Why Your Family Doctor Should Be Leading Asthma and COPD Care—But Guidelines Don't Say So

Family physicians manage over 80% of patients with asthma and chronic obstructive pulmonary disease (COPD) globally, yet international guidelines fail to explicitly name them as key decision-makers. Instead, documents from the Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) use vague terms like "primary care physician" or "healthcare provider," creating what experts call a "conceptual gap" that may undermine how well guidelines are actually implemented in real-world practice.

Why Does This Language Matter for Your Care?

The omission might seem like a minor semantic issue, but it has real consequences. Asthma and COPD together affect over 260 million people worldwide, with COPD alone projected to impact nearly 600 million people by 2050. In low- and middle-income countries, where access to pulmonologists and respiratory specialists is limited, family physicians are literally the backbone of chronic respiratory disease management. When international guidelines don't explicitly recognize them, there's a risk that family doctors feel less ownership of these guidelines, implement them less consistently, and rely too heavily on referrals rather than strengthening their own first-contact care.

The problem is particularly acute because asthma and COPD account for approximately 20% of all visits to family physicians. These doctors are doing the heavy lifting—managing early diagnosis, monitoring patients over time, optimizing treatments, educating patients about their conditions, and deciding when to refer to specialists. Yet the international guidelines that should guide their work treat them as interchangeable with any other "healthcare provider."

How Do Current Guidelines Actually Describe Specialists?

Here's where the asymmetry becomes glaring. While GINA and GOLD use generic language for primary care, they explicitly name specialists throughout their documents. GINA 2024 specifically states that patients with severe asthma should be referred to "a specialist or severe asthma clinic" and recommends "referral to a specialist center" for biologic therapy assessment. Similarly, GOLD recommends referral for "specialist advice" and "expert assessment" in complex cases. This creates a hierarchy that, intentionally or not, suggests that specialists are the real experts while primary care doctors are just generalists following instructions.

Family medicine advocates argue this framing misses the point. Family physicians aren't just following guidelines—they're the ones who should be developing them. They understand the real-world constraints of primary care, the complexity of managing patients with multiple conditions simultaneously, and the psychosocial factors that affect whether someone actually takes their asthma medication or quits smoking.

What Would Better Recognition Actually Change?

Experts propose three concrete steps to strengthen respiratory disease guidelines and improve outcomes worldwide:

• Explicit Naming: Future updates of GINA and GOLD should specifically identify family physicians (and equivalent primary care medical specialists) as key actors in respiratory disease management, not just generic "healthcare providers."
• Representation in Development: Include family medicine representatives in the committees that create and update these guidelines, ensuring the people who will implement them have a voice in shaping them.
• Practical Toolkits: Develop implementation resources specifically designed for family practice settings, rather than assuming one-size-fits-all guidance works across all care environments.

"Guidelines should be developed by those who will implement them," explains the International Primary Care Respiratory Group, a special interest group for respiratory care within WONCA (the World Organization of Family Doctors). This principle reflects decades of evidence showing that health systems with strong primary care—particularly those led by family physicians—consistently demonstrate better health outcomes, improved equity, and lower overall costs.

The stakes are especially high in low- and middle-income countries. COPD alone was responsible for 3.5 million deaths in 2021, with nearly 90% of mortality in people under 70 occurring in these regions. Without explicit recognition and support for family physicians in international guidelines, these countries lack the framework to strengthen primary care capacity and prevent the projected surge in respiratory disease burden.

Recognizing family physicians in asthma and COPD guidelines wouldn't diminish the role of specialists. Rather, it would reinforce coordinated care pathways where family doctors confidently manage stable disease, optimize medications, and know exactly when to refer to specialists for complex cases. For the millions of people worldwide who depend on their family doctor for respiratory care, that distinction could mean the difference between well-controlled asthma and preventable exacerbations, or early COPD detection and better long-term outcomes.