Tim Senior is a GP and Churchill Fellow working in Aboriginal and Torres Strait Islander Health in Australia
Everybody should have some favourite academic articles. These are the ones you can tell colleagues and students about at every opportunity. You can choose according to the situation and your mood whether you do this with a smug look and a tone of “I can’t believe you don’t know this paper,” or with childlike enthusiasm, as if you’re bringing an exciting gift to a best friend!
In this spirit, with no smugness to an audience of friends, let me tell you about one of my favourite academic articles. I’m sure you’ve read it.
It’s called the Paradox of Primary Care and was published back in 2009 in the Annals of Family Medicine.1 Essentially the paradox is this. Non-GP Specialists follow the guidelines for the conditions on their speciality more often than GPs. And yet, the patients of GPs get the better outcomes, at lower cost and more fairly.
How can this be?
Now, I’m not sure that this is a paradox at all. I rarely see patients with only one chronic disease, and so only one set of guidelines to follow. I see so many people with sets of symptoms that are a diagnostic mystery that has no guideline only clinical judgement. (I have been known to do a little dance when I see a condition that is so clearly a recognised diagnosis – shingles or erythema nodosum or something else in a textbook!)
If we don’t follow guidelines, it can’t be an anything-goes free-for-all. It must be with the knowledge of why not, or why not now.
It’s not that I don’t like following guidelines at all. On the contrary, they give a sense of direction, when otherwise all might be unformed chaos. However, in discussing these recommendations with patients, we always bump up against the fact that we are treating people not conditions. “I’m travelling to see my children, I’ll do the blood tests when I get back.” “I know you want to avoid tablets as much as you can. How about we start on just this one, and maybe add in others if this goes OK.” The balancing of risks in multimorbidity – the risk of falls and a potential fracture if blood pressure is low enough to minimise cardiovascular risk, springs to mind – may only set us up to fail according to one set of guidelines. This doesn’t even begin to understand the effects of severe depression on the management of chronic disease. This isn’t merely the interaction of two independent illnesses, but the pervading influence of an absence of motivation and being unable to imagine pleasure, which can tip over into a submission to illness that can border on self-harm. This requires not just the implementation of a treatment plan, but the walking alongside someone, holding their hope for them.
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n fact, potentially, widespread use of quality measures that depend on adherence to guidelines will make the quality of care worse overall.
If we don’t follow guidelines, it can’t be an anything-goes free-for-all. It must be with the knowledge of why not, or why not now.
I think this is why I tell everyone about this particular paper. If anyone wants to measure the quality of the care we provide by how well we adhere to guidelines, then this paper shows that this measure won’t be good enough. In fact, potentially, widespread use of quality measures that depend on adherence to guidelines will make the quality of care worse overall.
And when we know we’re not following guidelines, and we can explain why, this paper allows us to be proud and confident as GPs that there is evidence for our patient-centred, generalist approach getting better outcomes than rigorous application of inflexible rules. That’s something we should all know about, and be able to support each other in loudly telling everyone else.
Reference
1. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009 Jul-Aug;7(4):293-9. doi: 10.1370/afm.1023
Featured image by Markus Spiske on Unsplash
