The Netherlands has been ranked among the top 5 happiest countries, known for a bike- and family-friendly lifestyle. It also boasts famous artists, such as Van Gogh and Rembrandt, as well as famous physicians and scientists, including Boerhaave, Roentgen, and van Leeuwenhoek. Living among tulips, canals, cheese, and a thriving coffee culture might be appealing to many American-trained physicians looking for a modern society, rich with cultural and historical significance, and relatively low threshold for adapting to a new environment (more than 90% of the population speaks at least some English).
In the coming posts, I will introduce you to the Dutch healthcare system, the professional recognition procedures, options and considerations for finding a job, and the health care culture. Now would be a good time for a koffie and stroopwafel!
Principle of Solidarity
A core principle in The Netherlands is the principle of solidarity. It’s this principle which is the foundation for all social and health services provided in the country.
All residents of The Netherlands must purchase compulsory insurance, and all insurance is private. Compulsory insurance is an insurance mandate – unless you can prove you have sufficient health insurance coverage from another country/agency that covers comparable basic services in The Netherlands. As a migrant or expat, if you do not purchase insurance within 4 months of entry with a permit, then you will face steep fines. If you are not a resident, you will pay for healthcare through a fee-for-service model.
Compared to the US, the Dutch system prioritizes first-line care, eerstelijnszorg. Part of first-line care is the huisarts, or general practitioner (GP), who has studied or been recognized in huisartsgeneeskunde, or Family Medicine. Huisarts are the gatekeepers in the Dutch system. All residents know that they must go to their Huisarts for everything first. Need to see a specialist? See the GP first. Have an after-hours urgent care issue? Call the after-hours regional GP line. Trust me, unless you truly have a medical emergency, you’re expected to call or see the GP. Unfortunately, sometimes GPs are gatekeepers to a fault: paracetamol is no panacea. On the other hand, Dutch physicians will almost never overprescribe antibiotics or over-order expensive imaging with weak or no indications; as a result, antibiotic resistance is little to none across the country!
In anderhalvelijnszorg, or one-and-a-half-line care, a Dutch specialist physician works in the community in an office that is physically separate from a hospital. The closest equivalent in the US system is a specialist seeing patients for scheduled outpatient clinic appointments. In contrast, in the Dutch system, most specialist physicians typically see patients in a polikliniek, or poli for short. Poliklinieken are always found inside a ziekenhuis, or hospital, even though they have scheduled patient appointments for specialist visits as well. Interestingly, it’s possible, for example, to have a hospitalized patient be seen for a scheduled polikliniek visit if it’s not possible for the specialist to come to them on the wards (e.g. ophthalmology visit, which can involve specialized, non-portable equipment). It is far less common for a specialist — even Internal Medicine, Pediatrics, or Obstetrics/Gynecology physicians, who are all seen as specialists in the Netherlands — to work solely in the community, hence these doctors work in anderhalvelijnszorg.
Municipal Healthcare Services
The Dutch system also includes municipal health care services (Gemeentelijke Gezondheidszorg, GGZ) who implement the National Institute for Public Health and the Environment’s (Rijksinstituut voor Volksgezondheid en Milieu, RIVM) public health recommendations. The municipal health clinics are often staffed by non-specialty trained physicians (basisarts), which are the equivalent of a recently graduated medical student. They typically provide population-based preventive health services, such as recommended vaccinations for children and COVID-19 screening or vaccination. This GGZ is not to be confused with geestelijke gezondheidszorg, which are mental health services to which a huisarts can refer a patient. Families of eligible older patients or those with disabilities are also able to apply for home help and care services through the municipality.
Similarities with the US Healthcare System
The Dutch Healthcare system includes secondary and tertiary care, like spoedeisende hulp, or SEH (emergency care), verpleedafdelingen or klinieken (acute inpatient hospital wards), intensieve zorg (intensive care), as well as nursing facility and long-term care. There are alsoacademische ziekenhuizen (academic hospitals) and community medical centers, like in the US.
One unique care setting that builds on to the principle of solidarity is the presence of government-supported residential long-term and youth care, for example, for both adults and children with disabilities.
The Dutch are quite frugal in their utilization of resources. This is clear in their emphasis on the General Practitioner as a gatekeeper, but you may also experience the frugality elsewhere. When I get blood drawn or donate plasma, the phlebotomists do not wear gloves. A Dutch friend told me that after she cut her leg during a spartan race, she went to the SEH (emergency care) and got several stitches – without any local anesthesia. On further inquiry, this was normal practice – even she didn’t express any surprise when she recounted this and I reacted with shock!
Over the next couple blog posts I will detail the process of medical licensure, finding a job, and differences in workplace culture. More to come!
Tiffany I. Leung, MD, MPH, FACP, FAMIA is a U.S.-trained Internal Medicine physician and Assistant Professor at the Faculty of Health, Medicine and Life Sciences and PhD candidate at the Care and Public Health Research Institute at Maastricht University in The Netherlands. Her PhD work focuses on understanding and mitigating job distress among physicians especially when healthcare systems undergo redesign.
She has a special interest in physician suicide prevention, and promotion of physician well-being, gender equity, and diversity and inclusion in medicine. She is Co-executive Producer of The DEI Shift, a podcast promoting diversity, equity, and inclusion in medicine, and Editor-in-Chief of the Society of General Internal Medicine’s official newsletter SGIM Forum. Read more about Dr. Leung’s work on her website, find her on Twitter and Instagram @TLeungMD, and learn more about her experience with the Dutch Healthcare System. She has an active state medical license in the U.S. and maintains U.S. board certifications in both Internal Medicine and Clinical Informatics.