Healthy patients and ‘non–disease’

What has changed in my surgery in Denmark in the last ten years? The first thought: nothing! Changes take place so slowly it is not possible to notice them from day to day. It is not much different from looking at your face in the mirror every morning: it looks the same as it did yesterday. But a glance at a photograph taken ten years ago will bring you back to reality! Looking back in this way I must admit something has happened, also in my surgery. We have new drugs and more advanced technology and we are taught about evidence-based medicine and how to use guidelines. But even in the most central part of my work, in the contact between me and the patient, I have noticed changes.

But why have things changed in relation to the patient? Could it be just because I am ten years older and have more experience? I certainly do not talk about the same things as when I started as a GP in 1990. The technical, biomedical questions still take up a central part of the consultations, but it takes less time, and there has been a shift towards questions about life in general, about fears and joys in the patient's life and family. Increasingly I try to be more patient-centred. Some would argue that this is a feminine virtue, with female GPs working more with soft issues, bringing up questions about life in general. But I doubt it: many male colleagues tell about the same change in their professional attitude as they grow older and more experienced. Patients also changed. They have become more demanding – but seldom in an annoying way. The Internet provides them with lots of facts, and better-informed patients are better able to cope. I still feel they trust me, even if I do not always agree with the ‘Internet information’. But some patients are a problem, especially those who are not used to reading and are unable to pick out the relevant information, because clearing up misunderstandings is time-consuming. Ten years ago ‘yes’ or a ‘no’ would have been enough.

Patients are becoming healthier but spend more time worrying about future health risks and oncoming diseases. The waiting room is increasingly filled with people in good health instead of patients with acute or chronic diseases. We are living in a modern society’, and are experiencing mass focus on risk factors that may be susceptible to modification. Now I see people ‘suffering’ from risk factors – low bone density, high cholesterol or marginally elevated blood pressure and people asking for regular ‘servicing’ as if they were cars. Pregnancy has become more risky than ever, with pregnant women being examined for several conditions.

The introduction of drugs to treat minor symptoms (also called ‘non-disease’) or experiences earlier seen as ‘normal’ parts of life, also influences my daily work. Modern patients try to manage their own life, believing that their choices are their own and that they are responsible for achieving success and happiness. On this narrow and lonely road there is no room for illness, for pain, or suffering. Minor symptoms may lead to the involvement of the GP, and when the problem is looked at with a medical eye, the prescription is not far away. The rapid increase in the use of SSRI, not only for serious depression, is a clear example. The treatment of the sick will not be my concern in the future. We will, of course, always be there for our patients with our best possible skill and empathy, and they will always need us. But my concern is with the healthy. How do we treat ‘healthy patients’ and ‘non-disease’ in the best way – and without using up all our personal and economical resources on the subject? There are several dilemmas which, unfortunately, cannot be solved by drawing up new guidelines. Instead, I think it is necessary that we, as GPs, speak up in the debate, and draw attention to the side-effects of medicalization that makes healthy people feel ill and on the process of ‘disease- mongering’ as it invents new patients, new diseases and new target groups for medicine. Our goal must be to empower our patients, including the healthy ones, to be able to manage and take control of their daily lives.