Specialists vs Primary Care: Whose Guidelines Matter?

Alicia Ault

Disclosures

June 14, 2018

In This Article

Writing and disseminating clinical practice guidelines—always a tricky business—has become more fraught, in part because specialists and primary care clinicians have divergent views and approaches on how best to manage patients. What once might have been polite intellectual debate over methodology or the quality of evidence has morphed into more acrimonious dialogue about conflicts of interest, turf, and policy and financial implications.

Guidelines are often used to establish quality metrics and reimbursement rates, and they are picked up by the lay media, setting patients' expectations for when they walk into their doctor's office. Confusion over conflicting guidelines is increasingly tangible for primary care physicians.

But professional societies say that clinicians should not view guidelines as one-size-fits-all strictures without nuance or room for judgement.

A lack of concordance is a problem "that has been arm-wrestled in the 15 years I've been involved in guidelines," said Patrick O'Gara, MD. "It would be naive or blindingly defensive to say this doesn't exist." O'Gara told Medscape. But he also said that clinicians from all specialties should continue to chip away at differences. O'Gara is vice-chair of the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines.

"Different conclusions can be reached by well-intentioned people," Jack Ende, MD, immediate past president of the American College of Physicians (ACP), told Medscape. ACP, which represents internists, writes its own guidelines "to enable physicians to make the best possible choices for their patients," he continued. Ende stated, "We're not defending any turf. We're not out there in a pugnacious way to challenge subspecialists." Ende is also assistant dean and Adele and Harold Schaeffer Professor in Medicine at the University of Pennsylvania Perelman School of Medicine.

Even clinicians within a specialty are taking exception to guidelines and how they are written.

However, ACP did attract the ire of multiple specialty organizations in March, when it issued an evidence-based guidance statement[1]on type 2 diabetes that set higher target A1c values—between 7% and 8% for most patients—than had been called for by those societies.

The Endocrine Society, the American Diabetes Association, the American Association of Clinical Endocrinologists, and the American Association of Diabetes Educators issued a sternly worded press release strongly disagreeing with the ACP's guidance.[2]

Sometimes, even clinicians within a specialty are taking exception to guidelines and how they are written. In April, the AHA and American Stroke Association rescinded large sections of its stroke guideline,[3] which had just been announced in January and published in March.[4] The removal—labeled a correction—was done over the objections of the guideline writing committee.

"I don't think this has ever happened before. This is a challenging and unfortunate situation. It's not good for anyone—the AHA, the guidelines writing committee, or the patients," Mark Alberts, MD, told Medscape Medical News at the time. Alberts said many clinicians thought the guideline had been written "in a very narrow perspective, and this has now led to formal complaints being made to the AHA." Alberts is physician-in-chief of the Ayer Neuroscience Institute at Hartford HealthCare and chief of neurology, Hartford Hospital, Connecticut.

Patients Are Not a Single Disease

A too-narrow focus has given rise to some of the backlash against specialty society guidelines.

Specialty guidelines "are often written for one condition," as if the patient has one disease and nothing else, said Kenny Lin, MD, MPH, professor of family medicine, Georgetown University. When patients are being followed by multiple different specialists who all have different guidelines, "part of your job is to sort that out," Lin told Medscape.

A problem with a lack of a cross-disciplinary perspective is that "[an] excessive focus on one [body system] could lead to harms in another," said Lin, who is also associate deputy editor of American Family Physician.

"We treat the whole patient and consider more than just a single organ system or guidelines developed for one specific organ system," said Jennifer Frost, MD, FAAFP, medical director of Health of the Public and Science Division at the American Academy of Family Physicians (AAFP).

They're setting up primary care physicians to have to choose between offering what's best for their patient, and being told or mandated what they need to do.

Because of the primary care physician's scope of practice, he or she sees a larger cross section of the population, and is "positioned to intervene early on," Frost told Medscape.

When asked whether primary care or specialists should have the "final word" on which guidelines were most appropriate, Frost demurred. "The 'final word' is a positive patient outcome and the continued strong patient-physician relationship."

Mark E. Williams, MD, said he thinks specialty organization guidelines are typically unrealistic for primary care. "They're setting up primary care physicians to have to choose between offering what's best for their patient, and being told or mandated what they need to do in order to get good quality metrics on their scoring sheets," he told Medscape. Williams is a geriatrician with New Hanover Regional Medical Center, Wilmington, North Carolina.

Specialists can "offer their best unbiased opinion as a specialist," he said, adding that perspective is informed from a self-interested viewpoint. "I'm not saying the paragons of ethical virtue are primary care doctors—I don't believe that either," said Williams.

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