Editor's Choice

Familiarity breeds better outcomes

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j558 (Published 02 February 2017) Cite this as: BMJ 2017;356:j558
  1. Elizabeth Loder, head of research
  1. The BMJ
  1. eloder{at}bmj.com

Let’s be clear: familiarity breeds better outcomes. People who have a usual, continuous source of primary medical care generally do better than those who don’t. We know this, and yet everywhere primary care and general practice are in crisis.

The United Kingdom is no exception. Its medical schools are “training future doctors for yesterday,” say our editorialists John Oldham and Sam Everington (doi:10.1136/bmj.j294). Only 5.9% of UK medical school professors are GPs. As in the United States, there is prejudice and “institutional discrimination” by medical leaders against generalism. The result is that too few medical graduates pursue training in general practice. Instead, most seek specialty training for careers that are more prestigious and promise a better lifestyle. The proposed solution? Tie accreditation and funding to schools that produce doctors whose career choices are in line with population needs.

What is it that general doctors do so well? For starters, they can help keep you out of hospital. Barker and colleagues (doi:10.1136/bmj.j84) find that older patients who received more of their care from the same GP were less likely to be admitted to hospital for so called “ambulatory care sensitive conditions.” These are illnesses such as asthma, diabetes, hypertension, or epilepsy that can usually be controlled with careful outpatient management by a doctor who knows patients well and follows them over time. Admissions to hospital for these problems can be an indication of ineffective outpatient care. In a linked editorial, Peter Tammes and Chris Salisbury (doi:10.1136/bmj.j373) say that policies that promote and support continuity of primary care are needed “to improve job satisfaction for GPs and very likely reduce pressure on hospitals.”

Despite the best efforts of primary care doctors, every year millions of people visit a hospital emergency department. Some are admitted. Most, however, are evaluated, perhaps treated, and then sent home. Of these, a small portion drops dead within the week—0.12% to be exact, finds a study that used US Medicare data (doi:10.1136/bmj.j239).

Because there are so many emergency department visits, the authors calculate that this small percentage translates into 10 093 deaths a year in the US. The most common cause of such unexpected deaths was atherosclerotic heart disease. More deaths occurred among people sent home from hospitals that had lower rates of admissions through the emergency department, even though the patients in those institutions were healthier overall. Could some of these deaths be prevented? It is tempting to speculate that a lower threshold for hospital admission in borderline cases might make a difference, perhaps by allowing doctors to get to know patients and observe their conditions over time. Sound familiar?

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