who are unwell, particularly those working in catering, should stay away from work.
AIMS: Mental disorders are serious public health problems and mental disorders have an impact on individuals' health-related quality of life (HRQoL). Therefore, the aim of this study was to evaluate for differences in psychological distress and HRQoL outcomes between long-term social assistance recipients (LTRs) and the general population in Norway. In addition, differences in HRQoL outcomes were evaluated in LTRs and general population who reported clinically meaningful levels of psychological distress.
METHODS: In this cross-sectional study, which is part of a larger study that evaluated the health and functional abilities of LTRs in Norway, 393 LTRs were compared to a similar aged group (n = 3919) from the general population. Psychological distress was measured using the Hopkins Symptom Checklist.
RESULTS: LTRs were significantly younger (p 1.85 reported lower mental component scores on the SF-12 than general population.
CONCLUSIONS: In the total sample, LTRs experienced more psychological distress and reported poorer HRQoL than the general population. Clinically meaningful levels of psychological distress occurred more frequently in LTRs than general population. The LTRs and the general population with psychological distress rated both the physical and mental components of HRQoL lower than LTRs and general population without psychological distress.