Continuity in all matters

 

Regardless of political affiliation, all will concede the disruptive effect of the government shutdown.  It has been a sufficiently powerful event as to invite its use in analogy; in a treatment setting, the analogical subject would be the need for continuity.  The WBUR link (buprenorphine waiver processing concerns arising from the shutdown) illustrates one effect of the disruption.  

Continuity of care has been a linchpin of chronic illness management for as long as medical care has sought a rational basis, certainly as far back as Benjamin Rush, maybe back to Galen.  Once acknowledgment is made of an illness as being chronic, particularly when progressive and even when remitting, then we assume a long-term therapeutic relationship is wanted.  The participants in that may not be limited to physicians, and treatment may lean most heavily on other health care providers and families, but the plan will generally assume: sound diagnosis; an initial intervention; monitoring; and episodic response to crises.  Successful management obliges a long view.  Otherwise, misfortune, even disaster is simply delayed.  We even key our treatment strategies to the acuity or chronicity of the disease state: acute care; chronic management.  Instruction in subcutaneous injection of NPH insulin, a diet sheet, and hearty encouragement at a final office visit are just not in it for success with diabetes.  Despite this, therapeutic misconceptions and short-term economics conspire  to have us treat addiction with a time-limited course in mind.  Most of us would want a more continuous model to apply, realizing that development of trust requires 1) competence, 2) reliability.  They’re in it for the long run; so should we be.

So we have, or should have, at least a two-dimensional plot:  Type and intensity of intervention on the ordinate (Y-axis), time on the abscissa (X-axis), with the latter in most cases extending to the end of a patient’s life.  We have handled the Y-axis pretty well, with care-matching models such as The ASAM Criteria; we have been less persuasive in our argument for chronic disease management strategies.  

The Federal shut-down to which alluded in the WBUR link provides a risky simile, but I don’t think I am stretching it overmuch, and the simile has heuristic value:  to the same degree that the public loses confidence in continuity and competence, such that little reliance can be placed on the polity or on a physician’s plan, then adherence and cooperation will dissolve.  Relapse or exacerbation may be expected next; injury and scarring are predictable.   The solution, having assured access, is to assure continuity.   

- W. Haning, MD