Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and Family Physicians in England and Wales, the United States, and the Netherlands

Only three segments of family practitioners are studied. The scenario is different in different parts of the world besides those where this published study originated. The family doctor is supposed to be the first contact physician and gate keeper for secondary care; still he has a vital role in a comprehensive health care delivery system. Many nations ought to introduce the family practice chair in medical colleges.

Models like those in Pakistan and Sri Lanka have to be developed. Unless the policy makers stress the need for family practice this segment of GPs will disappear from health care amid vast expanding super- specialisation. Let us not ignore General Practice as a cost of specialisation. Primary care physicians have greater responsibility and a major share in health care delivery when compared with specialists. This is very much true when we talk about cost effective treatment. They form the heart and soul of health care in many developing countries.

This is a good study. As a post graduate in family medicine I endorse many of these views. My sincere appreciation for the authors and journal.

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The Family Practitioner is a personal doctor and health care provider for the members of the families he looks after. He is the first line and first person to be contacted regarding any health problem and that depends on the trust and doctor patient relationship, this trust and relationship could not be built without continuity of care and multiple contacts between the patient and same doctor. Imagine if the patient has to explain his problem everytime to a different doctor, how would he feel? Imagine if the patient/patients has/have to go looking for the specialist in the hospital to ask him a question regarding his condition or his medication, even over the phone, what will happen then? From my experience most patients need a family practitioner/GP,whom they trust to put them on the right track to solving their health problems and to be a reference for them in discussing and explaining the investigations, medications and follow up laid down by the specialist because most of the time no or very little explanation given to the patient. All that impose an immense responsibility on family practitioners to read and be updated in almost all medical specialities, which is very difficult!! To talk about the importance of continuity of care in few lines is very very difficult but it is, from my personal experience here, the most important medical service could be offered to patients who need sympathy and HEALTH EDUCATION.

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Having retired after some 45 year in General Practice (in the original sense of that term), I am really surprised that such a question should be raised. I was extremely lucky in having excellent relationships with "MY patients". After I had retired from full time practice, several of them drove (some 300 kms) to where I only worked part time - just to see me! Needless to say I was thrilled and delighted that I had managed to inspire such trust. I miss it all, but have now retired for the third and last time! However, my point is that patients deserve and NEED proper and continuous care, and must have someone who knows them, their family, their circumstances and who can be trusted.

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My Internal Medicine physician, and GI specialist have been my doctors since 1985. My eye doctor has been my doctor since 1976. My allergist has been my allergy doctor for 13 years. Continuity of care in all my physicians is very important to me, to the point that I am willing to pay extra for freedom of choice. I pay extra co-pays, and a larger portion of my bill, as well as a higher bill for my insurance.

Since I work in a hospital setting, where I could receive free services, you can see that I am willing to make a significant financial sacrifice to have continuity of care with a doctor of long standing, whom I trust. I don't want a physician who changes every year, as my insurance plan changes. If that happened, I would not go to the doctor until I had to go to the emergency room.

I believe that I am more compliant with treatment and preventive measures and tests, because I have a long term relationship with the physicians, and trust them. The personal doctor is still very important, because even though, I have two Master's Degrees, he provides me with basic information, information to make informed decisions, referrals to doctors he trusts and respects, etc. He is concerned about me as a person, the whole person, not just my vital signs.

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Stokes et al. provide results from a multi-national survey of general practitioners to assess perceptions of the importance of personal continuity of care. The underlying premise, expressed in the title of this article, “Continuity of Care: Is the Personal Doctor Still Important?” is that continuity is a part of the historical bedrock of general practice and therefore retains unique importance. This premise is a hindrance to rigorous scientific evaluation of the role of continuity in patient outcomes – a question that remains unanswered for many of us.

From these results, the authors caution policymakers, who may place relatively low priority on personal continuity, to consider this issue when redesigning health care systems. It may be more appropriate instead for policymakers, who must focus on devising systems to improve the health of the public (rather than the satisfaction of those providing care), to persist in asking questions that challenge such basic assumptions about the ways in which physicians provide care. Indeed, with the increasing use of electronic medical records and team-based approaches to care in primary care settings, it is all the more important that alternatives to personal continuity (i.e., informational and/or management continuity) be carefully examined. The argument that personal continuity cannot be replaced, in advance of such research, seems premature.

The key question that might support system redesign to promote greater personal continuity between provider and patient has, to date, not been definitively answered: are patients’ health outcomes consistently improved when they have greater continuity with a single provider? Evidence so far has been mixed. Until this is known, advocating for the needs of a satisfied provider without considering the needs of the patient seems short-sighted, professionally self-serving, and antithetical to patient-centered care.

Competing interests:   None declared

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General practitioners and family physicians value the relationships they form with their patients over time. I’m not surprised at this finding by Stokes et.al. in their survey of doctors from England and Wales, the Netherlands, and the United States. It fits with my personal beliefs about interpersonal continuity of care as well as previous research on this subject.

One interesting and more surprising part of this study is data presented in Table 5 regarding the “extent to which GPs agree that the provision of personal continuity of care to their patients can be substituted for by other types of continuity.” It appears that on average US FPs disagree with this statement, while GPs in England, Wales and the Netherlands neither agree nor disagree. Not knowing much about the inner workings of health systems outside of the US, I wonder what accounts for this difference. Could it be that US FPs overvalue what their relationships with their patients add to their patients’ health or could GPs from England, Wales and the Netherlands undervalue the healing power of the doctor-patient relationship? There is interesting data on continuity’s higher value for patients with chronic illness (1); I wonder if there are significant differences in the patient populations cared for by physicians in different countries.

Another point in this article that gave me pause was the simple analogy made by one respondent:

"People prefer to visit the same dentist and hairdresser, why should they be maneuvered into seeing any doctor? Medicine is personal. Patients don't want to be examined by a series of endless of strangers."

When one sees health as an intensely personal issue rather than simply a collection of data points, it follows that simply having access to all of the data cannot substitute for the nuances and emotions involved in a personal relationship between a patient and a physician.

We now have evidence that physicians as well as patients (2) prefer interpersonal continuity. We also have evidence that such continuity improves quality of care (3). I believe we can stop wondering whether we should strive for interpersonal continuity of care between doctors and patients. Let’s instead study how best we can achieve it.

1. Love MM, Mainous AG, 3rd, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract. 2000;49:998-1004.

2. Saultz JW and Lochner J. Interpersonal Continuity of Care and Care Outcomes: A Critical Review. Ann Fam Med. 2005; 3:159 – 166.

3. Saultz JW and Albedaiwi W. Interpersonal Continuity of Care and Patient Satisfaction: A Critical Review. Ann Fam Med. 2004;2: 445 - 451.

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Hooray for continuity of care. Family Physicians in the 3 countries studied value it highly. Patients do too, an even more important finding. What impresses me is how much continuity is valued in a traditional practice of episodic visits. Patients and personal family physicians have an intuitive sense that each are "out there and available" when needed. Having a personal physician is right up there with having family and friends. Being a personal physician makes being a family physician most rewarding. We see the urgent care and emergency room docs burn out and often seek experiences with continuity of care.

The best is yet to come as continuous access to electronic communication enters medical practice. The telephone is important, but it has the many inconveniences of trying to connect two parties who are usually unscheduled to connect. Asynchronous open communication from the patient's home adds a whole new layer of continuity, done at the mutual convenience of physician and patient. I've been doing this for 8 years now, and it allows a part time clinician to feel like Marcus Welby again. I hope family medicine eventually embraces electronic communication with patients as a supreme manifestation of continuity of care.

Competing interests:   None declared

This study reemphasizes the value of continuity for GPs across different health care systems and provides some evidence under which circumstances the attitude of GPs towards continuity might be influenced. Considering the body of evidence supporting continuity why should we drop it? Who´s interest would it be? In fact, is it in the interest of anybody or rather the consequence of ignoring the impact of continuity on patients, physicians and health care systems? While reducing total health care costs, does the provision of continuity need more money to reimburse the physician offering it? Are there political or ethical reasons to minimize ongoing clinician-patient- relationships? I rather suspect that our research results such as those about continuity of care are not made known efficiently enough to the public, the politicians and the profession alike. Therefore, continuity of care should be included into the main goals of all players BEFORE redesigning health care systems and the structure of their primary health care base.

Competing interests:   None declared