Rebuttal: Should primary care guidelines be written by family physicians?

Dr Allan’s “Yes” argument should be a “No” argument.¹ He begins by saying that specialists know the evidence and the latest products and innovations, and that family physicians might be doing an inferior job, which takes us in the wrong direction. Evidence-based and high-quality practice are not a matter of being a specialist or a family physician! Then he says that specialists are more likely to have conflicts of interest with industry. The potential for conflicts of interest does not belong solely to specialists and family physicians are not protected against conflicts. Among the challenges that family physicians face are the many interactions that occur between them and the members of the health care industry, whether involved in care, education, or other roles. As physicians, our best defence is not to ignore the risk but to err on the side of caution. Well aligned with this, many national professional societies have enforced regulations that go beyond only reporting conflicts of interest to excluding physicians with such conflicts and not allowing some to vote or to participate in making recommendations in the guideline.

What are we trying to fix here? The ultimate goal we have is to improve patient care. Does anyone really believe that we are going to achieve this with the proposed solution in the “Yes” argument to only endorse guidelines that are led by family physicians or to have family physician societies produce their own guidelines? The most important concern should not be who owns the right to make guidelines but rather starting a real transformation. This transformation needs to better address the new reality of our aging population, with the epidemic of chronic noncommunicable diseases and concomitant comorbidities, and to ensure implementation, which should occur at different levels: organizational, professional, and individual.

There should be a call to combat stereotyping, to learn from working together in referring to and consulting with one another, and to develop intraprofessional relationships. The lack of evidence about what makes these relationships work should not stop us. This transformation to a collaborative model—ie, making guidelines together—should be developed in an effort to improve patient care and foster effective management. Furthermore, this new collaborative model and such relationships will likely affect the comprehensiveness and continuity of care. Let’s also make sure this transformation includes examining patient and provider outcomes, and let’s hope this model of practice is just beginning.

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