Dr. Sophie Bruhl came up with a concept that would allow other general practitioners to be the best at they do: being doctors.

Sophie Bruhl: “GPs need space in their heart, head and in their schedule”

GP Sophie Bruhl saw how GPs succumbed to the pressure of work while young GPs gave up the profession and decided that things could be different. She came up with a concept that would allow GPs to do what they are good at: being doctors. Yet that is not enough, she argues. Prevention and context should be the future in healthcare.

What do you think is the biggest challenge in healthcare development?

“I did research on the work preferences of the young general practitioner. It turned out that there is a huge mismatch between what the young doctor wants, which is to work thirty hours, and what the old doctors do: buffering a 67-hour working week as a practice owner and doing everything themselves. That is why there are now areas in the Netherlands where there are no GPs left. And this becomes hugely problematic if you consider that forty percent of practice owners will retire in the next five years.”

Where does this mismatch come from?

“The old-style family doctor was a kind of grocer and now we have large supermarkets in terms of regulation. As a family doctor you are not only responsible for the care of patients between eight and five, but also for HR policy, ICT, broken lamps and calculating vacation pay according to the collective bargaining agreement, in addition to the patient administration. You’ve been given all sorts of additional tasks for which you are not trained at all. Usually these are not your competencies either, because you are a good doctor. That is the reason why all kinds of people are now quitting or only want to become observers. So they hop from one job to another and therefore have less long-term contact. Or context knowledge about the patients.”

Why is that problematic?

“When you have observers working in a different practice every week or every month you don’t know who lives next door to who. And you don’t know what’s going on at home. If you come in with a headache and I know your neighbor just died of a brain tumor I ask, ‘Are you afraid of a brain tumor?’ That’s seeing the patient in his or her context.”

How does your practice try to solve this?

“Together with my associate, we came up with the concept of Buurtdokters (Neighborhood Doctors). We combine practice ownership with continuity of care and context medicine. We take over the practice with all the staff, together with a young, starting GP or one who has lost interest in the profession because of overhead. Then we do all the things that you as a doctor are less good at or don’t like, so that the general practitioner has time for his patients and the things that give him energy.”

How does this work practically?

“We are co-owners of the practice. We buy in one half and the other half always belongs to a doctor. Together we enter into a kind of prenuptial agreement. We promise what services we provide and what the doctor does and has control over. In practice it means, for example, that we determine which HR system we work with. But how a consultation hour works and how many assistants you have is up to the GP. So you make clear agreements about who is responsible for what. We mirror, we are confrontational and challenging. Every month we have a discussion about what happens in the practice; why is it so busy on the phone for example? How much energy does the GP have left at the end of the day? What can you do differently? How can we help? This is how we ensure that the doctor keeps going because all those doctors and assistants are dropping out! We make sure that people are motivated to go to work, in this we really are a partner. We started shaping the concept over two years ago and have been in practice for a year. By now we have five partnerships and that number continues to grow.”

How do you ensure that the family physician is close to the community, both in terms of location and relationship?

“By making sure someone has a nice, manageable job with long-term commitment to the population. But you have to have time for that. Time you don’t have when you’re inundated with red tape all day. If you make sure that the requests for repeat prescriptions (and the blood pressure checks, for example) are done by someone else, you have time to think about why all the children in your district are so fat. Maybe you should go to the alderman, see if he or she can provide more playgrounds.”

Should that be the future, prevention?

“Yes, absolutely. How can I discuss with this gentleman who had a heart attack, with a son who is also overweight, what he needs to lose a few pounds? How do we make sure that his kids doesn’t get to where he is now. Then you’re on a good path, instead of reactively only responding to who comes through your door and who calls. For that you need space in your heart, head and in your schedule. That space is also needed to think about how to keep it going, what good care is and what your patient needs.”

And then who takes care of the repeat prescriptions?

“We do it together. The nurse practitioner provides continuity of chronic care along with the family physician who signs prescriptions. One of the other issues is that the insurer bills you for how many cholesterol tablets you prescribe. Whereas I stop the cholesterol tablets when people are in their nineties and have an oncology background. But then I get a discount from the insurer, because they say, ‘You’re not being protocular’. That makes GPs uncomfortable because they feel that the insurer is sitting on their chair. It’s a tough job in which you sometimes lack appreciation. Do you know what a general practitioner gets for a 10-minute consultation from the insurance company? 10.59 euros. And for longer than 20 minutes, it’s 21.19 euros. GPs do 95 percent of the care with 5 percent of the budget.”

What else do GPs need for the future?

“Long-term agreements and guaranteed budget. Trust. Not having to justify what you are doing every five minutes. I concluded that the insurer is sitting in the doctor’s chair, but we have allowed that to happen ourselves. We are such autonomous people that we find working together difficult. So we need to hold and strengthen each other, strengthen regional cooperation. Does it need to be different? Yes! Can it be done in the current climate? No!”

Lessons from Sophie Bruhl

• To provide good care you need to know people in their context
• Make room in the head, heart and agenda of the family doctor to do what he is good at: being a doctor
• The future of GP care should focus more on prevention and seeing people in their context