A practice-level look at how family physicians and general practitioners identify MASLD risk, respond when liver enzymes are normal, use non-invasive fibrosis tools, and decide when primary care should hand off to gastroenterology or hepatology.
Audience: Family Physicians / General Practitioners
Countries: 6
Completion Rate:71.4%
SGID: 8974049
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MASLD sits at the intersection of obesity, type 2 diabetes, dyslipidemia, hypertension, and liver fibrosis, which places family physicians and general practitioners close to the earliest practical opportunity for risk identification.
International pathways increasingly emphasize targeted case-finding and fibrosis risk stratification in people with cardiometabolic risk, rather than waiting for symptoms or relying on liver enzymes alone. The 2026 AGA clinical care pathway highlights adults with type 2 diabetes, overweight or obesity plus another metabolic risk factor, and incidental steatosis or elevated aminotransferases, and the EASL-EASD-EASO MASLD guideline similarly puts cardiometabolic risk at the center. The MDForLives survey examines what that shift looks like inside primary care: which profiles trigger assessment, how normal liver enzymes influence action, which non-invasive tools are used, how referral is decided, and what prevents a more repeatable pathway.
90.6% say obesity, dyslipidemia, or hypertension with metabolic risk would prompt MASLD assessment, yet 41.0% say assessment is incorporated selectively according to the patient’s metabolic risk profile.
The risk trigger is not limited to obesity: 83.0% also select type 2 diabetes, prediabetes, or multiple cardiometabolic risk factors, 83.3% select persistently elevated enzymes or incidental steatosis, and 50.4% add family history or other risk factors. But the tension is operational, because only 25.3% say assessment is routinely incorporated for appropriate high-risk patients. Primary care has broad risk awareness without a single, standardized entry point into liver-risk assessment.
34.7% say further MASLD assessment is likely when metabolic risk is significant despite normal liver enzymes, depending on the overall clinical picture.
The distribution matters because there is no single dominant reflex: some clinicians act on the risk profile while others wait for additional signals, and that variation is consequential in a disease that can stay clinically quiet. The AASLD practice guidance notes that aminotransferases can be normal even in advanced disease and should not be used alone to exclude clinically significant fibrosis, so the implication is not that every normal liver test needs escalation, but that metabolic risk and structured fibrosis assessment can still be relevant when enzymes look reassuring.
56.8% report using transient elastography or FibroScan, while 53.1% use FIB-4 or another structured fibrosis score.
These selections are not mutually exclusive, so fibrosis risk is being assessed through more than one route, shaped by local access, clinician familiarity, health-system design, and whether elastography is available before referral. Current pathways commonly stage the work: a simple blood score such as FIB-4 first, then a second non-invasive test such as vibration-controlled transient elastography when indicated. The building blocks clearly exist in practice; what is not yet consistent is their sequence.
51.2% are quite or moderately confident deciding who can remain in primary care, and 57.9% say they refer when non-invasive assessment suggests increased risk of advanced fibrosis.
Only 18.1% describe themselves as very confident deciding who can remain in primary care versus who needs referral, with 25.1% slightly confident and 5.6% not confident. The handoff is easiest when the risk signal is already strong; the less settled part is the middle, interpreting intermediate risk, choosing the next non-invasive test, deciding what can safely stay in primary care, and knowing when local referral criteria are met.
56.7% identify limited access to fibrosis testing and diagnostic tools as a barrier; 58.4% say greater access to non-invasive testing and clinical decision support would have the greatest impact.
The barriers run broader than testing alone: half cite limited time, training, or familiarity with MASLD pathways, 41.4% cite patient engagement, follow-up, or a lack of integrated pathways, and 36.4% cite unclear referral routes or limited specialist access. The response is notably practical, not another awareness campaign, but accessible tests, decision support, clearer pathways, and integration with the cardiometabolic work already happening in primary care.
Family physicians and general practitioners already see the patients in whom MASLD risk is concentrated, and the survey shows strong recognition of obesity, dyslipidemia, hypertension, diabetes, prediabetes, abnormal liver tests, and incidental steatosis as reasons to think about MASLD. The harder step is turning that recognition into a consistent fibrosis pathway.
Normal liver enzymes are one point of uncertainty; access to FIB-4 inputs, elastography, referral criteria, and specialist capacity are others. The gap is not awareness of MASLD but the ability to move reliably from metabolic risk to non-invasive assessment, from there to the right next test, and from higher fibrosis risk to specialist care while cardiometabolic management continues.
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