Addressing the future role of general practice at the 16th Nordic Congress in Copenhagen 2009: How can we ensure sustainable care in a complex world of evidence, context, organization, and personal care?

The purpose of the Nordic Congresses is to strengthen the network and identity among Nordic general practitioners, and to facilitate research, teaching, and qualitative development within the Nordic countries [1], [2]. The vision of the Nordic Congresses appeals to all of us to reflect on the uniqueness of our professional environment and to keep our ambitions high both with regard to the scientific programme and the contributions to the Congress [1]. In the following we, the members of the scientific committee, present how we intend to fulfil that vision at the May 2009 Nordic Congress in Copenhagen.

Under the heading “The future role of general practice” the congress will be organized around five topics: Organisation, Chronic disease, Prevention, Complex health problems, and Children. Furthermore, the conference will include sessions on methodological issues in research, education, and quality improvement. All the above themes reflect present and future central issues in Nordic general practice, identified through ideas and experiences obtained at previous Nordic Congresses, and through discussions with stakeholders in the Nordic countries.

Organization

Today's general practitioners (GPs) play an important and central role in a complex and sub-specialized healthcare system that is continuously changing. At the same time they are leaders, and often employers, in their own clinics. Future general practitioners will face growing demands from both external players who require better quality, larger capacity, and new ways of handling medical work in primary care, and employees who demand modern leadership and possibilities for personal development [3]. This scenario confronts our profession with several organizational challenges: there is a shortage of GPs; they are supposed to be proactive; and, they must coordinate the efforts between the many healthcare professionals involved from municipalities, hospitals, and others. How should GPs manage these tasks? We need to better understand how general practice should fulfil all these demands, organize with respect to incentives, and manage in order to improve and maintain the GPs’ competence in practice management. A strong primary healthcare system and access to GPs enhance the health status at population level [4], [5]. If this is to continue the above organizational challenges must be met.

Chronic disease

In recent years there has been increased focus on improving care of patients suffering from chronic diseases. Chronic and complex patient courses travel across sectors, specialities, and healthcare personnel and the distribution of tasks is often not evident or transparent. It has been indicated that a prerequisite for the successful course of a disease is well-functioning primary care, probably with a patient listing system, but there are many challenges to be met [6], [7]. For instance, it is likely that better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.

Challenges within the field of chronic disease range from the fact that evidence-based recommendations are often not used in clinical practice to the issue of continuing inequality in healthcare. Besides the lack of implementation and the use of guidelines, patients do not often adhere to specific treatment and advice; both of these factors reduce effectiveness of medical care [8]. Another challenging research question is to explore why all parts of the healthcare system still have problems with social inequality in healthcare of chronic disease; even cases of a publicly financed healthcare system intended to provide equal access for all are often less than ideal [9].

Prevention

Primum non nocere – first of all do no harm – as stated in the Hippocratic Oath. This is one of the defining features of best clinical practice when patients ask the general practitioner for help. Listening to the patient's narrative, the GP will draw on his/her medical knowledge, experience, and available treatments to help as much as possible and according to the best available evidence. However, all GPs know that any medical intervention – whether diagnostic technology, treatment, or prevention procedures – has potential side effects. The GP must consider the delicate balance between benefits and harms of any medical intervention before any action is taken [10]. This balance can be harder to maintain when weighing the possibility of side effects today against possible future benefits. Thus, when the GP proactively initiates preventive procedures, she/he is in a very different situation than when faced with relieving harmful existing symptoms [11]. Thus, the GP should have conclusive evidence that prevention can alter the prognosis in a significant proportion of patients [12].

Complex health problems

Medically unexplained symptoms and complex chronic diseases consume an increasing proportion of society's resources and represent a growing challenge in general practice [13]. Most practitioners know patients who suffer from subjective symptoms for which the doctor cannot find any objective findings or causal explanations [14]. Biomedical models of aetiology, pathogenesis, treatment, and prognosis are inadequate for understanding these disease and health problems. Currently, we are in need of a common language and a theoretical framework for the understanding of functional symptoms and disorders across medical specialties – clinically and scientifically [15]. Complex health problems comprise different areas of health problems as well as groups of people and they have to be handled with specific attention and good communication in daily practice [14], [15].

Children: opportunities and challenges

Children are frequent users of primary healthcare services, especially in their early years. Good health in childhood is essential for good health in adulthood, meaning GPs have a unique opportunity to influence lifelong health. Reasons for encounter are different in primary health and in paediatric clinics, but most paediatric conditions are described in paediatric settings. Epidemiology and treatment regimens that mirror primary healthcare settings are needed, along with descriptions of variations in ‘normality’ in children's health, development, and behaviour as these issues are frequent reasons for encounter.

Children are seldom seen in general practice without their parents, and this entails a specific challenge in communication and clinical investigation [16]. The parents’ expectations, fears, and experiences are central themes in the consultation with the child, and often demand specific attention by the general practitioner [17]. How to handle insecure parents, who frequently need reassurance for minor problems, requires further exploration. On the other hand, children with disabilities, cancer, and chronic diseases often disappear from general practice, and the needs and challenges for coordinating shared care in childhood chronic conditions are subjects that need further attention.

Methodological issues in research, education, and quality improvement

The past decades have seen an increase in research activity in general practice. General practice research uses an eclectic range of methodologies, often characterized by interdisciplinary, patient-centred, and community-based teamwork. These characteristics of research into general practice continually raise methodological considerations regarding design and analysis. An example is the increased use of the cluster randomized design, where groups of patients (e.g. within one practice) rather than individual patients, are randomized. How does this influence the type of knowledge obtained [18–22]?

In collecting information about people's knowledge, beliefs, attitudes, and behaviour, questionnaire studies are widely used [23], [24]. Often a qualitative approach is used beforehand to explore the territory and map key areas for further study [24]. However, discussion is needed about questionnaire research methods and the validity of scales and end-points in trials [25]. The use of the qualitative research process as an approach to a better understanding of the meaning and implications of findings also requires room for theoretical and methodological discussions [26], [27].

Finally, research on education and tools for quality improvement in primary care are important issues within primary care, and studies on the use of quality development methods have been widely published [28].

Conclusion

There is much in store for future Nordic general practice and for the participants in the 16th Nordic Congress of General Practice.

We hereby invite you both to contribute to the scientific programme and to participate in the elaborate social events that surround the Congress. In this way we will fulfil the proud vision of the Nordic Congresses, maintain and strengthen the bond of our nations, and have a good time, all at once. We know it may sound like a fairytale … but would you expect anything less in the country of Hans Christian Andersen?

Susanne Reventlow, GP, Research Director, DMedSci Henrik Sångren, GP, PhD student

John Brodersen, GP, Senior Researcher, PhD

Bo Christensen, GP, Professor, PhD

Anette Grauengaard, GP, Senior Researcher, PhD Dorte Jarbøl, MD, Senior Researcher, PhD Marianne Rosendal, GP, Senior Researcher, PhD Jens Søndergaard, GP, Professor, PhD

Members of the scientific committee of the forthcoming congress

Susanne.reventlow@gpract.ku.dk