Continuity of Care

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.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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