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Rationale, aims and objectives Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. Methods The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. Results The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. Conclusions Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

Background Restructuring labour markets offers natural population-level experiments of great social epidemiological interest. Many coastal areas have endured substantial restructuring of their local labour markets following declines in small-scale fishing and transitions to new employment opportunities. It is unknown how educational inequalities in health have developed in formerly fishery-dependent communities during such restructuring. In this study, we compare trends in social inequalities in health in Norwegian coastal areas with adjacent geographical areas between 1984 and 2019. Methods We used cross-sectional population-based data from the Trondelag Health Study (HUNT), collected four times: HUNT1 (1984-86), HUNT2 (1995-97), HUNT3 (2006-08) and HUNT4 (2017-19). Adults above 30 years of age were included. Using Poisson regression, we calculated absolute and relative educational inequalities in self-rated health, using slope (SII) and relative (RII) indices of inequality. Results Trends in absolute and relative inequalities in rural coastal health were generally more favourable than in adjacent geographical areas. We found a statistically significant trend of declining relative educational inequalities in self-rated health in the rural coastal population from HUNT1 to HUNT4. Absolute inequalities overall increased from HUNT1 to HUNT4, although a declining trend followed HUNT2. Nonetheless, the rural coastal population exhibited the highest prevalence of poor self-rated health across the four decades. Conclusions Although absolute educational inequalities in self-rated health widened in all geographical areas, the smallest increase was in rural coastal areas. Relative educational inequalities narrowed in this rural coastal population. Considering the concurrent processes of large-scale investments in the Norwegian public sector and welfare schemes, increased fishing fleet safety, and employment opportunities in aquaculture, our findings do not suggest that potential positive effects on public health of this restructuring have benefitted inhabitants with higher educational attainment more than inhabitants with lower educational attainment in this rural coastal population.

Multimorbidity - the occurrence of two or more long-term conditions in an individual - is a major global concern, placing a huge burden on healthcare systems, physicians, and patients. It challenges the current biomedical paradigm, in particular conventional evidence-based medicine's dominant focus on single-conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification, and optimal management cannot be deduced from clinical practice guidelines. In this article, we argue that person-focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. The approach offers an integrated and coherent perspective on the person's living environment, relationships, somatic, emotional and cognitive experiences and physiological function. The underlying principles include non-linearity, tipping points, emergence, importance of initial conditions, contextual factors and co-evolution, and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole people, given the constraints of their socio-ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? These questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical and contextual factors, to guide an integrated approach to the care of people with multimorbidity.

BACKGROUND The COVID-19 pandemic imposed an acute, sharp rise in the use of video consultations (VCs) by general practitioners (GPs) in Norway. OBJECTIVE This study aims to document GPs’ experiences with the large-scale uptake of VCs in the natural experiment context of the pandemic. METHODS A nationwide, cross-sectional online survey was conducted among Norwegian GPs during the pandemic lockdown (April 14-May 3, 2020). Each respondent was asked to evaluate up to 10 VCs. Basic demographic characteristics of the GPs and their practices were collected. The associations between GPs’ perceived suitability of the VCs, the nature of the patients’ main problems, prior knowledge of the patients (relational continuity), and follow-up of previously presented problems (episodic continuity) were explored using descriptive statistics, diagrams, and chi-square tests. RESULTS In total, 1237 GPs (26% of the target group) responded to the survey. Among these, 1000 GPs offered VCs, and 855 GPs evaluated a total of 3484 VCs. Most GPs who offered VCs (1000/1237; 81%) had no experience with VCs before the pandemic. Overall, 51% (1766/3476) of the evaluated VCs were considered to have similar or even better suitability to assess the main reason for contact, compared to face-to-face consultations. In the presence of relational continuity, VCs were considered equal to or better than face-to-face consultations in 57% (1011/1785) of cases, as opposed to 32% (87/274) when the patient was unknown. The suitability rate for follow-up consultations (episodic continuity) was 61% (1165/1919), compared to 35% (544/1556) for new patient problems. Suitability varied considerably across clinical contact reasons. VCs were found most suitable for anxiety and life stress, depression, and administrative purposes, as well as for longstanding or complex problems that normally require multiple follow-up consultations. The GPs estimate that they will conduct about 20% of their consultations by video in a future, nonpandemic setting. CONCLUSIONS Our study of VCs performed in general practice during the pandemic lockdown indicates a clear future role for VCs in nonpandemic settings. The strong and consistent association between continuity of care and GPs’ perceptions of the suitability of VCs is a new and important finding with considerable relevance for future primary health care planning.

The association between highly stressful life experiences and morbid obesity is well documented internationally, but this knowledge is not incorporated to any great extent in Norwegian clinical practices. We have studied the reports of previous life stresses from a sample of Norwegian patients under assessment for morbid obesity at a centre where the topic of life experiences was included during the recording of patient histories.In the summer of 2018, an invitation to participate in the study was distributed to the last 200 patients to have been examined at the Regional Centre for Morbid Obesity in Bodø. Information on lifetime adversity was collected in clinical interviews. Data were retrieved from the patient's discharge summaries, and these texts were analysed using a qualitative approach. Stressful life experiences were divided into twelve categories.The study recruited 70 participants (57 women) with morbid obesity. Of these, 64 (91 %) related at least one significant and stressful life experience, and 39 (56 %) reported three or more different types. The most frequent types included serious relationship ruptures, parental neglect and other negative childhood experiences.In a sample of Norwegian patients who were undergoing examination for morbid obesity there were many who reported distressing life histories. Lack of existential security in childhood, often linked to complex traumas, was prominent. In light of international research on the association between trauma and obesity, our results indicate that the patient's life history should be included in an assessment of patients with morbid obesity.

The contract GP scheme in Norway has been a success, but the scheme's sustainability has been weakened. In summer 2017, the so-called Trønder rebellion arose among GPs who wished to analyse the situation. In order to obtain a better understanding of their total daily workload, all GPs in Norway were invited to record all their activity on a typical day in their practices. This included 22 pre-defined, currently relevant issues that form the basis of this article.In 2018, all of Norway's 4 784 registered GPs received a web-based questionnaire survey. Altogether 1 032 doctors responded to the survey. The dataset elucidates more than 20 000 consultations throughout the country and more than 44 000 issues.On average, the GPs carried out 20 consultations addressing 43 different issues on a typical day in their practices. There were small differences between men and women doctors. Multimorbidity was a factor in 29 % of the consultations, mental disorders in 22 % and stress and life strains in 18 %. The GPs felt that they had a key role in providing support or life coaching in 15 % of the consultations.The study documents that complex and demanding issues are a frequent occurrence. The GPs play a key role in the treatment of multimorbid patients, prevention of disease and detection and follow-up of cancer. The study underscores the importance of broad-based knowledge and fundamental continuity in the doctor-patient relationship.

Background The association between highly stressful life experiences and morbid obesity is well documented internationally, but this knowledge is not incorporated to any great extent in Norwegian clinical practices. We have studied the reports of previous life stresses from a sample of Norwegian patients under assessment for morbid obesity at a centre where the topic of life experiences was included during the recording of patient histories. Material and method In the summer of 2018, an invitation to participate in the study was distributed to the last 200 patients to have been examined at the Regional Centre for Morbid Obesity in Bodo. Information on lifetime adversity was collected in clinical interviews. Data were retrieved from the patient's discharge summaries, and these texts were analysed using a qualitative approach. Stressful life experiences were divided into twelve categories. Results The study recruited 70 participants (57 women) with morbid obesity. Of these, 64 (91 %) related at least one significant and stressful life experience, and 39 (56 %) reported three or more different types. The most frequent types included serious relationship ruptures, parental neglect and other negative childhood experiences. Interpretation In a sample of Norwegian patients who were undergoing examination for morbid obesity there were many who reported distressing life histories. Lack of existential security in childhood, often linked to complex traumas, was prominent. In light of international research on the association between trauma and obesity, our results indicate that the patient's life history should be included in an assessment of patients with morbid obesity.

Background The contract GP scheme in Norway has been a success, but the scheme's sustainability has been weakened. In summer 2017, the so-called Tronder rebellion arose among GPs who wished to analyse the situation. In order to obtain a better understanding of their total daily workload, all GPs in Norway were invited to record all their activity on a typical day in their practices. This included 22 pre-defined, currently relevant issues that form the basis of this article. Material and method In 2018, all of Norway's 4 784 registered GPs received a web-based questionnaire survey. Altogether 1 032 doctors responded to the survey. The dataset elucidates more than 20 000 consultations throughout the country and more than 44 000 issues. Results On average, the GPs carried out 20 consultations addressing 43 different issues on a typical day in their practices. There were small differences between men and women doctors. Multimorbidity was a factor in 29 % of the consultations, mental disorders in 22 % and stress and life strains in 18 %. The GPs felt that they had a key role in providing support or life coaching in 15 % of the consultations. Interpretation The study documents that complex and demanding issues are a frequent occurrence. The GPs play a key role in the treatment of multimorbid patients, prevention of disease and detection and follow-up of cancer. The study underscores the importance of broad-based knowledge and fundamental continuity in the doctor-patient relationship.

Publisher's version (útgefin grein), Background and aim Use of ultrasound scans early in pregnancy is increasing, but we have limited knowledge about the actual prevalence, associated decision-making and impact on expectant women/couples in a general population. The aim of this study was to document the use of, and experiences related to, foetal scanning before the recommended 19th week scan among pregnant women in Iceland. Population and methods The data come from the Icelandic Childbirth and Health Cohort Study 2009–11. A total of 1111 women attending prenatal care at primary care health centres answered questionnaires before mid-pregnancy and after birth, including questions about the number of scanning procedures during pregnancy. These might include consumer-initiated ‘pregnancy confirmation scans,’ scans for clinical reasons, and screening for foetal anomalies in week 11–14 which is optional in Iceland. The questionnaires also addressed parental decision-making associated with the 11–14 week screening, perception of the pre-screening information, reasons for attending or declining, and whether/how early foetal screening affected the women’s concerns related to the unborn child. Results A total of 95% of the women reported some kind of foetal ultrasound scanning before the 19th week scan, and 64% reported two or more scans in this period. 78% of the women chose to participate in screening for foetal anomalies in week 11–14. Decision-making in relation to this screening was mainly informed by sources outside the healthcare system, and many women characterized participation as ‘self-evident’. Most women felt they got sufficient information about the scope of screening, whilst information regarding potential downsides and risks was frequently perceived as insufficient. Most women who chose the 11–14 week screening reported a reassuring or neutral effect, whilst 10% of the women reported that it increased their concerns related to their unborn child. Conclusions Ultrasound scans in the first half of pregnancy are in high use in Iceland and have apparently become part of a broader pregnancy culture, encompassing both high- and low-risk pregnancies. Whether this is a favourable development or to some extent represents unwarranted medicalization, can be debated. More balanced information might be provided prior to early screening for foetal anomalies., The study received financial support from the Research Fund of the Icelandic College of Family Physicians, The Primary Health Care of the Capital Area, Iceland, the Icelandic Midwifery Association Research Fund and the Landspitali (Icelandic National Hospital) University Hospital Research Fund. The funding bodies played no role in the design, data collection, analysis, data interpretation and writing of the manuscript.

Systems medicine, which is based on computational modelling of biological systems, is emerging as an increasingly prominent part of the personalized medicine movement. It is often promoted as ‘P4 medicine’ (predictive, preventive, personalized, and participatory). In this article, we test promises made by some of its proponents that systems medicine will be able to develop a scientific, quantitative metric for wellness that will eliminate the purported vagueness, ambiguity, and incompleteness—that is, normativity—of previous health definitions. We do so by examining the most concrete and relevant evidence for such a metric available: a patent that describes a systems medicine method for assessing health and disease. We find that although systems medicine is promoted as heralding an era of transformative scientific objectivity, its definition of health seems at present still normatively based. As such, we argue that it will be open to influence from various stakeholders and that its purported objectivity may conceal important scientific, philosophical, and political issues. We also argue that this is an example of a general trend within biomedicine to create overly hopeful visions and expectations for the future.

Background Rather than considering the state of medicine as a result of impersonal ‘scientific progress’, we must see ourselves as members of a reflective, responsible community in charge of continuously developing and re-thinking the field. And to counteract too much medicine, medical professionals need a fine blend of factual knowledge, critical reasoning skills, human sensitivity and courage. A daunting challenge for future doctors will be to navigate an ocean of possibilities in terms of monitoring, testing, diagnoses and interventions. We believe competent adherence to a ‘less is more’ strategy can safeguard genuine medical needs and protect patients from excessive burdens of treatment, in a socially accountable manner (overall cost containment). However, this will not materialise simply from epidemiological analysis of harm accruing from medical overactivity. Good doctoring springs out of a complex maturation process which involves the breakdown of medical silo-thinking in favour of a generalist perspective where doctors interact with patients as whole persons in a wider context, zoom in on medical essentials, and deal compassionately and wisely with the fundamental uncertainties of human existence. How can good, temperate doctoring be promoted? One answer might lie in stimulating, collective encounters with selected ‘core writings’ from the generalist medical literature. By core writings, we mean texts authored by professional role models who, from specific and recognizable perspectives, have identified viable principles of moderation and courage in solidarity with medicine’s moral mandate. Aim To explore the idea that well-tutored encounters with core generalist writings can help curb medical overactivity in an era of unprecedented belief in the powers of technology and overwhelming availability of medical (dis)information. Outcomes Raised awareness and moral purpose among participants to resist overuse in their different capacities as practitioners, policymakers, researchers, educators, etc. Format Brief plenary presentations focusing on how we currently use core generalist texts in Scandinavian general practice (family medicine) to nurture wisdom, moderation and courage. We will include examples from our own library that demonstrate what we believe characterises a core text and why we think it can have a significant, pedagogical impact. The main part of the workshop then involves discussions where participants share reflections, constructive critique and new ideas. Examples of core generalist texts to curb medical overactivity include the writings of McCormick, Marmot, Tudor Hart, Greenhalgh, Gotzsche, Malterud, Welch, Kirkengen and Gawande. However, our menu is still in the making, and new ideas are welcome. Please join in!

Escalating costs, increasing multi-morbidity, medically unexplained health problems, complex risk, poly-pharmacy and antibiotic resistance can be regarded as artefacts of the traditional knowledge production in Western medicine, arising from its particular worldview. Our paper presents a historically grounded critical analysis of this view. The materialistic shift of Enlightenment philosophy, separating subjectivity from bodily matter, became normative for modern medicine and yielded astonishing results. The traditional dichotomies of mind/body and subjective/objective are, however, incompatible with modern biological theory. Medical knowledge ignores central tenets of human existence, notably the physiological impact of subjective experience, relationships, history and sociocultural contexts. Biomedicine will not succeed in resolving today's poorly understood health problems by doing 'more of the same'. We must acknowledge that health, sickness and bodily functioning are interwoven with human meaning-production, fundamentally personal and biographical. This implies that the biomedical framework, although having engendered 'success stories' like the era of antibiotics, needs to be radically revised.

Aims To estimate the potential gain of national screening programmes for colorectal cancer (CRC) by stool occult blood testing in the Nordic countries, with comparative reference to the burden of other causes of premature death. Methods Implementation of national screening programmes for CRC was modelled among people 55–74 years in accordance with the 2011 Cochrane review of biannual screening, using the faecal occult blood test (FOBT) for 10 years, resulting in 15% relative risk reduction in CRC deaths among all those invited [intention-to-treat; relative risk 0.85; confidence interval (CI) 0.78 to 0.92]. Our calculations are based on the World Health Organization and national databanks on death causes (ICD-10) and the mid-year number of inhabitants in the target group. For Finland, Denmark, Norway and Sweden, we used data for 2009. For Iceland, due to the population's small size, we calculated mean mortality for the period 2005–2009. Results Invitation to a CRC screening programme for 10 years could influence 0.5–0.9% (95%CI 0.4–1.2) of all deaths in the age group 65–74 years. Among the remaining 99% of premature deaths, around 50% were caused by lung cancer, other lung diseases, cardiovascular diseases and accidents, with some national variations. Conclusions and implications Establishment of a screening programme for CRC for people aged 55–74 can be expected to affect only a minor proportion of all premature deaths in the Nordic setting. From a public health perspective, prioritizing preventive strategies targeting more prevalent causes of premature death may be a superior approach.

Objectives: Multimorbidity is prevalent, and knowledge regarding its aetiology is limited. The general pathogenic impact of adverse life experiences, comprising a wide-ranging typology, is well documented and coherent with the concept allostatic overload (the long-term impact of stress on human physiology) and the notion embodiment (the conversion of sociocultural and environmental influences into physiological characteristics). Less is known about the medical relevance of subtle distress or unease. The study aim was to prospectively explore the associations between existential unease (coined as a meta-term for the included items) and multimorbidity. Setting: Our data are derived from an unselected Norwegian population, the Nord-Trøndelag Health Study, phases 2 (1995–1997) and 3 (2006–2008), with a mean of 11 years follow-up. Participants: The analysis includes 20 365 individuals aged 20–59 years who participated in both phases and was classified without multimorbidity (with 0–1 disease) at baseline. Methods: From HUNT2, we selected 11 items indicating ‘unease’ in the realms of self-esteem, well-being, sense of coherence and social relationships. Poisson regressions were used to generate relative risk (RR) of developing multimorbidity, according to the respondents' ease/unease profile. Results: A total of 6277 (30.8%) participants developed multimorbidity. They were older, more likely to be women, smokers and with lower education. 10 of the 11 ‘unease’ items were significantly related to the development of multimorbidity. The items ‘poor self-rated health’ and ‘feeling dissatisfied with life’ exhibited the highest RR, 1.55 and 1.44, respectively (95% CI 1.44 to 1.66 and 1.21 to 1.71). The prevalence of multimorbidity increased with the number of ‘unease’ factors, from 26.7% for no factor to 49.2% for 6 or more. Conclusions: In this prospective study, ‘existential unease’ was associated with the development of multimorbidity in a dose–response manner. The finding indicates that existential unease increases people's vulnerability to disease, concordant with current literature regarding increased allostatic load. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

The emerging concept of systems medicine (or ‘P4 medicine’—predictive, preventive, personalized and participatory) is at the vanguard of the post-genomic movement towards ‘precision medicine’. It is the medical application of systems biology, the biological study of wholes. Of particular interest, P4 systems medicine is currently promised as a revolutionary new biomedical approach that is holistic rather than reductionist. This article analyzes its concept of holism, both with regard to methods and conceptualization of health and disease. Rather than representing a medical holism associated with basic humanistic ideas, we find a technoscientific holism resulting from altered technological and theoretical circumstances in biology. We argue that this holism, which is aimed at disease prevention and health optimization, points towards an expanded form of medicalization, which we call ‘holistic medicalization’: Each person’s whole life process is defined in biomedical, technoscientific terms as quantifiable and controllable and underlain a regime of medical control that is holistic in that it is all-encompassing. It is directed at all levels of functioning, from the molecular to the social, continual throughout life and aimed at managing the whole continuum from cure of disease to optimization of health. We argue that this medicalization is a very concrete materialization of a broader trend in medicine and society, which we call ‘the medicalization of health and life itself’. We explicate this holistic medicalization, discuss potential harms and conclude by calling for preventive measures aimed at avoiding eventual harmful effects of overmedicalization in systems medicine (quaternary prevention). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

n an opening paper Cyrille Delpierre, Cristina Barbosa-Solis, Jerome Torrisani, Muriel Darnaudery, Melanie Bartley, David Blane and Michelle Kelly-Irving explore the concept of Allostatic Load as a way of examining health inequalities. The impact of the environment on our biological systems is summarised by the concept of embodiment. The biological embedding of social conditions could therefore be a relevant mechanism to partly explain the social gradient in health. A key issue is how to measure the ‘physiological reality’, the biological expression of embodiment at individual and population levels. Allostatic load (AL) has been proposed as a measure of the overall cost of adapting to the environment, and may be a relevant tool or concept for measuring the way we have embodied our environment. The points they raise are then debated in commentaries by Linn Getz and Margret Olafia Tomasdottir, Tony Robertson and Per Gustafson. These commentaries are followed by a response from the authors of the opening paper. UCR::Vicerrectoría de Docencia::Salud::Facultad de Odontología

Objective: To study the self-reported prevalence of experienced violence among a cohort of women about two years after giving birth, their health during pregnancy, pregnancy outcomes and their experience of their child’s health. Setting and subjects: In 2011, a total of 657 women participated in phase III of the Childbirth and Health Cohort Study in Icelandic Primary Health Care, 18 to 24 months after delivery. The women had previously participated in phase I around pregnancy week 16 and phase II 5–6 months after delivery. Data were collected by postal questionnaires. Main outcome measures: Women’s reported history of experienced violence, sociodemographic and obstetric background, self-perceived health, the use of medications and their child’s perceived health. Results: In phase III, 16% of women reported experiencing violence. These women felt less support from their current partner (p

Rationale, aims and objectives Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline. Methods We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20‐74, who participated in the Nord-Trondelag Health Study (HUNT 2, 1995‐1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total). Results Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89‐0.99 per 1.0 mmol L -1 increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88‐1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92‐1.24) was not linear but seemed to follow a ‘U-shaped’ curve, with the highest mortality

Objective To study potential changes in attendance at emergency departments (ED) in Reykjavik immediately following the swift economic meltdown in Iceland in October 2008. Methods Using electronic medical records of the National University Hospital in Reykjavik, a population-based register study was conducted contrasting weekly attendance rates at Reykjavik ED (cardiac and general ED) during 10-week periods in 2006, 2007 and 2008. The weekly number of all ED visits (major track), with discharge diagnoses, per total population at risk were used to estimate RR and 95% CI of ED attendance in weeks 41–46 (after the 2008 economic collapse) with the weekly average number of visits during weeks 37–40 (before the collapse) as reference. Results Compared with the preceding weeks (37–40), the economic collapse in week 41 2008 was associated with a distinct increase in the total number of visits to the cardiac ED (RR 1.26; 95% CI 1.07 to 1.49), particularly among women (RR 1.41; 95% CI 1.17 to 1.69) and marginally among men (RR 1.15; 95% CI 0.96 to 1.37). A similar increase was not observed in week 41 at the general ED in 2008 or in either ED in 2007 or 2006. In week 41 2008, visits with ischaemic heart disease as discharge diagnoses (ICD-10: I20–25) were increased among women (RR 1.79; 95% CI 1.01 to 3.17) but not among men (RR 1.07; 95% CI 0.71 to 1.62). Conclusion The dramatic economic collapse in Iceland in October 2008 was associated with an immediate short-term increase in female attendance at the cardiac ED.

Summary Background. Human beings are reflective, meaning-seeking, relational and purposeful organisms. Although experiences associated with such traits are of paramount importance for the development of health and disease, medical science has so far failed to integrate these phenomena into a coherent theoretical framework. Material and method. We present a theory-driven synthesis of new scientific knowledge from a number of disciplines, including epigenetics, psycho-neuro-endocrino-immunology, stress research and systems biology, based on articles in recognised scientific journals and other academic works. The scientific sources have been deliberately chosen to provide insight into the interaction between existential conditions in the widest sense (biography) and biomolecular processes in the body (biology). Results. The human organism literally incorporates biographical information which includes experienced meaning and relations. Knowledge from epigenetics illustrates the fundamental biological potential for contextual adaptation. Intriguingly, different types of existential stresses can enhance disease susceptibility through disturbances to human physiological adaptation systems, mediated in part through structural influences on the

Background General practice is increasingly expected to deliver population care to indi-vidual patients. The feasibility and ethics of this policy shift have been challenged.Aim Our aim is to suggest how to deliver population care while protecting personal care.Methods We outline and discuss concepts of these types of care, their relation to theprevailing discourse regarding intervention benefits, and arguments for individualizedpopulation care .Results Individualized population care can enable general practice to meet the healthtargets of individual patients in the light of population-based goals. It unifies the conceptsof personal care and whole population care. Personal care focuses on the individual goodin particular consultations. Whole population care focuses on the overall health good of apopulation without reference to the individuality of each population member. These typesof care constitute elements of a continuum that varies in purpose and objects of focus. Thelimitations of a crude dichotomy of personal care and population care are made explicit inaseriesoffiveargumentsthatlendsupporttotheconceptofindividualizedpopulationcare.Conclusions We advocate a constructive but critical attitude towards the idea ofpopulation-based interventions in everyday general practice. Traditional personal care andwhole population care can theoretically be integrated into individualized population care.However, this presupposes clinical–epidemiological expertise and moral awareness inpractising clinicians.Whateverthepotentialmeritsofpublichealthandgeneralpracticeworking closely together, we believe that it is important to scruti-nize the trend in health policy, in countries such as the UK andNew Zealand, for generalpracticetoadoptanexpandedroleinthedelivery of population care [1]. While understanding this belief, alearned member of the Editorial Board of this Journal (Charlton,pers. comm. 27 July 2005) had predicted that the trend towards apopulation health role for general practice ‘is structurally inevi-table with general practice being a part of the public sector’. Now,2 years on, action by governments for whole population care hasindeed proven resilient in general practice.We are concerned that this continuing and uncritical implemen-tation of health policy may undermine the commitment and moralresponsibilityofpersonaldoctoringtoindividualpatientsandtheirpersonal interests [2]. These dangers may even increase if there isa failure to investigate theoretical opportunities for general prac-tice to manage the tension that exists between its responsibilitiesfor both population care and personal care. Therefore, this paperaddresses two central questions: What is the nature of these typesof care? Can individualized population care provide a conduitbetween them in general practice? Our answers emphasize theinteraction of general practitioners and their patients, even thoughNewZealandhealthpolicyhasbroadeneditsfocusbeyondgeneralpractitioners, to primary health care teams.

Rationale, aims and objectives The practicing doctor, and most obviously the primary care clinician who encounters the full complexity of patients, faces several fundamental but intrinsically related theoretical and practical challenges – strongly actualized by so-called medically unexplained symptoms (MUS) and multi-morbidity. Systems medicine, which is the emerging application of systems biology to medicine and a merger of molecular biomedicine, systems theory and mathematical modelling, has recently been proposed as a primary care-centered strategy for medicine that promises to meet these challenges. Significantly, it has been proposed to do so in a way that at first glance may seem compatible with humanistic medicine. More specifically, it is promoted as an integrative, holistic, personalized and patient-centered approach. In this article, we ask whether and to what extent systems medicine can provide a comprehensive conceptual account of and approach to the patient and the root causes of health problems that can be reconciled with the concept of the patient as a person, which is an essential theoretical element in humanistic medicine. Methods We answer this question through a comparative analysis of the theories of primary care doctor Eric Cassell and systems biologist Denis Noble. Results and conclusions We argue that, although systems biological concepts, notably Noble’s theory of biological relativity and downward causation, are highly relevant for understanding human beings and health problems, they are nevertheless insufficient in fully bridging the gap to humanistic medicine. Systems biologists are currently unable to conceptualize living wholes, and seem unable to account for meaning, value and symbolic interaction, which are central concepts in humanistic medicine, as constraints on human health. Accordingly, systems medicine as currently envisioned cannot be said to be integrative, holistic, personalized or patient-centered in a humanistic medical sense. © 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

BACKGROUND Blood pressure monitoring is one of the most common procedures in clinical medicine. Evaluation and treatment of hypertension are costly and have considerable implications for the individuals involved. Mercury manometers have been dominant for a century, but are currently being replaced by other types of equipment. No national guidelines/recommendations exist on types of blood pressure monitors to be used. The aim of this study was to assess the types of blood pressure monitors used in Norwegian general practice, and to what extent routines have been established for control and calibration of the equipment. MATERIAL AND METHODS In 2007, a questionnaire was distributed to 65 university-affiliated primary healthcare centres in Mid-Norway. The questions included what type of blood pressure monitors are in use and whether routines exist for calibration of them. RESULTS 45 healthcare centres with a total of 173 general practitioners (corresponding to 74 % of the doctors) responded. 18 (6 %) of the 320 monitors identified were of the mercury type, the rest were aneroid or oscillometric. Many centres had 24-hour monitors. Two healthcare centres (4 % of the doctors) had established routines for calibration of their blood pressure monitors. INTERPRETATION Routines should be established for quality assurance of blood pressure monitors in Norwegian primary healthcare services.

Offer up your best defense But this is the end This is the end of the innocence (Don Henley, lyrics, The End of the Innocence , 1989) Participation in cancer screening programmes is by many considered a “no-brainer” – take part, ask no questions. Recent evidence, however, indicates that the innocent and optimistic faith underlying medical slogans, such as “better safe than sorry” and “an ounce of prevention is worth a pound of cure”, is not necessarily valid for cancer screening [1]. As so often in medicine, reality proves more complex than expected. Statistics now show that population screening for cancer delivers little in terms of increased survival, whilst causing clinically significant harm to a large number of participants [1]. Some of medicine's basic assumptions regarding cancer development and human biology are thus being challenged – and the result is disillusionment and controversy. Some screening advocates choose to ignore the unpleasant news. But GPs have to keep up with reality [2] and prepare for scenarios like this one: in the doorway, after a consultation, a 50-year-old woman asks, “While I remember … I got a mammography invitation the other day. I feel a bit confused by the information about benefits and harm. I should go, shouldn't I? Or what do you think…?” What should an updated GP actually think about current cancer screening options? A general rule of thumb may be: a decision to attend screening may be just as wise and “ correct ” as a decision not to attend [3,4]. We will qualify this statement with a brief summary of recent evidence. But note – this is about cancer screening programmes in the general population. We are not questioning the pursuit of rapid and effective diagnosis of cancer among patients who present with symptoms in clinical practice [5]. A general benefit of early detection and treatment of cancer has long been taken for granted. However, no cancer screening programme has so far shown a decrease in total cancer mortality, or in total mortality – what has been achieved is only decreased mortality in relation to the specific cancer screened for. Finding a malignant tumour in its early stages should ideally lead to less aggressive treatment: less mutilating surgery, milder chemotherapy, and less radiotherapy. A major problem, however, is that this gain has high costs: many people become cancer patients unnecessarily. This phenomenon is called over-diagnosis. Screening programmes primarily detect non-aggressive, slow-growing cancers that already have a good prognosis [6]. Some cancers regress spontaneously, others will not grow further and will never lead to troublesome symptoms in the person's lifetime. Once such a cancer is subjected to screening, however, it is likely to be captured. Diagnosis of cancer can, in other words, occur too early , as has clearly been demonstrated in relation to neuroblastoma in children [7]. It is well documented that in cervical cancer screening there is a high spontaneous regression rate of dysplasia. More than half of women screened repeatedly for cervical cancer will be “captured” in a phase of dysplasia, and more than 50 will have to undergo conization for every cervical cancer death prevented [8]. In relation to mammography screening, randomized controlled trials show that for every prevented death from breast cancer, 10 women are “unnecessarily” over-diagnosed and treated for cancer [9]. This number may be even more unfavourable in ordinary screening settings [10]. In relation to prostate cancer screening (PSA testing) statistics indicate that 47 men are over-diagnosed with and treated for prostate cancer for every man whose life is extended [11]. And no one is able to distinguish winners (the few whose cancer deaths are prevented by screening) from losers (the many who are diagnosed with and treated for inconsequential cancer). False-positive test results represent another problem with screening. No cancer screening test is perfect; test sensitivity and specificity never reach 100%. Therefore, false-positive results are bound to occur. The affected individuals go through additional examinations that can sometimes be physically harmful and in rare cases even lethal, e.g. in cases with a perforated colon after colonoscopy, complications to a laparotomy on suspicion of ovarian cancer, or a perforated lung [12]. The diagnostic journey is stressful, and adverse psychosocial effects related to false-positive findings are well documented [12–14]. Negative psychosocial consequences may persist for months or even years after the person was declared free from cancer after a false-positive finding [12]. In mammography screening, 200 or more women will receive a false-positive result for every death from breast cancer prevented [9]. In colorectal cancer screening with faecal occult blood testing, approximately 125 persons will get a false-positive test for each death from colorectal cancer prevented [15]. Aggressive cancers with a worse prognosis are more likely to appear between two screening rounds: these are the so-called “interval cancers”. People diagnosed with cancer less than a year after an uneventful screening may lose confidence in the healthcare system [16]. False-negative routine screening results may cause diagnostic delay as both patient and GP may rely too much on a recent normal finding. Yet another harmful consequence of screening affects the many patients whose prognosis is not changed despite the fact that their cancer is detected early by screening. For these patients, earlier diagnosis does not mean a longer life. It simply means more time with a cancer diagnosis. The above-mentioned “downsides” of screening cannot be withheld from the public, although the facts are disturbing and bound to cause unease. Balanced and quantifiable information regarding the benefits and harm of screening (physical and psychosocial) must be made readily accessible to everyone. What effect this might have on the healthcare systems is hard to foresee. A rational strategy might have been to put current population cancer screening programmes on hold until better methods eventually become available. But this is unlikely to happen, as both politicians and professionals want to do everything possible to combat cancer. What is more likely to happen – and this process has already begun – is a transfer of the responsibility for decision-making: Potential participants will be expected to make their own, informed choices in relation to screening. But it is very hard to know when the statistical benefits of screening are likely to outweigh the potential for harm. The conclusion will in most instances depend on value judgements and personal experiences. But one thing is certain: if you present the general population with personal medical choices that involve life, death, and statistics, it will increase the pressure on primary healthcare. The idea that people should be allowed to take responsibility and make personal health choices has a strong appeal in contemporary society. In relation to cancer screening, we actually envisage that “respect for autonomy” can be used as a finalizing, rhetorical argument for screening, strongly upheld by faith and “the power of goodness” (fuelled by professional and commercial stakeholders, politicians, patients’ organizations etc.) and to a lesser extent by solid, scientific evidence. Let us therefore think twice before primary healthcare workers take on the role of personal screening counsellors. Every minute spent on counselling “the worried well” must necessarily divert resources from other tasks and activities. This will either increase healthcare costs, or reduce the resources spent on those who need healthcare the most.

This is a brief summary and a personal reflection on Anne Luise Kirkengen's PhD thesis "Embodiment of sexual boundary violations in childhood". It is written to encourage other clinicians to familiarise themselves with this original and important study. It has high relevance for every clinician who is ever confronted with patients that present medical histories that are "diffuse" or unexplainable according to traditional medical knowledge.

(2005). Individually based preventive medical recommendations – are they sustainable and responsible? A call for ethical reflection. Scandinavian Journal of Primary Health Care: Vol. 23, No. 2, pp. 65-67.

Published article Background and Aims: Life experience and existential circumstances have an impact on health. Within medicine, however, the significance to patient care of person-related, biographical knowledge receives only rudimentary emphasis and its substantial theoretical underpinnings are inadequately understood and infrequently applied. This study explores the types and extent of some Norwegian general practitioners’ (GPs’) person-related knowledge, exemplified by patients on the GPs respective lists who are currently in a state of frail health. Methods: Nine GPs were interviewed regarding 1 of their patients who had recently been admitted to the rehabilitation unit of a nursing home. Subsequent interviews with the individual patients served both to validate the GPs’ information and as a starting point for further inquiry into patient life stories. Interview transcripts were analyzed within a phenomenological-hermeneutical framework. Results: Most GPs were able adequately to characterize the personality of their patients and had acquired substantial knowledge about their occupation and closest family relationships. The GPs tended to have less knowledge regarding patients’ interests, hobbies, social network and their relationships to their parents and siblings. They had the least knowledge about patients’ childhood, upbringing and social background. Some GPs reacted with surprise or embarrassment when becoming aware of potentially significant “knowledge holes” regarding patients whom they had known for years. Conclusions and implications: We document limitations to healthcare professionals’ eliciting of knowledge about their patients as persons. A long-term doctor-patient relationship seems to enable GPs to identify and articulate their patients’ personal characteristics. It does not ensure that the GPs will accumulate knowledge regarding those biographical facts or experiences that, particularly during transitions to other caretakers, might prove most salient to their patients’ health and treatment. We believe the findings to have relevance both for clinical practice and medical education, but further research and reflection is needed before formal changes in current practice are to be recommended.

We endorse Timms and Bird’s preference for lifestyle adjustments as the first issues to discuss over “active treatment.”1 2 However, GPs often don’t have enough time, making it attractive to resort to medicalisation. Few patients succeed in lowering blood pressure or blood lipids below recommended values through lifestyle changes, at least in the longer term. We’re glad that Dr Timms has not experienced stigmatisation …

Providing information to enable informed choices about healthcare sounds immediately appealing to most of us. But Minna Johansson and colleagues argue that preventive medicine and expanding disease definitions have changed the ethical premises of informed choice and our good intentions may inadvertently advance overmedicalisation

The human being is a self-reflecting, relationship-oriented, goal-directed organism in search of meaning. The process of coordinating and developing knowledge about how experience associated with self-conscience, relationships and values can contribute to development of health and disease is a great challenge for the medical profession.We present a theory-guided synthesis of new scientific knowledge from fields such as epigenetics, psycho-neuro-endocrino-immunology, stress research and systems biology. The sources are articles in acknowledged journals and books, chosen to provide insight into associations between life history (biography) and the human body (biology) in a wide sense.Research shows that information about biography, i.e. experienced meaning and relationships, is literally incorporated into the human organism. Epigenetics illustrates the fundamental biological potential for context-dependent adaptation. Further, studies have shown that different types of existential strain may disturb systems for human physiological adaptation, affect structures in the brain and subsequently render the organism vulnerable for disease. However, a sense of belonging and a perception of being supported and acknowledged can contribute to strengthening or restoring health.The traditional approach to increasing biomedical knowledge has prevented insight into the medical significance of experience. The new knowledge necessitates a reorientation of theory and practice within the medical profession both with respect to individuals and society.

Blood pressure monitoring is one of the most common procedures in clinical medicine. Evaluation and treatment of hypertension are costly and have considerable implications for the individuals involved. Mercury manometers have been dominant for a century, but are currently being replaced by other types of equipment. No national guidelines/recommendations exist on types of blood pressure monitors to be used. The aim of this study was to assess the types of blood pressure monitors used in Norwegian general practice, and to what extent routines have been established for control and calibration of the equipment.In 2007, a questionnaire was distributed to 65 university-affiliated primary healthcare centres in Mid-Norway. The questions included what type of blood pressure monitors are in use and whether routines exist for calibration of them.45 healthcare centres with a total of 173 general practitioners (corresponding to 74 % of the doctors) responded. 18 (6 %) of the 320 monitors identified were of the mercury type, the rest were aneroid or oscillometric. Many centres had 24-hour monitors. Two healthcare centres (4 % of the doctors) had established routines for calibration of their blood pressure monitors.Routines should be established for quality assurance of blood pressure monitors in Norwegian primary healthcare services.

Rationale, aims and objectives Clinicians are generally advised to consider several risk factors when evaluating patients' cardiovascular disease (CVD) risk. Our aim was to study whether combined assessment of five traditional risk factors might help doctors demarcate a relatively distinct and manageable group of high-risk individuals. We selected five modifiable risk factors and estimated the proportion of a well-defined population with ‘unfavourable’ levels of at least two of them, as defined by four internationally renowned guidelines. The impact of including so-called ‘prehypertension’ among the risk factors was specifically addressed, and the results are discussed in a wider perspective. Material and methods Guideline implementation was modelled on data from a cross-sectional Norwegian population study comprising 62 104 adults aged 20–79 years (The Nord-Trondelag Health Study 1995–7). Total, age- and gender-specific point prevalences of individuals with zero, one, two, three or more factors, in addition to established disease, were calculated. Results One single CVD risk factor was exhibited by 12.4% of the population; two factors by 21.5%; and three or more by 49.7%. Established CVD or diabetes mellitus was reported by 12.5%. In total, 83.7% of the population exhibited a risk or disease profile with at least two factors, if prehypertension was included. Conclusions If guideline recommendations are literally applied, as many as 84% of adults in Norway could exhibit two or more CVD or risk factors and thus be considered in need of individual, clinical attention. This challenges the widely held presumption that ‘the net will close’ around a manageable group of individuals-at-risk if several risk factors are jointly considered. As the finding of this study arises in one of the world's most long- and healthy-living populations, it raises several practical as well as ethical questions.

Background: Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population. Methods: Implementation of the current European Guidelines for the Management of Arterial Hypertension was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling. Results: Among individuals with blood pressure ≥120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults. Conclusion: The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered. © 2009 Petursson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cardiovascular diseases constitute the leading cause of sickness and death in Western countries. They are therefore embraced with much attention in medical research, treatment and preventive programmes for which quantifiable biological risk factors comprise the common conceptual basis. We want to demonstrate that the current narrow biological focus may prohibit a deeper understanding of the sickness expressions. THEORY, MATERIAL AND METHOD: The present paper is grounded in a theory of human beings as self-reflecting and capable of creating and conveying meaning affected by culture, time and relationships with others. From such a perspective, the human body is seen as a lived body, a centre for expression of experience. Two cases are interpreted in light of more recent epidemiological evidence of associations between traumatic experiences and cardiovascular disease.Research shows that traumatic experiences in general and early trauma in particular are potent pathogens. Different types of trauma are, however, not consistently related to specific diseases, but rather to complex patterns of so called co-morbidity. These patterns blur the mind-body-distinction and thereby the classification systems for somatic and mental diseases. When such patterns are interpreted as expressions of embodied life, insight is provided into how traumatic experience informs the lived body.Correlations between traumatic experience and cardiovascular disease challenge the dominating biological framework of cardiovascular epidemiology. An analysis of the evidence by means of two cases opens up new perspectives. Knowledge about the path from particular and painful experience to particular and painful disease is an inevitable premise for an adequate treatment of the individual. It is also a prerequisite for development of adequate preventive measures.