Continuity of care was once a mainstay of the general practitioner. A recent study published in BMJ Open, a peer-reviewed medical journal, shows that continuity of care reduces patient mortality. Continuity even improves outcomes for specialist physicians and surgeons. Unfortunately, the trend in medicine is that delivery of care has become more fragmented with different parts of a patient’s care being rendered by multiple providers.
The patient-physician relationship has been largely replaced by a patient-medical team relationship. While using a patient-team approach helps with appointment availability and throughput (the number of patients seen per hour), the erosion of the patient-physician relationship has resulted in poorer outcomes. The emphasis on science has caused doctors to overestimate their effectiveness when consulting with patients they do not know and underestimate their effectiveness when consulting with patients they know.
Even though healthcare has moved toward evidence-based treatment and medical technology is constantly providing new techniques to diagnose and treat disease, the patient-physician relationship is important because not all disease is reducible to numbers and pictures.
Medicine, both art and science
Medicine is both an art and a science, and they are inseparable. Medicine is an art, because the physician must deal with a human being’s body, mind and soul. A patient’s outlook about a treatment often influences the success or failure of treatment. Medicine is also a science because we can measure many aspects of disease and health — but not all. Diagnostic and treatment certainty exists about half of the time. When a physician is unsure of the diagnosis, empirical treatment and patient feedback guide treatment. The “let’s try this and see if it helps” is still a part of “modern” medicine. When a patient cannot be diagnosed by the numbers, the feel for the patient that a physician gets with continuity of care, and the trust the patient develops in the physician, come into play and guide treatment.
A better interpersonal bond between the physician and patient encourages disclosure because patients perceive a doctor they see regularly as more responsive. They are more willing to disclose sensitive personal information, which can help the physician tailor care to the needs of the patient.
Personalized medicine requires that the patient be part of the treatment decision process — the benefits, risks, discomfort, time and cost of alternative treatments differ. Medicine is not a one-size-fits all commodity. When a physician knows a patient, subtle changes in a patient’s demeanor can often be recognized, leading to changes in care; this can only be accomplished by the same physician seeing the same patient.
Importance of following a patient over time
Another benefit of continuity of care, which the BMJ article did not address, is how continuity also gives the physician a “physical feel” for the patient. Subtle changes in a patient’s condition are only detectable when the same physician has seen and followed the same patient over time — whether a period of days during a critical illness or a period of months when treating chronic diseases. Past interactions provide a reference point for the physician to detect subtler clinical changes in a patient and provide intervention earlier. One example is the detection of subtle changes on an abdominal exam of a patient with acute abdominal pain. Tenseness of the abdomen to hand palpation over time can be best appreciated by the same hand of the same physician repeating the same examination.
Diagnostic tests can be ordered, such as CT and MRI, to assess changes in condition, but they are expensive and by the time something can be seen, valuable time can be lost. The science of medicine cannot replace the feel the physician gets for the patient when there is continuity of care. It is the feel for the patient that makes medicine an art and a science.
That continuity of care provides for better outcomes and is associated with lower mortality should be no surprise. Older physicians know this all too well. Unfortunately, modern medicine has moved toward more fragmentation, not less. Insurance companies are reluctant to pay physicians for the time required to take a thorough history, perform a complete examination, and learn about the patient because such time is not as easily accounted for as a test or imaging study. Solo practitioners are going the way of the dodo as they are being replaced by provider teams.
While modern medicine may increase the delivery of care, it does so at the expense of the patient-physician relationship. Continuity of care must be maintained for the physical and mental well-being of patients, and this requires recognition that there is no replacement for knowing the patient.