Primary care suffers from guideline overload

In my 3 years of residency, the nearly universal resident response to outpatient continuity clinic was a disturbing, guttural groan. I recognize that many aspects of primary care drag down even the most enduring physicians. But I have also found primary care — particularly with a panel of high-risk and complex patients — to be a welcome challenge. I recently spoke with one of my institution’s main advocates for academic primary care, who I know has wrestled with this standard resident reaction.

And we had a shared epiphany about the one of the main deterrent driving promising residents away from primary care: inadequate training in prioritizing outpatient problems.

It’s easy to see how primary care quickly overwhelms the inexperienced provider. An astonishing number of recommendations, guidelines, screenings, and vaccinations must compete with the patient’s own concerns and questions. This competition creates an immense internal tension for the resident who knows the patient’s needs — cardiovascular risk reduction, cancer screenings, etc. — but is faced with addressing competing problems.

At my institution, the resident continuity clinic also houses a generally sicker subset of patients. Take these complex patients and put them in the room with a thoughtful resident that suffers from a hyper-responsibility syndrome, and you get the perfect mix of frustration and exhaustion.

There are diverse external pressures that also conspire to make the trainee feel like he should do it all: the attending physician’s judgment, government-measured quality metrics, and expert-written guidelines for care.

In this environment of intense internal and external pressures, how can we give residents appropriate perspective in a primary care clinic?

I would argue that residency training needs to include explicit instruction on how to prioritize competing needs. Maybe residents intuitively prioritize health problems already, but I’ve witnessed enough of my residents’ frustrations with primary care and preventive health. Let’s face it: there is probably a lot more value in a colonoscopy than an updated Tdap, but we don’t always emphasize this teaching point.

At times, perceptions of relative value can be skewed. “Every woman must get an annual mammogram” is a message hammered into the minds of health professionals and lay people. Yet counseling on tobacco abuse might give the provider and patient a lot more bang for the buck. Our medical education systems do not emphasize this concept very well. Knowing statistics like the number needed to treat (NNT) might be a rough guide for the overwhelmed internist, but the NNT does take into account the time invested in clinic to arrange for preventive care or the cost of the intervention.

Worse yet, there are simply too many recommendations and guidelines these days. Sure these guidelines are often graded or scored. But as Allan Brett recently pointed out in Journal Watch, many guidelines conflict with other societies’ recommendations or have inappropriately strong recommendations. Residents and experienced but busy PCPs alike are in no position to sift through this mess.

Our experts in evidence-based medicine need to guide us toward the most relevant and pressing needs, guidelines about guidelines, so to speak. We need our educational and policy leaders to help reign in the proliferation of practice guidelines rather than continuing to disseminate them.

Physicians in training have their eyes toward the potential prospects of pay-for-performance reimbursements and public reporting of physicians’ quality scores. No one wants to enter a career in which primary care providers are held accountable for an impossibly large swath of “guideline-based” practices.

So how might we empower our next generation of physicians to feel OK with simply leaving some guidelines unfollowed? In my experience, our clinician-educators contribute to the problem with suggestions like, “You know, there are guidelines recommending screening for OSA in all diabetics.” Campaigns like “Choosing Wisely” represent new forays into educating physicians on how to demonstrate restraint, but they do not help physicians put problems in perspective. Our payors don’t seem to have any mechanism to reward restraint or prioritization and can, in fact, skew our priorities further.

I hope that teaching relative value and the art of prioritizing problems will be a first and critical step toward getting the next generation of physicians excited about primary care.