Letters from Maine

The team and I

Publish date: July 28, 2017

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

^{Tomwang112/Thinkstock}

doctor child exam

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

Dr. William G. Wilkoff

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

The team and I

Recommended Reading