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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The Need for an Ecological/Systemic Perspective on Continuity of Care
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Robert C. Like, New Brunswick, New Jersey, USA Associate Professor of Family Medicine, UMDNJ-Robert Wood Johnson Medical School
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TRACK Online Discussion Forum Comments relating to: Nutting PA, et al. "Continuity of Primary Care: To Whom Does It Matter and When?" Annals of Family Medicine 2003; 1(3):149-155. This is an interesting and well-done multimethod study that adds to the continuity of care research literature in primary care settings. The authors' major finding that "continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients" is certainly consistent with other published results. Given the increased interest in practice-based research and the need for thinking about clinical practices from an ecological/systems perspective, it would be interesting to know if the authors were also able to examine questions such as: (1) How did patients' valuing of continuity of care vary both within and/or across different practice settings?; (2) What value did participating physicians and/or practice teams place on having continuity of care?; and (3) How important is continuity of care as a predictor of patient satisfaction along with other interpersonal clinical encounter characteristics (verbal and nonverbal communication behaviors, request fulfillment, etc.)? The authors also point out the relevance of context and circumstances, and it would be interesting to see a triangulation of their qualitative and quantitative findings to provide a "richer" and "thicker" description. That is, it would be useful to move from the idea of "continuity of care" (noun) to "continuities of caring" (verb) in order to develop a more grounded, dynamic, processual view of clinical encounters and episodes of care. Finally, as the authors point out, there is a need to study the continuity of care experience in diverse populations, especially given national and state efforts to eliminate racial and ethnic health disparities and provide more culturally competent care. If "vulnerable patients" have never had access to a "medical home" or "personal physician/health care provider," but have made use of emergency departments, had fragmented care, or received limited or no care at all, I would not be surprised if future studies were to find lower valuing of continuity of care. We will need to be very careful not to stereotype or overgeneralize based on these results because continuity of care may prove to be an "acquired taste" for those who have not yet had the opportunity to experience it. Historical, institutional, societal, and environmental barriers to care as well as the various "isms" (racism, ageism, sexism, classism, heterosexism, ableism, etc.) need to become more fully integrated into ongoing research about both "continuity and discontinuity of care." A fundamental question that the late Brazilian educator Paolo Freire might ask is, "Whose interests are being served by providing (or not providing) continuity of care?" Robert C. Like, MD, MS Associate Professor and Director Center for Healthy Families and Cultural Diversity Department of Family Medicine UMDNJ-Robert Wood Johnson Medical School October 13, 2003 Competing interests: None declared |
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