Mild by nature, clear on issues

The great leap

«You took on a considerable task when you agreed to become president of the Norwegian Medical Association. Weren’t you afraid of biting off more than you can chew?»

«When I was asked to stand for election in the Norwegian College of General Practice (NFA) and later in the Norwegian Medical Association, I spent a fair amount of time talking to people around me whom I trust. It is difficult to see oneself clearly – so you have to see yourself through the eyes of others and trust those who know you well and who also know what you will be getting into. If they say that I’m qualified and will do a good job, then I choose to rely on that.»

She doesn’t disguise the fact that she enjoys being president. ‘In a way I have felt like one of those Duracell bunnies darting from one task to the next – our profession is so big and wide-ranging! I find that my background as a GP is useful. You see, we’re used to relating to many issues with no opportunity to specialise. The art lies in finding practical solutions to complex problems.

I don’t feel that we are so liberated from gender roles that it is unnatural to ask whether she has encountered the glass ceiling that many women come up against during the pursuit of their career.

‘I think glass ceiling was a good term to use a few years ago, but today it doesn’t stop women from pursuing their career. I believe the challenge is more related to being in a minority. You don’t get to be part of the informal meetings, the code, the tacit rules. Women can experience this in male-dominated settings, and I think that those with different cultural backgrounds find the same thing. When I stood as candidate for president, I gave serious thought to whether I was sufficiently qualified, but I did not focus on being a weaker candidate as a woman than as a man.

Can doctors tolerate change?

In Hermansen’s first months as president, the Norwegian Minister of Health has submitted a white paper on primary health care as well as a proposal for a new national plan for hospitals. Not unexpectedly, there is a storm of protest.

‘Is the medical profession opposed to change on principle?

‘No, absolutely not. In recent years we have helped to carry through significant changes that we believe have a solid professional basis. Many responsibilities have become highly centralised, while others have been decentralised. Hospital doctors can do increasingly more for an increasing number of patients, and GPs today do a great deal that was previously perceived to be the domain of hospital medicine. We participate actively in these developments in our profession, but we have to speak up when we see that proposals for change make little sense. I am proud of the broad consultation on the two white papers that we have had internally in the Norwegian Medical Association. Of course, there are differing opinions within the association, but when I make statements on its behalf, I stand firmly by the decisions adopted at our annual general meeting. I also want to praise the minister for inviting debate on the national plan for hospitals very early in the process. It paved the way for an open debate, rather than a closed process into which we had no insight.

The interview is interrupted regularly by phone calls. Many people want a few words with the president. She leaves the table and stands discreetly in a quiet corner of the restaurant. However, I cannot avoid overhearing the odd sentence. When there is clearly some disagreement, she asks: «Isn’t it possible that…», and I have a strong feeling that her counterpart finds it difficult to disagree with her interpretation of the matter at hand.

Back to the Minister of Health and the plan for hospitals. «The closing down of the accident and emergency function in the smallest hospitals is being presented as a choice between proximity and quality. Is that the case?»

‘The way they are presenting it is wrong. It undervalues the small hospitals which are very good in many key areas. It is one thing to centralise responsibilities for professional reasons; but in recent years, many small hospitals have had responsibilities in which they excel taken from them for economic reasons. This makes them less well-placed to recruit new professionals and creates a downward spiral. In my opinion, the small hospitals must be allowed to invest in excellence in some areas to be attractive, while of course they must also cope with assessments and treatment of the most common conditions. Voss is an example of a hospital that has mastered this. They have taken over some specialist functions from Haukeland University Hospital, and therefore have no difficulty in recruiting professional staff.

The municipality’s responsibility for the primary health service

‘You have stated that the white paper on primary health care lacks vision. What do you mean by this?

«The municipal councils feel little responsibility for either the GPs or the nursing homes. Things carry on in the same way, but no one tackles the problems that are slowly building up. We have not managed to fulfil the expectations raised by the Coordination Reform, and the newly established municipal 24-hour emergency units do not appear to be successful either. Do the local politicians actually know what is happening? Often the most newly qualified doctors are those who have responsibility for the sickest patients. Many of them have not even undergone the foundation programme before they are given sole responsibility for nursing home patients. Someone should feel a sense of urgency, but the Norwegian Association of Local and Regional Authorities and the municipal councils remain silent. So we cannot persuade Høie, the Health Minister, to speak out about the situation either,» she states, and continues:

«Quality work, competence enhancement and further education require a person to have time and resources; it can no longer be unpaid work performed in one’s leisure time. To achieve something better, it’s essential to invest. We must set equally high demands for diagnosis and treatment in the primary health service as in the hospitals, but base it on principles of general medicine. We also need better networks and increased systemisation in the primary health service.»

I venture to apply her method of asking a gentle but clear counter-question: «Might it be that you place responsibility on the municipal councils for matters that are actually beyond their control? Many people claim that regardless of how much you promote the recruitment of nursing home doctors, it will be difficult to motivate doctors to take these jobs as long as nursing home work does not qualify as a separate specialty. It was in fact the Norwegian Medical Association that originally voted against making it possible to take parts of the geriatric training in nursing homes, even though that is where the great majority of geriatric patients are.»

«Geriatrics is a specialist health service, and nursing home medicine is a primary health service. There needs to be a requirement for specialisation for nursing home doctors too, but based on a specialisation in general medicine with supplementary training in nursing home medicine. The municipal councils must make provisions for this type of specialisation.»

She points out that the Norwegian Medical Association has wanted a standard for staffing of nursing homes, and that all doctors should undergo a supervised foundation programme. ‘Høie has said that 2016 should be a year of implementation, and so the municipal councils should be busy following up the white paper on primary health care. We know from experience that they are far too good at putting things on hold.

She leans forward slightly and says: ‘I like the type of changes that we need here. They are not a matter of all-encompassing reforms, but small, manageable steps. Some municipal councils have already achieved a lot, while others should ask themselves what they can learn from them. Many people living in small municipalities are satisfied, and I ask myself whether proximity to the service is not the key word here. What has to be sacrificed in the quest for larger units?

The phone rings again. There is no sharp-tongued conflict now either – she conducts her conversation in a mild tone and ends with: «I can hear that you have done good preparatory work.» Is there a better way to inspire someone to further efforts?

Small is beautiful

In 2010, Marit Hermansen was awarded the Anders Forsdahl prize for community and rural medicine. She herself wonders why she received such an honour, but when she summarises her work, it is quite obvious that the award was well deserved. For many years she has worked partly as a GP and partly as chief municipal medical officer in Grue municipality, just two hours’ drive from Oslo. With the forest of Finnskogen as its nearest neighbour, the municipality’s claim to be rural is more than good enough. In her work as chief municipal medical officer, she has focused on nurturing a good health service in the municipality. Proximity is a key word. «It isn’t always the case that big is beautiful. In the absence of a large professional community, I have found that home nursing care, with proper support from a stable medical service, has achieved a great deal of sophisticated treatment, because committed staff are willing to improvise and dare to try something new. That said, I am not blind to the fact that in small municipalities, some things can also be too small and restrictive.»

Her choice of where to live was made early on; her husband had allodial rights to a farm, situated in lovely surroundings on the banks of the river Glomma. «It’s been wonderful for the children to grow up there; we have plenty of space and a beautiful natural landscape.» Marit tells me that they can fish just down the hill from the farm, but admits that her sons have been responsible for the food supplied from that source. It’s mainly pike that they catch, but that’s fine. «The problem with pike isn’t the taste, but all the bones,» she explains. «So we make pike fishcakes, and we actually grind the bones that are left after filleting the fish.»

Young doctors and the future

‘You have stated that doctors provide good patient treatment when they are secure in their work. In this context, perhaps we should think especially about our younger colleagues. What do you think is needed to give them this security?

«I think we must work to cater for them in a better way. The working life of young doctors today is entirely different from when I entered the profession in the 1990s. The roles were easy to interpret, and the labour market was very open. Today, young doctors have to accept long-term locum work that entails a great deal of insecurity. For example, many of them see that accepting the office of union representative and speaking out about matters that the management does not want to hear about at worst may mean the end of their career.»

«What are your thoughts on the future challenges for the health services?»

«It’s marvellous that we achieve what we do today – people are living better and longer, we have a lot of good treatment for many conditions that we were previously powerless to deal with. However, I wonder if we are good enough at addressing the existential problems that patients struggle with. Do we focus enough on the human aspects of being ill? I’m afraid that this aspect disappears when we’re told we must choose between proximity and quality. Using language that refers to deliveries and production does something to our humanity. The hospitals must deliver properly and efficiently, but also with warmth and consideration. We are not manufacturing cars.»

«What do you think the Norwegian Medical Association should prioritise to maintain its position in future years?»

‘The Norwegian Medical Association enjoys a high degree of legitimacy in Norway. A full 97 % of practising doctors are members of the association. I am very happy with the authority we have with regard to medical questions. Society needs a strong medical premise setter that is independent of the government, and only the Norwegian Medical Association can assume that role. So we must continue to put forward good, well-structured political arguments. Before Christmas we received clarification that we will continue to play a key part in specialist training – an important and correct decision.

By nature or nurture?

Some of us are good at being happy. Irrespective of the problem, they choose to focus on the positive aspects of life then and there. Marit has this ability in abundance. What does she do to be happy?

‘I’ve actually thought a quite a lot about this. I regard being happy as a choice that I make. I certainly think I’m lucky to have the kind of personality that makes it easy to spot the positive aspects of a situation, which is almost like a God-given talent. Moreover, I choose to dismiss from my mind things that I can’t do anything about – why spend time on them?

Marit’s father was an officer, her mother a nurse; we strongly suspect that her orderliness is a family trait.

«What was it about your upbringing that made you who you are?»

‘Certainly the most important thing is that I was a child who was loved and I had a good, secure upbringing. Having two brothers who were much older, I was left in peace to grow up, no one pushed me in any direction, but I had many people to look up to.

The interview takes place in one of the city’s better restaurants on a Monday afternoon. The menu features a delicious cod dish. It is past 2 p.m. and I feel I must offer a glass of wine.

‘No, thank you, I have almost become a teetotaller since I started this job. I am offered alcohol at almost every event that I attend. It could easily add up to many glasses of wine per week, so I soon decided to stick mostly to alcohol-free drinks. Often my working day doesn’t end until late in the evening, and I like to keep a clear head throughout the day. I don’t want all the accompanying calories either, and alcohol addiction is always a risk, even if one feels as safe as can be in that respect. Right now, I allow myself practically no more than one glass of wine at the cabin with my husband at weekends.

A temperate Francophile

‘My interest in the French language and culture is due to «the sins of my youth», she says, laughing a little. At 17 years old, she chose to spend an exchange year in France, without knowing a word of French before she left. ‘What you experience in those years leaves its mark on you for the rest of your life. I often felt uncool, but I gained a love for the country and the language that brings me great joy today and wonderful holidays. My pleasure in all things French, our cabin at Skeikampen and sitting on the steps at home with a cup of coffee on a lovely summer morning, are the things that enrich my life. That’s all I need to feel that life is good.