Why primary care guidelines are not prepared by family physicians

In the September issue of Canadian Family Physician, Drs Pimlott and Allan make a case for why primary care guidelines should be prepared by family physicians.^1,2 I applaud them for raising critical issues around guideline development that include conflicts of interest, the hidden curriculum, and the ever increasing number of guideline documents we have to translate into practice. While I wholeheartedly support the intent of the premise they promote, some might argue that it lacks contextual credibility.

For example, few would argue that much of what we do in clinical practice is intended to be driven by the best available evidence. A large component of many primary care guidelines involves pharmacotherapeutic intervention. In fact, drug costs represent the second-largest component of health care spending in Canada and family physicians prescribe about 80% of medications across many therapeutic areas. Unfortunately, family physicians play a minimal role in drug research and this likely explains why they are not more represented on guideline development panels.³

Underrepresentation in other research areas might also be a contributing factor. Without this fundamental research engagement, which could promote studies that are relevant to primary care and possibly mitigate some concerns around conflicts of interest, why should primary care physicians feel entitled to have more representation on guideline panels? What if the shoe were on the other foot and our specialist colleagues were asking for a seat at the table without making the type of contribution that has been traditionally linked to guideline development?

Although many of the criticisms around current guideline development offered by our colleagues are certainly relevant and very important, the suggestion that our leadership, including the College of Family Physicians of Canada, not endorse guidelines targeting primary care unless they are led by primary care physicians seems unrealistic. If the latter were the case, what is the alternative scenario given primary care’s limited role in the type of knowledge generation that ultimately fills endless pages of guideline documents? What would primary care have left to endorse or use as a guiding light given the current guideline development process?

Critical appraisal on its own without original research from primary care surely cannot be the primary prerequisite for guideline development by primary care physicians. We have to consider that many of the problems related to guideline use and outcomes in primary care are not driven by underrepresentation on guideline panels, but by our lack of involvement in generating original knowledge that is directly relevant to primary care.

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