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Spring 2014
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FIELD NOTES
 
Haus Calls
A ride through Germany’s urgent care system.
Knock, knock, knock. It was 7:45 in the evening as Dr. Anne Meister and I stood in a darkened hallway, waiting. In one hand I carried an unwieldy metal suitcase containing Dr. Meister’s medical supplies. In the other I grasped a pocketsized German-English dictionary. At length, the door opened, revealing Mrs. F, an asthmatic woman of 70 who was wheezing audibly.

“Hello,” Dr. Meister chimed brightly, “I’m the doctor. I understand you are having trouble breathing.” Mrs. F led us a few steps into a tiny living room and motioned for us to sit. Her breaths were coming so quickly that she could speak no more than a few words at a time. Observing the woman’s distress, Dr. Meister focused on the situation. I unclasped the suitcase, splaying it open. Inside lay bottles of medication, disposable syringes, bandages, a blood pressure cuff, and numerous other supplies. We quickly removed our winter coats, and Dr. Meister began to auscultate Mrs. F’s chest. Several minutes after an albuterol treatment, her respiratory rate began to normalize and she was able to speak in full sentences. Dr. Meister wrote instructions for Mrs. F to take a tapered course of oral steroid and gave her a referral slip to see her own internist the following day. We then chatted with Mrs. F until Dr. Meister was convinced that it was safe to leave her.

Earlier that evening, Dr. Meister and I had sat at a small table in her kitchen, becoming acquainted over coffee and ginger cookies. I had come to Hamburg, Germany, for a month with my fiancé to study the language and explore a unique aspect of the German national health system. I am particularly interested in primary care and issues of access to care. My fiancé, an emergency physician and a German national, and I had filled many hours discussing ER use and overcrowding in the United States. When he told me of the traveling urgent care physician network in Germany, I was intrigued.

German Engineering

Since 1969, primary care physicians in Germany have been making house calls to patients on an after-hours, urgentcare basis as part of a broader municipal urgent care service that also includes two adult urgent care clinics, four pediatric urgent care clinics, and a psychiatric call service. The Kassenaerztliche Vereinigung (KV) is an organization that represents doctors participating in the national health care system. It requires outpatient physicians to take about one urgent care shift per month. The KV for Hamburg has divided the city into eight districts. Physicians travel in KV cars driven by EMTs and equipped with GPS navigation. Unless the volume is unusually high, each physician takes calls only from within his or her district, to maximize efficiency. In the compact neighborhoods of Hamburg, it rarely takes more than 15 minutes to travel from one address to the next.

Hamburg residents can call one of two numbers: one, like “911,” contacts the local emergency medical service. The other reaches a KV call center, where triage staff determine the best level of care for the caller. The first level is a telephone consult with the on-call physician. The next is a house call. For emergencies, the triage service notifies EMS directly. Each house call is subsequently assigned a level of urgency: very urgent cases require that the physician reach the patient within 20 minutes; urgent cases, within 30 minutes; and regular, within 2 hours. Mrs. F had been assigned “very urgent” status.


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