Guideline evolution in family medicine

This month’s issue of Canadian Family Physician features a commentary by Drs Leslie and James Rourke and colleagues on the Rourke Baby Record (RBR),¹ which for almost 4 decades has been an indispensable aid to primary care providers who care for infants and children.

Canadian Family Physician has been committed to publishing clinical practice guidelines (CPGs) developed by family physicians for family physicians since it began publishing the RBR in 1985.² Why? Because there have been, and remain, many problems with CPGs developed by specialists for use in generalist clinical settings. These include their focus on single diseases (making them hard to apply in generalist settings); guideline panelists’ potential conflicts of interest³; most recommendations being based on expert opinion rather than on the highest-quality evidence³; failure to consider how to support implementation by end-users; and insufficient representation of family physicians and patients—although in this area improvements have occurred in some recent disease-specific CPGs.⁴

This approach to CPG development reflects the traditional hierarchy of medicine and fails to recognize the truth of the ideal relationship between generalists and specialists, which Dr Iona Heath articulated so well in her 2011 Harveian Oration, “Divided we fail”: that generalist and specialist physicians share a common undergraduate education and then differentiate to develop distinct but complementary skill sets that, when deployed optimally, allow health care systems to function optimally.⁵

The RBR provides a template for developing CPGs relevant to family physicians. It was created by 2 family physicians to address unmet needs for high-quality, effective, and comprehensive care to support the healthy growth and development of children. Other characteristics that made it unique among guidelines of the time were its commitment to producing iterative updates as evidence evolved (most recently in 2020),⁶ a focus on making the guidelines easy to integrate into family practice, and egalitarian collaboration with specialists in children’s health.

The PEER (Patients, Experience, Evidence, Research) group from the Department of Family Medicine at the University of Alberta in Edmonton provides another, more recent template for CPG development led by family physicians.

Over the past 7 years PEER has published several CPGs in this journal, such as its simplified lipid guidelines in 2015 and its CPG on chronic pain in 2022.^7,8 The PEER group’s CPGs meet the Institute of Medicine’s best practices for guidelines by avoiding financial and academic conflicts of interest; focusing on clinically impactful patient-oriented outcomes; involving external review committees that include patients and family physician end-users; and being easy to integrate into practice.⁹

Much remains to be done. Specialist, disease-focused CPGs aimed at family physicians are abound, and many family doctors, influenced by a persisting medical hierarchy, remain uncertain about whose advice they should follow in caring for their patients.

It is heartening that the RBR is as valuable to family physicians and their patients now as it was at its very beginning and that there are plans to continue this work. It is heartening, too, to see the PEER group take up the mantle of leadership in improving the way CPGs for family physicians are developed and disseminated. It is more heartening still that the College of Family Physicians of Canada has embraced PEER CPGs within its Programs and Practice Support department. Canadian Family Physician has been privileged to support this groundbreaking work.

As family doctors, we are in the unique position of knowing our patients well. When we help create and publish guidelines, it is our patients who truly benefit.

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