Continuing Responsibility

One of the essential functions of the family physician is the willingness to accept ongoing responsibility for managing a patient's medical care. After a patient or a family has been accepted into the physician's practice, the responsibility for

Table 1-2 Attributes of the Family Physician*

• A strong sense of responsibility for the total, ongoing care of the individual and the family during health, illness, and rehabilitation.

• Compassion and empathy, with a sincere interest in the patient and the family.

• A curious and constantly inquisitive attitude.

• Enthusiasm for the undifferentiated medical problem and its resolution.

• Interest in the broad spectrum of clinical medicine.

• The ability to deal comfortably with multiple problems occurring simultaneously in a patient.

• Desire for frequent and varied intellectual and technical challenges.

• The ability to support children during growth and development and in their adjustment to family and society.

• Assists patients in coping with everyday problems and in maintaining stability in the family and community.

• The capacity to act as coordinator of all health resources needed in the care of a patient.

• Enthusiasm for learning and for the satisfaction that comes from maintaining current medical knowledge through continuing medical education.

• The ability to maintain composure in times of stress and to respond quickly with logic, effectiveness, and compassion.

• A desire to identify problems at the earliest possible stage or to prevent disease entirely.

• A strong wish to maintain maximum patient satisfaction, recognizing the need for continuing patient rapport.

• The skills necessary to manage chronic illness and to ensure maximal rehabilitation after acute illness.

• Appreciation for the complex mix of physical, emotional, and social elements in personalized patient care.

• A feeling of personal satisfaction derived from intimate relationships with patients that naturally develop over long periods of continuous care, as opposed to the short-term pleasures gained from treating episodic illnesses.

• Skills for and a commitment to educating patients and families about disease processes and the principles of good health.

• A commitment to place the interests of the patient above those of self.

*These characteristics are desirable for all physicians, but are of greatest importance for the family physician.

care is total and continuing. The Millis Commission chose the term "primary physician" to emphasize the concept of primary responsibility for the patient's welfare; however, the term primary care physician is more popular and refers to any physician who provides first-contact care.

The family physician's commitment to patients does not cease at the end of illness but is a continuing responsibility, regardless of the patient's state of health or the disease process. There is no need to identify the beginning or end point of treatment, because care of a problem can be reopened at any time—even though a later visit may be primarily for another problem. This prevents the family physician from focusing too narrowly on one problem and helps maintain a perspective on the total patient in her or his environment. Peabody (1930) believed that much patient dissatisfaction resulted from the physician's neglecting to assume personal responsibility for supervision of the patient's care: "For some reason or other, no one physician has seen the case through from beginning to end, and the patient may be suffering from the very multitude of his counselors" (p. 8).

Continuity of care is a core attribute of family medicine, transcending multiple illness episodes, and it includes responsibility for preventive care and care coordination. "This longitudinal relationship evolves into a strong bond between physician and patient characterized by trust, loyalty, and a sense of responsibility" (Saultz, 2003). Trust grows stronger as the physician-patient relationship continues and provides the patient a sense of confidence that care will always be in his or her best interest. It also facilitates improved quality of care the longer the relationship continues.

The greater the degree of continuing involvement with a patient, the more capable the physician is in detecting early signs and symptoms of organic disease and differentiating it from a functional problem. Patients with problems arising from emotional and social conflicts can be managed most effectively by a physician who has intimate knowledge of the individual and his or her family and community background. This knowledge comes only from insight gained by observing the patient's long-term patterns of behavior and responses to changing stressful situations. This longitudinal view is particularly useful in the care of children and allows the physician to be more effective in assisting children to reach their full potential. The closeness that develops between physicians and young patients increases a physician's ability to aid the patients with problems later in life, such as adjustment to puberty, problems with employment, or marriage and changing social pressures. As the family physician maintains this continuing involvement with successive generations within a family, the ability to manage intercurrent problems increases with knowledge of the total family background.

By virtue of this ongoing involvement and intimate association with the family, the family physician develops a perceptive awareness of a family s nature and style of operation. This ability to observe families over time allows valuable insight that improves the quality of medical care provided to an individual patient. A major challenge in family medicine is the need to be alert to the changing stresses, transitions, and expectations of family members over time, as well as the effect that these and other family interactions have on the health of individual patients.

Although the family is the family physician's primary concern, his or her skills are equally applicable to the individual living alone or to people in other varieties of family living. Individuals with alternative forms of family living interact with others who have a significant effect on their lives. The principles of group dynamics and interpersonal relationships that affect health are equally applicable to everyone.

The family physician must assess an individual's personality so that presenting symptoms can be appropriately evaluated and given the proper degree of attention and emphasis. A complaint of abdominal pain may be treated lightly in one patient who frequently presents with minor problems, but the same complaint would be investigated immediately and in depth in another patient who has a more stoic personality. The decision regarding which studies to perform and when is influenced by knowledge of the patient's lifestyle, personality, and previous response pattern. The greater the degree of knowledge and insight into the patient's background, as gained through years of ongoing contact, the more capable is the physician in making an appropriate early and rapid assessment of the presenting complaint. The less background information the physician has to rely on, the greater is the need to depend on costly laboratory studies, and the more likely is overreaction to the presenting symptom.

Families receiving continuing comprehensive care have a decreased incidence of hospitalization, fewer operations, and less physician visits for illnesses compared with those having no regular physician. This results from the physician's knowledge of the patients, seeing them earlier for acute problems and therefore preventing complications that would require hospitalization, being available by telephone or by e-mail, and seeing them more frequently in the office for health supervision. Care is also less expensive because there is less need to rely on radiographic and laboratory procedures and visits to emergency departments.

Continuity of care improves quality of care, especially for those with chronic conditions such as asthma and diabetes (Cabana and Jee, 2004). Because about 90% of diabetic patients in the United States receive care from a primary care physician, continuity of care can be especially important. Parchman and associates (2002) found that for adults with type 2 diabetes, continuing care from the same primary care provider was associated with lower HbA1c values, regardless of how long the patient had suffered from diabetes. Having a regular source of primary care helped these adults manage their diet and improve glucose control.

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