How We Could Actually Do Prevention in Primary Care

Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at  Common Sense Family Doctor.

Kenneth W. Lin, MD, MPH

One of the most cited studies in the preventive medicine literature estimated the amount of time it would take the average US primary care physician to provide all clinical preventive services recommended by the US Preventive Services Task Force (USPSTF) to a nationally representative patient panel. In 2003, this task would have required 1773 hours annually, or 7.4 hours per working day. A different team updated this estimate for a patient panel of 2500 adults based on the 2020 USPSTF recommendations and found that it would now require 8.6 hours per working day, leaving no time for a primary care physician to provide care for patients' acute or chronic medical problems.

Some healthcare systems attempt to shift some of the burden from the physician by empowering support staff to provide certain preventive services. For example, in my practice, medical assistants perform the Patient Health Questionnaire-2 for depression and the AUDIT-C for risky alcohol use; administer influenza vaccines; and determine whether patients are due for cancer screenings before I enter the room. But this time-saving measure can backfire when screenings happen too frequently or clinicians fail to act on the results. A study of electronic health record data from a network of 24 federally qualified health centers examined how frequently adults with at least one visit in 2019 were asked to complete six standardized screening questionnaires compared with best-practice recommendations. Researchers found that more than two thirds of patients received at least one excess screen, with patients receiving more than six excess screens per year on average.

The other limitation of screening is the need for clinicians to initiate appropriate treatment for new diagnoses. For example, although the USPSTF recommends screening adolescents for major depressive disorder, a recent cohort study found that screening increased the number of adolescents diagnosed with depression or another mood-related disorder but did not change the number who received psychotherapy or antidepressants. Similarly, the few randomized controlled trials of depression screening in adults showed little to no improvement in mental health outcomes.

As long as primary care remains the preferred entry point for patients to receive preventive services, I see two possible ways forward. First, payers and health systems should restructure financial incentives to support giving family physicians, general internists, and pediatricians more face time with each patient. Although more research is needed, evaluations of direct primary care and concierge practices, and modified payment models, suggest that in "slow medicine" settings with longer visit lengths (and more time to discuss prevention), hospital use and overall health costs are substantially lower than in traditional practices.

Another approach is to explicitly acknowledge the impossibility of satisfying every one of the USPSTF's recommendations for every patient and to instead prioritize services based on individual benefit. A research group developed a visual decision aid that incorporates risk factors in electronic health records to generate personalized estimates of life expectancy gains from recommended preventive services relative to the effort required from the patient. If deployed widely, this kind of tool could improve shared decision-making with patients and allow primary care physicians in diverse practice environments to provide preventive care that is more efficient and effective.

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.

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