Growing up, I knew there was something special about the relationship I had with my family doctor, the only physician I knew for my first two decades of life.
For those two decades, our family doctor formed my ideas of what it was like to be a health professional. I distinctly remember the kind face and unhurried tone, but also the multiple roles played – at once scientist, advisor and connector. Most importantly, my doctor worked to understand my values and earn my trust. We built this relationship slowly, over countless visits and many years, and although unspoken, my doctor, my family and I all understood the immeasurable value from this relationship in keeping me and my loved ones healthy.
Now as a family physician myself, I know there really is something special about the relationships we develop with the people and families we serve. I know that my understanding of Mr. X and his family, for instance, will allow me to care for him in a way that is more human, has higher quality and ultimately is less likely to do harm. I also understand that these relationships are not unique.
In fact, continuity of care is a foundational element in family practice. Continuity of care captures several ideas but at its most basic involves the concept of seeing the same clinician or team over time, thereby building understanding and trust.
Forms of continuity
People need care at different times, from unique sets of expertise, and in various access points to the healthcare system. There are different forms of continuity that capture these needs. Informational continuity, for example, is the idea that all health professionals involved in a person’s care should be able to access and contribute to the health record and have a shared understanding of a person’s care goals. Team-based continuity involves care that is continuous within a highly collaborative and often co-located team of health professionals.
It is easy to see how there are benefits and drawbacks to the various forms of continuity. No matter how dedicated, a single family doctor cannot be available at all times and in all places. On the other hand, an unfamiliar doctor who has access to a record but no prior understanding or has not built trust with a person may have a hard time sharing in decision-making and, worse, runs the risk of missed preventive care, delayed diagnosis or incorrect treatment.
In other words, an unfamiliar clinician may be good enough for an uncomplicated urinary tract infection but not ideal for a sensitive dialogue or important diagnosis. Continuity of care has many forms and each form may contribute to good care in different ways.
Benefits of continuity
A continuous relationship with a family doctor or care team comes with immense rewards. People who can see the same doctor live longer. In a forthcoming paper, my research team and I show the qualitative evidence around continuity bringing person-centeredness, quality and confidence in care. Continuity also has systems-level outcomes. A classic 2005 paper on its contributions describes primary care’s six most significant impacts: access, quality, prevention, early management, whole-person care and appropriate specialist use. There has since been an abundance of literature on continuity supporting cost savings, lower hospitalizations, improved health and higher quality care. It is no surprise that the lack of continuity can be devastating. A focus on continuity in primary care is core to a health system that strives to be person-centred, safe, effective, equitable, accessible and efficient.
Continuity versus access
When discussing primary care, it is critical to note the contrast between accessible and continuous care. Many people are fortunate to receive continuous and ultimately meaningful care through their lives. They receive quality well-baby care, up-to-date vaccinations, wise preventive and lifestyle coaching, chronic disease and mental health care and end-of-life planning. Tragically, this kind of care is not guaranteed for many Canadians. In Ontario, more than 1 million people are without a family doctor or primary care professional. People living in central Toronto live in an area with convenient access to primary care (via numerous walk-in clinics), for example, but one in nine still lack continuous care. Walk-in clinics are, of course, an important safety net. Unfortunately, people without some form of continuity will receive fragmented care by multiple professionals and often no longitudinal health guidance. Policy failures in our healthcare system let countless Canadians without continuity fall through the cracks.
Continuity is a matter of equity
Location, language, office hours, legal status, trust and a variety of other factors all play a role in access to continuity of care. Primary care policy failures disproportionately impact newcomers to Canada and those already poorly served by the healthcare system. In the Hamilton Spectator’s Code Red series, the investigators found that neighbourhoods with the fewest residents connected to a family doctor were also the ones with the most emergency visits for mental health crisis, lowest incomes, highest rates of poverty and the worst maternal health outcomes. Without these continuous relationships with a care team, health disparities worsen in those already impacted by the social determinants of health. Continuous relationships matter because of their immense impact on equitable quality.
The way forward
In all of its forms, continuity of care brings humanity, quality and equity to clinical care. The onus should not be on people, families or caregivers to ask for the same clinician or care team, to repeat traumatic stories at each point of care, or to compile tomes of health information to bring to appointments. Our current state is failing many and it is the responsibility of provincial ministries of health to ensure that every Canadian has a continuous medical home, regardless of location, language, status or determinants of health. As we shift to a more digital system and seek to integrate existing care silos, we must commit to providing every Canadian with meaningful primary care with the strength of continuity in all its forms. Continuity of care matters. It is beyond time that we incorporate continuity as a core value for the care of all Canadians, in all contexts, with all clinicians.
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There is little doubt that some form of continuity is desired and perhaps even required for truly high quality healthcare. But the devil is in the details as it always is. Traditional continuity meant you saw a single provider (your physician) for essentially everything, even if that provider was not well suited to dealing with you issue, that is who you saw. That individual would struggle to be all things to all people at all times. Women’s health and delivering babies, ok that’s on 24/7 availability. High acuity emergency acute care like a Heart Attack. Another 24/7 availability as well as a second highly specialized of knowledge and skills. Palliative care in the home. Again 24/7 availability. Little pay and lots of knowledge required. Patients in the hospital or in the nursing home. Yet another 24/7 demand on your life.
It’s simply not sustainable and it hasn’t been for decades. If we want a goal of continuity of care (which is laudable), it is team continuity that we need to strive for no individual responsibility. When I am forced out of work for fourteen days on C19 quarantine sometime this fall, do I remain responsible for this continuity even though I’m not funded in anyway to provide such a complex continuity. Even in a more “regular” time, is it really reasonable for me to be on-call and available 24/7/365 for all fifteen hundred patients in my roster? The patients need to be rostered to a team. They get to know how the team works, the team understands the patients, the team learns to communicate well in person and using technologies. Then it doesn’t matter so much which of the four docs, three NPs, two PAs or six RN/RPNs help your out because we all know who you are. And there are enough of us to cover most eventualities in terms of time.
I worked as a full service family doc/GP for fifteen years. My practice did little shared care so your only real continuity was trying to get back into your family doc. As we developed an NP/PA program they definitely helped put more communication and continuity in place with the family doc acting as a quarterback mostly in coordinating care.
For the past eighteen months, I’ve don’t focused practice in the ER. We have no continuity beyond what little is in our charts and the surprisingly high number of patients that use the ER as a “medical home”. The lack of continuity is a huge burden to us as practitioners but I also don’t grudge primary care needing balance. I work 60-80 weeks, at least two if not three overnight shifts most weeks and haven’t had a weekend off since April (it’s the end of October now) so please skip the arguments that I’m lazy and if I was committed to patients, continuity would be easy. I know a decent number of family docs who’s work hours would be almost as bad as mine.
So let’s talk continuity but let’s figure out how to do it without killing our providers.
I think continuity of care is overrated. Canadians want access to care, when they need it – they don’t always care if their family doctor is available. Family doctors are often not available 24/7. I think this argument of continuity of care is a figment of policy wonks and healthcare providers and so called “system thinkers” who are so far away from reality and the patient. It really doesn’t matter if my family doctor didn’t help me with my strep throat that flamed up on a sunday afternoon, nor do I care if he gets a copy of the visit i had with my virtual doctor for this matter. These policy wonks need to think more of healthcare as a service that we pay for. Heck we pay for these family doctor salaries through our tax dollars! Real-talk!!
“Jordan”:
You’re absolutely right that in the end, it probably doesn’t matter if your family doctor isn’t involved in treating your Sunday-night strep throat. But you know what? If the worst medical issue you’re facing is a strep throat, then that’s a sign of privilege in and of itself. Continuity _does_ matter if you’re the Ukrainian-speaking vulnerable senior you referenced in a previous comment, the one who is on 8 prescription medications for various age-related ailments, just got discharged from hospital after her hip replacement, and now is feeling faint and light-headed because a hospital mistakenly prescribed a medication that exacerbated her heart condition and interacts with one of the other prescriptions she’s on. That’s where continuity matters. A doctor working at a walk-in clinic, real or virtual, who doesn’t have access to the patient’s records, who doesn’t know the previous history, will be completely hampered when trying to care for such a vulnerable patient. The patient’s own family doctor (or nurse practitioner), who knows her previous medical history, knows what medications she’s been prescribed (and whether or not she tends to take them as prescribed), and knows when something’s off, is the one who’s most likely to actually help someone in this situation.
We may not be perfect in family medicine, but I think your comments are really misguided and don’t reflect the work that we actually do to get people healthy and keep them healthy, especially the ones who are mots vulnerable because of demographics or socioeconomic status.
Mr. Weiss,
I’m not sure I agree entirely with you. I am foreign-trained medical graduate from India. In my home country, we do not have such luxuries as continuity of care, neither in mega-tier 1 metros like Mumbai or rural villages. A physician’s ability to be an expert diagnostician should be good enough to provide high quality care, of course this concept of continuity is important but its not the end-all. We have Even our globally recognized All India Institute of Medicine (AIIMS) operates like this without systems that enable continuity of care. I think in North America, the practice of family medicine can be stifled with such demands on continuity of care, it may be the “holy grail” but I’m not so sure its realistic expectation, especially to serve the vulnerable members of the population.
Jordan,
You are quite right, that healthy young to middle-aged adults with no children, and earning well, seldom need continuity of care, since even walk-in clinics can assist with single, specific acute issues. Though we need to be careful that “quick-fix” medicine does not cause more trouble, for example by giving antibiotics on demand for every viral infection. Your family doctor will need to know what you were given when the drug reaction occurs! But once you leave that privileged state, and get chronic illness, depression, or an injury that takes rehabilitation, then continuity of care suddenly becomes critically important. So health care policy should not try to ensure that everyone has a family physician, rather that one is available for everyone who needs them. Then the tax dollars provide real value, and payment systems need to be structured to encourage that, including the availability of quality care at nights and weekends.
Great article! The more we invest in primary care and a medical home, the more we can offer continuity and access. Having worked in a walk-in clinic and having my own practice, I can’t tell you how important the long term relationship & context are for helping care for and support patients.
Dominik.. I think that the biggest benefit of continuity is a sense of responsibility and trust. I need my family doctor to care about me as an individual, be engaged in my journey and I trust him/her to help me make the best decisions for my life. Even though I am a doctor myself, I still need an objective stable and educated voice to do the right thing or weight the best options for my health and treatments. I need to be able to trust. This trust can be built in an instant when we show compassion, empathy and honesty with our patients. It’s built with careful listening, framing and conversation. It’s easier after 10 years of knowledge of each other’s worlds, but possible even in my urgent care clinic in a large family health team. We do not think about this as much when we are healthy as when we are sick. But we will all wish for it eventually .
My challenge to you… how as an educator do you think we should build relationship into the way we teach? How do we convince our colleagues that family medicine is more than a transactional 9 – 5 job? How do we allow ourselves to be vulnerable enough to build strong lasting relationships with our patients? I see this being eroded in the current medical model, and like you, I am worried.
Thanks for writing this, Dominik.
ummm… interesting perspective, but its one that i bet comes from white privilege my friend. Where do you live? in a quaint 3 bedroom in Leaside? engaged in my journey? seriously – the primary care system that we need has to serve the vulnerable senior who just waited 18 months for hip surgery, speaks ukranian only and relies on shitty meals on wheels because her kids don’t come around to help her. its for the single black mother, overweight with diabetes, working 2 jobs and her kids are eating mcdonalds all day, about to be on the same diabetes train that she is. These are only a few examples of the 20% that are driving 80% of the primary care utilization….far from the privileged few who are looking for some sort of sage guru that will be my spritual healer along my health journey. that crap is for rich white folk can afford to think about how they can lose that extra 10lbs to move their BMI from 16 to 15.5.
Thanks for this article – I think it makes a critical and often overlooked point about the importance of relationships. There is certainly value in having same day/next day access to health care for urgent needs and this should be balanced with seeing the same provider for overall management of health.
Great article Dominik.
My parents have had the same FP since the mid-1980s. It has been a blessing.
The only reason my brother and I aren’t still in the practice is because we moved away to other cities but both of us and our families now have long standing FPs of our own now.