better health by designLearn More

The simplest way to create a powerful first impression with your patients

 

The probability that your family doctor will need to make heroic efforts at your next visit is very low. That’s because you are most likely to go with a minor self limiting illness and the best she will be able to do is reassure you that the rash, cough, discharge or fever will resolve in a few days. She might recommend paracetamol, rest or exercise and above all apply judicious tincture of time. You will leave the room feeling better or decide that you have wasted time. Either way it will influence how you feel about going back to see that doctor and inform your opinion about whether it was worth the dollars you, the funder and or the government invested in that visit.

A desk, chair and a couch furnish most consulting rooms. How that furniture is arranged may have an impact on how you feel about being in that space. We know that posture, eye contact and verbal communication matters. However we might also consider that where we sit in a room, and what we sit on also influences the interaction. This is true of boardrooms but it also applies when there are only two at a desk. There are three factors in raising perceived status and power using chairs: the size of the chair and its accessories, the height of the chair from the floor and the location of the chair relative to the other person. Executive chairs, the kind the doctor might sit on are bought because they are perceived to convey authority. ( OK, may be also because they are comfortable). But nonetheless they create an impression:

The height of the back of the chair raises or lowers a person’s status…the senior executive has a high backed leather chair and his visitor’s chair has a lower back.

Therefore from the moment the person enters the room they glean the impression that they are less important than the person in another spot. Unlike the situation where the seating arrangements make the person feel valued.

Picture by Cacau & Xande

First impressions are the love-at-first-sight of the business world.

If you are a doctor have you ever considered letting the patient have the high back leather chair? How doctors position themselves physically relative to the patient matters. There is some evidence in the literature but there’s nothing better than trying it yourself.

Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. Swayden et al

The perception that the doctor is spending more time is important because in some cases there isn’t more time available.  There is not much doctors can do in the short term about healthcare policy or resourcing. However just by changing the seating arrangements in the consulting room they can convey to patients that they matter. That’s before they even begin the consult. I’ve tried it, I think it works.

Picture by banlon1964

What can hairdressers teach their doctor?

SONY DSC

I had to try a new salon and it was an incredible experience. A long scalp massage, warm towels for my hands and an aroma-therapy treatment (3 sniffs of an oil??) made me feel ultra-pampered. I marveled at Elysa’s ability to tame my mane. The Power of a Haircut

Every shopping centre in Australia also now appears to have a massage parlour.

Stiff, painful muscles? Treatment: Myotherapy. Cost: From $100. Some companies cover myotherapy treatments under their insurance. My body+soul

Each year Australians spend over $4 billion on complementary and alternative medicine (CAM) and visit CAM practitioners almost as frequently as they do medical practitioners. But the spending doesn’t stop there:

The national survey of Australians (18-64 years)…. found over the past four weeks Australians spent an average of $594 each on clothes, accessories, beauty products and cosmetic services.Victoria, the self-proclaimed fashion capital of Australia, is home to the biggest spenders, who spend 19 per cent more than the national average at $707 a month. New South Wales spent $669 on average, 13 per cent more than average, followed by South Australia ($618) and Western Australia ($616). Suncorp bank

On the other hand a family doctor or GP might charge $50 for a standard consultation. The Medicare rebate for this is $36.30, leaving a gap of $13.70 for Australians to pay out of their own pocket. The average amount an Australian pays out-of-pocket for access to a GP is $29.56 a year (averaged across Australia).

So it seems that we are willing to pay up to $100 for one massage, $90 for one hair cut but pay a third of that sum for the services of a GP over a whole year. (Note: people pay far more for a ‘specialist’). The Value Tunnel explains this because the price is a function of the alternative options and the perceived value of that good or service. On that basis the cost of personal grooming is greater than a visit to a family doctor. It may be perceived that the alternative to visiting the doctor in your neighbourhood is to pick one who doesn’t charge above the Medicare rebate, visit a pharmacy or go to an emergency department. There are fewer viable alternatives to a haircut or massage from ‘that’ salon. There is constant downward pressure in the ‘Value Tunnel’ so that as the market accommodates more competition it drives the price down. That’s why a cup of coffee costs less than $5 and is unlikely to increase.

untitled

What can GPs do to move up the Value Tunnel ? They must increase the perceived value while honing a niche market. While doctors no longer hold the monopoly on a range of things they also do things that others can’t offer. How can family doctors recast their brand in a way that sustains if not enhances the perceived value? Like every other business healthcare is subject to market forces. A recent survey offers businesses the following takeaways;

  • Know your customer and form a genuine relationship. What do the doctors know about their patients?
  • Make it easy for your customers to do business with you. To what extent are patients able to access what they need at the practice?
  • Solve your customer’s problems and go beyond what is expected. To what extent is the practice a one stop shop? What does the practice offer that other providers do not? ( Note: pharmacists and video consultations don’t include physical examination)
  • Look for opportunities to make an impression. Does the practice communicate well at every touchpoint?
  • Invest in your frontline staff; they are of course the face of your company, so it is essential that they happily reflect the core values you wish to promote. What are the reception staff like in the practice? Can patients be expected to be treated the same way by everyone they come across at the practice?

Picture by ndemi

Will patients ever benefit from dubious surveys published in academic journals?

Untitled

The headline in the newspaper was provocative:

One in 10 parents do not trust GPs with their child’s healthcare: survey

Three questions arise:

  • Is it new?
  • Is it true?
  • So what?

It didn’t resonate. Children under the age of fifteen constitute at least one in ten encounters with General Practitioners (Family Physicians). That means there are at least 12 million consultations with children in Australia every year. The notion that parents don’t trust their GPs is questionable. Even in the study reported by the newspaper most parents (91%) had a regular GP and more than one in three children had visited a GP at least five times a year. The conclusions reported by the journalist were based on a study in which 666 parents were approached in a paediatric outpatient clinic to participate in a survey by a ‘trained research assistant’ and offered $10 for participating.  The context is important given that the conclusions as reported in the newspaper headlines were about people’s views on GPs.

100 parents in each of five specialties and 50 parents in each of the subspecialties was the ‘target number’- but we are given no justification for that number. The validity of the survey depends, in part, on the sample size which is governed by what was anticipated to be the likely response.

The questionnaire was ‘developed’ by the research team and pilot tested with 39 parents across both hospitals. We are not told how the questionnaire was developed and refined or how the validity and reliability of the responses were tested. Nor are we told why piloting ceased at 39. No scientific framework is cited. Without this information the interpretation of the findings is speculative.

It is reported that only half of the new patients seen in the paediatric speciality clinics were referred by a GP. The remainder were referred by other doctors. Therefore these participants were receiving their care from specialists and hospital doctors and it is reasonable to assume that their views were influenced by this experience.

If we are to read on notwithstanding the limitations evident early in the paper we note that only 45% of respondents were ‘completely confident’ that ‘a GP’ can provide general care to their child. From the way the question is posed we don’t know why the respondents were not ‘completely confident’. It could be because they think:

  • A GP doesn’t have access to the resources their child might need
  • Their child has had an illness that requires specialist to monitor their care
  • A GP doesn’t offer appointments when it suits them
  • A GP doesn’t do blood tests, X-rays, scans or prescribe the drugs they think their child needs
  • A GP isn’t qualified to look after their child
  • Someone they trust told them their child should see ‘specialists’ every time

Our understanding of this paper depends on which of these was meant by the respondent but the question was never posed in a meaningful way. The paper does not report the perspective of either the referring doctor or the specialist about the need for that specific referral. Without that information we can only draw conclusions based on our perspective on the issues. We certainly cannot conclude that GPs need more training in paediatrics unless we were looking for an excuse to come to that conclusion. Why publish a survey that cannot be interpreted meaningfully?  The concept explored is not new, the data can’t be safely interpreted and the only question is so what? Who benefitted from this ‘research’?

Picture by KristyFaith

How can doctors remain the health practitioner of choice?

13397331035_dd80d2f94d_z-2

You work as a checkout assistant at a supermarket. It’s Thursday. You’ve got a sore throat. It started a few days ago. You’re sneezing, you’re tired, you’ve got a headache. You’ve taken paracetamol already today it didn’t take away all the discomfort you still feel dreadful. You have several problems.

You want to feel better. Secretly you may be concerned that this is more than just a cold. You want to reassure the people that you are going to be well again in a few days. You want people to understand and accept that you are not functioning at your best at the moment. You want it all now not next week when you might be better or worse.

You may want information but you probably also want to have your discomfort validated and acknowledged. You’ve got some choices to make. You can try and get a doctor’s appointment. You can Google the symptoms and treatment. You can go to the local pharmacy or to your favourite alternative health practitioner. You can also try the emergency department. What you choose will depend on your previous experience of a similar episode but also on what your friends and or family suggest.

Upper respiratory tract infections are among the commonest reasons that patients seek the services of a general practitioner in Australia. It’s a presenting problem in one in twenty consultations. In the majority of cases these infections are viral and don’t require a prescription from a registered medical practitioner.

On the other hand there may be a financial cost to attending a doctor. You will need to take some or all of the day off and you may be required to queue despite you physical discomfort and it is more than likely that the doctor will tell you what everyone has already suggested that you will probably feel better in a few days. Whether you consider it useful to attend the doctor will depend on whether your needs were met last time. How do you feel at the end of the consultation? Did you feel that your visit was welcomed and that you were treated sympathetically? Did the doctor listen to you? Did they examine you? How did they convey the news that there isn’t any curative treatment available? How did they make you feel about the decision to make an appointment at the practice?

If we consider that such ‘trivial’ problems could be managed by another healthcare practitioner then we are asking for one in twenty encounters in practice to cease. How do we convey this message to our patients.

Colds are generally mild and shortlived, so there’s usually no need to see your GP if you think you have one. You should just rest at home and use painkillers and other remedies to relieve your symptoms until you’re feeling better. NHS Choices

The challenge is that most of what the patient is likely to present with as a new problem is similar: bronchiolitis, gastroenteritis, sprain/ strain, viral disease, contact dermatitis, back pain, bursitis, solar keratosis/ sunburn, tenosynovitis, tonsillitis, vaccination. These conditions or problems form a substantial chunk of the workload.

What can doctors add to these encounters that would make them a worthwhile experience for patients? Not just what might be ‘evidence based’ but also perceived as useful by the patient? Experiences that will retain the doctor and not a pharmacist, nurse, chiropractor, naturopath, homeopath, Dr. Google or ‘McDoctor-dial-a-doc’ as the healthcare practitioner of choice. In Australia doctors have typically 15 minutes. Here are some possible value adds:

  1. Offer advice on weight loss and exercise
  2. Advise on smoking cessation
  3. Review the patient’s medication
  4. Promote cancer screening
  5. Advise on vaccinations
  6. Examine the patient
  7. Document any possible risk factors for chronic illness
  8. All of the above

Back to the checkout assistant who is feeling dreadful, wants more than anything to go home after sitting in your waiting room, nursing a fever and a runny nose. It’s up to you of course but it I know which of the above I would want my doctor to do at that time. Patients tell it as they’ve experienced it and research has suggested what they are willing to pay for.

Picture by Tina Franklin

Practitioner income as a function of Freakonomics

According to headlines this year more than one in three GPs in Australia report feeling somewhat or very dissatisfied with their income. Two things determine health practitioner income:

  1. What is a (funder / government / insurer) willing to pay?
  2. What is a (patient / customer / client) willing to contribute?

What is beyond doubt is that when it comes to their pet’s healthcare the Australian public is very willing to pay. In fact Australians would alter their spending habits rather than compromise their pet’s quality of life.

Of the 2,500 Australians, aged between 18 and 65 that were surveyed in the 2015 Financial Health Barometer, only 14 per cent of pet owners would reduce spending on their pets if their income dropped Remarkably, almost half (48 per cent) of respondents would take steps to minimise their power usage. We’d be more likely to reduce spending on essentials (47 per cent), switch to using cheaper products (35 per cent) or look for additional work (16 per cent) rather than curb spending on our furry friends. Hayley Williams.

Similarly spending on beauty treatments is remarkable:

The online survey of close to 1300 Australian women was conducted by Galaxy Research and commissioned by at-home hair removal brand Veet.
And, while 10 per cent of the women surveyed spent $5000 on average and and almost 60 hours in the beauty salon annually, 40 per cent admitted to putting their beauty regimens ahead of sleeping, shopping and their social life, with 4 per cent of those women also choosing a salon visit over their sex lives.

In contrast national statistics document that a significant proportion of Australians are reticent to seek healthcare because of the perceived cost. It was not surprising that a proposed $7 co-payment proposal for general practitioner visits in Australia was dumped before it was enacted.  It is evident that some doctors get paid far more than others. Secondly some parts of the country attract more doctors but as a general rule where there is a scarcity, by dint of geography or specialisation, it is more likely that doctors will earn more.

What people are willing to pay for health care is a function of economics, or perhaps “Freaknonomics” (study of economics based on the principle of incentives.) From this perspective “incentives matter.” Consumers try to maximize total satisfaction, while providers try to maximize profits. Whenever there are a lot of people willing and able to perform a job, that job doesn’t pay well. In a capitalist society, intense competition will drive prices down. When a technological advance occurs, it results in a shift of the supply curve to the right. All other things equal, this will lower the equilibrium price of a good, which then increases demand. Both producers and consumers need to be fully informed regarding their consumption or production decisions for a market to be efficient.

So how might this apply to primary care? 

  1. There are more doctors per head of population than ever before- in other words more people willing and able to perform the job- especially in primary care.
  2. There is a global trend in developed economies for “alternative providers” for primary care services- including vaccination, cancer screening and treatment of ‘minor’ illnesses.
  3. Technology offers new ways to ‘consult’ a practitioner other than by having practitioner and patient in the same room.
  4. Because of the internet doctors no longer hold the monopoly on information.

So doctors’ incomes in primary care experience downward pressure because suppliers of the services are increasing. We might therefore consider what people would consider paying for a consultation at a doctors’ clinic. Research published in 2008 (Annals of Fam Med) offers one perspective:

  • Overall, patients were willing to pay the most for a thorough physical examination ($40.87).
  • The next most valued attributes of care were seeing a physician who knew them well ($12.18),
  • Seeing a physician with a friendly manner ($8.50),
  • Having a reduction in waiting time of 1 day ($7.22), and
  • Having flexibility of appointment times ($6.71).
  • Patients placed similar value on the different aspects of patient-centered care ($12.06–$14.82).

It seems that two sectors (Pets and Beauty) appear to have no difficulty with their income. What might they have to offer by way of advice?

  1. The art of creating added value starts with the ability to see your business through the eyes of your customers.
  2. Although the debate over whether the customer is always right (or not!) continues, lack of customer satisfaction is a sure-fire way to keep people from coming back.
  3. Implement marketing models into your strategy.
  4. Most importantly, memorable customer experience models aim to deliver unexpected intangible value that cannot be packaged or sold. This includes personalized service, attention to detail, and showing a sense of urgency to address concerns as they arise.
  5. Whether it’s a free guide, a printable PDF, or a company branded calendar, free resources are a great way to create added value and showcase your brand’s ability to offer ‘a little something extra’ to customers.

In the case of healthcare the ‘customer’ is not just the patient but also the pay master. These ideas may need to be translated for this sector. In many cases it probably already has been. However for others there is something to learn from how successful businesses add value that translate into better rewards.

Picture by Pexels

Clinicians can make a bad situation worse

He looked unremarkable.

I’m tired all the time. Otherwise I’m well he said smiling. No symptoms. Could eat more healthily I suppose. Don’t like alcohol and don’t smoke. Not losing weight. Can fall asleep on the couch at 11 in the morning. Not been anywhere abroad. Like going to the footy but don’t do much exercise.  Am not interested in sex. I want to rule out a physical cause.

His notes were scant. He’d consulted a few times over the years. Mostly self limiting conditions. A previous normal blood pressure was recorded. He wasn’t overweight. No psychiatric illness. No medications. We quickly went through every system recording a lack of any specific symptoms. Then paused.

Me: Are you married?

Him: Yes

More conversation about his children and his job as a retailer. His lack of exercise and his junk food diet.

Then we started talking about the elephant in the room.

Me: When did you start to lose interest in sex?

Him: It’s going on for a while. I’ve tried Viagra and that didn’t work. I’m moving out of the house tomorrow, we are trying a separation. We have been attending a counsellor and I just want to rule out a physical cause.

I was thinking.

So you don’t think that this might be contributing to your tiredness?

I bit my tongue. We went on to establish that he did not have ‘erectile’ dysfunction. From the history he had no difficulty achieving and maintaining an erection when he was on his own. His poor performance in the marital bed was not related to a physical cause. However the counsellor had sent him along just in case it might help the situation to be able to disclose that the relationship was suffering from some readily identified and treatable physical problem.

The consultation could have gone in another direction. I had a range of tests at my disposal that could have led us down any number of dead ends. We might even have discovered an incidentaloma to add to the confusion.

Sexual dysfunction is thought be to present in thirty five percent of male patients. It takes a bit of proactive questioning to get disclosure.

Despite this, sexual problems were recorded in only 2 per cent of the GP notes. Read et al

We were not going to solve the mystery on that occasion. I did a physical examination. It was normal. The hammers in my tool kit were put away, this wasn’t a nail. When it comes to sex, humans are complicated:

Research findings have implicated 5 factors that seem to differentiate sexually functional Ss from sexually dysfunctional Ss suffering from inhibited sexual excitement. These factors include differences in affect during sexual stimulation, differences in self-reports of sexual arousal and perception of control over arousal, distractibility during sexual stimulation, and differential sexual responding while anxious. David Barlow

I couldn’t establish what went on behind closed doors or in his mind at that time. We wouldn’t be talking about that but it was of critical importance to this man’s well being. This couple would get the help they deserved but it would take a recognition of the limitations rather than the expertise at my disposal that would assist them.

Picture by David Goehring

Why doctors say ‘it depends’.

She looked harassed. She flung herself into the chair.

I’ve just about had enough. This cold is driving me mad. I’m coughing all day. Nothing helps. I’m still working for that pig of a man and we are short staffed this winter. I’m not sleeping at night. The kids are all down with this bug and my husband is on night shift. I can’t go on like this.

She left with a prescription for amoxycillin and a seven-day course of hypnotics. She also agreed to come back the following week to report on her progress. The consultation included a conversation about the natural history of viral illnesses and advice to defer the antibiotics, a discussion about her job as a reluctant telemarketer who left school without any qualifications and how to promote restful sleep. The only part of the consult that could be easily audited were the prescription data. The ‘real’ issue was not a microbe it was the milieu.

It is possible to publish papers in prestigious journals demonstrating that clinicians deviate from the evidence base. The list of misdemeanours is not insubstantial:

If you were a clinician you might say:

I never do that.

In which case you might reasonably be asked to outline your goals for consultations. If we accept that it is to be celebrated that people are free to make choices good or bad then we must accept that people smoke, eat more than they need, work in occupations that make them miserable or under bosses who are tyrants. They may choose to remain in abusive relationships or be addicted to drugs, alcohol, pornography or gambling. They are free to make choices but they must also live with the consequences of those choices. Eventually in most cases people will consider alternatives. The role of the clinician is to try to make that sooner rather than later whilst keeping channels of communication open.

The clinician advocates for the patient. In which case the answer to the question ‘would you do this’ is more likely to be:

It depends on the circumstances

You aim ‘never’ to cause harm. To avoid that which will diminish the patient’s choices by engendering physical or psychological adverse outcomes. Technological medicine can and does harm. However what is seldom reported is how the practitioners of the art of medicine help people to cope with life, not just today or tomorrow but in the longer term. That precludes slavery to ‘evidence’ that was never indicated for the very specific circumstances in which a person presents on one occasion. Compassion is not weakness. There is a narrative behind decisions in practice and simply reporting data does not present the whole story.

Picture by Vishweshwar Saran Singh

Cases too complex for a specialism other than general practice

It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:

I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.

I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:

No organic pathology. Refer elsewhere.

A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:

Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:

  • Birth trauma.
  • Injury from stretching.
  • Pressure from tumours.
  • Damage from radiation therapy.

Brachial plexus neuropathy may also be associated with:

  • Birth defects.
  • Exposure to toxins.
  • Inflammatory conditions.
  • Immune system issues.

There are also numerous cases in which no direct cause can be identified.

We also know that:

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia

Diagnosis is difficult, tests and examination can be normalprognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.

While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al

Picture by Mahree Modesto

An illness is never minor when you’re ill

After 20 years in practice I’d never seen one of these in my career. Until that day. It’s called a quinsy. Essentially an abscess deep in the throat. Not really surprising because according to a recent review:

Most patients with quinsy develop the condition rapidly, and many do not present with a respiratory tract infection to their GP first. BJGP

The incidence is estimated to range from 10-41 cases per 100,000 per year. It’s unusual to see a case in practice. Given Australia’s 23 million people you’d expect an incidence of about 2,300 cases per year nationwide. Similarly I consulted a young child with nephrotic syndrome, similar incidence (3.6 per 100,000). Both cases were referred to hospital as emergencies. The odds of seeing one of these is in the same order of magnitude as being struck by lightening in your lifetime.

On the other hand in the same week I saw several people with:

I also saw a victim of domestic violence:

Just under half a million Australian women reported that they had experienced physical or sexual violence or sexual assault in the past 12 months. Domestic violence prevention centre.

And a drug seeker:

Australian GPs write more than 15 million prescriptions per year for drugs known to be misused, with the main prescription drugs misused currently being narcotic analgesics and benzodiazepines, as well as stimulants, barbiturates and other sedative–hypnotic agents. Martyres et al

So apart from quinsy and nephrotic syndrome (both of which I recognised) I spent most of my week managing conditions that didn’t need to be referred to specialists.  And yet the people who were offered reassurance or simple and effective treatment for their ailments were immensely grateful. Every day general practitioners provide this service to the community. They save lives by identifying people who need urgent care but much more than that they make the lives of the community so much more tolerable. There is no such thing as ‘minor illness’.

The last word has to be on pityriasis rosea:

I finally found out what the rashes on my back, arms, torso, and now my foot are. I have herolds patch too. I hate it! I can’t stop scratching. It took 1 hospital visit and a trip to my doctor to find out what this thing was. The doctor at the hospital thought the big round patch was a ringworm and he thought all the other small rashes that had just appeared was scabies. I was terrified..did some research on scabies and tried to treat that myself. Then I decided to just go to my doctor and he told me it wasn’t scabies…and showed me a picture of hereld’s patch. He knew what it was right off the bat. I guess there is no cure for it and it just goes away by itself. I just wish I could take something so I can stop scratching. SkinCell forum

Picture by Col.Sanders

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