In the Netherlands: a day in a GP practice (Part 2)
Why are Dutch GPs called “huisarts” — house doctors? In Part Two of her visit to a Nijmegen clinic, Dr. Tara Kiran talks with Dr. Suzanne Ligthart about the Dutch tradition of home visits. She then meets Kris Arts, a practice assistant, and learns how these highly trained team members serve as the doctor’s right hand — expertly triaging patients, coordinating follow-up, and keeping the clinic running smoothly. Dr. Kiran ends the episode with reflections on what Canada might learn from the Dutch approach to primary care. Stay tuned for Part 3 where Tara takes listeners behind-the-scenes to explore the Dutch after-hours care system.
If you missed Part One of the documentary series on the Netherlands, click here to catch up.
See a gallery of Dr. Kiran’s photos from her trip to the Netherlands.
Hear Dr. Kiran speaking about her trip on CBC’s White Coat, Black Art
Read Dr. Kiran’s 4-part series for the Canadian Health Network on her trip
Read an article about Tara’s host, Dr. Tim Olde Hartman: A Giant Standing on the Shoulders of Giants
Subscribe to our Substack newsletterto get bonus content.
Take the OurCare national survey to share your experiences with primary care.
Do you have an idea for an episode? Email primary.focus@unityhealth.to
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In the Netherlands: a day in a GP practice (Part 2)
Primary Focus Podcast — Netherlands Series, Part 2
Introduction
Dr. Tara Kiran (00:02) Welcome back to Primary Focus. I'm Dr. Tara Kiran.
In our last episode, I introduced you to one of the primary care teams I met on my trip to the Netherlands. This episode is Part Two, so if you missed Part One, now's a great time to hop back one episode and catch up.
If you'd like to read about and see photos from my trip to the Netherlands, you can find them at primaryfocus.substack.com. And if you're all caught up, let's just dive back in.
Shadowing Dr. Suzanne Ligthart
Dr. Tara Kiran (00:48) Remember Dr. Suzanne Ligthart? She's one of the practice owners who gave me a tour when I first arrived at the [uncertain: Nijmegen] clinic. It was a really busy day when I was visiting, but I got to shadow her during some of her patient appointments in the afternoon.
The appointments were reminiscent of patient visits in Canada. But between appointments, Suzanne shared a lot about what she loves about being a GP in the Netherlands and where she sees some of the challenges.
She pulled out this beautiful dark [uncertain: leather] doctor's bag to show me something.
Dr. Suzanne Ligthart (01:25) This will be personalized.
Dr. Tara Kiran (01:28) Yeah, so everybody has a standard doctor's bag.
Dr. Tara Kiran (01:31) She and her colleagues all have similar bags made by a local [uncertain: craftsperson].
Dr. Suzanne Ligthart (01:38) — blood pressure, temperature, also —
Dr. Tara Kiran (01:48) Inside, the doctor's bag is fully stocked with everything she needs for a home visit: a blood pressure monitor, thermometer, [uncertain: stethoscope], urine tests, nose [uncertain: swabs], glucagon — yeah, glucagon.
Home Visits: A Routine Part of Dutch GP Practice
Dr. Tara Kiran (02:04) If you're a doctor or even a patient, you'll know that in Canada most of us practice out of clinics almost exclusively, and our exam rooms have the tools we need. But for GPs in the Netherlands, home visits are a routine part of practice. Every day from 1 to 2 PM, all GPs but one in the practice have their schedules blocked off for home visits. This was true not just in Suzanne's practice in Nijmegen, but also in the practice I visited in Amsterdam.
Each GP has their own doctor's bag that they take with them.
Dr. Suzanne Ligthart (02:49) [uncertain: Morphine, adrenaline] —
Dr. Tara Kiran (02:52) You've got [uncertain: resuscitation supplies]. Have you had to use those in people's homes?
Dr. Suzanne Ligthart (02:56) Yeah, sometimes. Yeah, especially when —
Dr. Tara Kiran (02:58) Like if they're having a [uncertain: cardiac event]. Yeah.
GPs here commonly do home visits. And before you ask how they can offer this care within a one-hour block, remember: patients are supposed to live within a fifteen-minute drive of the office, and usually it's even closer. Tim talked about how he commonly rides a bike for home visits. Fittingly, the Dutch word for GP is huisarts, which literally translates to "house doctor."
Dr. Tara Kiran (03:17) So you're called house doctors, and you do home visits.
Dr. Suzanne Ligthart (03:30) And we do home visits, yeah. But not so many now. Yeah.
Dr. Tara Kiran (03:34) Not as many doctors do home visits in Canada. Is it pretty standard for a GP to do home visits here?
Dr. Suzanne Ligthart Every GP does it.
Dr. Tara Kiran (03:43) Suzanne says that since the COVID-19 pandemic, they've been doing fewer home visits. But it's obvious to me that these in-person home visits mean a lot to her.
As we chatted, she picked up a card from her desk. It has a picture of an older gentleman on it.
Dr. Suzanne Ligthart (04:05) He passed away. Is that your dad? No, no, it was one of the patients. They sent a card. I think it's so touching. He wanted to stay at home. He lives across the street — there's a park where people live. Yeah, it's a park. It can be so special. People live there year-round — no holiday, just the whole year around.
Dr. Tara Kiran (04:15) Because you saw him a lot — you saw him a lot at home.
A trailer park, I think. So he was living at the trailer park and he wanted to pass away there.
Dr. Suzanne Ligthart (04:36) One pathway was home. But we didn't manage to do it because home care was not available and we are not used to this. This was actually one week ago — he passed away. But now we have the shortage of doctors, but also nurses, like home care nurses.
Dr. Tara Kiran (04:49) What is it — with the pandemic?
Dr. Suzanne Ligthart (05:04) We were really sitting together, all of us, because we are not used to this happening.
Dr. Tara Kiran (05:11) Suzanne explained that palliative care patients require intensive nursing and home support in addition to a doctor. In this case, there was a shortage of home care nurses, and so the patient wasn't able to receive palliative care at home, despite the fact that Suzanne was personally able to support it medically. She says that's the first time she'd seen that happen. And even just last week, a colleague of hers had patients who were not able to get the home care they needed because of nursing shortages.
With this patient whose photo she has on her desk, the shortage of home care meant they had to send him to a hospice.
Dr. Suzanne Ligthart (05:50) It was a transition, and it really worries me. He should have been able to die at home. It was okay, in the hospice — for his children, it was okay. But still, I think this is not a good thing.
Dr. Tara Kiran (06:03) Yeah. But it means a lot to them that you took care of him, I'm sure — because you'd known him for a long time, I'm guessing. Yeah.
Comparing the Netherlands and Canada
Dr. Tara Kiran (06:19) Things aren't perfect in the Netherlands. Like us, they're facing an aging population and workforce challenges. As we heard, GPs are becoming less interested in running a practice, and new graduates increasingly want to work part time. But there are also big differences between how GPs operate in our two countries.
Almost everyone has a GP in the Netherlands. For urgent issues, they have same-day access. They have efficient information systems. Patients easily access their own records through an app. And GPs regularly do home visits.
It's not just the practice I visited here in Nijmegen — at the practice I visited in Amsterdam, while the city's culture and context was different, I still observed many of the same things. The infrastructure and context may have been different, but the approach to organizing care, the types of health professionals they've integrated and how they've integrated them — all of that was actually pretty similar.
Above all, I think what the Netherlands does better than we do is that there is a team in place, each team member has a specific job, and there is a system to funnel patients to the right kind of care — the right person, at the right time.
And how they do it is something I've been holding back on until now. It's the secret sauce of the Dutch primary care system. To bring you there, we're going to jump back into my tour with Tim.
The Secret Sauce: Practice Assistants
Tim Olde Hartman (07:49) Here is some room for administration. Our practice manager is always sitting here. This is the back office where the practice assistants sit and take all the phone calls and do the triage. Yeah, the practice assistant. No, they are not nurses, but they are almost nurses.
Dr. Tara Kiran (08:04) [Kris Arts enters]
Okay — they're not nurses, you say. Okay, but these are the three practice assistants up here — plus you have two downstairs as well, so five in total?
Tim Olde Hartman (08:21) It depends on the day. So on Monday morning —
Dr. Tara Kiran (08:23) Tim's talking about practice assistants. Not the same as a physician assistant — the kind of professional we have here in Canada. To me, practice assistants seem to perform a role somewhere between a medical office assistant and a nurse. It's a pretty unique role that I actually haven't seen in Canada.
These team members are, it turns out, the key to explaining why GPs in the Netherlands can look after so many patients and still provide timely care.
In Tim's practice there were about six practice assistants on a Monday. Four were answering the phone in the morning — each at their own desk with a computer and a headset. One was at the front desk, and another was doing consultations. By 4 PM, those on the phone had fielded about two hundred calls, resolving many of the issues themselves.
I got a chance to ask them a few questions. Can you tell me your name?
Kris Arts (09:14) Yes — Kris Arts.
Dr. Tara Kiran (09:16) And what is your role?
Kris Arts (09:19) I don't know the word in English. It's a doctor's [uncertain: assistant]. After four minutes I have to call my next patient.
Dr. Tara Kiran (09:23) Yeah — okay, perfect.
What Practice Assistants Do
Dr. Tara Kiran Practice assistants play a huge role in triage. They resolve issues that don't need to be seen by a GP, and they're trained to ask appropriate questions for a number of the most common reasons patients call in. They can also provide related advice for things that don't need to be seen by a doctor.
For example, they might counsel a parent calling about a child who's had a fever for just a day or two. On that call, they'll ask a few questions and figure out: is this child showing red flags that mean they need to be seen by a doctor? If not, they can give the parent advice on what they can manage at home.
Dr. Tara Kiran (10:35) So for something like a cold, you're able to counsel patients and reassure them — and then they don't need to come in.
Kris Arts (11:07) So they call us and we think: is it something bad? Does he have to see the doctor? Yes or no — [uncertain: pneumonia]? Yeah, exactly. When I think it's not serious, we give advice.
Dr. Tara Kiran (11:24) Practice assistants do more than just counsel patients on the phone. They handle administrative tasks too. If a referral needs to go to a different place, they'll redirect it. They suggest prescription renewals — when those requests come in, they review them, tee everything up to be renewed, and the doctor then just needs to approve with a click. If a patient has an urgent issue, they'll book a same-day appointment with a doctor. But they're also well trained to know what things can wait a day or a week. And if they're unsure how to respond to a call, they'll consult the physician — often by scheduling a quick chat when the physician has a break in their schedule. The doctor would then call the patient back themselves.
They also see patients one-on-one in the office, in what they refer to as a consultation.
Kris Arts (12:12) It's very diverse — every day is a different day. My job is to speak with people on the phone, but my job is also to see people on my own.
Dr. Tara Kiran (12:25) And what are the kinds of things you do in consultation?
Kris Arts (12:29) I take care of wounds, or I remove stitches, or I remove a Mirena [IUD] spiral.
Dr. Tara Kiran (12:33) Yeah, okay. You can remove IUDs?
Kris Arts (12:42) Yes, we do it. The doctor will place it, but we can remove it.
Dr. Tara Kiran (12:47) Practice assistants can give vaccinations, do Pap tests, syringe ears, do wound care, take blood pressure measurements, and more.
Kris Arts (12:59) We are the right hand of the doctor. We pick up the little things that we can do.
The Challenges of the Role
Dr. Tara Kiran (13:05) What would you say is one of the more challenging parts of your job?
Kris Arts (13:11) Some conversations with people when they are really worried — or some people are very aggressive. Not [always] hard. We also have conversations with people who are suicidal. Yeah, that's a hard conversation. One time the emergency line rang and I picked up. There was a woman standing on a high bridge. I could hear the wind through the phone. She said she wanted to talk to the doctor — she wanted to thank her. And I thought: what do I have to do now? Call an ambulance? I don't want to hang up. I don't know what to do. So you have to think really fast.
Dr. Tara Kiran (14:10) What did you do?
Kris Arts (14:10) I asked my colleague in the back office to go get the doctor, and the doctor came to me and took the line. And everything — the police and everything — it was good. It happens a lot of times.
Training and Communication
Dr. Tara Kiran (14:37) They have a tough job. They're the front door, and even in Canada, the job of the person answering the phone is hard. They need to figure out how to help the patient, and patients may often be in distress, angry, or upset.
What impressed me about the practice assistants in the Netherlands is that they seemed very well trained. You can become a practice assistant with three years of training, right out of high school. The training is thorough and practical, and very contextual to the primary care setting — both classroom and clinic time. They're trained to ask patients the right questions based on what the patient is calling about, so that they can triage them effectively. Triage is based on algorithms — actually just a website — developed in partnership with the Dutch College of GPs.
So GPs, as a profession, have had input into how practice assistants are trained. That means GPs have confidence in the way practice assistants ask patients the right questions, counsel them, and decide on the next step. Should the patient be seen? If so, how urgently? And by whom?
It's striking that the role is so specific to primary care — practice assistants are trained in a way that's specifically designed to reflect what a general practice might see day to day. They're not trained as generic healthcare assistants who could work in any setting.
What was also interesting was that, in addition to training on clinical matters, they spent a lot of time learning how to build trust and communicate — including how to de-escalate when a patient gets angry.
Kris Arts (16:27) We got trained in how to communicate. Because when you go and ask the doctor about something you don't know, and you come back to the patient and say, "I think it's going to be fine" — don't say "I think," because the patient will wonder why you only think, not know. So they teach you how to talk to them so they don't get —
Dr. Tara Kiran (16:46) Anxious, yeah.
Kris Arts (16:52) — not anxious. And also: don't say "but," because when you say "but," you cancel out everything you said before. So you have to know how to say things so that you don't make more worry.
Dr. Tara Kiran (17:12) Absolutely, that makes sense. Yeah.
Kris Arts (17:15) Yeah — it's knowing how to communicate with people so they don't interrupt you or get more worried.
Dr. Tara Kiran (17:25) Being a good doctor is also about learning to communicate well with patients, and we do go to school for that. So it makes sense that if you're on the front line and you're the doctor's assistant, you also have that training — and are able to de-escalate, connect with people, and help them feel reassured when they don't need to see the doctor.
Kris Arts (17:45) You do. Yeah.
Dr. Tara Kiran (17:47) Okay, well, this has been really educational for me. I really learned a lot — because we don't have doctor's assistants like this. And I think this is one of the big differences. In Canada, one of the big problems is that patients often have a hard time getting a timely appointment. Even if they have something urgent, it can be really hard to get seen in time, and then they have nowhere to go. It's very challenging.
But here it sounds like most doctor's offices accommodate urgent issues on the same day — and I think part of the reason is that the practice assistants are triaging the phone calls.
Kris Arts (18:28) Yeah, yeah. We speak to them and we say: you can come in, you don't have to come in, you can come tomorrow, or you can come right now. So we filter everything before it gets to the doctor.
Dr. Tara Kiran (18:39) And what do you do if the doctor's schedule is full?
Kris Arts (18:43) It happens a lot — this week the doctor was fully booked. But we know when something is urgent. So when something is urgent, I say to the doctor: "Doctor, this person has to come in today." It's my job to know. And so the doctor looks at the schedule to see where maybe there's a phone appointment or an administrative block — somewhere they can be squeezed in. The doctor listens to us, and it's nice — they take us seriously. We can always ask the doctor for advice: "I think this person has to come in — not really today, but the first appointment is next week. That's too long — what do you think?" So the doctor will look at the schedule with us. We work as a team.
Dr. Tara Kiran (19:46) You're working as a team. Very important. And they stand up for you. Yeah. Okay, thank you — I know you have to go back to your job.
Reflections on the Dutch System
Dr. Tara Kiran (19:55) The role of the practice assistant is one of my main takeaways from my visit to the Dutch health system. It's a role we could relatively easily adapt here in Canada, and I think it's one of the key reasons GPs in the Netherlands can look after large numbers of patients and still provide timely care. I love that practice assistants receive formal training in communication, and that the triage algorithms they use come from the Dutch College of GPs. Their training is standardized and only three years — which actually means it's a workforce we can train up far faster than the minimum nine years it takes to become a fully licensed family doctor in Canada.
It's great that practice assistants are also empowered to resolve issues on their own, with the skills needed to manage demand coming through the front door: figuring out if, when, and by whom patients need to be seen.
In Canada, we talk a lot about patients being seen in the right place, by the right person, at the right time. Everyone agrees that's the goal — but making it a reality is a real struggle. Practice assistants make this happen. They also take work off of nurses and doctors, freeing up their time to focus on more complex issues.
I was also struck by how efficient prescription renewals were — just one or two clicks, compared to the more cumbersome process in my practice. And it was great to have those renewals integrated with decision support, so you didn't have the cognitive load of trying to figure out the right prescription from scratch.
Making referrals was pretty easy too. Most tests and specialist referrals are managed through hospitals, and there seemed to be one standard referral portal for all hospitals in the country. Contrast that to most jurisdictions in Canada, where there are umpteen different referral forms and no centralized system. Referrals become a huge headache for family doctors to manage in Canada.
I also noticed that doctors in the Netherlands didn't seem to write long notes, and I wondered if that's because there are fewer medico-legal concerns in general there.
Tim and Suzanne's practice had started using e-consultations a couple of years before I visited, and they'd already begun to see some of the efficiencies. Patients could submit their questions through an app, book appointments through that same app, and the app was seamlessly integrated into the doctor's chart. I did learn that not all GPs in the Netherlands were this far ahead with integrating technology, so I need to be careful not to generalize.
One of the most striking things to me was what GPs in the Netherlands do not do. As we talked about, they don't manage much stable chronic disease care directly. But they also do very little preventive care — and that's not because people don't get preventive care in the Netherlands; it's just that they get it elsewhere.
Pap tests are done by practice assistants. Colorectal and breast cancer screening is actually handled by a national agency — family doctors have nothing to do with it. Well-baby checks and immunizations are handled by a totally different type of provider. And in general, patients are not booked for routine preventive health checkups — it's just not considered a cost-effective use of GP time.
In contrast, family doctors in Canada spend a lot of time on preventive care: counseling patients on cancer screening, doing well-baby checks, providing immunizations, and conducting preventive care visits where the expectation is for us to use guidelines and counsel people on a whole variety of things. It made me wonder: how much family doctor time could we free up if we took that work away and gave it to someone else? It could be other people in the clinic, another agency, or health promotion campaigns that educate the public about healthy lifestyles.
But what if we freed up that physician time? What could that mean for all those people who are struggling to access primary care in Canada? Doctors could use their very advanced skills, training, and experience to assess and manage the hardest stuff in primary care — urgent things, patients with new problems, and patients with complex medical and social issues that interplay with one another.
Unfortunately, right now in Canada, there are so many people with acute and complex medical issues who have nowhere to turn.
The Ethos of GP Access
Dr. Tara Kiran (26:12) The other striking thing in the Netherlands was just the ethos of GP access. It's ingrained that GPs need to provide patients with timely access. And it's tradition that GPs are responsible for their patients' ongoing care, twenty-four hours a day, seven days a week.
Now, that sounds pretty onerous — but the Dutch have figured it out. They have what I think are the best after-hours care systems in the world. When your GP office closes at 5 PM, it's still easy to get care. More on that in our next episode.
[Clip from car ride with Tim:]
"Okay Tim, so we're driving over to this out-of-hours place. It's the out-of-hours centre — basically a cooperative of the GPs in the area, and it collectively serves about —" [uncertain: remainder not captured]
What's Coming Next
Dr. Tara Kiran (27:21) I hope you'll join us next as we dive into the Dutch system for after-hours care. And then we'll end the four-part series with a conversation with Rosemary [uncertain: Hannem], who was actually on the trip with me. We'll talk about how Dutch doctors are held accountable for providing timely care to their patients, and we'll discuss our key takeaways and reflections for the Canadian system.
Credits
Primary Focus was created by Dr. Tara Kiran. Maryam Danesh supports our research and fact-checking. Seema Marwaha and Emily Holton are our storytelling and media advisors. Our producer is Avery [uncertain: Moore Kloss].
A big thank you to Rosemary [uncertain: Hannem], and a huge thank you to the many Dutch people who took time out of their day to tell me about their primary care system — including many who weren't featured in this episode but who really informed my understanding of the system. Their comments and thoughts are reflected throughout.
If you'd like to read more content from Dr. Kiran about Canada's primary care system, join the Substack newsletter at primaryfocus.substack.com or visit primaryfocus.ca. For more information on the Our Care standard and how it could help us solve the primary care crisis, visit ourcare.ca.
Primary Focus is supported by a grant from the St. Michael's Foundation. Dr. Kiran is supported as the [uncertain: Fidani] Chair in Innovation at the University of Toronto, and as a scientist by the Departments of Family and Community Medicine at St. Michael's Hospital and the University of Toronto.
Our Care Survey (Closing Announcement)
Dr. Tara Kiran (29:11) Hey, it's Tara again. Something you hear me talk a lot about on this podcast is the Our Care standard — a clear outline of what every person in Canada should be able to expect from the primary care system. The standard was shaped by feedback we received from nearly [uncertain: ten thousand people] in 2022–23. And now we've just launched another survey, and we want to hear from you.
Whether you have a family doctor or not, we want to know how your healthcare stacks up against the Our Care standard. It only takes ten to fifteen minutes to share your story. It's completely confidential, and it'll help researchers like me understand what's needed for a stronger, more equitable healthcare system in Canada. More importantly, it will help us all hold our governments to account to deliver the system we all want and deserve.
You can take the survey anytime between now and July 9th. Just head to ourcare.ca/survey or click the link in the show notes. The Our Care Survey is a research study led by me, Dr. Tara Kiran, at the MAP Centre for Urban Health Solutions at St. Michael's Hospital, in partnership with the Canadian Medical Association.
The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.