[Does knowledge hurt?]. / Gjør kunnskap vondt?

The rate of production of medical knowledge is high and increasing, and medical practitioners find it hard to keep up. Still, production of new knowledge is normally considered to be unambiguously desirable. This paper is a philosophical reflection upon this assumption of desirability. It is noted that the health sector appears to be subject to the law of diminishing returns; this implies that more doctors and more medical technology may at some level do more harm than good. We argue that Bacon's legitimization of knowledge (knowledge is power) is less forceful in the face of biological and psychosomatic complexity. Medical research may lead to unintended harm through at least two mechanisms. First, biomedical knowledge is reified through the introduction of new medical technology whose effects are not fully known, and may lead to uncontrollable adverse effects on a clinical and societal level. Second, exaggerated attention paid to the production and implementation of biomedical factual knowledge may prevent the development and teaching of personal clinical skills, including phronesis, the individual judgemental powers that enable us to judge which goals are worth striving for, and which are not.

[Destiny-zapping--medical education, students' world view and the ethical challenge]. / Skjebnezapping--medisinsk grunnopplaering, legestudenters dannelse og den etiske fordring.

Three medical students describe their search for professional and personal identity midway through medical school. The article focuses on their concrete experience of human suffering and vulnerability, which is set against elements from the relational ethics of Danish philosopher KE Løgstrup. Løgstrup's ontology is based on a relational understanding of being human, and implicitly opposes the strongly objectivating and individualised view of human existence promoted through the experiences of everyday medical education.

[Knowledge of human nature as clinical competence]. / Menneskekunnskap som klinisk kompetanse.

Western medical education has little tradition for critical reflection and discussion. There is a professional overemphasis on the biological and technical aspects of illness and health, with little attention being paid to the phenomenological aspects. The article argues that health depends on two dimensions denoted by the terms meaning and belonging, central in postmodern philosophy in the tradition of Heidegger and Gadamer. Meaning and belonging emerge through dialogue and interpretation. Good clinical communication secures correct medical information and understanding, both of them worthy goals. The most important function of medical dialogue is, however, its ability to strengthen the self-healing interpretational processes of the patient.

[Patient centered medicine--a review with emphasis on the background and documentation]. / Pasientsentrert medisin--en oversikt med vekt på bakgrunn og dokumentasjon.

BACKGROUND: In this paper we present the patient centred clinical method from a historical viewpoint with emphasis on its philosophical and ethical foundations. The paper reviews the documentation and discusses the relevance of the method. MATERIAL AND METHODS: Literature review. RESULTS: The patient centred method was introduced in western clinical medicine as a result of a general shift in science and the introduction of systems theory and relational understanding. The ethical basis for the method is humanistic values with emphasis on respect and mutuality in human relations. Observational studies suggest that the method improves outcome for patients. Experimental evidence is sparse and conflicting. The concept of patient centredness is vague with regard to the management phase of consultations. The relationship between doctor-patient communication, the concept of patient centredness, patient satisfaction, empowerment and outcome needs further clarification and research. INTERPRETATION: Clinical medicine has to encompass the personal and relational level of human life in order to help and guide patients. The patient centred method demonstrates how this can be achieved during the diagnostic phase of the consultation. We need, however, firmer knowledge and ethical consideration of how management negotiations may empower patients and improve their outcome.

[Clinical communication--a structured teaching model]. / Klinisk kommunikasjon--et strukturert undervisningsopplegg.

A 16-hour course of patient-centered consultation skills, aimed at senior medical students and clinicians, is presented. The goal is to train participants in communication skills which at the same time stimulate the development of a good therapeutic relationship and allow effective gathering of relevant clinical information. The article describes a consultation model in five consecutive steps--opening, exploration, hypothesis testing, negotiations over management, and closure. Each phase confronts the doctor with typical tasks to be solved through adequate dialogue with the patient. The course is based on active student participation through role play, dialogue, reciprocal observation and group analysis of videotaped consultations between the participants and real patients. The article gives a detailed presentation of structures and techniques applied in the course, and describes how this training in consultation skills was developed.

[Consultation course in medical education--students' evaluation]. / Konsultasjonsundervisning i medisinstudiet--studentenes evaluering.

BACKGROUND: Final-year medical students at the University of Bergen take a 16-hour consultation course. The students are trained in an educational setting focusing on structured elements of the patient-centred consultation method, self evaluation and peer evaluation. The course has a strong emphasis on learning by doing. The objective of this study was to evaluate the learning process and the subjective outcome of the course. We used a focus group technique and a self-administered free text based questionnaire. MATERIAL AND METHODS: Transcriptions from the focus groups and free text from the questionnaires were analysed using qualitative methods. RESULTS: The qualitative analysis revealed three main categories of statements about the learning process: about the process of selfchange in the consultations; about the pain of self evaluation; and about insufficiency faced with clinical uncertainty. INTERPRETATION: We conclude that the course seems to initiate changes in consultation strategies. The students' evaluation also underline the need to take care of the students during a process of change in which they are vulnerable.

[Should we make a bid for SATS? Evaluation of a new educational project in family practice]. / Bør man satse på SATS? Evaluering av nytt allmennmedisinsk utdanningsprosjekt.

A new method for education of general practitioners and for quality assurance in primary health care has been employed in Norway since 1996. The practitioners collect data from their own practices using computerized medical records. Peer groups of four to ten general practitioners meet regularly to present their results, agree on local standards and plan improvements. They may choose among four medical topics. This article presents an external evaluation of participants' experiences conducted by focus group interviews of five groups. Satisfaction with the project was partly dependent on the topic addressed by the group. Groups of participants who felt that they improved their medical knowledge were most favourable to the project. Data collection from their own practices, presented and discussed in the group, was considered a very good basis for learning. Although the project's aim was not properly clarified, we regard this method as promising.

[Home-brew and alcohol drinking of adolescents]. / Hjemmebrent og ungdomsfyll.

Studies have shown that adolescents in Nordland county consume more alcohol than the national average, and that home-made liquor is an important element in the local alcohol traditions. We conducted a school based survey of 435 high school students in the municipality of Alstahaug, Nordland county, with a response rate of 85%. We found that home-made liquor was frequently consumed by students of all ages. Boys started drinking at an earlier age than girls, and continued drinking higher amounts. Access to alcohol was easy for students of all ages. The students bought alcohol themselves, had others buy it for them, or they made their own liquor. Nearly all interviewees who drank much beer, wine or brandy, also had a high consumption of home-made liquor. The consumption of liquor among adolescents in the Alstahaug community seems to be unusually high and warrants preventive action.

Adolescent smoking prevention--primary health care in cooperation with local schools. A controlled intervention study.

OBJECTIVE: To evaluate a secondary school smoking prevention program in a small rural Norwegian municipality. DESIGN: The project applied grade specific intervention strategies to all students grades 6-9 and comprised a total of 32 lessons over a period of 3 years, with high student activity. A non-randomised control group was constituted by all 6th-9th grade students in municipalities of similar characteristics in the same county. Results were recorded in annual class-based surveys. SUBJECTS: The intervention group totalled 187 and the control group 364 students. MAIN OUTCOME MEASURES: Prevalence of daily and occasional smoking and number of cigarettes smoked, during the intervention period. RESULTS: An 80% lower rate of daily smoking and 50% fewer cigarettes smoked by daily smokers. Lower rates of smoking in 9th grade occurred mostly among girls. CONCLUSION: The project resulted in a lower recruitment of daily smokers up to grade 9, as well as fewer cigarettes smoked by daily smokers. The intervention was more successful among girls than boys.

[Practice is learned by practice]. / Praksis laeres i praksis.

Efficient continuing education for experienced physicians should build upon and reflect doctors' concrete everyday experiences and self-defined learning needs. Reciprocal practice visits among general practitioners, afford excellent opportunities for colleagues to see and be seen, to reflect, discuss, learn from each other and develop networks, using commonly experienced consultations as a starting point. Practice visits have been credited within the Norwegian continuing medical education system since 1989, but very few practitioners have made use of the method. We have developed a course where groups of 10-12 experienced general practitioners conduct four whole day practice visits over a 2-month period. Group sessions, totalling 20 hours, are used to develop cohesion and trust among colleagues through discussions and exercises. In the later stages, plenary sessions are used to present and discuss experiences from all of the practice visits, and participants are encouraged to develop ideas and strategies concerning their professional future. The participants in the three courses arranged so far (n = 31) were general practitioners with, on average, ten years of experience. Evaluations were positive, and emphasized the value of the course as an opportunity to break the relative isolation of general practice, and share experiences, insights, frustrations and ideas with colleagues.

[How does professional competence develop?]. / Hvordan utvikles profesjonell kompetanse?

The reality of medical practice demands not only proficiency but also educational provisions, an aspect which traditionally has been given little attention in medicine. The competence of a general practitioner does not consist solely of professional knowledge and practical skills; it consists to a large extent of personal (intuition and creativity based on personal experience) and communicative elements, both of which are necessary in managing the unpredictable complexity and the many controversies of general practice. Such competence is difficult to develop outside the practice. By sharing the experience of actual consultations with experienced colleagues, and reflecting upon this experience within a small group, general practitioners will probably develop better professional judgement and increased awareness of their learning needs, as well as of their limitations and potential. This article discusses these topics using the authors' personal experiences in the continuous medical education effort which is based on reciprocal practice visits among a small group of experienced general practitioners.

[Compulsory collegial guidance. What do candidates in general practice think about training of practical procedures?]. / Obligatorisk kollegaveiledning. Hva mener spesialistkandidatene i allmennmedisin om utdanningen i praktiske ferdigheter?

In 1994 a new module addressing the quality of practical procedures was added to the Norwegian general practice specialisation programme. Over a five-year period 31 practical procedures must be performed under the supervision of fellow GPs. In 1995 a survey was carried out by questionnaire among all specialist candidates registered in the new programme (n = 165, response rate 83%) and a control group consisting of all candidates registered in 1993 (n = 162, response rate 62%). The aims of the survey were to evaluate the candidates' motivation, self-rated level of competence, and the presence of barriers to programme implementation. The main group and control group were almost identical; mean age has 36.5 years, 37% were females. There were no differences in the self-rated levels of competence between the groups. The majority (80%) reported a need to improve their performance of practical procedures, and 93% stated that mutual guidance with colleagues would be of considerable benefit by improving technical performance, professional confidence and the quality of relationships with colleagues. The main barriers to mutual guidance were shortage of time, lack of structured opportunities for performing procedures in the presence of colleagues, and lack of instruction manuals or videos detailing the correct performance of procedures.

[Competence centers fo clinical skills for general practitioners]. / Kompetansesenter for kliniske ferdigheter hos praktiserende leger.

For a number of years not enough attention has been paid to training in practical skills, neither in pre- nor postgraduate medical education. Lack of training and experience poses particular problems for the general practitioner, who often works alone with little opportunity for assessment by and feedback from colleagues. The Clinical Skills Training Centre was established to develop and implement methods for training general practitioners in clinical skills. Its main objective is to develop teaching methods that will encourage doctors to adapt their professional behaviour as and when necessary. The centre has developed a series of short, 2-day courses for small groups of 10-12 participants where focus is on selected clinical topics. The courses are continuously evaluated including assessment by the participants themselves of their procedural proficiency. Results are encouraging, with the majority of doctors reporting implementation of one or more of the relevant procedures at the final evaluation. An interesting new concept is a programme of reciprocal visits among groups of 10 to 12 general practitioners. The intention of the programme is to break the isolation of the consultation and utilize the potential for learning that exists when colleagues are able to observe each other at work and draw on each other's experiences.

The impact of military service on young men's smoking behavior.

In a cross-sectional study of 2,112 Norwegian army conscripts ages 18 to 25, the prevalence of daily smoking was 50.9%. Among the smokers, 55.7% had increased smoking during military service, and 7.8% of the nonsmokers had started to smoke. These changes in smoking behavior were correlated with having a best friend who smoked, with dissatisfaction with the military service, with physical inactivity, and with frequent alcohol consumption. Ninety percent lived in dormitories when cigarette smoking occurred regularly. Attitudes toward smoking restrictions were determined mainly by the subjects' smoking behavior and subjective discomfort caused by cigarette smoke. Smokers as well as nonsmokers having a best friend who smoked were significantly less bothered by cigarette smoke than others. The findings support the conclusion that military service has a negative influence on the smoking behavior of young Norwegian men. Intervention strategies are recommended.

A strengthening experience? Mental distress during military service. A study of Norwegian army conscripts.

Conscription compels 70% of male Norwegians to invest 1 year of their lives in military training. For 19-to 20-year-old men, the military service is an important arena of secondary socialization. In a cross-sectional study of mental health in army conscripts using the 12-item General Health Questionnaire (GHQ), the case prevalence was 48% (cut-off 2/3). This was remarkably high, given that the study population had been screened for mental disease on several occasions, and a large number of recruits with symptoms of mental disease had been excluded before the survey began. Statistical analyses indicated that the high case prevalence was mainly due to situational factors. Four dimensions were identified: (1) social relations with officers, peers and family, (2) structural factors inherent in the system of obligatory military service, (3) the meaningfulness of daily tasks and (4) financial problems. GHQ caseness was statistically associated with physical inactivity and consumption of junk-food, tobacco, alcohol and cannabis. It is concluded that military service in its present form may have undesirable consequences both for civilian society and for military efficiency. Recruits need help to cope with the complex psychosocial and transactional challenges of military service.

Tobacco habits, lifestyle, and reactions to smoking restrictions among Norwegian military officers.

A 1989 cross-sectional study revealed that Norwegian army and air force officers smoked considerably less than civilian men. The prevalence of smokeless tobacco use, on the other hand, was higher than among civilians and similar to that of conscripted soldiers. Reactions to new smoking restrictions were largely neutral, but smokers were more negative than non-smokers. A majority of the officers reported low compliance with smoking regulations. Smokers generally belonged to the oldest cohorts and had less education, higher alcohol consumption, less physical activity, and more unhealthy dietary habits than the other subjects, whereas snuff use was more common among the youngest and more healthy officers. This indicates that the health hazards of prolonged snuff use are underestimated, and that this habit may gain increased popularity if nothing is done to prevent it. Intervention strategies are suggested.