Islon Woolf MD
- Apr 22, 2020
- 4 min read

Concierge Medicine and continuity of care

Updated: Jun 28, 2020

Your health is dynamic. Events happen, diseases wax and wane, and none of us can escape the process of aging.

Your health is also complex. The human body has many systems, all of which interact with one another. Diagnosis and treatment is rarely straightforward. Tests are ordered, treatments are tried, and specialists get involved.

This requires coordination, documentation, and followthrough by someone that knows you well. This is continuity of care. Continuity of care is concerned with how your health is followed over time.

Your health is dynamic and complex requiring good continuity of care

Components of continuity of care

Continuity of care can be broken down into three components: relationship continuity, information continuity, and management continuity:

Relationship continuity - A relationship with a primary care doctor is where continuity of care begins. It is essential. The same doctor over time - from phone call to phone call, visit to visit, and year to year. With time, this doctor begins to accumulate knowledge about you - your values, your passions, and your fears; knowledge difficult to record in a chart, yet key to making good medical decisions.
Information continuity - Medical care produces a mountain of information. Your health records need to be collected and accessible in a central location. Only with full access to complete information can your doctors help you make good medical decisions.
Management continuity - The complexity and dynamic nature of your health requires coordination. A single entity needs to assume accountability. An entity with the infrastructure to monitor tests, treatments, chronic conditions, and specialty consultations, and ensure followthrough.

From observational studies, patients with good continuity of care have better health outcomes. These outcomes include: greater patient satisfaction, increased adherence to medication, fewer ER visits, reduced hospital use, and even reduced mortality.

Poor continuity of care

A major criticism of current medical practice is poor continuity of care. It is widespread. There are several reasons for this:

Uncertain accountability - Continuity of care is shared between primary care doctors and specialists, it’s not clear who is responsible.
Inappropriate incentives - Primary care doctors are not incentivized to ensure continuity of care - it is not reimbursed. Instead, primary care doctors are reimbursed for more offices visits, more tests, and more procedures.
Resources - Most primary care doctors do not have adequate time or personnel to ensure continuity of care.

This leads to care that is fragmented. Care from multiple players, with poor access to your records, unfamiliar with your case. Let me illustrate with the following examples of poor continuity of care:

The lost test result.

A doctor orders a mammogram. A suspicious lesion is found and the report is faxed to the office. However, it does not make its way to the doctors desk. The patient assumes the result is negative, not hearing back from the office. The office does not have a system in place that ensure followthrough of tests and test results.

The after-hours call.

David has a long history of episodic chest pain. Extensive testing has ruled out heart problems; it's likely due to anxiety. Over the weekend, he experiences a severe attack and calls his doctor's answering service. His doctor is not on-call, and instead, the service connects him with another doctor. Not knowing his history or having access to his chart, she tells him to go to the ER. She views David's chest pain as a heart attack until proven otherwise. Why take a risk or expose herself to litigation? The ER doctor treats the situation similarly; David gets admitted to the hospital for a full workup and more testing. This exposes him to the dangers of a hospital stay and unnecessary testing. Ironically, the entire incident generates more anxiety for David, and none of it is documented in the chart because the practice lacks personnel to retrieve hospital records. All of this could have been easily avoided had David spoken with his regular doctor in the first place.

The Executive Physical.

The Executive Physical entails an extensive annual check-up with a large battery of tests, often requiring travel to another city. As a resident in Internal Medicine at Mayo Clinic and Cleveland Clinic, I helped conduct many of these evaluations. It turns out, many patients use their Executive Physical doctor in lieu of a primary care doctor at home. This leads to poor continuity of care; a different doctor is often assigned at each executive physical, and between physicals you live in another city. Consequently, the doctor who knows the you best is not present when you need them the most - when you become ill between physicals.