Milestones in the development of Nordic general practice*

Abstract

The common history and development of Nordic family medicine is important and interesting. This paper looks back on the aspects and factors influencing academic family medicine in the Nordic countries and especially the central position of the Nordic Congresses and the Scandinavian Journal of Primary Health Care. The importance of pioneers and bringing people together is emphasized. More than 30 years of Nordic academic family medicine has indeed had an incredible impact and has initiated development from only a few people to become world leading.

• Knowing our professional history is key to influencing our future.

• The Nordic Congresses of General Practice and Scand J Prim Prim Health Care represent a gateway to a global treasure, the welfare state.

Excitement, expectation and joy swirled in the air. The first Nordic Congress of General Practice had become a fact. This was in Copenhagen in June 1979 [1,2]. As a young GP trainee in Gothenburg I attended the congress with great interest and curiosity. It was then I met Paul Backer, president of the Congress and professor of general practice in Copenhagen, for the first time. Backer was one among a handful of charismatic pioneers who were developing the young field of general practice in the Nordic region around that time.

The primary focus of this first congress of general practice was clearly the importance of research, and Backer was setting the scene. In his keynote lecture he addressed the ideology and unique position of general practice within the healthcare system in general [3]. He strongly emphasized the importance of establishing a scientific base for the discipline by conducting “research in and on primary health care” [3]. The argument was thrilling and it strengthened my faith in general practice as a discipline worthy of ambitious dedication. The other keynote lecturers, Björn Smedby [4], Christian F. Borchgrevink [5,6], and Mauri Isokoski [7] continued to discuss the importance of research in general practice from different perspectives. In addition, some 60 research projects were presented at the congress. Paul Backer expressed his concerns regarding other specialities’ strict demarcations in biomedical diagnoses, which blocked the view of the whole person, and devalued the importance of people's narratives and life circumstances.

Perhaps inspired by Ivan Illich, Christian Borchgrevink talked about the risks and downside of medicalization. Too many resources spent on healthcare might lead to worse health. Borchgrevink illustrated his concerns with a graph of “how-more-can-become-worse”. Some 20 years later I encountered this graph again, depicted by US doctors in a cutting-edge discussion paper in JAMA [8]. Borchgrevink also presented to us new studies in general practice on the topic of medical screening and concluded that the more screening was subjected to scientific scrutiny, the fewer conditions appeared suitable for screening programmes. The evidence for such a sceptical attitude has continued to grow since then [9,10]. So as I now look back, I realize that many of the key ideas and radical viewpoints regarding scientific evidence and the importance of research in general practice presented in Copenhagen 1979 had an almost visionary character: they are even “hotter” debate topics today, not only for GPs, but also for medicine as a whole [11].

The first Nordic GP congress, however, was not completely Nordic. The few Icelanders attending pointed out to President Backer and his associates that Iceland had in fact not been included in the organization of the event. This was immediately changed, and a truly Nordic Network of General Practice/Family Medicine was thereby established. Consequently, the first GP congress in Copenhagen in 1979 can be seen as a major milestone on the road to a common identity for Nordic general practitioners.

The second Nordic GP congress took place in Bergen in 1981– arranged by all five Nordic countries [2]. The enthusiasm for research in general practice and primary health care in the Nordic countries was still booming. But it had become increasingly clear that many research topics related to primary health care fitted poorly with the traditional demarcation lines of the biomedical sciences. Specialized medical journals tended to submit complex studies of real life to “linear” peer reviewers, who did not value research which involved topics such as “complex reasons for contact” or were based on the idea that “illness” could be a variable as relevant to record as a conventional biomedical diagnosis [12]. This trend, where medical specialists define what is the appropriate way to think scientifically in “their” domain, has in fact continued to this day and has recently been nicknamed “silo” thinking [13].

The idea of a Nordic GP journal in English, accessible to the international scientific community, was conceived in the late 1970s [14]. The success of the 1st and then the 2nd Nordic Congress in General Practice in Bergen in 1981 accelerated these ideas. The same year an Editorial Board was appointed for the upcoming journal led by Paul Backer, with financial aid from the Nordic Council of Medical Research [14].

The name of the journal was a hot topic. The word “Scandinavian” was not fair to all the Nordic countries, but was finally chosen for marketing purposes. The concepts “Primary Care” on one hand and “General Practice” on the other were also hotly debated among the leaders of the associations and editors. It was at last decided that the journal should encompass a wide range of primary healthcare, not only general practice [15]. In 1982 we had the first draft of a contract between the editors and our publisher, Almqvist & Wiksell Periodical Company, which also published Acta Medica Scandinavica and certain other “Scandinavian Journal of ...” series at that time. The layout of our journal was therefore the same as for the other journals in this series. Paul Backer took on the task as the journal's first Editor-in-Chief. The first issue of the Scandinavian Journal of Primary Health Care appeared in 1983. The journal's presented aims [15] reflected the well-defined ideology and research policy that had shaped the 1979 and 1981 congresses.

In many respects, our journal's ideology and publishing policy has remained quite stable throughout its first 30 years (1983–2012). During this time the Editors-in-Chief have been: Paul Backer 1983–1987, Harald Siem 1987–1988, Christian F. Borchgrevink 1989–1995, Calle Bengtsson 1996–2003, Jakob Kragstrup 2003–2011, and Peter Vedsted 2011 to the present day. The choice of editors and editorial committees has been fortunate along the way, resulting in a fine balance between stability and innovation. The impact and contribution of these important resource persons and teams among our GP colleagues has been highlighted earlier in this journal [14–22].

As a member of the editorial team from 1983 to 2010, I would also like to emphasize the contributions of three additional key persons who have contributed much to the journal's safe life until now, keeping their fingers on the pulse of all activities, organizing and participating in all editorial meetings and keeping track of the editorial “family” between 1981 and 2010. They are the editorial secretaries Karin Dolven in Oslo, Lolo Humble in Gothenburg, and Lise Keller Stark in Odense. They made all the voluntary work of the editorial committees run smoothly and professionally. I hereby extend a warm welcome to the newly appointed editorial secretary Dorthe Toftdahl Nielsen in Aarhus, as a member of the journal's team.

From the start, subscription to the Scandinavian Journal of Primary Health Care has been on a professional group basis, linked to membership in the five national professional GP associations. The associations viewed, and still regard, this procedure as the best way of supporting scientific development in our discipline, upon which all practising clinicians ultimately depend. It is no secret that some members have been unhappy with this compulsory subscription. The greatest threat to the existence of the Scandinavian Journal of Primary Health Care, and simultaneously a new challenge, came in 1996 when our Danish colleagues terminated their collective subscription. This event raised the question of who the actual owner of the SJPHC was! Calle Bengtsson, the Editor-in-Chief at that time, and leaders of the Danish College of General Practitioners (DSAM) took the lead in solving this riddle. In 1999 a limited-liability company was founded for the journal, owned jointly by the five Nordic professional associations as formal shareholders in the company [23]. In 2005 followed the next important milestone in the Nordic GP collaboration: the Nordic Federation of General Practice was founded under the firm leadership of Anna Stavdal. The Federation has since then featured as the owner of both the Nordic general practice congresses and the journal [23].

An important step in the Scandinavian Journal of Primary Health Care's recent evolution involves adaptation of the journal to the world of electronic publishing. This work started under the management of Jakob Kragstrup and is still in progress.

A few years ago, we presented the argument that the Nordic Congresses of General Practice can be seen as “a gateway to a global treasure” [2]. I think this vision is even more important today. Together with colleagues in the National Health Service (NHS) in the UK, Nordic general practitioners can be seen as holding a key to high-quality healthcare on the basis of the welfare state's idea of solidarity, accessibility and affordability for all. In an impressive artistic contribution to the opening ceremony of the London 2012 Olympics, the NHS was presented as a jewel in the British cultural crown. The Nordic Congresses and the Scandinavian Journal of Primary Health Care can similarly be seen as precious elements in the Nordic welfare states, with the potential for spreading ideas and inspiration far beyond our national borders. I hope the Scandinavian Journal of Primary Health Care and the Nordic congresses will maintain their high ambitions and continue to represent Nordic healthcare development at its best, based on innovative and critical thinking and sound science.