Medicine has historically progressed by addressing anomalies that its prevailing conceptual framework could not explain, subsequently expanding that framework to incorporate them. This essay, the first of two, contends that the current anomalies confronting medicine-chronic multimorbidity and suffering arising from the interactions between conditions and lived experiences-are fundamentally different. These challenges cannot be resolved by merely broadening a framework designed to isolate components, as they represent anomalies of interconnection and interdependence. What is needed is not an expanded biomedical frame, but an entirely new conceptual approach. Drawing on systems and complexity sciences, this essay differentiates four phenomena that medicine often conflates-health, illness, dis-ease, and disease-and introduces the somato-psycho-socio-semiotic (SPSS) model, which conceptualises health as a dynamic equilibrium rather than simply the absence of pathology. The consultation is redefined as the fundamental unit of care, and the health system is reconceptualised as a purpose-driven organisation, described as a health care vortex, centred on the patient's experience of health. The argument is illustrated through the case of a single, representative patient and concludes by identifying unfinished work at three levels: the physician, medical education, and medicine's social license. A companion essay addresses the common objections to this argument.

Community pharmacists in high-income countries assess sore throat using clinical scoring and rapid antigen detection testing, yet consequences for general practitioner workload, prescribing and safety have not been systematically reviewed from a primary care organisation perspective. We searched PubMed, CINAHL, Scopus, Web of Science and the Cochrane Library from 2006 to 15 February 2026 for studies of pharmacy-led sore throat services reporting impact on general practitioner use. Risk of bias was assessed with the JBI Critical Appraisal Checklist for Prevalence Studies for single-arm and descriptive studies, and ROBINS-I for the comparative cohort; certainty was assessed using GRADE. The review followed PRISMA 2020 and SWiM, and was registered on the Open Science Framework (osf.io/tx9y8). In total, 9 studies (5 countries; > 100,000 consultations) were included: 1 comparative cohort with linked data (n = 72,736), 1 interrupted time-series (n = 27,441) and 7 descriptive service evaluations. In the comparative study, pharmacy antibiotic provision at index consultation was 21% versus 39% in general practice (adjusted odds ratio 0.30, 95% confidence interval 0.27-0.32). Across studies, 91%-97% of consultations were managed in pharmacy without general practitioner referral. Peritonsillar abscess rates were similar between settings (0.31% vs. 0.41%; not significant). Certainty was low for antibiotic prescribing and non-referral, and very low for reconsultation and safety outcomes. Heterogeneity precluded meta-analysis; findings were synthesised narratively following SWiM. Available evidence suggests pharmacy services may reduce antibiotic prescribing and manage most presentations without referral. Whether this reflects task redistribution or rapid antigen testing, equally deployable in general practice, remains unresolved. Pharmacy and general practice, moreover, did not manage comparable populations, so lower pharmacy prescribing may in part reflect case-mix. Review Registration: Open Science Framework (https://osf.io/tx9y8).