“I was spellbound from the very beginning. I thought it was amazing.”
Minna Johansson is a general practitioner working clinically at Herrestads healthcare centre a healthcare centre in Uddevalla, a small town on the Swedish west coast. She is an Associate Professor at Gothenburg University, director of Cochrane Sustainable Healthcare.
She is the lead investigator of the Global Center for Sustainable Healthcare, focused on finding novel ways to make healthcare more sustainable for patients, clinicians, health systems, societies, and for our planet. Minna feels just as passionate about her clinical work as she does about her research. “My goal is to contribute to a more sustainable healthcare through research inspired by the problems me and my patients face in clinical practice.”
Her PhD in 2018 was titled “Evaluating benefits and harms of screening – the streetlight effect?”. Her research interests include methodological aspects of evaluating benefits and harms of screening when up-to-date data from randomized trials is lacking, informed choice/shared decision making, overdiagnosis/medicalization and how values and context can be integrated in evidence-based medicine.
“First, I thought I wanted to be first an orthopaedic surgeon, and then a cardiologist, and then E.R. doctor. But when I came to family medicine, I thought, okay, now it all falls into place”
Welcome to this MedicsVoices conversation, where we talk to the key opinion leaders in health and medicine around the world. Today we’re in Sweden and I’m talking to Minna Johansson. Growing up in Sweden, what interested you in medicine?
Minna Johansson: I had a friend who was moving up to the far north of Sweden, and I wanted to join her. So, I applied to the University of Umea, I got in and I absolutely loved it. I was spellbound from the very beginning. I thought it was amazing.
DMacA: But let’s take you back before that, because you worked as a care assistant.
MJ: Yes, I worked for a couple of years as a care assistant in nursing homes. And I learned a lot from that, both in terms of caring for people who are very vulnerable and what that means, and also the situation for the care workers, which was not very good in many cases. So, maybe that did inspire me to want to start medicine.
DMacA: What else were you doing at that time? Were you at school or was this your main occupation?
MJ: After I finished gymnasium, which is what call school in Sweden, I worked for about three years as a nurse assistant or as a care assistant. I didn’t study at the same time, just worked. And, I think it’s good, whatever occupation you choose. If you choose to go to university and study then later in life many of us will end up in quite privileged positions. And I think it’s a good thing to have gotten some experience in the world before you start university. That was very valuable to me. And I still think about it quite often; the people living at these nursing homes, what I learned from them, and also my colleagues with whom who I worked.
DMacA: You moved to a university in the far north of Sweden. Tell us a bit about that.
MJ: I had a lot of fun there. I met my future husband. And it was a very good environment to study in. There was little hierarchy, it was quite a new university, not so much traditional, and it was quite progressive in what was taught and how we learned to understand medicine. And I’m very grateful for studying medicine there. It was quite cold and quite dark but, as a Swede, I like that. I met a lot of friends. Not many people live there so most of us had moved there. People in my class had moved from all over Sweden so it was easy to get to know new friends.
DMacA: Were you as dynamic at university as you have been afterwards, were you a keen student?
MJ: I was very enthusiastic and motivated to learn, not only the curriculum, but what does this actually mean? What’s the point of all this?
DMacA: During that time, what was your exposure to family medicine?
MJ: In Sweden, after we finish medical school, we go to different specialties for about one and a half to two years. Everyone has to do an internship. And I really liked every place I went to. First, I thought I wanted to be first an orthopaedic surgeon, and then a cardiologist, and then E.R. doctor. But when I came to family medicine, I thought, okay, now it all falls into place. I really love to not have to fragment everything but to be able to understand the problem here, to be allowed to zoom out and understand the problematic situation that this person is in and I how I can help in the best way possible to try to help solve that situation, and also, of course, the continuity of the relationship. I work now as a mentor for GP residents at the health care centre, and after being a GP resident for one year, one of them said something like, ‘I feel like I have lived 100 years from just this experience’.
You meet people in extremely vulnerable situations and they share their lives with you and you follow them through this journey through sometimes extremely difficult experiences. That’s just such an honour and a gift and a privilege to be in that situation with vulnerable people in vulnerable situations and just be able to be part of their journey. So, after a few months in the family medicine centre, I was stuck. I could not even imagine another place to work.
DMacA: For those of us who aren’t familiar with the Swedish system, just recap on the process from medical school to becoming a GP.
MJ: First you go to medical school for five and a half years, and then you have an internship for about one and a half to two years where you rotate through different specialties. You end that rotation with family medicine for six months, and then, if you want to be a GP, you go to specialty training for a further five years full time. Compared to many other countries, I think it’s perhaps a little bit more. You can’t call yourself a GP after internship, you must go through the specialty training of five years to become a GP. During those five years you work at the health care centre, you have to be responsible for nursing homes, for children’s checks, and you also have to do some rotations, you work a little bit in psychiatry, in the internal medicine wards etc
“… we are very focused on understanding the problem of preventing disease and disease in terms of an individualistic lens, but we don’t zoom out and understand it in the wider landscape.”
Minna’s PhD thesis.
DMacA: Were you based at an academic centre and were you interested in research and academia?
MJ: No, I live in a small town in the countryside on the west coast of Sweden, so there’s not much research going on around me. When I started as a GP, I felt this massive frustration that all the guidelines and all the quality metrics and all these incentives pushed me towards caring for people with low risk and low benefit. And at the same time, I did not have time to care for the people with much higher risk and who would have much greater benefit from the care that I could give. That was a constant frustration and every day when I came home from clinical practice, I would complain to my husband about the misery, and it made me very frustrated and angry.
So, I started with research driven by this kind of anger and frustration. I wanted to change the situation, to have a better prioritization, a better, a more human, more efficient and more sustainable prioritization of my clinical work. I was very fortunate to get in contact with so many brilliant world leading researchers who have supported me and helped me and developed different ideas with me. It’s been a very fortunate and privileged research journey in that sense.
DMacA: Let’s talk about that journey because you’re in a small practice ins a coastal area, and you then did a PhD. It was a fascinating topic, and a fascinating title. Tell us about that.
MJ: I did a PhD on the evaluation of screening programs; the benefits and harms of screening. And it included studies on screening for malignant melanoma and screening for abdominal aortic aneurysm. It was very controversial and created a lot of debate in Sweden, which was not always positive. For example, I got like anonymous hate mail with very sexist content etc. So it was hard in that sense. Basically the study was evaluating the current screening program for abdominal aortic aneurysm and how large the benefit was compared to the trials that were done previously, and also how much overdiagnosis and overtreatment occurred due to the screening program.
DMacA: You described it as the ‘streetlight effect’. What is that?
MJ: I think that with a lot of the stuff that we do in medicine, we don’t understand how much our own perspective affects how we understand interventions and what we decide to do. The point with a ‘streetlight effect’ is that we tend, in screening as an example or in preventive medicine in general, to focus our gaze towards the research questions, interventions and outcomes that are very individualistic and biomedical. But we miss everything that is outside of the streetlight. If, for example, we take screening for lung cancer, it’s estimated to save about 12,000 deaths from lung cancer every year in the US. And that might very well make lung cancer screening worth the effort. But in the same country, interventions to decrease smoking are estimated to save more than 160,000 deaths, so more than ten times as many deaths. And, it’s much cheaper and has less potential for harm for the individual. For, of course, lung cancer screening will lead to overdiagnosis, unnecessary biopsies from the lungs, etc. with sometimes serious side effects. And so, we are very focused on understanding the problem of preventing disease and disease in terms of an individualistic lens, but we don’t zoom out and understand it in the wider landscape.
DMacA: So you’ve done your PhD. What happens next?
MJ: I was very tired at research so I took a break and just worked clinically for a while. But then I was recruited for a new Cochrane Centre that had just started in Sweden and the director there, Matteo Brushettini a very kind and generous professor, convinced me to start working for the centre. So I did, and was teaching and supervising master’s students, and then after a while, I just couldn’t stop myself. It was just too interesting. So I started with research projects again. I left screening behind because it was such an inflammatory topic and now I’m more focused on the sustainability of health care. And I’m very interested in how we prioritize our time as clinicians. That’s my specific interest. But it’s also much wider than that. I’m also interested in how we prioritize between individualistic oriented prevention efforts within health care versus more structural interventions targeting populations from a more policy perspective. I have two PhD students for whom I’m the main supervisor and a few that I’m co supervising.
“… in the last few decades, prevention efforts within medicine have expanded almost exponentially. We have gone from trying to prevent disease in a small proportion of the population with very high risk, to lowering the cut-offs for what is considered problematic.”
DMacA: Tell us about the Global Centre for Sustainable Health Care.
MJ: I felt that one of the major problems within medicine, all the way from primary research, to evidence synthesis, to guidelines and policy decisions, was permeated by an almost extreme inability to prioritize. We seem to understand professional healthcare as an infinite resource, but it’s not. It’s a finite resource. The consequence is that we don’t prioritize, that health care becomes inefficient and unequal. And I think that the problem needs to be handled from a more zoomed out perspective. We need to not work in silos. Rather than looking at one issue at the time we need a wider lens to understand medicine through a sustainability perspective. And that’s what we want to do with this Global Center for Sustainable Healthcare. https://globalsustainablehealthcare.org . It’s a group of many people from across the world, from many different countries working on these issues from different perspectives. That means understanding what we do in medicine through a lens of sustainability and that means sustainability for patients, for clinicians, for health systems, for societies and communities, economies and the planet. We are group of people getting together on this platform, the Global Centre for Sustainable Health Care, to try to figure out these issues together in many different projects. The work is permeated by this idea that it’s not for our own academic benefit, it’s about generosity, sharing ideas, and trying to advance medicine and the way we do medicine for better benefits to the patients and also to our communities.
DMacA: Through your work, I’ve come across a number of absolutely fascinating concepts. Talk to me about the “time needed to treat”.
MJ: The background is that there are lots of studies that have shown that it’s impossible for clinicians to follow guidelines. For example, one U.S. study shows that GPs would have to work 27 hours every day to follow the guidelines that apply to our patients. There is a similar one from Norway showing that it we would need more GPs than are available today to follow only the hypertension guidelines and we would have to stop everything else and just do hypertension. There’s a study from the UK, with which I was involved, that showed that we need more doctors of all specialties, and five times as many nurses as currently working in the NHS, just to follow the guidelines on lifestyle interventions. So obviously there is a massive mismatch between what is recommended and expected of us and the time that we have to care. The consequence of not prioritising what we are supposed to do is that we don’t spend our time on patients with the greatest care needs, and we don’t spend our time on the interventions with the greatest benefit.
I was super frustrated by this. And I remember being at my health care centre with a new guideline that had no consideration of the opportunity costs. It recommended a lot, but there was no considerations of all the patients that I serve that would not get care if I implemented this guideline. I went home on my bike, was very angry, and that evening I wrote a draft for this paper about the time needed to treat. I contacted Professor Victor Montori from Mayo Clinic, who is just a brilliant and super generous person with whom I’ve worked a lot, and I’m so fortunate to do that, and Professor Gordon Guyat from McMaster University, who is one of the founders of evidence based medicine, and we worked out this concept. The concept of time needed to treat is basically a very simple model that aims to help guideline panels understand that clinician time as a finite resource that needs to be prioritized. You estimate that if clinicians follow a recommendation, what proportion of the total time that they have available for patient care would be spent on this intervention? In many cases you end up with very large numbers. The idea is that the guideline panel should then take a step back and consider is this reasonable and how it relates to the benefits of the intervention. And if there is benefit, what care should they recommend that clinicians stop doing to make space for this new intervention. Time needed to treat. https://www.bmj.com/content/380/bmj-2022-072953
DMacA: And this brings us on very nicely to a paper you wrote recently that suggests that lifestyle guidelines don’t actually work. https://www.acpjournals.org/doi/10.7326/ANNALS-25-01852
https://www.gu.se/en/news/uncertain-if-lifestyle-advice-actually-works
MJ: One of the biggest problems related to this is when a patient comes to us with the problem that they want our help with, it makes sense to discuss all the interventions, even those with low evidence to support it or a small chance of benefit. But, in the last few decades, prevention efforts within medicine have expanded almost exponentially. We have gone from trying to prevent disease in a small proportion of the population with very high risk, to lowering the cut-offs for what is considered problematic. That’s true for hypertension and lipidaemia and for a wide range of other risk factors and diseases. So we end up wanting to prevent disease for a very large proportion of the low risk population. That’s done by drugs, medicines to lower risk factors, but it’s also done through this idea that clinicians should try to change the lifestyle of our patients. Its intuitively a very appealing idea, because a lot of the problems with health and wellbeing today are related to lifestyle factors. But, just because it’s good to lose weight for health outcomes, it doesn’t mean that doctors giving people advice to lose weight is good because it might not help them change their behaviour. And in fact, when you look at the totality of the evidence, it seems that in the majority of cases, lifestyle advice has a very small benefit and a very low likelihood to help people change behaviour. Its introduced on a mass scale but the evidence to support a benefit is very weak. It has massive opportunity cost because the time that I would spend on giving my patients lifestyle advice takes away all time to discuss other key issues such as, for example, suicidal thoughts or knee pain, or anything else that matters to the patient. I’m not saying that we should never talk about lifestyle with a patient, but we should be very humble, acknowledging the fact that our advice rarely helps people change behaviour, that it might have harms like stigmatization, and that it has opportunity cost. If we spend a lot of time on it, that will reduce our time for something else, and that might not be worth it.
My interest in this lifestyle intervention topic started when I met a patient that I had known for a couple of years, and she came for advice on pain and she had obesity. I thought that I brought up her weight in a very respectful way. But she said something like- you know, doctor, I’ve been struggling with self-hate, body hate and eating disorders my whole life. I have finally accepted that I’m fat and I would like to be able to go to the doctor just for once without having my weight pushed up in my face. I learned so much from that. We had a very good discussion afterwards, which I thought was really helpful for me to understand this.
DMacA: That was an incredibly powerful consultation…
MJ: Yes. It was. I felt terrible at first. It felt like the weight of a horse pushing in on my chest. But, as I said, I learned a lot and I gave it a lot of reflection. Our relationship grew from that. She’s still my patient and she has also agreed that I can share this story.
“…the expansion of individualized prevention within health care in the last decades takes so much time and effort that we don’t have enough time to spend on the people who are ill. It’s a distortion of general practice.”
Sacrificing patient care for prevention: distortion of the role of general practice.BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2024-080811 (Published 21 January 2025)
DMacA: This brings us on to some of your most recent work, where you talk about the false promise of prevention.
MJ: I wrote a paper together with also some brilliant colleagues, Iona Heath , Stephen Martin, Richard Lehman and Christina Korownyk which was published in the BMJ. https://www.bmj.com/content/388/bmj-2024-080811 In this, we argue that the expansion of individualized prevention within health care in the last decades takes so much time and effort that we don’t have enough time to spend on the people who are ill. It’s a distortion of general practice. We sacrifice the care for people who are ill for prevention in low risk populations, which does not have strong scientific evidence and a very slim benefit at best.
DMacA: You are working this 27 hour day, you’re writing all these papers, you’re an academic, you’re running this Global Centre, you have a number of PhD students, where do you find time to relax?
MJ: I am a little bit of a workaholic. I love working. I mean, it’s very rewarding and fun, but I’m also very good at compartmentalizing. When I come home to my kids, I just shut it off and it’s full focus on them. And I think its also very important to always know what you prioritize. My kids and my family are my highest prioritization.And if they need me, everything else is just secondary. I think it’s very important to make that decision and follow that through everything. My family helps me relax and enjoy other stuff in life other than just work.
DMacA: That’s a lovely note to end on. Thank you very much for sharing so much of your life, your career and your philosophy. It’s been wonderful chatting to you. Thank you very much indeed.
