Practice organization for preventive screening

Preventive screening practice within a broader context

To understand the shifting paradigm underpinning preventive health care (Figure 1), we reflect on 2 important converging trends.

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Figure 1.

Paradigm shift in preventive screening practice organization

First, irrespective of the culture of care, practitioners often have to make sense of “weak” or “conditional” guideline recommendations and help their patients make screening decisions based on their values and preferences. A conditional recommendation means that the guideline developers judge that most patients would follow it (whether for or against screening), but some would not. At least 3 issues can feed into a conditional recommendation: the overall balance of benefits and harms is close, there is considerable uncertainty in the research evidence underpinning the recommendation, and there is uncertainty about the outcomes that are most important to patients.¹³ When patients are presented with such uncertainty in the form of conditional recommendations, we expect some variation in what they choose to do.

Second, it is argued that we are witnessing an ongoing cultural shift in health care—once termed patient-centred care, now sometimes called collaborative health.¹⁴ The defining attribute of collaborative health (care) is not just a shift to shared decision making or greater patient engagement, it is the relocation of power from professionals and the system to individual patients, citizens, and families. “Increasingly people can source information widely, integrate and manage their financial, social and domestic, and medical spheres, and decide who and who not to share information with.”¹⁵ The health professional’s role as medical authority is evolving into one of trusted adviser. In the current discussion about preventive screening, this changed perspective places competence in facilitating shared decision making as the very least that should be expected of a health professional.

What does this mean for organizing preventive screening in a primary care context?

In simple terms, a primary care team aspiring to organize itself to comprehensively implement evidence-based preventive screening in a collaborative care approach faces a number of important tasks:

• as a team, identifying the priorities for preventive screening;

• identifying and selecting relevant, credible guidelines¹⁶;

• developing systems within the practice to support implementation, such as alerts and reminders,¹⁷ and protocols shared with other team members to facilitate efficient patient assessment (eg, for Nadia, calculating her diabetes risk category,⁷ calculating her pack-years of smoking for lung cancer screening eligibility,¹⁰ taking her blood pressure adequately,⁶ and measuring her height and weight to calculate her body mass index¹¹);

• assembling a portfolio of tools to support shared decision making, such as information sheets and patient decision aids¹⁸;

• attending to team members’ needs for education to support shared decision making—including their ability to understand and communicate risk information to patients accurately and understandably,¹⁹ and eliciting patient values and preferences¹³; and

• developing an audit or evaluation system to check in on the effectiveness of their efforts, focusing on shared decision making outcomes rather than counting tests ordered.²⁰

Importance of a team approach

Although it presents a substantial agenda, the list of tasks above is no more than a high-level road map for shifting a practice toward a successfully implemented preventive approach. Developing systems to support implementation, in particular, suggests the need for involving many different team members. Many clinical activities in primary care are already carried out by nurses, nurse practitioners, or other colleagues, and working as a team to develop a practical system of preventive care is a logical route to the most efficient use of time and human resources. There are also other compelling reasons for collaborating in a team approach: it makes good use of complementary professional skill sets, it helps ensure congruence in the messages communicated by different professionals seeing the same patient, it increases opportunities for a team to build relationships and trust with patients, and it encourages team members to collaborate in developing a genuinely practice-led approach to preventive care.

Complexity of typical primary care practice

Every reader will appreciate that the blueprint provided above cannot be more than a starting point at best. Primary care teams exemplify the idea of a complex adaptive system,²¹ and some argue that members’ “natural tendency … to learn, form patterns of relationships, organize and evolve”²² might be usefully harnessed to develop more change interventions that are more likely to be effective than simplistic, prescriptive approaches. Table 2 summarizes 4 of the key attributes of complex adaptive systems.²² Drawing on this, we recognize that setting up an electronic medical record–based alert system would not address complexity, but linking reminders to relevant background information and the rationale for a recommendation would (agents who learn). Similarly, other complexity attributes might be within the scope of a practice’s approach—for example, physicians and nursing staff working together to develop practical shared decision making processes (interconnectedness), different professional groups agreeing to work out for themselves how to make different activities sustainable in practice (self-organization), and adapting processes as a team, as members gain experience with the system over time (co-evolution). Perhaps this seems like a formalization of on-the-ground common sense? Leykum and colleagues²² provide evidence that implementation approaches embedding complexity thinking appear more likely to be effective than simple interventions. This evolving area of implementation science seems to support the argument that it is primary care practitioners themselves who are best placed to develop and adapt their practice to achieve, for their own patient populations, the preventive screening goals that they themselves have prioritized.

Back to Nadia

Primary care is not a schedule of discrete encounters and services, but the orchestration of care delivered over time, across problems, and through conversations.

W.R. Phillips²³

In a genuinely collaborative care approach, what we do not yet know about Nadia is more important than knowing which guidelines seem to apply to her. Table 1 embeds a disease-specific, vertical approach and, considered in isolation, communicates an implicit pressure on the practitioner to find a way to work through it in shopping-list style.^5–11 Do we start by discussing the results of the lipid profile ordered by a colleague, then turn to the strong recommendations? Is measuring blood pressure the easiest screening intervention (perhaps it was already done)? Maybe we can step back a little and try to elicit a bit of insight into her understanding and values as they apply to screening in general—does she have a realistic sense of her disease risks? Is her faith in screening tests overly optimistic? These are all places to start the conversation that will hopefully morph into a shared decision making approach.

However, proponents of the collaborative care approach would probably start somewhere else altogether—who is Nadia in her own terms? What is her life like? What are her most important relationships and how are they going? What are her own perspectives on her health and health care decisions? And is she just hoping we will listen to her instead of talking at her?²⁴ At some point, we will get to exploring her personal thoughts about preventive screening interventions, working out whether she is OK with the disruption that following preventive recommendations might cause,²⁵ and following her lead on where to start, if anywhere. As Phillips suggests, the continuous relationship of a patient with her personal physician is central to family medicine, “the specialty devoted to care of the whole patient the whole time.”²³