Resolved.

The power of continuity in medicine.

The first physician I shadowed worked in the emergency room.

He’s a fun-loving military physician who’s caring and attentive to his patients.

I loved the quick pace and the instant gratification that comes with solving people’s problems in real time. But I would often find myself wondering about the patients in the days following a shift: had they continued to improve? Were they out of the hospital? Did they make it to the wedding?

That’s when I realized if I became a doctor, I wanted to have more continuity with my patients. I wanted to know what happened. And, eventually, that’s part of why I became a family doctor.

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Now that my practice has been open for almost 2 years, I’ve been able to start seeing the fruit of continuity in my practice. Relationships with patients are a little deeper as we continue to get to know each other and our “values, goals, and dreams” as one mentor likes to put it. Follow up appointments often feel like coffee with a friend. Imagine an afternoon filled with coffee-with-a-friend meetings. It can be pretty great sometimes!

As more and more patients come in for annual exams (i.e., I’ve been caring for them for a year or more), it’s brought to my attention a benefit of continuity in family medicine that comes with more long-term relationships: being able to resolve problems.

While many of us docs love the instant gratification that comes with the suturing a wound or treating a cold, I’ve been rediscovering the more delayed joy of resolving problems has its own, unique satisfaction. Much like the victory of a marathon that required months of preparation and investment of effort: there’s just something different about the wins when you’ve really dedicated yourself to the outcome.

On my EMR, each patient’s chart has a list of their “problems”. As a part of annual exams, I like to review that list to see the progress we’ve made. Under each problem, there’s a little drop down option to edit the problem, remove the problem, or resolve it. I love clicking “Resolve it”. And often, given the interconnectedness of health problems, we’re resolving more than one at the annual exam. I like to show the patients my screen and share in the fun moment of hitting that button.

Of course, when new patients come in with a list of problems, I’m quick to say, “We’ll work on this together. And, I’m not God.” That is, there’s always hope, but I can’t make promises.

A friend shared that mantra with me once (i.e.,“I’m not God”), and it’s been an incredibly helpful part of my practice approach. It takes the pressure off of the physician for being omniscient while helping us focus on what we do know, as I’ve written about in a prior blog. It lets patients know I’m on their team, I’m rooting for them, I will offer my best effort to help, AND ultimately I do not have all the answers or power to heal. Unfortunately, some problems I will not get the joy of resolving with that patient - but hopefully another physician or person or God will share in that healing.

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When it comes to continuity, the science is clear: it’s good for patients and it’s good for physicians.

Continuity of care refers to seeing the same physician over time for healthcare. More continuity of care is associated with:

• Lower all-cause mortality

• Fewer hospitalizations

• Reduced healthcare costs

• Fewer emergency room visits

• Improved chronic disease management

• Higher patient-reported quality of life

• Improved quality of care

• Improved health of the community

Not only is more continuity of care good for patient health, the loss of continuity (e.g., primary care) is associated with worse health outcomes and increased healthcare utilization.

“Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review.”

-American Academy of Family Physicians

For example, consider a patient with recurrent sinusitis. The patient may go to an urgent care and be treated for the same issue every month or two. If the patient were seeing their family doctor, that doctor would typically make note of the recurring issue and set up an appointment to better address and heal the problem, as well as prevent the potential harms of recurrent antibiotic exposure and infections.

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Factors that Affect Continuity

Unfortunately, with volume-based care (i.e., health insurance incentives) and our general emphasis on efficiency and immediate service in our healthcare system, patients are choosing more and more to be seen at an urgent care or by another doctor vs their family doctor for acute illnesses.

A recent study published in Annals of Family Medicine reported that while the majority of patients prefer to see their family doctor for annual exams, chronic disease management, sensitive exams, or mental health conditions, patients prefer to see any available clinician for new or urgent symptoms (82% and 92%, respectively). And this isn’t a purely American healthcare trend - similar results were previously published in an Australian study. Patients prefer efficiency when it comes to acute illness, but at what cost to long-term health?

Volume-based care (e.g., health insurance-drive care), is a set-up for lack of continuity. It’s impossible to be able to provide continuity of care to a panel of 2,000+ patients (the estimated average for primary care physicians in my area based on my informal polling). If, for the sake of example, we reduced continuity of care just to annual exams (and we make them 45-minute appointments), a panel of 2,000 patients would require 90,000 minutes or (assuming a 48-week working year) 1,875 minutes or 31 hours per week.

And 31 hours might sound doable - if the only appointment the physician offered was a once a year exam.

Of course, that’s far from the case for the average family doctor who spends, on average, 30% of appointments with patients on chronic disease management. That translates to about 10-12 more hours worth of work based on a 30-40 hour work week, leaving no time for sick visits or to address the growing burden of administrative tasks. Therefore, continuity of care for a panel of 2,000+ patients is impossible for a typical family doctor in the insurance-based healthcare model.

Because insurance-driven care is based on patient volume, there is an incentive to fill the schedule as much as possible, leaving little room for the acute visit. If doctors aren’t seeing patients, generally money is not being made for that clinic. This has contributed to the rise of urgent cares and the like to meet the needs of patients for acute care. A loss of continuity by “necessity”. Really though, this is loss of continuity by failure of systemic design.

I’ve previously discussed how our over-emphasis on efficiency in healthcare has resulted in harms to our effectiveness.

As a society, I don’t think it’s hard to appreciate that we generally prefer immediate vs delayed gratification. We’re used to drive-through oil changes, self check-outs, and fast-food. We’ll eat the marshmallow now, thank you. Fast-food medicine is quick, it’s easy, and it aligns with these societal values.

But we still cook at home. Sometimes we dress up to go to a nice restaurant. It’s more than just convenience that drives our behaviors. As noted above, research shows that patients actually prefer to see their own doctor when it comes to annual exams, chronic disease management, sensitive exams, or mental health conditions. This suggests that lack of continuity isn’t simply behavioral (i.e., patients would see their family doctor for acute care if it were more timely), but driven in part by the design of the insurance-based healthcare system.

“As trends show an increase in the use of urgent care centers in the United States, as well as health systems prioritizing expedient access over continuity, data from our study and others suggest that these shifts do not align with patient preferences for care, or with important health outcomes such as emergency department and hospital use.”

-Annals of Family Medicine

How Continuity Affects Physicians

Continuity - or actually the systems that promote continuity - have several benefits for physicians as well. Increased professional satisfaction and improved work schedules being the more obvious ones.

Time pressure is the “inability to complete necessary work in the time allotted”. It tends to be present when physicians need more time to care for a patient than is scheduled. Not surprisingly, it is associated with physician stress, burnout, and intent to leave a practice.

A brilliant article a kind friend shared with me recently that outlines appointment types in the family doctor’s office. Notably, when physicians have a mixture of annual exams, chronic disease management and acute appointments in their day (or what the article refers to as “routine, ceremony, and drama”), it allows the schedule to flow more smoothly compared to a physician filling their day with one type of appointment. For example, a quick sick visit allows the physician to catch up on schedule from an annual exam that went overtime. While being on time isn’t the ultimate goal, generally seeing patients on time mitigates physician distress. [Additionally, longer wait times do impact the patient experience.]

Professional satisfaction is also affected by continuity. As I noted earlier, many of us choose a career in family medicine or primary care because we value relationships with our patients. As with any other relationship, it takes time and repeated exposure to get to know someone. Studies show that increased or adequate time with patients increases both patient and physician satisfaction.

For those involved in the management of other physicians, these factors spell physician retention. Hiring physicians is expensive. Some estimate $500,000 to $1,000,000 per physician hired. Just one reason among many for healthcare systems to take patient continuity and factors that affect it more seriously.

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Some Possible Solutions (because I’m learning to be an optimist)

Continuity is important - to patients and physicians. Factors such as time for visits, panel size, accessibility to the physician affect continuity. A glaring common denominator in each of these factors is the volume-drive, insurance-based, healthcare system.

Are there any healthcare models that do continuity well by addressing these factors?

A model that supports continuity in patient care would allow for adequate and more accessible visit times, as well as a realistic panel size per physician.

My residency program was unique and very forward-thinking in that the clinic schedule was designed to preserve some level of clinic continuity. Patients were scheduled as much as possible with the same resident physician. Same- and next-day appointments were regularly blocked on the calendar, making sure space existed in the schedule to see acutely ill patients. Did we always see our own sick patients? No, but that was the intention as much as possible. Of course, much of this is driven by the ACGME requirement for family medicine residents to have individual panels. Kudos to the people that designed that policy with continuity in mind.

Of course, adopting a similar system in larger clinics would be somewhat problematic for the reasons we mentioned above (namely, financial incentives and panel size. Resident physician panels are limited to a few hundred patients at the most), but certainly a variation on this could be possible and is sometimes practiced in clinics to offer a level of continuity in a system designed against it.

Value-based care: while promising in theory to improve continuity it has yet to produce compelling outcomes regarding patient-centered care and continuity.

Two models that currently hold the most promise for the future of continuity in family medicine include direct primary care (DPC) and concierge care. Both models generally tick the boxes of adequate and more accessible visit times as well as a realistic panel size per physician. Because physicians are paid in these models through a membership or subscription (as opposed to by volume of patients seen or RVUs), physicians are able to have smaller panels of a few hundred patients.

We could debate the pros and cons of these models of care, but if our focus is continuity, DPC and concierge care are the best options our current healthcare environment has to offer. Improved continuity increases both patient and physician well-being. And we’re not getting enough of it in our current, insurance-driven, healthcare system.

Let’s resolve it.