Person-centred health care and continuity of care
I was struck by an article that was recently published by the British Medical Journal (BMJ Open) authored by Pereira Gray, Sidaway-Lee, and White (et al), entitled, “Continuity of care with doctors – a matter of life and death? A systematic review of continuity of care and mortality”. I was excited to read that this was the first published review which revealed that continuity of care by doctors is associated with lower mortality rates. That is, patients will live longer when being cared for by the same doctor or the same group of doctors.
The studies which were reviewed found that patients across ages, cultural boundaries and all conditions appear to benefit from continuity of care with both generalist and specialist doctors. This research is significant because it validates the need for continuity of care to be given a higher priority in healthcare planning. The authors of the paper concluded that despite numerous technical advances, continuity of care is an important feature of medical practice with interpersonal factors remaining important in patient care.
As I continued reading, I was amazed to find that research on human aspects of providing medical care has lagged behind other aspects of medical research because internationally there has been a decrease in the perceived value of personal contact between patients and doctors. In fact, an editorial in the New England Journal of Medicine suggested that non-personal care should become the “default option” in medicine.
The idea of diminishing personal contact between medical professional and patient was again raised at a lecture about artificial intelligence (AI) which I attended recently. The speaker described the power of AI technology and other advancements that can potentially replace the need for doctors in the future. This technology is in fact happening now with many of the highly technical but repetitious areas of medicine like cancer cell diagnosis and pathology laboratory processes being increasingly managed by AI technology. In June this year, researchers demonstrated that AI can identify skin cancer more accurately than dermatologists when put head to head in a small study. The deep learning Convolutional Neural Network (CNN) AI was able to perform better than a group of 58 dermatologists when distinguishing melanoma from benign moles. However, don’t give up going to your dermatologists too soon as this AI is only just been trialled and there is no system available widely at this time, but watch this space!
As a GP, I get patients’ feedback when they attend specialists or have interactions with the health system. My patients tell me that they value their interaction with their doctors and it is the kindness, respect, expertise and care they receive from their health provider that is mentioned consistently. By way of contrast, no one actually talks as passionately about the machines or technology that were used in their medical care. It seems difficult to understand why some researchers and other health and medical professionals continue to talk down the importance of the personal contact between patients and doctors. As society places more and more emphasis on technology such as CNN for medical purposes and concerns regarding medical costs increase, my hope is that we will still remain conscious of personalised care and other important patient needs.
As a GP who supervises and teaches medical students and junior doctors, I try to share my 30 years of clinical experience, especially around the importance of patient-centred care. I believe this could be better taught in medical schools and during hospital rotations. Patient-centred health care emphasises the importance of continuity of care and the “art of medicine”.
All medical students who succeed in obtaining a place in an Australian medical school have secured their place through an onerous and competitive selection process. High school students wanting to gain admission to medicine have to do exceptionally well at Year 12 then sit for a medical school specific entrance exam and then face the final hurdle of being selected via interview with the respective university. A similar process is undertaken by postgraduate students, however they face even more intense competition as they have to compete against their cohort of extremely talented students, many of them already having achieved honours, masters or even PhD degrees.
Today’s medical graduates, while highly intelligent, motivated and knowledgeable, must also be able to communicate effectively with patients. They need the understanding that medicine is not just about knowledge but includes the application of the specific knowledge to the circumstances of the patient and also the way that knowledge is communicated.
People are complex and their individual circumstances often require interpretation, communication and consideration of the whole person in collaboration with their carers or family to make the right decisions for the individual patient. This is the patient-centred model of care and it’s the art of medicine which is required to bring these together. I am sure when we drill down to the reasons why continuity of care by doctors is associated with low death rates, it’s because the doctor understands this aspect of their patient and is able to provide the best advice and therefore management for their patients.
Unfortunately, the “art of medicine” and these “soft” concepts cannot be easily researched as this data is considered difficult to quantify, which impacts on health funding considerations.
Dr Aline Smith is a GP in private practice and lectures at the UNSW Academic Unit at Fairfield.