Trends in absolute and relative educational inequalities in health during times of labour market restructuring in coastal areas : The HUNT Study, Norway

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The new holism: P4 systems medicine and the medicalization of health and life itself

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)

Komplekse problemstillinger – allmennlegens ekspertområde

En allmennlege er en generalist. I litteraturen omtales generalisttilnærmingen gjerne som biopsykososial, personsentert eller holistisk. Uansett navn innebærer det en kombinasjon av generell biomedisinsk kunnskap og individuell kjennskap til den enkelte pasienten eller familien. Relasjoner, livserfaringer og sosiale levekår påvirker helse og sykdom i vesentlig grad gjennom livsløpet. I helsetjenestens første linje står håndtering av sammensatte og uavklarte symptombilder og problemstillinger sentralt. Målet med denne artikkelen er å bidra til økt forståelse og vitenskapelig anerkjennelse av allmennlegens faglige kompetanse ved hjelp av kompleksitetsteori. Kompleksitetsteoriens begrepsapparat favner både molekylære og relasjonelle perspektiv på helse og sykdom og kan understøtte allmennmedisinske arbeidsteknikker og handlingsvalg. Vi håper å gi leger og andre lesere skjerpet interesse for avansert hverdagsmedisin

Komplekse problemstillinger – allmennlegens ekspertområde

En allmennlege er en generalist. I litteraturen omtales generalisttilnærmingen gjerne som biopsykososial, personsentert eller holistisk. Uansett navn innebærer det en kombinasjon av generell biomedisinsk kunnskap og individuell kjennskap til den enkelte pasienten eller familien. Relasjoner, livserfaringer og sosiale levekår påvirker helse og sykdom i vesentlig grad gjennom livsløpet. I helsetjenestens første linje står håndtering av sammensatte og uavklarte symptombilder og problemstillinger sentralt. Målet med denne artikkelen er å bidra til økt forståelse og vitenskapelig anerkjennelse av allmennlegens faglige kompetanse ved hjelp av kompleksitetsteori. Kompleksitetsteoriens begrepsapparat favner både molekylære og relasjonelle perspektiv på helse og sykdom og kan understøtte allmennmedisinske arbeidsteknikker og handlingsvalg. Vi håper å gi leger og andre lesere skjerpet interesse for avansert hverdagsmedisin

Are persons with fibromyalgia or other musculoskeletal pain more likely to report hearing loss? A HUNT study

Background Leading theories about the pathogenesis of fibromyalgia focus on central nervous dysregulation or sensitization, which can cause altered perception. There is growing evidence that fibromyalgia involves altered perception not only of pain, but also other sensory stimuli. On this basis, we investigated whether individuals with fibromyalgia are more likely to report subjective loss of hearing, adjusted for audiometrically measured loss of hearing, compared to persons without any musculoskeletal pain disorders. In addition, we studied persons with other musculoskeletal pain than fibromyalgia and persons who did not have any musculoskeletal pain. Methods The study includes 44 494 persons from the second health survey in Nord-Trøndelag (HUNT2) who had undergone audiometry and answered a comprehensive questionnaire that mapped fibromyalgia, musculoskeletal pain at various sites and subjective hearing loss. Respondents with other musculoskeletal pain problems than fibromyalgia were divided into two groups with respectively localized and widespread musculoskeletal pain. Data were analyzed with logistic regression models adjusting for age, education, anxiety, depression and hearing thresholds. Results In adjusted analysis, individuals with fibromyalgia had increased likelihood to report subjective hearing loss, compared to persons without fibromyalgia or other musculoskeletal pain (OR 4.578, 95% CI 3.622–5.787 and OR 4.523, 95% CI 3.077–6.647 in women and men). Furthermore, people with local and widespread musculoskeletal pain not diagnosed with fibromyalgia, also had increased likelihood to report subjective hearing loss, compared to people with no musculoskeletal pain. This relationship was greater for widespread pain than for localized pain (OR 1.915, 95% CI 1.627–2.255, and 1.796, 95% CI 1.590–2.029, in women and men with local musculoskeletal pain and OR 3.073, 95% CI 2.668-3.539, OR 3.618, 95% CI 3.225–4.058, in women and men with widespread pain, respectively). Conclusions Our findings are consistent with the hypothesis that fibromyalgia is related to a general dysregulation of the central nervous system. The same might also be the case for other local and, in particular, other widespread, musculoskeletal pain

Beyond multimorbidity: What can we learn from complexity science?

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

Komplekse problemstillinger i allmennpraksis-en prevalensstudie

BAKGRUNN Fastlegeordningen i Norge har vært en suksess, men ordningens bærekraft er svekket. Sommeren 2017 oppsto det såkalte Trønderopprøret blant fastleger som ønsket å analysere situasjonen. For å øke kunnskapen om totalbelastningen i arbeidshverdagen ble alle landets fastleger invitert til å registrere all sin aktivitet på en typisk praksisdag. Her inngikk blant annet 22 forhåndsdefinerte, tidsaktuelle problemstillinger som danner grunnlaget for denne artikkelen. MATERIALE OG METODE Alle Norges 4 784 registrerte fastleger mottok i 2018 en web-basert spørreundersøkelse. Undersøkelsen ble besvart av 1 032 leger. Materialet belyser i overkant av 20 000 konsultasjoner fra hele landet og mer enn 44 000 problemstillinger. RESULTATER I gjennomsnitt gjennomførte fastlegene 20 konsultasjoner med 43 ulike problemstillinger på praksisdagen. Det var små forskjeller mellom kvinnelige og mannlige leger. Multimorbiditet forekom i 29 % av konsultasjonene, psykisk lidelse i 22 % og stress og livsbelastninger i 18 %. Fastlegene opplevde å ha en sentral rolle som støttespiller eller livsveileder i 15 % av konsultasjonene. FORTOLKNING Undersøkelsen dokumenterer at komplekse og krevende problemstillinger er hyppige. Fastlegene er sentrale i behandling av multimorbide pasienter, forebygging av sykdom og påvisning og oppfølging av kreft. Studien underbygger viktigheten av breddekunnskap og grunnleggende kontinuitet i lege–pasient-relasjonen

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs

Background: In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs. Aim: To document GPs’ gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway. Design & setting: A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020. Method: Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities. Results: A total of 1234 (25.4%) of Norway’s GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations. Conclusion: During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits

Trends in absolute and relative educational inequalities in health during times of labour market restructuring in coastal areas : The HUNT Study, Norway

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 Trøndelag 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