On September 17, 2013, at SETMA’s September provider training session, everyone received a copy of The Familiar Physician by Peter B. Anderson, MD.   The central message of this book which begins from page one is “One of the most important (factors€¦to create good medical care) is the human connection that develops over time between a doctor and a patient.”  The premise of this ideal is that “The family physician knows the patient well enough to identify a health issue better than a medical colleague who would be unfamiliar with the individual being treated.” 

While this brief review will not allow a detailed critique of this book and while I find much to be valued in this book, I do not agree with this as a foundational principle of primary care medicine.  In October, 1999, eighteen months after purchasing our electronic medical record, SETMA published a booklet entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management.   The following three quotes from that paper clarify why I think that the focus of healthcare in the future will not be personality driven.  The paper stated:

“When I was a child, medical records were kept on a 3x5-file card. The information essentially reflected the date and a one-word statement of what transpired in the visit to the doctor, often related merely to a shot or medicine, which was given. Patients paid a dollar for the visit, a dollar for the shot and a couple of dollars for the medication. Expectations were low and expenses were, also. The physician kept most of the important patient information in his/her head. Therefore, when the physician wasn't available, data on the patient wasn't available€¦This system was extremely personal and was often very satisfying for the patient and the physician. When I was born, Dr. Culpepper was my family doctor. In 1949, my family moved and did not use Dr. Culpepper as a physician again. In 1973, when I graduated from medical school, I called Dr. Culpepper and said, ‘Dr. Culpepper, I wanted to say hello and tell you I have graduated from medical school.’ Dr. Culpepper was in his early eighties and said spontaneously, ‘How are Bill and Irene,’ calling my parents by their first names, after not having seen them in 24 years. Dr. Culpepper had a wonderful mind, but it could only be in one place at a time.”

“Recently, the mother of a prominent citizen in our community became our patient. After completing an extensive history and physical utilizing the computerized patient record, I asked this lady, ‘Do you think I now know you well enough to make appropriate decisions about your healthcare?’ She responded, ‘You know more about me than the doctor who has taken care of me for twenty years. He has never asked me all those questions.’ This testimonial can be repeated multiple times. EMR creates tremendous confidence in the patient that an accurate and complete database is available to the healthcare provider.”

“Recently, an elderly patient of mine came to the emergency room at 5:30 AM. I met her there as she walked in. When she sat down in the exam room, she pulled out of her purse a copy of her computerized patient record from her last visit to my office. It was complete and had all of her past history, allergies, medications, diagnoses and physical examination. I have known this patient for twenty-five years, but this record was more complete than my memory. I was able to quickly assess her condition and safely allow her to return home, after dictating an emergency room encounter, which would appear as if I had spent hours with the patient rather than a few minutes.”

SETMA’s experience does not argue against the value of and particularly the personal satisfaction of having a personal relationship with your primary care provider.  When I was a child our family physician was our closest friend even though we lived very different life styles.  SETMA’s experience does introduce the idea that the healthcare provider may not be a physician, and that in 21st Century, technological healthcare, a team made of multiple and multi-disciplinary providers is a superior model of care to that of Marcus Welby.

Increasingly, different methods will be used to measure the personal interactions of providers with patients.  Decreasingly, those measures will be an intimate, personal relationship between provider and patient.  Dr. Anderson’s concept of “familiar” will never be lost but the complexity of 21st Century society and healthcare will see that emphasis on personality gradually replaced with patient-centric interaction and with that interaction increasingly measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and by Consumer Assessment of Healthcare Providers and Systems (CAHPS) in the ambulatory setting.  There is a tendency for friends to answer HCAHPS and CAHPS surveys positively without regard to the content of the healthcare encounter, whereas when the scores are excellent with a stranger, or a less-familiar provider, it more probably relates to a quality encounter which provides more healthcare value to the patient.

When the patient interacts with a provider with a granular healthcare portrait of the patient via a complete electronic patient record, rather than a silhouette, and when the patient-centered provider  is skilled at patient/provider dialogue, being cared for by a “non-familiar” provider can be as satisfying as seeing your “old friend.”  And, as is even now often the case, a new perspective from a non-familiar provider can result in improved care.  In the case of healthcare familiar does not breed contempt but it can breed carelessness.  Improvement in care is particularly true when the “non-familiar” provider is familiar with and has access to the patient’s complete medical history and experience.  And, when that “non-familiar” provider invites a detailed dialogue about the patient’s former, current and future health needs and concerns, patient satisfaction with “non-familiar” providers increases even more..

In the future, continuity of care will less and less be personality driven and will increasingly become data driven, as all of a patient’s data is available and accessible.  And, the continuity previously related to personality and personal relationship will be maintained when the provider is skilled in relating to and conducting a patient-centered conversation with a patient whether familiar or stranger.  And, there is a risk that in the real world, the closer you are to your healthcare provider and the more of a friend he/she is, the more likely it is that your healthcare time will be spent on personal rather than professional issues.  That is not to say that it is always the case but it is a danger.  I have often argued, I think validly, that changing doctors every ten years, can be a positive thing.  With the change you can break out of the “ruts” of your care and get a new perspective and a fresh look at your health.  Of course, in a clinic setting, such as SETMA, where you see your personal provider about 60%, the other 40% of your encounters provides the balance without you having to change healthcare providers.

Dr. Anderson repeats the standard description of medical home and the National Committee for Quality Assurance’s support of a personality-driven concept of continuity of care.  SETMA believes that future iterations of medical home will be less driven by personality dependency and will be increasingly driven by the provider’s personal concern for the patient supported by data and by the desire for the measurably best outcome.  Then, when the provider leaves practice, moves from the community, dies or otherwise is no longer available, the patient is not left isolated.  The healthcare system providers the personalized care the patient has come to depend upon and that care survives the provider and survives the patient/provider relationship.