Primary care reforms that are perceived by family physicians as threats to professional autonomy and the traditional role of community-based family medicine can lead to reduced satisfaction and perceived value, and can make recruitment and retention difficult.1,2 Over the past 8 years, Canadian family physicians have experienced many changes to their practice landscape.
Government cutbacks to primary care remuneration in Ontario have recently forced family physicians to defend their financial autonomy.3
A move toward interdisciplinary care and patient rostering has led to the creation of complex primary care teams, with not only the positive benefits of collaborative care, but also the potential loss of physicians’ control over their own practices and the policies and management of organizations.4
Clinical autonomy (ie, the ability to make decisions about patients’ care) might be reduced in communities where a large number of specialists provide care to family physicians’ patients, or in clinics that implement protocols and standards that limit physicians’ individual decision-making ability.
The roles of allied professionals, such as nurse practitioners and pharmacists, have expanded to overlap some of the roles traditionally dominated by family physicians, leading some to fear that allied professionals will one day usurp the role of family doctors.5–7
The increase of government monitoring with the use of pay-for-performance incentives and electronic medical records might also be seen as a threat to clinical and political autonomy.8–10
Internal conflict is occurring within the profession with respect to the role of family physicians, most notably in the form of intergenerational professional dissonance. An increasing number of younger family physicians looking to strike a work-life balance no longer perform some of the responsibilities previously considered integral to the role of the family physician (eg, deliveries, hospitalist work) or choose to focus their practices (eg, sports medicine, psychotherapy).11
Strong patient movements such as informed consumerism (eg, increased use of online health information)12,13 and an increasing uptake of complementary and alternative medicine14,15 might threaten some family physicians’ sense of autonomy.
Many family physicians are increasingly uncertain about their future in primary care.5,6 Clinical uncertainty is not foreign to family physicians, but what happens when the discipline itself is faced with professional uncertainty?
Professional uncertainty
In the 1990s, when the United Kingdom and, later, Australia introduced primary care reform, general practitioners felt the strain of change and perceived loss of professional autonomy.1,2 Professional dissatisfaction increased, and the intention to leave family medicine rose.16 In Canada, as family physicians face current challenges to their autonomy and uncertainty about their profession’s future, they risk a similar increase in dissatisfaction. However, these challenges also present opportunities to reinvigorate the discipline, modernizing the role of family physicians and earning the support of patients, colleagues, other health care providers, and policy makers alike.
One such opportunity relates to the application of evidence-based medicine (EBM) in primary health care. Evidence-based medicine is “the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.”17 It is used by clinicians to aid in predicting the potential benefits and risks of an intervention or lack of intervention, and it is intended to improve trust and reliability in clinical decisions. However, criticisms of EBM include publication bias, poor focus on outcomes important to patients, and philosophic foundational considerations. Scientific status continues to drive EBM, while other dimensions of trust, such as the provider-patient relationship, might be more crucial for patient outcomes.18,19 For example, clinical practice guidelines have tended to promote a “one size fits all” approach.20
Evolutions in EBM are taking place to address these criticisms and provide family physicians with practical tools for improving their ability to provide up-to-date, patient-centred care, including evidence-based decision support, without placing excessive demands on their already-limited time.
Primary health care and EBM
Patient-centredness in appraising and applying evidence-based clinical guidelines
Patient-centred care involves the active participation of patients and their families in clinical decisions. It includes consideration of each patient’s unique context and an effort to ensure that patients have the education and support they need to make decisions and participate in their own care.21 It is inadequate, both in terms of patient-centred care and professional satisfaction, for family physicians to become “protocol driven automatons”2 who memorize or click through a computerized list of evidence-based recommendations. In order to provide patient-centred care in applying evidence-based guidelines, we need to know not only the clinical recommendation itself, but also the probability of the benefits and harms (certainty of evidence). Bearing in mind the probabilistic nature of evidence,22 we must be able to critically appraise evidence and determine the validity and relevance of specific recommendations, and to do this with an understanding of the patient’s life circumstances, preferences, and values, and the costs of implementing the recommendation.
Progress is being made in the creation of evidence-based clinical guidelines that better address these needs. One example is the adoption of the GRADE (grading of recommendations, assessment, development, and evaluation) system for evidence-based recommendations by the new Canadian Task Force on Preventive Health Care.23 Developed in 2004, GRADE aims to help physicians contextualize evidence-based guidelines and support a patient-centred approach.24 However, in order to fully rise to this opportunity, more emphasis must be placed on teaching future and current family physicians to evaluate evidence with a focus on patient-centredness. For example, several studies have demonstrated physicians’ lack of knowledge or understanding of EBM, including important terms such as absolute risk, relative risk, and number needed to treat.25–28 Specialists who provide much of the continuing medical education for family physicians must also become more adept at both understanding and presenting evidence in a clear and useful format.25 Other commonly identified barriers to EBM implementation such as time constraints26,28 and availability of evidence26 must also be addressed. As GRADE and other critical appraisal and decision aid tools emerge to address these latter barriers and elicit and include patient-centredness in decision making, family physicians are uniquely poised to contribute to the process.
Evidence-based decision support: becoming a “broker of choices.”
As mentioned above, a critical element of patient-centred care is ensuring that patients are equipped with the education and support needed to participate in their own care. Communicating evidence is thus an important skill, and while it is increasingly demanded by patients, it is often not adequately addressed by family physicians.29,30 Many of today’s patients are captivated by science and technology; however, they are often lacking in their understanding of science and their certainty in whom to trust and what evidence to believe.31 Compounding the issue is the paucity of data on how to best communicate evidence to patients. Epstein and colleagues found that different patients prefer to have evidence presented in different ways, and that time, patience, and judgment are necessary.29 Moreover, health numeracy—the way that patients handle quantitative information when it relates to their health—might be a relatively new construct that we still need to better understand.32
In the face of these challenges, family physicians might still be in one of the best positions to address patients’ decision-support needs. Years of training provide family physicians with diagnostic and treatment expertise, and while intuition and experience continue to be considerable factors in day-to-day decision making,33 family physicians generally perceive EBM as a positive and important element of improved patient care.27 Furthermore, long-term relationships with patients might afford us the opportunity to understand each patient’s values, needs, and expectations. Two broad skills that might support shared decision making34 are relational competencies (ie, the ability to demonstrate empathy and create a relationship with the patient) and risk-communication competencies (ie, the ability to translate and communicate the evidence to help the patient make an informed decision).
A foundation therefore exists upon which family physicians can improve their ability to understand, appraise, and interpret best evidence within the context of each individual patient’s life world.35 This might in turn improve patients’ trust and satisfaction. Emerging tools that might assist in this process include the 5-step communication framework proposed by Epstein et al,29 scenario-specific decision boxes for various clinical topics such as prenatal screening,30 and the recently validated 4-item SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) checklist for detecting decisional conflict in patients.36
As asserted by the Future of Family Medicine Leadership Committee, a US-based entity created to develop a strategy to transform and renew family medicine as a discipline, in order to successfully ensure the profession’s future viability, family physicians must re-articulate family medicine’s identity to emphasize their expertise in communicating complex medical evidence to patients in a context that humanizes medicine by taking into account the individual attributes and values of the patient.31 In so doing, family physicians move away from the role of controller of the decision-making process and toward a more patient-centred role as a “broker of choices,” in which even uncertainty is shared with the patient.22,37
Looking ahead
With strong skills in patient-centred care, including evidence-based decision support, and our core valuing of relationships, we will be well positioned to address the emerging focus on the potential harms of overscreening, overdiagnosing, and consequently over-treating, as well as iatrogenic harm.38 As an evidence-based lens increasingly requires reporting on harms and consideration of unreported negative randomized controlled trials, many of our screening, diagnostic, and treatment approaches are being more closely scrutinized. Termed “minimally disruptive medicine,”39 an approach to patient-centred care is emerging in which the burden of treatment is emphasized as an important component of the overall burden of illness. As we move forward and find ourselves managing increasingly older, more complex patients with chronic diseases, it will be imperative, in terms of both minimizing harm and nurturing a trusting patient-doctor relationship, to consider the risks posed by overburdening our patients with tests and treatments that are unlikely to lead to what they, within their individual contexts, determine to be meaningful outcomes. As such shifts in paradigm take place, family medicine’s grounding in patient-centred care will help our discipline remain a strong contributor to the health of our patients.
Conclusion
Primary health care reforms are happening in many countries and Canada is no exception. Through its holistic and generalist approach, family medicine continues to be uniquely differentiated from other allied health professions, but changes that are under way have created a tension between a desire to retain traditional roles and the opportunities that come from adopting new ones. In the current context, family physicians have an opportunity to evolve with changes in the health care landscape, reaffirm professional influence, and lead the way to improving Canada’s primary health care system. In order to do so, it will be of paramount importance to maintain and nurture trust among our patients. We can begin this process by refining our skills in providing patient-centred, evidence-based decision support as a reinforced foundation for our discipline. Further research into patients’ evolving preferences, values, and expectations might be needed in order to determine how best to meet future primary care needs.
Footnotes
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 421.
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
- Copyright© the College of Family Physicians of Canada
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