Family Medicine

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World Book of Family Medicine – European Edition 2015 with patients, but also an “essential” in the special way GPs work; as shown above. If this is no longer possible or the number of contacts between GP and patient are reduced considerably (e.g. by shift work, special services for extramural care etc.), GPs would not know enough about patient's life-circumstances, values, and their coping ways of handling symptoms – and by this also lose their abilities to engage patients in shared decision-making based on understanding the patient. If continuity of care and comprehensiveness are reduced considerably, as is happening in some countries, General Practice will lose its allure for society and the patient - due to a loss in the described special ability of General practice to provide cost-effective care as well as reducing overtreatment. Should it be “personal continuity” or “institutional continuity”? Personal continuity is the only guarantor for obtaining optimal knowledge of a patient and a joint experience with each other, which is absolutely essential for a solid doctorpatient-relationship. Institutional continuity is only a second-best substitute because joint experiences of patient and doctor cannot be “transported” from one doctor to the next through writing notes. In most developed countries today, these core values of comprehensiveness and continuity of care are under pressure due to the developments in medicine bringing in sophisticated technical and analytical skills and knowledge on the one hand, and young doctors insisting on a limited number of working hours (including half-time work) on the other hand. Group practices and, within these, a division of functions also undermine these core values. “Emergency services” and “hotlines for health”, supported by the health care system, are additional institutions reducing the number of contacts with the GP. In some rich countries, like Germany, without a) a gate-keeper function of General practice and b) a work force of specialists as large as that of GPs, working full-time outside the hospital, the core values of continuity and comprehensiveness are seriously threatened. Additionally, patients are more and more attracted by the modern developments of technical medicine - which they expect to receive from specialists. In countries with fewer specialists and less funding on health care, General practice has to face another threat: contacts to one GP are massively reduced by installation of shift-work in health care, hospital ambulances for immediate care, and several different paramedic professions doing some of the work previously undertaken by GPs. Without the core values of comprehensiveness and continuity of care as well as an underlying solid patient-doctorrelationship, General Practice will, in the long run, lose any justification for its existence: Under such circumstances, specialists- with little information about the patient - would perform better because they are better educated for medicine of the “details”. But knowing that often these “details” are not the real problem, and that the patient's complaints have to be interpreted in the context of the whole person, the time and circumstances of developing a symptom or illness, we have to fear about the quality of care in a future without GPs. Take home messages General Practice is a very cost-effective way of caring. For this it is absolutely necessary to have detailed knowledge of and experience with the patient. Only a system allowing GPs to care comprehensively and in continuity makes this possible. Without these two core values General Practice will lose its base. And society its cost-effective health care. Original abstract http://www.woncaeurope.org/content/155-comprehensiveness-and-continuity-care-core-values-necessary-survival-germangeneral References Boulton M, Tarrant C, Windridge K, et al. How are different types of continuity achieved? A mixed methods longitudinal study, British Journal of General Practice 2006,56:749-755 Boyd CM, Darer J, Bould C. et al. Clinical practice guidelines and the quality of care for older patients with multiple comorbid diseases. JAMA 2005; 294:716-24 Freeman G, Hughes J. Continuity of care and the patient experience. The Kings Fund, London 2010 Haggerty JL, Roberge D, Freeman GK, et al. Experienced continuity of care when patients see multiple clinicians: A Qualitative Metasummary. Annals of Family Medicine 2013,11: 262-271 186
World Book of Family Medicine – European Edition 2015 Miles A. Complexity in medicine and healthcare: people and systems, theory and practice. Journal of Evaluation in Clinical Practice 2009; 15: 409–410 Reeve J. Interpretive medicine – Supporting generalism in a changing primary care world. Royal College of General Practitioners, Occasional Paper 88, London 2010 Starfield B, Lemke, KW, Herbert R. et al. Comorbidity and the use of primary care and specialist care in the elderly. Annals of Family Medicine 2005; 3: 215-222 Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 2005, 83 (3):457–502 187
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