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Over the past 10 years there have been significant developments in general practice regarding diagnostics, differentiation of competences of general practitioners, cooperation within primary care and with secondary care, task delegation and patient information provision. Less progress has been made in other areas: E-health applications are rarely used, and there is no clear guideline for an integrated policy in patients with multimorbidity. General practitioners also continue to suffer from excessive regulatory pressure, excessive protocols and standardization. In the coming decade, GPs will continue to work in accordance with the core values ​​of their profession: 'person-oriented', 'medical-generalist', 'continuous' and 'jointly'. Their function to provide guidance is becoming increasingly important. In addition, more diagnostics and treatment will take place at the interface between general practice and secondary care. Chronic care will focus more on the needs and wishes of the individual patient. GPs retain their important role in terminal palliative care and emergency care.

An effective approach to health problems and a sustainable health care system requires more attention to prevention, primary health care and public health in research. For this to be achieved, university medical centres (UMCs) should strengthen the academic basis of prevention and primary care, as the Dutch Health Council recommended in its report 'Research that matters'. We are now three years on and the NFU, the association of the UMCs, recently published its plan 'Research and innovation with and for the healthy region'. This is a step in the right direction, but we are not there yet.

The relationship between doctors and patients often becomes tense when the patient has medically unexplained symptoms: doctors may experience frustration because they feel ill-equipped to provide their patients with a plausible explanation of the symptoms. Patients often feel that their doctor does not take them seriously and would like to understand why they are having symptoms. Research into the effect of the quality of the doctor-patient relationship and doctor-patient communication where medically unexplained symptoms are concerned has led to some recommendations for communication. A thorough exploration of all dimensions of the symptoms, i.e. the somatic, cognitive, emotional, behavioural and social dimensions, almost always yields starting points for explaining what is happening to the patient and for therapy. The provision of an explanation which is acceptable to the doctor as well as to the patient is an important condition for drawing up and carrying out therapy. If the doctor expresses confidence in the prognosis and outcome, this has a favourable effect on the development of the symptoms.

Relational continuity of care has traditionally been an important core value of primary care. Research shows that relational continuity of care contributes to better patient health. However, due to social changes and an altered organization of our health system, it has become more difficult to put this core value into practice. General practitioners, for example, increasingly work part-time and general practices have become larger-scaled. Within practices, there is also an increase of delegation and specialization, leading to fragmentation of healthcare. A weekly rota involving at least three clinical consultation days for each doctor, the establishment of small general practice teams within a larger organisation, and a reduction in the size of a standard practice can facilitate relational continuity of care. In addition, it is necessary for GPs to concentrate on the core activity of their profession: direct personal care.

Most people claim that health is an important prerequisite for a happy life. Our society puts much effort into promoting a healthy lifestyle, prevention and timely risk detection. After all, prevention is better than cure. The increased attention to health and the strong focus on prevention, risk reduction and risk avoidance have their downsides, as Ivan Illich already pointed out in the nineteen-seventies. Overdiagnosis, overtreatment and the transformation of many everyday complaints and phenomena into abnormalities lead to medicalisation. In 2013, this trend was reason for the BMJ to start their 'Too much medicine' campaign. Steering between too much medicine and too little medicine requires helmsmanship from doctors; correcting unrealistic expectations, alleviating unnecessary health worries and promoting resilience are all important in the promotion of normalisation.

In recent years disease-specific outpatient clinics have gained a foothold in the Netherlands. In some instances, this is warranted. An example would be an outpatient clinic for early-onset Alzheimer's disease to ensure that patients get optimal diagnostic procedures and receive state-of-the-art treatment. However, the initiation of outpatient clinics for common diseases predominantly treated in primary care, such as a one-stop-shop for the diagnosis of asthma, is a more questionable development. It may lead to patients assuming that such a referral is always necessary for the diagnosis, patients seeking a second opinion in case the diagnosis is not confirmed, and to the exhaustion of available clinical capacity to the detriment of other patients. Furthermore, it may lead to higher costs and add to the complexity of an already complex healthcare system.

Although the prescription of SSRIs for patients with medically unexplained physical symptoms (MUPS) has increased in past years, there is still remarkably little evidence for their efficacy in adults with MUPS, as shown by a recent Cochrane review. As there is virtually no evidence that SSRIs are effective in adolescents with MUPS, doctors should think twice before prescribing SSRIs for this patient group; SSRIs can have serious side effects, particularly in adolescents. Increasing numbers of off-label prescriptions and a great improvement in symptoms in two adolescents with MUPS and psychiatric problems as described in a recent article in the Dutch Journal of Medicine (NTvG) do not justify the, albeit cautious, recommendation to consider prescribing SSRIs for adolescents with MUPS and depressive or anxiety symptoms.

Lyme disease is the cause of a lot of anxiety and discussion. Patients are demanding more preventive actions to avoid tick bites, and earlier and better diagnosis of Lyme disease. However, only a minority of people bitten by a tick go on to develop Lyme disease. Although physician delay may lead to a late diagnosis of disseminated Lyme disease, these patients are still treatable and even in bad cases, symptoms will subside within a few years. While we know that serious complications of late disseminated Lyme, e.g. neuroborreliosis, are very rare, there is still uncertainty about how often Lyme disease occurs, and how often the diagnosis is delayed. The high prevalence of seropositive people in the population suggests that many people clear the infection without any symptoms and without any treatment. Some decades ago mononucleosis infectiosa also had a bad reputation but this largely disappeared when it became clear that recovery is the rule. Lyme disease may also shed its reputation once the facts are known.

It has been suggested that chronic dizziness in older people may constitute a multifactorial geriatric syndrome. Considering dizziness to be a geriatric syndrome with multiple contributory factors may provide additional leads for treatment. A structured history, followed by physical examination and additional tests if necessary, can yield clues to factors that may contribute to dizziness. To illustrate such a multifactorial approach, we present two patients with chronic dizziness. In both cases, the general practitioner considered multifactorial dizziness with several treatable contributory factors. By treating these contributory factors, the frequency of dizziness and dizziness-related impairment decreased temporarily in one patient and permanently in the other.

The multidisciplinary guideline 'Diagnostics and treatment of irritable bowel syndrome (IBS)' provides the basis for a properly coordinated collaboration between the patient suffering from IBS and all healthcare providers involved in his or her treatment, such as the general practitioner, gastroenterologist, internist, occupational-health physician, dietitian and psychologist. The diagnosis 'IBS' is often made in accordance with diagnostic criteria, such as the Rome III criteria, but a somatic condition needs to be excluded first. If there are no indications for this, additional diagnostic tests are not necessary. Management of the condition consists primarily of advice on life-style plus non-pharmacological interventions, in addition to explaining the condition and providing information. Drug treatment is rarely indicated. If the IBS symptoms have a significant impact on quality of life and patients do not respond to the measures taken in accordance with this general policy, there are three options for psychotherapeutic treatment. When the symptoms result in absenteeism or other work-related problems, the doctor can advise the patient to contact the occupational-health physician and to search for specific solutions in consultation with the employer. When individual advice is required or if the patient's diet is not well-balanced, a referral to the dietitian will follow.

Doctors often feel pressured by patients to prescribe antibiotics for a common cold or a sore throat, against their better judgment. Yet do patients really put pressure on their doctor or even expect a prescription for an antibiotic or some other medicine? Several interesting studies shed some light on this issue. Doctors in an emergency department, for example, prescribed an antibiotic much more frequently than their patients expected them to. Only in 25% of cases were the doctors correct in their assumptions about patient expectations. In a Norwegian study, the authors found that parents wanted more time and explanation for their coughing children and fewer prescriptions. So instead of assuming that patients want antibiotics for innocent symptoms, we should put more effort into exploring patients' expectations and providing them with relevant information. That way we can step out of the folie a deux.

The syndrome diagnosis 'irritable bowel syndrome' (IBS) is often made on the basis of exclusion, but the question is how many diagnostic tests should be performed in order to establish this diagnosis with a degree of confidence. We present the diagnostic value of various IBS criteria for excluding IBS, based on a systematic review. The potential of the various criteria for distinguishing IBS from organic disease is extremely variable and disappointing. Patients fulfilling IBS criteria have, however, a lower risk of organic disease than patients with abdominal symptoms who do not fulfil the criteria. The same holds true for the diagnostic performance of individual alerting symptoms. These seem to be present frequently in IBS patients in whom there is no underlying organic bowel condition. An organic condition cannot be accurately excluded on the basis of symptom criteria. However, the low prior risk of organic conditions among patients who consult a primary care doctor and who meet IBS criteria argues against exhaustive diagnostic evaluation.