Continuity of care is a good thing right?

There’s a wonderful video that illustrates the point I’m making this week. You can see it here.

It is assumed that continuity of care is a good thing. That if you consult the same doctor every time then you will benefit with better health. We all have relatives who insist on seeing the same doctor every time. No one but Dr. X will do. Yet doctor X has all sorts of interesting approaches to their problems and despite knowing Aunt Mildred for years hasn’t twigged that her latest symptoms may be a manifestations of some family drama. She might suddenly be more bothered about her aching hip because Uncle John is making her miserable or making her carry the shopping on their visits to the supermarket.

So, is there strong evidence that people who consult the same doctor at every visit are:

  1. Less likely to be prescribed inappropriate drugs or have unnecessary tests?- Maybe.
  2. More likely to have symptoms of life limiting illness recognised early?- Not really.
  3. More likely to be counselled about poor lifestyle choices addressed?- Maybe.
  4. More likely to be screened for chronic illness? – Maybe
  5. More likely to be immunised?- Maybe.
  6. More likely to have better outcomes from chronic illness?- Maybe

The evidence is equivocal at best. Even the most ardent supporters of continuity conclude that there is ‘lots more research needed’.

So what does that tell us?

Perhaps it suggests that simply because people choose to see different doctors does not necessarily mean they are opting for, or receiving, inferior care.

When it comes to test ordering ‘walk-in’ patients are not necessarily after tests and there is some evidence that those doctors who order tests in the hope of ‘satisfying’ the patient are misguided.

There is lots of evidence that ‘continuity of care’ increases trust in a doctor. As per the example of Aunt Mildred. But there is no evidence that Aunt Mildred will be better off trusting her doctor because ‘trust’ ( which isn’t consistently defined) does not guarantee better outcomes. If Aunt Mildred attends here GP presenting with symptoms of bony metastases and is referred for urgent investigation because her GP recognises the clinical signs then she will have been well served regardless of whether she attends Dr. X, Dr. Y or someone at another practice. The point is one of them should spot the moonwalking bear.

Picture by torbakhopper

5 thoughts on “Continuity of care is a good thing right?”

  1. You are actually mistaken. Having a “usual source of care” reduced costs, improves outcomes and increases efficiency of the system as a whole. This data goes back to the work at Hopkins in the 1980’s and should be treated as common knowledge. Last year’s Annals of Family Medicine article even suggested that the benefit persisted regardless of the evidence based perspective of the provider, much to my dismay. And mortar, more research is ALWAYS required. That is how science works. And a hypothesis regarding continuity of care is to be continually tested, which is why contradictions emerge from time to time. Nuance is a difficult thing.

  2. I wonder if the evidence was collected after the upsurge in e-records. In my case, continuity led to diagnostic over-shadowing and assumptions about my health based on my appearance.

  3. Thank you Dino,
    I don’t believe anything can or should be taken for granted- that’s the essence of a scientific approach. Not to decry the need for ‘more research’ but to point out that the evidence for something that is ‘treated as common knowledge’ is inconclusive. The experience of people in many parts of the world where you have no choice but to attend one practitioner is that they come home with requests for X-rays, scans, antibiotics, antidepressants and statins when they are not likely to benefit. What seems to have established as conventional wisdom is that seeing the ‘same practitioner’ is an acceptable proxy for evidence based care, efficiency and cost effectiveness. There is much empirical evidence that the emperor is naked. In Australia one in three people consult a different doctor every time they need healthcare. Some of us would argue that this is not a bad thing of itself. What evidence exists resonates with practice that spending more time with patients leads to better outcomes. In Australia we need to argue for increasing the focus on the time spent with patients- that’s how we bill medicare- and not on forcing people to see the same clinician every time.

  4. Back in the day, as a senior RMO at the QVH in Melbourne, I was so desperate for continuity of care I’d ask people to come back to the A&E department for review on a day I was rostered on duty. With lots of current patient histories going back to the last millennium, they’ve become old friends. This contributes a whole lot to work satisfaction and everything which flows from that. The service and quality of care still have to be good, to retain customers.

  5. Agreed James! Trouble is patients are often very poor judges of good service. The good GP might not prescribe, refer or test because it is unhelpful if not harmful. But good old doctor Jones always does and may well have a long list of appointments because people see him as the one who ‘does’ things.

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