{"id":35496,"date":"2015-10-19T12:50:47","date_gmt":"2015-10-19T11:50:47","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=35496"},"modified":"2015-10-19T12:55:25","modified_gmt":"2015-10-19T11:55:25","slug":"william-cayley-continuity-over-efficiency","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/10\/19\/william-cayley-continuity-over-efficiency\/","title":{"rendered":"William Cayley: Continuity over efficiency"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-31912\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg\" alt=\"bill_cayley_2\" width=\"178\" height=\"220\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg 243w, https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg 551w\" sizes=\"auto, (max-width: 178px) 100vw, 178px\" \/><\/a>It has become <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2690145\/\">fairly clearly established<\/a> that a strong primary care system is associated with better overall health for a society and a more equitable distribution of health in the population.<\/p>\n<p>A <a href=\"http:\/\/www.annfammed.org\/content\/13\/5\/456.full\">recent modeling study in the <em>Annals of Family Medicine<\/em><\/a>, which\u00a0evaluated the \u201cprimary care paradox\u201d (lower levels of evidence based care for individual diseases, but healthier populations, less use of resource, and reduced levels of health inequality), suggests that this is because primary care leads to increased disease prevention visits and reduced illness visits in disadvantaged neighborhoods. Other <a href=\"http:\/\/stfm.org\/fmhub\/fm2013\/May\/Richard311.pdf\">research has suggested<\/a>\u00a0that individualized management of new symptoms and chronic conditions may be the key advantage of primary care.<!--more--><\/p>\n<p>The increasingly pressing question as we move further and further into 21st century medicine, especially in high income countries with their <a href=\"https:\/\/en.wikipedia.org\/wiki\/Pandora's_box\">Pandora\u2019s jars<\/a> of high-tech testing and multispecialty referrals, is how to foster and sustain such continuity.<\/p>\n<p>A recent pair of editorials in the <em>New England Journal of Medicine<\/em> <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMp1508270\">debate the value<\/a>, <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMp1507485\">or lack thereof<\/a>, of the \u201cannual physical\u201d for promoting the continuity of the physician-patient relationship. While the pros and cons of this discussion are illuminating, and raise questions about the place of evidence vs relationship in determining what healthcare services should be \u201ccovered,\u201d true promotion of continuity of care requires a more fundamental change in the way we structure healthcare services and payment.<\/p>\n<p>\u2022 We need to promote scheduling of physicians&#8217; time so that when a patient is sick, s\/he can see their\u00a0primary physician, rather than being referred to an \u201cacute care\u201d or \u201curgent care\u201d clinic\u2014even an \u201curgent care\u201d clinic that is part of a larger system is still not the same as seeing one\u2019s own physician. (<a href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/07\/02\/william-cayley-planning-for-uncertainty\/\">I\u2019ve posted a few thoughts on this sort of scheduling previously<\/a>).<\/p>\n<p>\u2022 We need to support the provision of continuity of care across settings through family doctors, GPs, and other primary care specialties. The American shift of primary care physicians away from hospital care, with in-patient care instead provided by hospitalists, <a href=\"http:\/\/annals.org\/article.aspx?articleid=479624\">undermines continuity and may, in the long run, be more expensive<\/a>.<\/p>\n<p>\u2022 Electronic\u2014and sometimes \u201casynchronous\u201d\u2014care is now in vogue with the growth of \u201cweb based\u201d society, and now<a href=\"https:\/\/amwell.com\/\"> some American insurers are offering \u201conline\u201d visits<\/a> with a remote physician to address acute illnesses. Rather than promoting visits with an unknown, remote physician, insurers wanting to participate in web based medicine should be promoting\u00a0the\u00a0use of electronic remote visits with a patient\u2019s own primary care physician.<\/p>\n<p>Admittedly, some of these problems and solutions may be uniquely American\u2014and may sadly be beyond the reach of our currently fragmented kaleidoscope of healthcare systems in the US.<\/p>\n<p>However, if we are to genuinely realize the full potential and benefits of primary care, we need healthcare systems that, in both their service structures and their financing, prioritize continuity rather than efficiency.<\/p>\n<p>(Who knows, in the end continuity may be more efficient too!)<\/p>\n<p><em><strong>William E Cayley Jr<\/strong>\u00a0practices\u00a0at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.<\/em><\/p>\n<p><strong>Competing interests:<\/strong> \u201cI declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"<p>It has become fairly clearly established that a strong primary care system is associated with better overall health for a society and a more equitable distribution of health in the [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/10\/19\/william-cayley-continuity-over-efficiency\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1357,14769],"tags":[],"class_list":["post-35496","post","type-post","status-publish","format-standard","hentry","category-us-health-care","category-william-cayley"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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