Sacrificing patient care for prevention: distortion of the role of general practice

Expansion of preventive clinical recommendations in primary care has had the unintended consequence of destabilising this foundation of the healthcare system, argue Minna Johansson and colleagues For thousands of years, clinicians cared exclusively for people who were sick. Only over the past five decades has primary care’s focus been increasingly redirected towards risk, not symptoms.1 The change to medical prevention was ushered in during the late 1960s, when diuretic treatment of diastolic blood pressures of 115-129 mm Hg was found to prevent cardiovascular events with a number needed to treat (NNT) of 6 people a year.234 This beneficial intervention was targeted at a high risk population. However, today primary care is increasingly asked to prevent disease in lower risk populations that, at times, compose the majority of the population. Lower baseline risk leads to higher numbers of patients needed to screen and treat—ranging from the hundreds to infinity.5 Although the principle of “prevention is better than cure” is intuitively appealing, it is also empirically limited and distorts clinical relationships: the expansion of and focus on primary prevention interventions for low risk patients is incongruous for a profession dedicated to the relief of suffering. This expansion of medical territory—without a commensurate benefit or an impossible expansion of time—is a major contributor to the primary care crisis in many high income countries. To save primary care from collapse, the enthusiasm for minimally beneficial clinical preventive services in asymptomatic, low risk populations must be curbed and responsibility for primary disease prevention returned or reassigned to public health. Each new prevention activity or expanded target population exacts an unacknowledged opportunity cost on primary care.6 Because time cannot proportionally increase, each extra act of prevention should create improved health outcomes beyond the status quo of caring for sick people. …