Is There Enough Time for Prevention in Primary Care?
Kenny Lin, MD, MPH
Posted on February 24, 2025
Family physicians are being squeezed by two accelerating trends: (1) too few of us to care for the growing US population and (2) the rising number of tasks that we are asked to accomplish for each patient. A 2024 analysis projected that by 2040 a shortage of 58,000 primary care clinicians (including nurse practitioners and physician assistants) will occur. Meanwhile, the estimated time needed to provide guideline-recommended preventive care, chronic disease care, and acute care to a nationally representative panel of 2,500 adult patients is an impossible 26.7 hours per day, with more than one-half of that time (14.1 hours) allocated to preventive care.
As science advances, the number of US Preventive Services Task Force (USPSTF) A and B graded recommendations grows, and the size of the affected populations expands. Since 2020, the starting ages for breast, lung, and colorectal cancer screening were lowered to 40, 50, and 45 years, respectively. The USPSTF also has endorsed screening most adults for anxiety disorders and unhealthy drug use. In an editorial in the February 2025 issue of AFP, Dr. Mark Ebell and I discussed concerns about the quality of the evidence for several recommendations. We cautioned,
to justify the extra time and effort associated with implementing new or expanded screening recommendations, clinicians must have confidence in the reliability of USPSTF assessments regardless of the task force’s membership at any point in time.
A 2025 commentary in the BMJ proposed a radically different solution to the workforce crisis: Take prevention for low-risk patients off the plate of primary care. The authors noted that as measured by the number of patients needed to treat to prevent one negative outcome, “care for symptomatic patients provides substantially greater benefit than preventive care.” Rather than counseling patients individually to quit smoking, drink less alcohol and sugar-sweetened beverages, and consume fewer highly processed foods, medicine should defer prevention to public policy measures (eg, taxes on cigarettes and laws restricting where people can smoke) that achieve these goals more effectively. Not only would this approach free time for family physicians to focus on patients with acute complaints and chronic diseases, the authors argued, but it would also remove the “ethical stress” that comes with “the mismatch between the patient’s needs and the burden of preventive care” in the form of quality metrics.
The problem with this proposal is that in the United States, the public health workforce is not positioned to handle routine screenings and immunizations. In the past week, the Centers for Disease Control and Prevention (CDC) and the federal agency sponsor of the USPSTF’s sister panel, the Community Preventive Services Task Force (CPSTF), was forced to lay off 10% of its work force. Most of the CPSTF’s website, including all of its findings on individual community health topics, is still missing after thousands of CDC web pages were abruptly removed or altered. There may not be enough time for prevention in primary care, but family physicians need to keep providing it the best we can.