Allmennmedisin som forskningsbasert fag. Peder A. Halvorsen Fastlege, Byhagen legesenter, Alta Professor, Institutt for samfunnsmedisin

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1 Allmennmedisin som forskningsbasert fag Peder A. Halvorsen Fastlege, Byhagen legesenter, Alta Professor, Institutt for samfunnsmedisin

2 Allmennmedisin som forskningsbasert fag? Allmennmedisin - kunst eller vitenskap?

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4 Sjakk som vitenskap

5 Sjakk: Er det vitenskap?

6 Are you aiming to play the best moves, or are you aiming to win? Many players aim merely to play the best moves, objectively speaking. They never succeed of course, but it doesn t stop them from trying. But chess is not science, it s a game, a struggle between to mortals who makes mistakes, deceive themselves and each other, get tired, allow themselves to be distracted, and altogether have no hope of attaining perfection at the chess board. If you want to become a tiger, you must forget about playing the best moves and concentrate on winning.

7 Are you aiming to make the best decisions? Many doctors aim merely to make the best decisions, objectively speaking. They never succeed of course, but it doesn t stop them from trying. But medicine is not science, it s a practice, a struggle between two mortals who makes mistakes, deceive themselves and each other, get tired, allow themselves to be distracted, and altogether have no hope of attaining perfection in the consultation room. If you want to become a doctor, you must forget about always making the best decisions and concentrate on.?

8 Medicine: A science using practice

9 The Misdescription of Medicine: Science and art When physicians who conduct research return to their clinical duties, they are no longer scientists, but physicians who take care of patients.

10 The Misdescription of Medicine: Science and art The laws that could establish medicine as a science become increasingly useless in a practical sense the more general they become.

11 Clinical judgment: The goal of education and the pride of expert physicians The practice of medicine requires knowledge of human biology, a store of clinical experience, good diagnostic and therapeutic skills familiarity with the vagaries of the human condition.

12 Medicine: A science using practice eksempler?

13 Resultater fra allmennmedisinsk forskning som vi bruker i vår daglige klinikk Antibiotika er ikke bedre enn placebo ved akutt bronkitt Wark P. Acute bronchitis. Clin Evid 2003; 10:

14 Resultater fra allmennmedisinsk forskning som vi bruker i vår daglige klinikk Antibiotika er ikke bedre enn placebo ved akutt bronkitt Antibiotika gir ikke raskere tilfriskning hos de fleste med akutt sinusitt. Dobbel innsykning og purulent nesesekret er tegn på bakteriell sinusitt og noen vil ha nytte av antibiotika. Lindbæk M, Hjortdahl P, Johnsen UL. BMJ. 1996;313(7053):

15 Resultater fra allmennmedisinsk forskning som vi bruker i vår daglige klinikk Antibiotika er ikke bedre enn placebo ved akutt bronkitt Antibiotika gir ikke raskere tilfriskning hos de fleste med akutt sinusitt. Dobbel innsykning og purulent nesesekret er tegn på bakteriell sinusitt og noen vil ha nytte av antibiotika. CRP-test er et godt hjelpemiddel i pneumonidiagnostikken Hasse Melbye et al. Scand J of Prim Health Care 1988 og 1992

16 Spiller det noen rolle hvor vi setter kortisonsprøyten?

17 Conclusion No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease.

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20 The RUT principle The Relative Unimportance of Therapy "I knew that there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."

21 Archie Cochrane ( ) Professor, Welsh National School of Medicine, Cardiff, Wales. RCT Metaanalyser Systematiske oversikter Evidence Based Medicine Best practice

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23 Not exactly the RUT principle.

24 Arven etter Cochrane: Asking critical questions The RUT principle I was afraid that I shortened the lives of some of my friends by unnecessary intervention."

25 Asking critical questions European guidelines for CVD prevention europeiske studier n=205178, 7934 kardiovaskulære dødsfall Separate versjoner for høy- og lavrisikoland Høyrisikoland : Norge, Danmark, Finland

26 % av individer 100 Linn Getz kurve: Kolesterol 5 mmol/l og ikke inkludert nedenfor BP 140/90 og/eller på antihypertensiv behandling Alder Scandinavian Journal of Public Health 2003

27 Current European guidelines for management of arterial hypertension: Are they adequate for use in primary care?

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29 99% of all y.o. should attend regular follow-up visits or receive drug treatment for high bp!

30 How many physicians are needed? Follow-up visits / 100,000 adults / year = 296,624 Number of GP positions = 296,624 / 3,000 consultations / year = physicians needed for bp control only per 100,000 adults Current status in Nord-Trøndelag: 87 GPs per 100,000 adults

31 Irene Hetlevik, Linn Getz, Anna Luise Kirkengen. TDNLF 2008;128:

32 Winding back the harms of too much medicine John Brodersen Professor i allmennmedisin Københavns Universitet Linn Getz Professor i allmennmedisin NTNU Irene Hetlevik Professor i allmennmedisin NTNU

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34 The mission of Choosing Wisely is to promote conversations between clinicians and patients by helping patients choose care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary

35 Hvordan har vi havnet her? % av individer Kolesterol 5 mmol/l og ikke inkludert nedenfor BP 140/90 og/eller på antihypertensiv behandling Alder Epidemiologiske studier Eldre studier Få studier av og i vår kliniske praksis

36 Hva kan vi gjøre med det? Hvordan kan allmennmedisin bli et mer forskningsbasert fag?

37 Hva kan vi gjøre med det?