Feature Article: Are Danes too pampered?
The health authorities recommend both visiting the doctor in time and not “abusing the system”. This kind of unclear advice contributes to placing responsibility for the use of healthcare services squarely on the population's shoulders.
By Rikke Sand Andersen, Flemming Bro, Peter Vedsted and Svend Brinkmann
A standing joke among doctors is that a healthy individual is simply a person who has not been examined well enough yet.
The joke plays on the fact that the range of possible symptoms or signs of illness is ever increasing in step with advances in detecting diseases earlier and earlier with the use of advanced technology.
But this also illustrates the dilemma which arises in line with the growing range of symptoms: that it is becoming increasingly difficult for people themselves to distinguish between what is "normal bodily noise" and what might be a sign that we should go to the doctor.
On the part of politicians and healthcare professionals there is plenty attention focused on the population's demand for healthcare services and regulation of the ever-increasing pressure on the healthcare system and its resources. The Danish Liberal Party's (Venstre) proposal to introduce user fees in general practice is the latest example.
And the pressure is real. In 2013, each Dane on average contacted their own general practitioner (GP) eight times, either by email or telephone or consultation, and our contact with our own GP has overall increased by around 20 per cent in the past two decades.
In the public debate this increase is often explained as people becoming more and more pampered and going to the doctor with trivial complaints, and it is proposed that we should make sure that only "really ill" people visit the doctor.
However, the question is whether it is possible to regulate the consumption of healthcare services and whether it is possible to inform and control Danes, so they come to make more sensible use of their own GP.
In this feature article we will argue that the reason we go to the doctor more is rather that the medical field has expanded. Because society today organises, thinks and practices disease detection in a manner that makes it difficult – if not impossible – to establish criteria for when you should, on a reasonable and informed basis, seek help from a doctor.
This means that the responsibility for an increase in the use of general practice can only be laid on the shoulders of Denmark's citizens.
It is about how we as a society put the question of responsibility for consumption of healthcare services into words. In a still more health-focused society, it is crucial that we try to answer these questions.
Why do we visit the GP more often?
Our health service does not only focus on treating us when we become ill. There is also a high degree of focus on preventing serious diseases from breaking out and discovering serious diseases at still earlier stages.
The general increased focus in many western healthcare systems on early detection of chronic and serious diseases such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease (COPD) and cancer is taking place with a view to increasing life expectancy and reducing the effects of time-critical, serious diseases.
The focus on earlier detection of diseases has been made possible by our ability to continuously learn more about how the body functions. But it is also due to the fact that we continually experience an increased access to various forms of technology such as scanning and laboratory tests. In other words, we can look into the body and detect signs of potential diseases at ever-earlier stages before they provide forewarnings in the form of symptoms or discomfort.
My own body – or my perception of my own body – has thus become an "unreliable tell-tale" about disease and illness. I am dependent on my doctor and my doctor's access to various tests if I want to know whether I am walking around with increased cholesterol levels, or whether my blood sugar level forewarns that I am on my way to becoming a diabetic patient.
If we take cancer as an example, access to better examinations now means that e.g. ovarian cancer and colon cancer can be detected earlier than they could previously. This can potentially lead to better cancer survival rates and if we are to profit from the benefits of this, then people also have to visit their doctor with more and more "weak signs" of illness.
A focus on the early detection of disease results, as it were, in a simultaneous gradual increase in the number of symptoms which all of us have to navigate in. And at the same time, the symptoms become less specific and clear, in part because more and more of our normal bodily changes can be viewed as possible signs of illness, and also because these changes are ambiguous.
Early signs of colorectal cancer, which is one of the most widespread cancer diseases, may thus be changes in a person's bowel movements, but can also be abdominal pain, fatigue and weight loss.
Some of the early symptoms of ovarian cancer are often diffuse abdominal pain, inflated stomach and fatigue – all of them symptoms which in the vast majority of cases will not turn out to be a sign of serious illness and which, in many cases, will be due to normal physical changes. But people do not know if this is the case and they therefore need to ask a doctor for advice.
In a recent study of approx. 50,000 Danes and their experience of symptoms, around 50 per cent stated that they had experienced "fatigue" within the last four weeks. Around one in eight of all the participants reported that they had changes in their bowel movements while approx. 15 per cent of female respondents said that they had experienced pain in or around the pelvis.
This does not mean that all these people are walking around with an undetected illness. But it does mean that the human body "makes noise", as it were, and that it can be difficult to separate this noise from signs of illness. This also means that it is not easy to point to the person who is "really ill" and that while it is difficult for the doctor to do this, it is naturally even more difficult for the individual person.
I could rightly consider whether my stomach aches are signs of an undetected illness that I ought to react to because I will have a better chance of being cured. On the other hand, it could just be harmless – as it most often is – and I am just wasting my time and society's resources if I go to the doctor without reason. Then there is the question of how much of a stomach ache I really need to have before considering whether I might be ill?
In other words, it is fair to say that the uncertainty – not as a human trait, but as something that clings to the meaning of "signs of illness" – is a fundamental condition when we today must decide whether what we are experiencing could be a sign of illness.
It is therefore to be expected that we go to the doctor more, because we are concerned, think about elevated cholesterol levels or believe that our stomach aches are due to an as yet undetected illness.
The uncertainty associated with the interpretation of the body's signals is e.g. reflected in the Danish Cancer Society's latest campaign "The seven signs", where we are told that weight loss, a long-term cough or changes to bowel movements may be "alarm symptoms" of cancer which we ought to react to. But in the same breath the campaign also states that "Almost all signs of cancer can just as well be signs of something else" and that "you should in general keep an eye on changes in the body".
It is difficult to know whether the Danish Cancer Society's campaigns really do help when we need to decide whether everyday "bodily noise", fatigue or weight loss are trivial complaints or not.
But one thing is certain: The campaign illustrates the mishmash of contradictory messages that we are invited to consider: Don't go to the doctor too much – hurry to the doctor if you feel something you think may be a sign that you are seriously ill – but don't be so worried and whiney.
Consequences for the population
As becomes clear when looking at the Danish Cancer Society's latest campaign, a focus on the early detection of illness will rather result in a sensitization of the population, so that ever more physical changes, "noise" and minor issues will be viewed as possible signs of illness. And this increased sensitization will (rightly!) definitely increase public concerns and the use of general practice.
It is also clear that we can expect an increased consumption of resources to clarify whether minor issues or people's concerns are signs of actual illness if we continuously lower the bar for when we want to see people go to the doctor.
These are important points at a time where both health professionals and politicians are focusing on the prevention and early detection of disease, as illustrated in the Danish government's health proposal "The sooner, the better" and initiatives within cancer treatment, which some of the authors of this feature article have been involved in.
Voices in the medical field and in the humanities have pointed out that it is not only "healthy" to encourage us humans to carry out monitoring of ourselves so as to detect the early signs of illness; it may also create unnecessary concern and overdiagnosis. But we lack more insight into these issues.
Which types of concerns lead to sensitization? And how do they affect our lives? What are the consequences for our expectations to the healthcare system? Do we risk becoming "test addicts"? Do we – and our GP – lose confidence in our own bodily awareness? And is it only a good thing that we go to the doctor more often so that we can detect more diseases in time?
Then there is another challenge; our research shows that "early detection" primarily benefits the affluent and the well-educated. So how do we ensure that the healthcare system does not in itself help to increase the inequality in health?
As a society we cannot on the one hand support a form of illness detection which creates an increased sensitization of the population, while we on the other hand say that it is too bad that people go to the doctor more and more often. So when we in future talk about the population's increased use of GPs, we ought to think a bit more about what the figures actually express. One thing is certain; the responsibility for the increased health costs in general practice should not only be placed on a population which is not "really" ill.
Consequences for the healthcare system
We must also relate to what an increased sensitization of the population means for the healthcare system and in particular for our GPs, as they are the first people we turn to with our symptoms. Our research shows that it is not possible to both have a population that increasingly goes to the doctor and, at the same time, maintain consultation-free, fast access to medical assessment, as is the case today for our GP.
So how do we ensure that our GPs can handle the increasing number of concerned patients, while at the same time having more tasks to take care of as part of general practice? There are both contradictions and a lack of coherence between what the population is encouraged to do, as it were, and what the health service can offer and the resources available in general practice.
There is no reason to believe that the mechanisms that cause this sensitization will become weaker in the future – on the contrary. Essentially it has to do with processes which cannot be controlled, but which we can only attempt to deal with.
But when it comes to campaigns initiated by health authorities, we should as a minimum demand that the sensitization aspects are well thought out, that the effect on the healthcare system and on the population have been considered, and that plans have been made for handling the "wave of concern" following the campaigns. In most cases it is the GPs and their staff who have to pick up the pieces, and there is a need for this section of the healthcare system to be prepared for the increased pressure from sensitization in the future.
In Denmark we have a publicly financed health service in which everyone has his or her own GP. For society this is an effective way to ensure equal access for all to the healthcare system and its services. For the individual it means that when we experience symptoms that concern us, we meet highly qualified professionals that we have chosen and whose task is to have us and our health as their first priority.
Our own GP is trained as a generalist and we must continue to ensure that he or she is able to embrace biomedical, psychological and social explanations when interpreting symptoms.
However, the system only functions if the population have confidence in the competence of their own GP and the fact that the GP has the patient's health and well-being as their overriding priority and can also easily send the patient for further diagnostic workup when this is required. The healthcare system is also compelled to constantly ensure that these preconditions have been met if a generalist-based gatekeeper system is to function. Otherwise, we risk that it will be ignored.
The system only functions if the population has access to their own GP. This speaking with two tongues from society: Go to the doctor in time and avoid "abusing the system" is untenable and places too unequivocally the responsibility for consumption of healthcare services on the shoulders of the Danish population.
It is probably also the type of thinking we see in the Liberal Party's latest proposal on user fees for general practice. User fees will, of course, not make it easier for the population in general to assess when they "legitimately" need to go to their GP. We should rather expect that affluent and well-educated Danes will expect a higher level of service when they go to the doctor, while others such as the vulnerable and marginalised will stay away.
The way that we currently think of and practice disease detection in our society thus requires a balancing act between sensitization of the population and access to healthcare expertise. This demands political leadership and decision-making – and it also demands that we as a society discuss and decide which health care system we want to have.
Let the discussion begin!
- This feature article was originally published in the Danish newspaper Politiken on 8 April 2015.
By Rikke Sand Andersen, Flemming Bro, Peter Vedsted and Svend Brinkmann
A standing joke among doctors is that a healthy individual is simply a person who has not been examined well enough yet.
The joke plays on the fact that the range of possible symptoms or signs of illness is ever increasing in step with advances in detecting diseases earlier and earlier with the use of advanced technology.
But this also illustrates the dilemma which arises in line with the growing range of symptoms: that it is becoming increasingly difficult for people themselves to distinguish between what is “normal bodily noise” and what might be a sign that we should go to the doctor.
On the part of politicians and healthcare professionals there is plenty attention focused on the population's demand for healthcare services and regulation of the ever-increasing pressure on the healthcare system and its resources. The Danish Liberal Party's (Venstre) proposal to introduce user fees in general practice is the latest example.
And the pressure is real. In 2013, each Dane on average contacted their own general practitioner (GP) eight times, either by email or telephone or consultation, and our contact with our own GP has overall increased by around 20 per cent in the past two decades.
In the public debate this increase is often explained as people becoming more and more pampered and going to the doctor with trivial complaints, and it is proposed that we should make sure that only “really ill” people visit the doctor.
However, the question is whether it is possible to regulate the consumption of healthcare services and whether it is possible to inform and control Danes, so they come to make more sensible use of their own GP.
In this feature article we will argue that the reason we go to the doctor more is rather that the medical field has expanded. Because society today organises, thinks and practices disease detection in a manner that makes it difficult – if not impossible – to establish criteria for when you should, on a reasonable and informed basis, seek help from a doctor.
This means that the responsibility for an increase in the use of general practice can only be laid on the shoulders of Denmark’s citizens.
It is about how we as a society put the question of responsibility for consumption of healthcare services into words. In a still more health-focused society, it is crucial that we try to answer these questions.
Why do we visit the GP more often?
Our health service does not only focus on treating us when we become ill. There is also a high degree of focus on preventing serious diseases from breaking out and discovering serious diseases at still earlier stages.
The general increased focus in many western healthcare systems on early detection of chronic and serious diseases such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease (COPD) and cancer is taking place with a view to increasing life expectancy and reducing the effects of time-critical, serious diseases.
The focus on earlier detection of diseases has been made possible by our ability to continuously learn more about how the body functions. But it is also due to the fact that we continually experience an increased access to various forms of technology such as scanning and laboratory tests. In other words, we can look into the body and detect signs of potential diseases at ever-earlier stages before they provide forewarnings in the form of symptoms or discomfort.
My own body – or my perception of my own body – has thus become an “unreliable tell-tale” about disease and illness. I am dependent on my doctor and my doctor's access to various tests if I want to know whether I am walking around with increased cholesterol levels, or whether my blood sugar level forewarns that I am on my way to becoming a diabetic patient.
If we take cancer as an example, access to better examinations now means that e.g. ovarian cancer and colon cancer can be detected earlier than they could previously. This can potentially lead to better cancer survival rates and if we are to profit from the benefits of this, then people also have to visit their doctor with more and more “weak signs” of illness.
A focus on the early detection of disease results, as it were, in a simultaneous gradual increase in the number of symptoms which all of us have to navigate in. And at the same time, the symptoms become less specific and clear, in part because more and more of our normal bodily changes can be viewed as possible signs of illness, and also because these changes are ambiguous.
Early signs of colorectal cancer, which is one of the most widespread cancer diseases, may thus be changes in a person’s bowel movements, but can also be abdominal pain, fatigue and weight loss.
Some of the early symptoms of ovarian cancer are often diffuse abdominal pain, inflated stomach and fatigue – all of them symptoms which in the vast majority of cases will not turn out to be a sign of serious illness and which, in many cases, will be due to normal physical changes. But people do not know if this is the case and they therefore need to ask a doctor for advice.
In a recent study of approx. 50,000 Danes and their experience of symptoms, around 50 per cent stated that they had experienced “fatigue” within the last four weeks. Around one in eight of all the participants reported that they had changes in their bowel movements while approx. 15 per cent of female respondents said that they had experienced pain in or around the pelvis.
This does not mean that all these people are walking around with an undetected illness. But it does mean that the human body “makes noise”, as it were, and that it can be difficult to separate this noise from signs of illness. This also means that it is not easy to point to the person who is "really ill” and that while it is difficult for the doctor to do this, it is naturally even more difficult for the individual person.
I could rightly consider whether my stomach aches are signs of an undetected illness that I ought to react to because I will have a better chance of being cured. On the other hand, it could just be harmless – as it most often is – and I am just wasting my time and society's resources if I go to the doctor without reason. Then there is the question of how much of a stomach ache I really need to have before considering whether I might be ill?
In other words, it is fair to say that the uncertainty – not as a human trait, but as something that clings to the meaning of “signs of illness” – is a fundamental condition when we today must decide whether what we are experiencing could be a sign of illness.
It is therefore to be expected that we go to the doctor more, because we are concerned, think about elevated cholesterol levels or believe that our stomach aches are due to an as yet undetected illness.
The uncertainty associated with the interpretation of the body's signals is e.g. reflected in the Danish Cancer Society's latest campaign “The seven signs”, where we are told that weight loss, a long-term cough or changes to bowel movements may be “alarm symptoms” of cancer which we ought to react to. But in the same breath the campaign also states that "Almost all signs of cancer can just as well be signs of something else" and that "you should in general keep an eye on changes in the body".
It is difficult to know whether the Danish Cancer Society's campaigns really do help when we need to decide whether everyday “bodily noise”, fatigue or weight loss are trivial complaints or not.
But one thing is certain: The campaign illustrates the mishmash of contradictory messages that we are invited to consider: Don't go to the doctor too much – hurry to the doctor if you feel something you think may be a sign that you are seriously ill – but don’t be so worried and whiney.
Consequences for the population
As becomes clear when looking at the Danish Cancer Society’s latest campaign, a focus on the early detection of illness will rather result in a sensitization of the population, so that ever more physical changes, “noise” and minor issues will be viewed as possible signs of illness. And this increased sensitization will (rightly!) definitely increase public concerns and the use of general practice.
It is also clear that we can expect an increased consumption of resources to clarify whether minor issues or people's concerns are signs of actual illness if we continuously lower the bar for when we want to see people go to the doctor.
These are important points at a time where both health professionals and politicians are focusing on the prevention and early detection of disease, as illustrated in the Danish government's health proposal “The sooner, the better” and initiatives within cancer treatment, which some of the authors of this feature article have been involved in.
Voices in the medical field and in the humanities have pointed out that it is not only “healthy” to encourage us humans to carry out monitoring of ourselves so as to detect the early signs of illness; it may also create unnecessary concern and overdiagnosis. But we lack more insight into these issues.
Which types of concerns lead to sensitization? And how do they affect our lives? What are the consequences for our expectations to the healthcare system? Do we risk becoming “test addicts”? Do we – and our GP – lose confidence in our own bodily awareness? And is it only a good thing that we go to the doctor more often so that we can detect more diseases in time?
Then there is another challenge; our research shows that “early detection” primarily benefits the affluent and the well-educated. So how do we ensure that the healthcare system does not in itself help to increase the inequality in health?
As a society we cannot on the one hand support a form of illness detection which creates an increased sensitization of the population, while we on the other hand say that it is too bad that people go to the doctor more and more often. So when we in future talk about the population's increased use of GPs, we ought to think a bit more about what the figures actually express. One thing is certain; the responsibility for the increased health costs in general practice should not only be placed on a population which is not “really” ill.
Consequences for the healthcare system
We must also relate to what an increased sensitization of the population means for the healthcare system and in particular for our GPs, as they are the first people we turn to with our symptoms. Our research shows that it is not possible to both have a population that increasingly goes to the doctor and, at the same time, maintain consultation-free, fast access to medical assessment, as is the case today for our GP.
So how do we ensure that our GPs can handle the increasing number of concerned patients, while at the same time having more tasks to take care of as part of general practice? There are both contradictions and a lack of coherence between what the population is encouraged to do, as it were, and what the health service can offer and the resources available in general practice.
There is no reason to believe that the mechanisms that cause this sensitization will become weaker in the future – on the contrary. Essentially it has to do with processes which cannot be controlled, but which we can only attempt to deal with.
But when it comes to campaigns initiated by health authorities, we should as a minimum demand that the sensitization aspects are well thought out, that the effect on the healthcare system and on the population have been considered, and that plans have been made for handling the “wave of concern” following the campaigns. In most cases it is the GPs and their staff who have to pick up the pieces, and there is a need for this section of the healthcare system to be prepared for the increased pressure from sensitization in the future.
In Denmark we have a publicly financed health service in which everyone has his or her own GP. For society this is an effective way to ensure equal access for all to the healthcare system and its services. For the individual it means that when we experience symptoms that concern us, we meet highly qualified professionals that we have chosen and whose task is to have us and our health as their first priority.
Our own GP is trained as a generalist and we must continue to ensure that he or she is able to embrace biomedical, psychological and social explanations when interpreting symptoms.
However, the system only functions if the population have confidence in the competence of their own GP and the fact that the GP has the patient's health and well-being as their overriding priority and can also easily send the patient for further diagnostic workup when this is required. The healthcare system is also compelled to constantly ensure that these preconditions have been met if a generalist-based gatekeeper system is to function. Otherwise, we risk that it will be ignored.
The system only functions if the population has access to their own GP. This speaking with two tongues from society: Go to the doctor in time and avoid “abusing the system” is untenable and places too unequivocally the responsibility for consumption of healthcare services on the shoulders of the Danish population.
It is probably also the type of thinking we see in the Liberal Party's latest proposal on user fees for general practice. User fees will, of course, not make it easier for the population in general to assess when they “legitimately” need to go to their GP. We should rather expect that affluent and well-educated Danes will expect a higher level of service when they go to the doctor, while others such as the vulnerable and marginalised will stay away.
The way that we currently think of and practice disease detection in our society thus requires a balancing act between sensitization of the population and access to healthcare expertise. This demands political leadership and decision-making – and it also demands that we as a society discuss and decide which health care system we want to have.
Let the discussion begin!
This feature article was originally published in the Danish newspaper Politiken on 8 April 2015.