Continuity of care should be Dr Ian McWhinney’s lasting legacy

Craft skills

Much is made of the contrast of art and science within the history and practice of medicine. Both are fundamental, but it is impossible to deliver care without craft skills. These crucial skills create and sustain continuing therapeutic relationships between doctor and patient and include welcoming, listening, examining, explaining, and reassuring.

When a family doctor provides health education or preventive health care to a patient in the context of continuity of care, advice can be tailored to the unique biography, context, and hopes of the individual, and to the particular episode of illness. For example, advice to stop smoking cigarettes is much more powerful in the context of an acute chest infection, and the patient’s doctor will often be aware of the particular context that can make it more or less difficult for the patient to follow the advice, such as a strong family history of smoking-related illnesses, the presence of young children in the home, a life partner who still smokes cigarettes, or the stress of poverty or unemployment. Moreover, gynecologic or urinary problems provide a precious opportunity for gentle inquiry about sexual difficulties or abuse.

The doctor knows not to attempt taking blood pressure measurements when the patient has been triggered by an emotional trauma during the consultation, such as a bereavement or family catastrophe, because the patient’s blood pressure measurement is almost certain to be elevated, and knowing this will make it more difficult to contain the patient’s distress and provide needed comfort. The ongoing personal relationship between physician and patient provides “the place where uncertainty is carried, sense made, and decisions agreed,”⁴ and where mutual respect and trust are nurtured.

In his book The Craftsman,⁵ sociologist Dr Richard Sennett cites post–Second World War Dutch architect Aldo van Eyck, designer of the Amsterdam Orphanage in the Netherlands⁶: van Eyck insisted architecture must be practised on a human scale. Two statements from his abundant writings exemplify his aspirations:

When are architects going to stop fondling technology for its own sake—stop stumbling after progress?⁷

And:

Modern architects have been harping continually on what is different in our time to such an extent that even they have lost touch with what is not different, with what is always essentially the same. This grave mistake was not made by the poets, painters and sculptors. On the contrary, they never narrowed down experience. They enlarged and intensified it.…⁸

If we substitute the word “doctors” for “architects” in both statements above, they become intensely relevant to the predicament of doctors obliged to neglect their hard-won craft skills, ignore McWhinney’s third principle, and implement industrialized and bureaucratized preventive medicine within contemporary health care systems.

The industrialization of preventive medicine

The prevention of disease and premature death is the pinnacle of public health. Since at least the time of Hippocrates, doctors sought to prevent diseases as well as offer treatments and cures. The history of medicine is marked by major successes in prevention that range from avoiding scurvy through dietary provision of vitamin C to discovering the link between smoking cigarettes and developing lung cancer.

All major improvements in public health have been achieved at the policy level (eg, cigarette smoking bans in public places and increasing tobacco product prices resulting in a reduction in cigarette smoking rates⁹) rather than by blanket decontextualized advice given to patients by health care professionals.

The industrializing rot really set in more than 30 years ago when the prevailing attitude about medicine in England was that general practice was ideally situated to enact the public health agenda. The disastrous implications of this deeply misguided sentiment played out in health policy in England over subsequent decades, resulting in enormous damage to primary care and public health, alongside harm to patients and the population.³

Generations of general practitioners and other primary care professionals suffered moral harm as they were diverted from caring for the sick to monitoring the well for an ever increasing number of risk factors.¹⁰ I also suspect many public health professionals felt their training and commitment were similarly betrayed as the focus shifted downstream to interventions at the level of the individual patient; and much more could have been done to prevent ill health and premature death by restructuring the underlying fiscal policy driving inequality. The United Kingdom (UK) has experienced more than 20 years of the National Health Service Quality and Outcomes Framework¹¹ for primary care, and despite systematic diversion of medical attention from the sick to the well, health inequalities continue to widen and rising longevity has stalled.¹²

The UK National Institute for Health and Care Excellence now recommends 379 lifestyle interventions, of which almost 100 apply to more than 25% of the population. Only 3% of the interventions are supported by high- or moderate-certainty evidence these help people change behaviour.¹³ The mismatch between patients’ needs and the burden of preventive care inevitably leads to ethical stress, especially when imposed quality metrics and other incentives—primarily focused on prevention—trump patients’ needs and financially penalize physicians for prioritizing sick patients.

In 2002, Dr David Sackett, clinical epidemiologist and pioneer of evidence-based medicine, reacted to the industrialization of preventive medicine:

Preventive medicine displays all 3 elements of arrogance. First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy…. Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.¹⁴

Prevention on the industrial scale we now experience in the UK uses crude financial incentives to apply standardized interventions across populations, and demonstrates with stark clarity the perpetuation of this arrogance. It bears almost no relation to McWhinney’s third principle. McWhinney’s careful adaptation of advice to each individual is a craft skill, which is the antithesis of the impersonal, inflexible arrogance of screening.

This contrast underpins Sennett’s assertion that medicine “finds its place in this long debate about the nature and value of craftsmanship in a mechanical, quantitative society.”⁵ The arrogance of contemporary prevention follows directly from its mechanical and quantitative nature, and every patient and doctor becomes a standardized unit of production to be exploited in the interests of the medical industrial complex.

Like so much else, medicine, and particularly preventive medicine, is being grossly distorted in the interests of the rich and powerful across the world. Guidelines focus particularly on pharmaceutical and investigative technologies and are continually manipulated to extend the thresholds for intervention.¹⁵

Fondling technology

So much of today’s industrialized and bureaucratized prevention evokes van Eyck’s notion of fondling technology for its own sake and stumbling after progress.⁷ It relies on the simplistic metaphor of the body as a machine to justify a standardized intervention that ignores the extraordinary complexity of each different human being. No wonder it has made so little difference to the health prospects of the population, particularly the poorest. Compliance is coerced at every level and, again, this runs completely counter to McWhinney’s craft skill because a hallmark of craft, according to Sennett, is the application of minimum force.⁵

More than 40 years ago, when McWhinney was formulating his principles, relatively few risk factors for future ill health had been identified. Since then, the relentless fondling of technology has ensured the number has grown exponentially, each apparently requiring investigation and mitigation. Effectiveness is demonstrated in small and often flawed trials, but long-term follow-up has been almost uniformly disappointing. Treatment of disease and relief of pain and suffering do not demand limitless resources, but the wholesale treatment of all known risk factors for serious disease undoubtedly has the capacity to bankrupt any health care system funded through taxation.¹⁶

When doctors use pharmaceuticals to treat patients with diseases defined by signs or symptoms, the outcome of treatment can be assessed at the level of the individual patient. If the signs or symptoms recede, the treatment can be continued; if not, it can be stopped. If treatments are applied to risk factors, the outcomes can only ever be probabilistic at the level of the individual. Thus, it is impossible to know whether the medication is working for any particular individual and so, once it is started, it must be continued indefinitely or any possibility of benefit is lost.¹⁷ This results in the systematic medicating of an ever greater proportion of the population at enormous financial cost to the taxpayer, and much of the investment will prove futile.

What is always essentially the same

In medicine, what is always essentially the same is the inevitability of suffering, loss, and death. The 17th century English physician Sir Thomas Browne declared:

I that have examined the parts of man and know upon what tender filaments that fabric hangs, do wonder that we are not always [sick], and considering the thousand doors that lead to death do thank my God that we can die but once.¹⁸

It seems the more preventive health care teaches people about these “thousand doors,” the more fearful they become, and the more absurd the aspiration to prevent all the risks of all the possible means of death seems. Each of us must die, but only once. When, for example, someone dies of a rapidly invasive cancer, all the years of treatment for raised blood pressure readings and raised cholesterol levels have been wasted, and all worry about these conditions misdirected.

Already in 1989, Susan Sontag was describing a “radical expansion of the notion of illness created by the triumph of modern medical scrutiny” and raising the possibility of this creating “a new class of lifetime pariahs, the future ill.”¹⁹ Since then, things have only got worse. All those so identified are obliged to live their lives under a shadow of fear, but just because we can does not mean we should.

Patients who are known to the physician

For McWhinney, the commitment of the physician to creating and maintaining a continuing relationship with their patients is the bedrock of family practice. I think he would be shocked and saddened if he could see the extent to which these continuing relationships have been disrupted in the name of efficiency and in the interests of the rich and powerful; particularly when research has finally caught up and demonstrated beyond doubt what he had intuited from experience.

We now have strong evidence that continuity of care by a regular family physician is associated with reduced need for after-hours services, acute hospital admission, and decreased mortality in a dose-dependent way.²⁰ If the practitioner-patient relationship has lasted more than 15 years, the probability of these occurrences is reduced by 25% to 30%.²⁰ Policy-makers seriously committed to effective prevention in primary care should be investing in re-establishing continuity of care by regular family physicians. Achieving this for future generations should be McWhinney’s legacy.