Continuity of care starts with caring

We often speak of the importance of continuity of care, but there is confusion about what this really means.

When I first joined our small clinic twenty-five years ago, continuity was the reason every medical group in the five town area had its own night-call roster. This way, patients who called after hours could reach a doctor from their own doctor’s office. Even if the covering physician didn’t know the patient, there was at least an illusion of familiarity. Continuity of care often motivated primary care doctors to do many procedures, which they nowadays may refer patients to specialists for.   Continuity of care was also the reason doctors traveled between their clinics and the hospital more than twenty miles away to care for hospitalized patients.

Over the years, some practices began sharing night call. Many primary care doctors stopped treating fractures and performing high-risk office procedures. The hospitalist movement came to our area in the 1990’s. Many physicians stopped providing inpatient care, leaving this to specially trained, full time hospital doctors.

Many people lamented the loss of what they thought of as the old-fashioned country doctor, one who did everything and was always available. At the same time the level of sophistication in medicine made it harder for any single primary care doctor to deliver the same quality of care as a specialist in every area of medicine.

Family medicine has struggled over the past twenty years to make peace with the new division of labor and what may look like a fragmentation of care. Family physicians can and should be the glue that holds the fragments together. The latest name we use for this old concept is “medical home.”

Twenty-five years ago I had a chance encounter with another family physician in another community, much like my own newly adopted home town. I have seen his name now and then over the years, but we never met again after that day.

The other day I saw his name in JAMA, the Journal of the American Medical Association. He was the author of an inspiring essay about what real continuity of care is. He describes seeing a patient, who after a failed spine operation wanted to give up. Dr. David Loxterkamp knew the man from treating his aging mother and disease-stricken wife. He knew Bud had the resources to fight for his recovery, but he recognized that Bud was lost in what had happened to him. That knowledge, gained over years in the same community and through sharing in Bud’s family’s tragedies, helped Dr. Loxterkamp guide and motivate his patient to a full recovery.

Dr. Loxterkamp writes:

Continuity of care is a pillar in the portico of primary care. But it promises more than customer satisfaction or improved health outcomes. When all we measure is the ratio of patient-physician continuity, we miss the point. The tragedy is not when others care for our patients, but when no one cares for them at all.

The purpose of continuity is to deepen our relationship with others, something that is utterly impossible if it never begins. It begins in every encounter where the patients feels known and – despite it – loved, or at least respected and cared for by another human being.

It cannot be enforced, taught or measured. It must be lived and experienced in the cross connections of real community. As physicians, we are chosen to witness the destruction wreaked by illness and age. Our challenge is to see the patient who has lost sight of himself. Thus, we are called to live where we serve, anchored against the currents of geographic mobility and “professional distance”. How else can we relocate those who have been dislodged from their identity?

His words reflect my own experience and echo the words of Sir William Osler, the father of modern medicine, mentor to generations of physicians:

Medicine is an art, not a trade, a calling, not a business, a calling in which your heart will be used equally as much as your head.

Recognize … the poetry of the commonplace, of the ordinary man, of the plain toil-worn woman with their loves and their joys, their sorrows and their griefs.

…gain the confidence of a patient and inspire him with hope.

Continuity of care starts with caring.

A Country Doctor is a family physician who blogs at A Country Doctor Writes:.

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  • Steven Reznick MD FACP

    Great read and point of view. Family practice and general internal medicine were sold down the river by the ACP and AMA in recognizing and encouraging hospitalist medicine and destroying caring continuity of care. Good primary care physicians are good primary care physicians as inpatient doctors, outpatient physicians, on home visits , on visits to SNF’s.They are no better and no worse than hospital based physicians who are caring and good at what they do despite the effort of leaders of both specialities attempts to manipulate data to support their point of view.
    The decision to stay in the office and not go elsewhere was an economic decision made as reimbursement dropped, time out of the office became less cost effective and outpatient private family doctors had to see more patients in less time to cover overhead and make a living. At the same time , hospital systems saw the advantage of hiring full time hospital based physicians who represented their interest on utilization and to have a primary care network under contract. For the specialty surgeons and procedural medical doctors it was just as easy to work with the hospital based physician to admit your fractured hip and see the patient as a consultant rather than come in , do a history and exam and admit the patient to your service. It was more cost effective to stay in the OR and do procedures and let the hospitalist or PA do the post operative medical work.
    Continuity of care and longitudinal care were destroyed as well by employers changing insurer every year forcing the employees to change primary care doctors yearly. Continuity of care was lost because outpatient generalists couldn’t or wouldn’t fight back and demand to hold on to their scope of practice.
    The loss of having a doctor who knows you over time is a tragedy which will effect the quality of the health care system forever. People need a physician who knows them , cares about them, fights on their behalf and guides them through a complex health system. Any excuse for giving up that role and then trying to justify it is nothing more than a rationalization of a poor excuse.

  • sophie hankes

    Excellent topic and approach, however….unfortunately there is no continuity of care for victims of medical errors. Physicians impose the Wall of Silence, in stead of doing the right thing after the medical error:
    provide honest information , adequate diagnostics and remedial medical care. And …physicians should learn from their registration and research.
    How to achieve honesty and continuity of care for those who need it most: the victims of medical negligence?

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