Continuity and Fragmentation in Health Care
Elizabeth J. Rourke has published a thoughtful piece looking at the advantages and disadvantages of specialization for patient care from the perspective of a primary care physician.
“The tension between the continuity of care provided by seeing a doctor you know and getting specialized services from a doctor you don’t has afflicted American medicine since the postwar period, when medical knowledge began to expand rapidly. This growth in specialization has resulted in a U. S. physician workforce in which more than two thirds of practicing doctors are specialists.”
She notes concerns about continuity of care led to the formation of family practice as a specialty in 1969.
“For the intellectual architects of family medicine, such as Barbara Starfield, continuity was a foundational component of primary care, one of the four “pillars” of care, along with providing the patient’s first contact with the health care system, comprehensiveness, and care coordination…family physician John Saultz arranged these different aspects of continuity into a hierarchy, which included informational, longitudinal, and interpersonal continuity.”
The rise of computerized medical records and the notion of team-based care, beginning in the 1990’s changed the issue yet again.
“Ironically, electronic medical records and team-based care, which offered solutions to the challenges of informational and logistic continuity, also rendered interpersonal continuity less straightforward. Making it possible for multiple providers to participate in the care of patients necessarily reduced the amount of contact patients had with one, central provider, and decreased opportunities for relationship building.”
Dr. Rourke notes division of labor is the classic economic term for what has happened, and that it has benefits for both patients and doctors. But, she notes, there are the (largely unpaid) coordination costs imposed on primary care offices, and that is yet another barrier to interpersonal continuity. But does it matter? Certainly, those who tout artificial intelligence and algorithms think the road to the future is paved with de-personalized, “value-based” care.
Dr. Rourke noted there is only one randomized trial of continuity, from 1984, which showed veterans in a provider-continuity group had fewer ER visits, shorter lengths of stay if they were admitted, and some improvement in patient satisfaction. Since these studies would be difficult, if not impossible, to repeat, she notes a recent study of discontinuity in Medicare patients created when a primary care doctor died, retired, or transitioned out of practice. The study found total spending increased $189 per patient in the first year after the doctor departed.
Dr. Rourke does not offer a glib resolution to these tensions and neither will I. Perhaps it is better if we think of it as a paradox. As medicine’s ability to actually modify the course of disease and to delay death and disability has increased, people have become increasingly dissatisfied with the service. Now this could be a “revolution of rising expectations.” I do remember a patient I was called to see in the ICU after hours, who was not quite as catastrophically ill as was usually the case. Attempting to convey some optimism to the family I started out by saying that she was doing fairly well at the moment, “all things considered.” They challenged me on that phrase, so I clarified by saying, “Well, she is 88 years old.” Their response? “What’s that got to do with anything?” Uh-oh.
I think there are things that can be done to help, though they won’t resolve the paradox. First, the EMR can and should be retooled in such a way as to enable longitudinal graphing of things like hospitalizations. Currently, most EMR’s are structured to capture an encounter, be it in the office or hospital, and has in-depth data. But, as we all know, the longer the note, the less people get out of it. Another paradox is now that notes are legible, we know they contain only data, not information. Yet, as we all know, for patients with advanced chronic disease there is a trajectory of decline. If we identify it earlier, we can offer specific services, such as advanced care planning and perhaps provide better patient-centered care.
Second, good surgeons have always understood they had to consider not only the operation, but the condition of the patient who needed it. I remember one noteworthy instance where an orthopedic surgeon was consulted about a hip fracture in a frail, non-ambulatory, elderly patient. He frankly advised against the operation on the basis she hadn’t been walking and surgery would not get her walking again. Unfortunately, he was the first one to broach the issue, and was the subject of a family complaint. His judgment was correct, but the “team” had all been avoiding the issue and looking for a technologic “fix.” There is clearly room for improvement on the part of all of us, to not offer the patient and family the false hope that their problem is amenable to a “fix” when such is obviously not the case. In an ideal world, the orthopedist would never have been consulted. Physicians, like people at large, are subject to the rule that the more people who are involved, the less likely anyone is to act. This “bystander effect” should be actively taught to the medical young so they can do their part to prevent it from happening.
These two steps might help mitigate patient distress, but won’t necessarily do anything to reduce costs. I think we are stuck with our paradox that the more we can actually do, the less people are satisfied with it. Maybe it is a case of “what have you done for me lately?” But “high-tech, high touch” really is what people want from us. If we can remember that, we can soften the edges sometimes by just listening and understanding.
29 November 2021
 Rourke EJ. Continuity, Fragmentation and Adam Smith. N Engl J Med 2021;385(19):1810-1814. DOI:10.1057/NDJMms2103844.
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