Continuity in the age of virtual care

Be silent as to the services you have rendered, but speak of favours you have received.

Seneca

Recently, I participated in a debate at my home hospital. The title was “Virtual care is here to stay—but should it be?” The resolution was, “Be it resolved that the majority of clinical care can be delivered most efficiently virtually.” I argued against the resolution.

One of the main arguments I made was the importance of continuity of care. Dr Ian McWhinney captured this concept best: “What does it mean to be a family physician? For me it means that our relationship with our patients is unconditional … ended only by death, by geographical separation, or by mutual consent.”¹

There are different ways of thinking about continuity of care—a physician’s willingness to take responsibility for a person’s longitudinal care—and its central importance in the work of family doctors. One way is at the level of relationships and their effect on individuals and communities.

Few have described this better than Dr David Loxterkamp does in his recent essay “The lost pillar: does continuity of care still matter?”² At the heart of it is a story he first heard when he established his own practice more than 3 decades ago. It is a story we could call “You’ve done a great job, Doc” (read the essay).²

A second way of thinking about the value of continuity of care is at the systems level. In 2018, Pereira Gray et al published the first large systematic review of the literature demonstrating that continuity of care by both specialist and generalist physicians is associated with lower mortality rates across cultures.³ That same year, Bazemore et al showed that higher continuity with a primary care physician results in fewer hospitalizations and lower health care costs.⁴ In a recent systematic review, Baker et al found an inverse relationship between all-cause mortality and continuity of care.⁵

However, as evidence mounts for the impact of continuity of care, why is it that, as Dr Loxterkamp argues, family medicine has neglected continuity as a core principle? There have been powerful social forces acting over the past half century that have undermined the kind of personal continuity of care captured in Dr Loxterkamp’s essay—urbanization following the Third Agricultural Revolution of the 1950s and 1960s, atomization of families, the rise of consumer culture, and the growth and increased complexity of medical care itself. Perhaps those who have chosen to practise in rural and remote communities are among the last of us to experience the kind of continuity Dr Loxterkamp describes.

In the first few months of the pandemic, family physicians and their patients enthusiastically embraced virtual care as “good enough” care. But could the expansion of virtual care during this time lead to further disruption in the pillar of continuity? One of the unexpected consequences was “a corporate stampede into primary care” as described by family physicians Drs Sheryl Spithoff and Tara Kiran in an article published a year into the pandemic.⁶ Among the concerns they raised was that this corporate buyout of primary care practices could lead to the promotion of transactional over relational care, further disrupting continuity and exacerbating the inverse care law.⁷

In a valuable Teaching Moment article in this month’s issue (page 74), Drs José François and Émilie Fowler tackle the challenge of how to provide experience with continuity of care for residents within the context of the Patient’s Medical Home model.⁸ The 4 principles they articulate are ensuring that residents understand and value continuity in the model, ensuring that patient needs are at the centre, embracing the interprofessional model for clinical and educational continuity, and optimizing resident scheduling to allow for continuity.

Every generation of family physicians faces challenges to the principles we value and the kind of care we provide. On the cusp of a virtual revolution, it is vital that we commit to teaching the value of continuity of care and preserving it in our practices, difficult though this may be.

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