Health Reform and Continuity of Care

In the chaos of health care efforts both nationally and in Iowa, today I seek to go back to two basic beliefs: 1) the hope of future generations to learn from past generations’ mistakes and 2) the value of continuity of care for primary health care and ultimately, health care in general.

Given that the U. S. Senate is now debating a tax cut bill that includes eliminating the Affordable Care Act (ACA) individual mandate for health care coverage—a basic tenet for true health care reform—and in Iowa, the for-profit managed health care Medicaid fiasco, which now has one managed care organization (MCO) leaving the state and another MCO not able to take new patients. These actions leave the state with only one MCO left to serve Medicaid patients, I shift gears by presenting to you a guest blogger.

She is a third-year medical student who recently spent a month with me in my clinic. She plans to be a pediatrician. I choose not to provide her name. Although she would allow it, I am not sure her medical school would.

She is a wonderful example of a new generation of physicians who hopefully will help lead our country into universal health care coverage. I fear my generation will fail at that goal. She is caring, intelligent, dedicated, and well-taught.  She writes about continuity of care which I believe is fundamental to good health care and is necessary for true health reform. I share her thoughts below.

This rotation was a wonderful opportunity for me to see continuity of patient care and the benefits that it can offer both the physician and the patient. Dr. Carlyle has a practice of approximately 2300 patients. He started working at McFarland Clinic in Ames 24 years ago and some of his patients today have been with him that long! He has developed special relationships with his patients. They respect him, value his opinion, and trust his judgment. Nearly all of his patients come in for an annual physical exam. Most of his patients get an annual flu shot. This relationship allows the patients to have better care. It also allows Dr. Carlyle to enjoy his work with patients that he knows and truly cares about on a personal level.

When Dr. Carlyle’s patients are hospitalized at Mary Greeley Medical Center, Dr. Carlyle is the physician responsible for caring for them. He orders tests, consults, and prescribes appropriate medications. He routinely has one or two patients in the hospital.

When his patients are discharged, he sees them in his office one week later. I think this continuity of care was really remarkable. It allowed Dr. Carlyle to be tremendously more familiar with the patient’s hospital course than he would have been if another provider had been caring for the patients.

One patient, in particular, stood out to me. He was a 60 something-year-old man who was admitted for pericarditis with effusion and cardiac tamponade. He seemed to be doing well initially but ended up transferring to the ICU. He had his effusion drained and began to improve. While he was hospitalized, he experienced anxiety and was given lorazepam a couple of times to help him to calm down and get a good night’s sleep. When the patient returned to the clinic one week after discharge, he seemed to be doing great. He really had no complaints of shortness of breath or chest pain. However, he was having continued anxiety at night. He felt anxious about lying flat in his bed, so he was avoiding getting in bed at night and ultimately not sleeping well over the last week. Dr. Carlyle has known this patient for many years, and this man has never had a problem with anxiety or depression, and other than the lorazepam in the hospital, the patient had not been treated for anxiety before. Because Dr. Carlyle knew the full history of this patient, including the details of his recent hospital course, he was able to safely prescribe a short course of lorazepam to take at bedtime. This will significantly improve the patient’s sleep, which will ultimately make a big difference in the patient’s quality of life overall and aid in his recovery from pericarditis.

I think it is because of the relationship that Dr. Carlyle has with his patients that they receive such good care, both inside the hospital and as outpatients. His patients keep coming back to him, and I definitely believe this continuity results in better outcomes. As a future general outpatient pediatrician, I can’t wait to develop these sorts of relationships with my own patients because I’ve seen firsthand how rewarding they are on so many levels.