PRIME Whole Care Bulletin May 2012: Faithfulness
I first met June about 30 years ago. She was a smart, well-dressed woman with immaculate blonde hair. She was suffering from an undiagnosed thrombotic disorder and was on long-term anticoagulants. Since I worked in a hospital, I did not usually see my patients for more than one or two occasions, they were then returned to the care of their family practitioner. However June’s condition was rather unstable and, amongst her many problems, it was clear she was suffering from endogenous depression. At the time this was treated with tricyclic antidepressants and her condition rapidly improved. June was an intensely private person and had difficulty admitting to any symptoms even though she was beginning to know me quite well. I remember one occasion, several years after I first met her, she came into the consulting room with her usual confident manner, but with her hair looking like a bird's nest. It was clear to me that her depression had returned, something she eventually admitted after a little gentle probing. I'm sure that if I had been seeing her for the first time she would have resisted the suggestion. It was only because I had developed a long-term relationship with her that I was able to notice the changes in her appearance and she was able to open up about her feelings.
It is widely accepted that long-term relationships between doctor and patient are vital for good health care in family practice. There is evidence that ‘faithful’ relationships are more satisfying for doctors as well as for patients; patients need fewer laboratory tests and, as in the case of June, patients are more likely to disclose personal problems which helps the doctor or nurse to heal their illnesses. However, most of the published studies have, with a few exceptions, been of relatively short duration. Research published on American patients over the age of 65 examined the impact of the duration of physician- patient relationships on the processes and costs of medical care. The authors found that the longer the relationship between doctor and patient the less the likelihood that the patient would require hospital admission. Furthermore the overall health costs decreased as the length of the relationship increased[1]. The control of diabetes and the likelihood of diabetic complications are significantly increased where there is no continuity of care[2]. Continuity is associated with better diagnosis, more effective preventive care, greater patient satisfaction, better adherence to medical advice, better quality of life shown on scores for mental health, improved perception of health and greater freedom from pain. According to patients, one of the main factors responsible for maintaining continuity the relationship was "friendship with a physician’. Compassionate relationships of seem to be particularly deepened by home visits[3]
Patients who to value long-term relationships the most seem to be those with chronic illnesses, taking large numbers of medications, experiencing significant amounts of pain and who have difficulty doing their everyday work[4]
Increasingly, continuity of physician care, where it ever existed, is under threat. Health care managers believe the continuity of care with a team, a group of doctors or a health care unit is equally good. The evidence suggests they are likely to be quite wrong. A study of over 13,000 patients compared the likelihood of hospitalisation in patients who had continuity of care with a specified individual physician with those who only had continuity with a particular group of physicians. Continuing care by an individual physician was associated with significantly less hospitalisation with its associated inconvenience, cost and morbidity.[5]
When I retired from hospital practice June and I said goodbye. We had been faithful to each other and enjoyed a continuing therapeutic relationship lasting many decades. The personal and professional satisfaction it brought me made me envy my colleagues in family practice. For them it is, or should be, an everyday experience.
David Chaput de Saintonge
[1] Weiss, LJ, Blustein MD. Faithful patients: effect of long-term physician-patient relationships on the cost and use of health care by older Americans. Amer J Pub Health 1996;86:1742-7
[2] Hanninen J, Takala J, Keinannen-Kiukaanniemi S. Good continuity may improve quality of life in type 2 diabetes. Diabetes Res Clin Pract 2001;51:21 -7
[3] Gray DP, Evans P, Sweeney K, Lings P, Dixon M, Bradley N. Towards a theory of continuity of care. J Roy Soc Med 2003; 96:160-166
[4] Nutting P, Goodwin MA, Flocke SAS, Zyzanski SJ, Stange KC. Continuity of primary care: to whom does it matter and when? Ann fam Med 2003; 1:149-155
[5] Mainous AG, Gill M. The importance of continuity of care in the likelihood of future hospitalisation: is site of care equivalent to a primary clinician? Am J Public health 1998; 88: 1539-41
