Family Practice Vol. 18, No. 4, 461-462
© Oxford University Press 2001
Continuity of care revisited
Associate Professor of Rural Health, PO Box 5695, Wagga Wagga, NSW 2650, Australia
A concept revisited by Douglas Fleming [WONCA News 2000; 26(6) x–xi] requires some comment. Having been at the presentation and having been on the expert panel at the end of the day, I guess it would be fair to say that Dr Fleming's viewpoints were resonant neither with the majority of the conference participants nor with the panellists.
However, more importantly, it needs to be pointed out that the dimensions of continuity and their characteristics are misquoted in several ways. Hennan1 only described four dimensions (not seven), the information aspect being seen as the means of achieving those; Roger and Curtis2 added the other three. It should also be noted that the interpretation of the meaning of these dimensions is rather selective; the attached table summarizes the original authors' meaning.
Dr Fleming's concern about being able to implement personal continuity is one to be shared. The point that "continuity can be delivered on a personalized doctor– patient basis is a myth", however, has to be rejected. As Hennan, and Roger and Curtis pointed out, the personal dimension is the essence of the concept. Practices need to have the mental strength as well as the organizational structures to encourage and nurture predominant personal continuity of care within their institution.
Dr Fleming rightly points out that patients these days exercise discretion in choosing a doctor. To say that "In the final analysis, choice is the negation of continuity, if the notion of continuity is ‘individually’ rather than ‘team based’" oversimplifies the equation of the doctor– patient relationship. Rather than the old autocratic way imposing continuity, doctors of the 21st century have to earn themselves the right to be a personal physician.
There may be no direct evidence that personal continuity of care demonstrates health gains; there is, however, plenty of indirect evidence most of which has been provided by Per Hjortdahl. The challenge to GP researchers interested in continuity will be to provide the direct evidence.
A point of contention is the notion that good record systems are more important than personal knowledge about the patient. Reviewing the literature about medical records shows that medical records provide an adequate approximation of what happened in the consultation but do not record the finer points of the doctor–patient interaction, which in an ongoing relationship form the doctor's tacit knowledge about the patient, his/her family and the community.
The last point to be made is one of judgement about the patient's as much as the doctor's expectation of what medical care can ‘truly’ offer—is it cure or is it care. For medicine to survive, we should recall Feinstein's3 remarks about the virtues of the clinician "A clinician's privilege and power in clinical therapy is his ability to make both the therapeutic and the environmental decisions concomitantly. The clinician combines treatment for the patient, as a personal case of disease, with concern for the patient, as a personal instance of mankind, into the unified mixture that is clinical care . . . The care of a patient is the ultimate, specific act that characterizes a clinician".
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References
1 Hennan BK. Continuity of care in family practice. Part 1: dimensions of continuity. J Fam Pract 1975; 2: 371–372.[Medline]
2
Rogers J, Curtis P. The concept and measurement of continuity in primary care. Am J Public Health 1980; 70: 122.
3 Feinstein AR. Clinical Judgement. New York: Robert E Krieger Publishing Co., Inc., 1967.
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