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'Positive health' is a new concept that arose in response to shortcomings in the broad WHO definition of health. It has similarities with earlier holistic health concepts. The question is what 'positive health' adds for medical practice. On the one hand, the concept rightly emphasizes the gradual and dimensional character of health and the importance of (appealing to) people's resilience. On the other hand, there are also disadvantages. The comprehensive nature of the concept can lead to medicalization of social- and life-problems, and the emphasis on adaptation and self-management can contribute to individualization of health. In practice, the concept offers starting points for health policy and can promote cooperation across borders. For doctor and patient, the question is whether the concept adds much to, for example, the biopsychosocial model. The focus on resilience is a positive innovation, but it does not remove practical obstacles to a broad view of health.

Traditionally, diagnosis is the basis for clinical decision-making and regarded as the guide to prognosis and treatment. Although some patients may particularly benefit such a diagnosis-oriented approach (e.g., patients with acute pathology for which effective treatment is available), this approach is not suitable or sufficient for others (e.g., patients without a diagnosis, patients with a diagnosis for which no treatment is available, and patients for whom the current treatment is insufficient). Furthermore, other factors than diagnosis or diagnosis-guided treatment are likely to influence an individual's outcome (prognosis), including biological, clinical, and social factors. The authors propose a prognosis-oriented approach as an alternative starting point for medical decision-making: not only ask yourself 'what is the explanation for my patient's complaint?', but also 'which factors contribute to the future outcome of this complaint?' and 'can I address these to benefit my patient's outcome?'.

There's an on-going discussion about chronic Lyme Disease: are the persisting symptoms some patients experience due to an inadequately treated Borrelia infection or is something else going on? In 2017 the National Lyme Disease Centre (NLe) has been established in the Netherlands. Two university medical centres, the RIVM and the Lyme Organization participate in the NLe where diagnostics and treatment are offered to patients and research into Lyme disease is carried out. Ideally, collaboration between doctors, researchers and patients leads to research that addresses relevant and urgent questions. Regarding chronic Lyme disease not as a hype but a hypothesis that needs to be verified or falsified, could help both doctors and patients, assuming that they can conclude together that some notions might have seemed rational, but nonetheless have to be discarded based on the results of sound scientific research. That might open new ways to explore treatment of persisting symptoms.

Over the past 10 years there have been significant developments in general practice regarding diagnostics, differentiation of competences of general practitioners, cooperation within primary care and with secondary care, task delegation and patient information provision. Less progress has been made in other areas: E-health applications are rarely used, and there is no clear guideline for an integrated policy in patients with multimorbidity. General practitioners also continue to suffer from excessive regulatory pressure, excessive protocols and standardization. In the coming decade, GPs will continue to work in accordance with the core values ​​of their profession: 'person-oriented', 'medical-generalist', 'continuous' and 'jointly'. Their function to provide guidance is becoming increasingly important. In addition, more diagnostics and treatment will take place at the interface between general practice and secondary care. Chronic care will focus more on the needs and wishes of the individual patient. GPs retain their important role in terminal palliative care and emergency care.

An effective approach to health problems and a sustainable health care system requires more attention to prevention, primary health care and public health in research. For this to be achieved, university medical centres (UMCs) should strengthen the academic basis of prevention and primary care, as the Dutch Health Council recommended in its report 'Research that matters'. We are now three years on and the NFU, the association of the UMCs, recently published its plan 'Research and innovation with and for the healthy region'. This is a step in the right direction, but we are not there yet.

Burnout is a serious health problem and the cause of career disruption in 15% of women and 9% of men who quit their job. Of all work-related complaints, 37% is attributable to workload and stress. Many workers visit their general practitioner with work-related complaints. Recently, the Dutch College of General Practitioners (NederlandsHuisartsenGenootschap) published a guideline on burnout. While the guideline provides a good framework for managing patients with a burnout, additional attention could be paid to prevention and how to distinguish burnout from depression.

The relationship between doctors and patients often becomes tense when the patient has medically unexplained symptoms: doctors may experience frustration because they feel ill-equipped to provide their patients with a plausible explanation of the symptoms. Patients often feel that their doctor does not take them seriously and would like to understand why they are having symptoms. Research into the effect of the quality of the doctor-patient relationship and doctor-patient communication where medically unexplained symptoms are concerned has led to some recommendations for communication. A thorough exploration of all dimensions of the symptoms, i.e. the somatic, cognitive, emotional, behavioural and social dimensions, almost always yields starting points for explaining what is happening to the patient and for therapy. The provision of an explanation which is acceptable to the doctor as well as to the patient is an important condition for drawing up and carrying out therapy. If the doctor expresses confidence in the prognosis and outcome, this has a favourable effect on the development of the symptoms.

Relational continuity of care has traditionally been an important core value of primary care. Research shows that relational continuity of care contributes to better patient health. However, due to social changes and an altered organization of our health system, it has become more difficult to put this core value into practice. General practitioners, for example, increasingly work part-time and general practices have become larger-scaled. Within practices, there is also an increase of delegation and specialization, leading to fragmentation of healthcare. A weekly rota involving at least three clinical consultation days for each doctor, the establishment of small general practice teams within a larger organisation, and a reduction in the size of a standard practice can facilitate relational continuity of care. In addition, it is necessary for GPs to concentrate on the core activity of their profession: direct personal care.

Most people claim that health is an important prerequisite for a happy life. Our society puts much effort into promoting a healthy lifestyle, prevention and timely risk detection. After all, prevention is better than cure. The increased attention to health and the strong focus on prevention, risk reduction and risk avoidance have their downsides, as Ivan Illich already pointed out in the nineteen-seventies. Overdiagnosis, overtreatment and the transformation of many everyday complaints and phenomena into abnormalities lead to medicalisation. In 2013, this trend was reason for the BMJ to start their 'Too much medicine' campaign. Steering between too much medicine and too little medicine requires helmsmanship from doctors; correcting unrealistic expectations, alleviating unnecessary health worries and promoting resilience are all important in the promotion of normalisation.

In recent years disease-specific outpatient clinics have gained a foothold in the Netherlands. In some instances, this is warranted. An example would be an outpatient clinic for early-onset Alzheimer's disease to ensure that patients get optimal diagnostic procedures and receive state-of-the-art treatment. However, the initiation of outpatient clinics for common diseases predominantly treated in primary care, such as a one-stop-shop for the diagnosis of asthma, is a more questionable development. It may lead to patients assuming that such a referral is always necessary for the diagnosis, patients seeking a second opinion in case the diagnosis is not confirmed, and to the exhaustion of available clinical capacity to the detriment of other patients. Furthermore, it may lead to higher costs and add to the complexity of an already complex healthcare system.

The Netherlands Federation of University Medical Centres (NFU) has published a report 'Research Agenda for Sustainable Health', in which the authors outline the Netherlands' medical scientific agenda for the coming years. Although this is a laudable initiative, we question the sustainability of this agenda, which seems to promise a world without disease thanks to the efforts of medical researchers as they delve deep into the human genome and cellular mechanisms. In our opinion, putting this agenda into practice will not address many of the current health problems, and the underlying causes of these problems, with which patients and doctors struggle daily. Moreover, this agenda might strengthen expectations of what doctors and patients can achieve, which are already too high.

From an analysis of data from 23 European countries to determine the impact of primary care on avoidable hospital admissions for uncontrolled diabetes it appeared that, contrary to expectation, countries with strong primary care did not have a lower rate of avoidable hospital admission. It is clear that Roemer's law, 'a bed built is a bed filled,' still applies. However, the validity of this sort of analysis can be questioned, as these data are highly aggregated, and registration quality differs between countries. It is also questionable if these datasets can be considered as 'big data' as there are relatively small numbers per country. Big data analyses are useful for discerning patterns and formulating hypotheses, but not for proving causality. An unwanted side effect of this kind of analysis might be that policymakers use these not so valid results to underpin their policy to their advantage.

Although the prescription of SSRIs for patients with medically unexplained physical symptoms (MUPS) has increased in past years, there is still remarkably little evidence for their efficacy in adults with MUPS, as shown by a recent Cochrane review. As there is virtually no evidence that SSRIs are effective in adolescents with MUPS, doctors should think twice before prescribing SSRIs for this patient group; SSRIs can have serious side effects, particularly in adolescents. Increasing numbers of off-label prescriptions and a great improvement in symptoms in two adolescents with MUPS and psychiatric problems as described in a recent article in the Dutch Journal of Medicine (NTvG) do not justify the, albeit cautious, recommendation to consider prescribing SSRIs for adolescents with MUPS and depressive or anxiety symptoms.

Lyme disease is the cause of a lot of anxiety and discussion. Patients are demanding more preventive actions to avoid tick bites, and earlier and better diagnosis of Lyme disease. However, only a minority of people bitten by a tick go on to develop Lyme disease. Although physician delay may lead to a late diagnosis of disseminated Lyme disease, these patients are still treatable and even in bad cases, symptoms will subside within a few years. While we know that serious complications of late disseminated Lyme, e.g. neuroborreliosis, are very rare, there is still uncertainty about how often Lyme disease occurs, and how often the diagnosis is delayed. The high prevalence of seropositive people in the population suggests that many people clear the infection without any symptoms and without any treatment. Some decades ago mononucleosis infectiosa also had a bad reputation but this largely disappeared when it became clear that recovery is the rule. Lyme disease may also shed its reputation once the facts are known.

It has been suggested that chronic dizziness in older people may constitute a multifactorial geriatric syndrome. Considering dizziness to be a geriatric syndrome with multiple contributory factors may provide additional leads for treatment. A structured history, followed by physical examination and additional tests if necessary, can yield clues to factors that may contribute to dizziness. To illustrate such a multifactorial approach, we present two patients with chronic dizziness. In both cases, the general practitioner considered multifactorial dizziness with several treatable contributory factors. By treating these contributory factors, the frequency of dizziness and dizziness-related impairment decreased temporarily in one patient and permanently in the other.

The multidisciplinary guideline 'Diagnostics and treatment of irritable bowel syndrome (IBS)' provides the basis for a properly coordinated collaboration between the patient suffering from IBS and all healthcare providers involved in his or her treatment, such as the general practitioner, gastroenterologist, internist, occupational-health physician, dietitian and psychologist. The diagnosis 'IBS' is often made in accordance with diagnostic criteria, such as the Rome III criteria, but a somatic condition needs to be excluded first. If there are no indications for this, additional diagnostic tests are not necessary. Management of the condition consists primarily of advice on life-style plus non-pharmacological interventions, in addition to explaining the condition and providing information. Drug treatment is rarely indicated. If the IBS symptoms have a significant impact on quality of life and patients do not respond to the measures taken in accordance with this general policy, there are three options for psychotherapeutic treatment. When the symptoms result in absenteeism or other work-related problems, the doctor can advise the patient to contact the occupational-health physician and to search for specific solutions in consultation with the employer. When individual advice is required or if the patient's diet is not well-balanced, a referral to the dietitian will follow.

Doctors often feel pressured by patients to prescribe antibiotics for a common cold or a sore throat, against their better judgment. Yet do patients really put pressure on their doctor or even expect a prescription for an antibiotic or some other medicine? Several interesting studies shed some light on this issue. Doctors in an emergency department, for example, prescribed an antibiotic much more frequently than their patients expected them to. Only in 25% of cases were the doctors correct in their assumptions about patient expectations. In a Norwegian study, the authors found that parents wanted more time and explanation for their coughing children and fewer prescriptions. So instead of assuming that patients want antibiotics for innocent symptoms, we should put more effort into exploring patients' expectations and providing them with relevant information. That way we can step out of the folie a deux.

The syndrome diagnosis 'irritable bowel syndrome' (IBS) is often made on the basis of exclusion, but the question is how many diagnostic tests should be performed in order to establish this diagnosis with a degree of confidence. We present the diagnostic value of various IBS criteria for excluding IBS, based on a systematic review. The potential of the various criteria for distinguishing IBS from organic disease is extremely variable and disappointing. Patients fulfilling IBS criteria have, however, a lower risk of organic disease than patients with abdominal symptoms who do not fulfil the criteria. The same holds true for the diagnostic performance of individual alerting symptoms. These seem to be present frequently in IBS patients in whom there is no underlying organic bowel condition. An organic condition cannot be accurately excluded on the basis of symptom criteria. However, the low prior risk of organic conditions among patients who consult a primary care doctor and who meet IBS criteria argues against exhaustive diagnostic evaluation.

In a recent study, Bos et al. (JAMA 2007) showed that patients with nonfocal transient neurological attacks (TNA) have a higher risk of major vascular disease, comparable to patients with focal TNAs. This may prompt GPs to take a more active approach when dealing with patients experiencing short-lasting attacks of dizziness, paraesthesia and weakness. However, the category of nonfocal TNAs in the abovementioned study was very broad, and subgroup analysis for specific symptoms was not possible. Moreover, a third of nonfocal TNAs consisted of loss of consciousness or decreased consciousness, which might be responsible for the heightened risk of cerebrovascular accident. Also, a quarter of patients with nonfocal TNA had not presented their symptoms to a physician and reported the symptoms during a follow-up meeting, leaving room for recall bias. Since symptoms like dizziness are very frequent among elderly patients and nonfocal TNAs are difficult to recognize, both physicians and education campaigns should be careful not to arouse anxiety without good reason.

The diagnosis of 'irritable bowel syndrome' can usually already be established after history-taking and a limited physical examination, particularly if the symptoms have persisted for many years in the same form. Additional investigations are indicated in the case of diarrhoea which lasts longer than 2 weeks, especially if the patient is also severely unwell or has rectal bleeding; further investigations are also required if older patients experience the symptoms for the first time, if there is blood loss upon defecation, if unintentional weight loss occurs or if a mass is felt on the left side of the abdomen. Further investigations consist of a rectal examination, measurement of the sedimentation, haemoglobin concentration and leukocyte count, sigmoidoscopy and an X-ray of the colon. Treatment should aim to reduce unnecessary concern and avoidance behaviour, and to positively influence additional stress-inducing factors, nutrition and physical activity. Medication is not indicated except for laxatives if constipation plays an important role and if advice about nutrition and physical activity provide insufficient relief.