Why seeing the same doctor matters

Seeing the same doctor feels like a preference, in the way that liking a particular barber is a preference. Pleasant, slightly old fashioned, not really a clinical matter.

The research suggests otherwise, and the size of the effect is larger than most people, including many patients, would guess.

The review

In 2018 Pereira Gray and colleagues published a systematic review in BMJ Open with a title that does not hedge: "Continuity of care with doctors, a matter of life and death?"

They identified 22 studies meeting their criteria. Of those, "18 (81.8%) showed that greater continuity of care was significantly associated with lower mortality rates", with 16 of those showing reductions in all-cause mortality.

The effect was not confined to family doctors. "These significant protective effects occurred with both generalist and specialist doctors."

Eighteen out of twenty-two studies, across countries and health systems, pointing the same way, on the hardest outcome there is.

Read it honestly

This is observational evidence, and the authors say so. Nobody has randomised patients to have a consistent doctor or a different one each time, and it is hard to imagine anyone could.

That matters because of reverse causality. People who are sicker, more transient or more chaotic in their lives may find it harder to keep seeing the same clinician, and are also at higher risk of dying. Some of the association may run that way rather than the way it appears.

The exceptions are worth knowing too. Two studies found no significant association, both measuring continuity over very short periods. One found no association except in less deprived areas. And one produced a genuinely odd result: continuity measured from insurance claims was associated with higher mortality, while "patient-reported continuity were associated with lower mortality rates".

That last finding is a useful caution about what is being measured. Repeatedly seeing the same name on a claim form is not the same thing as a patient feeling they have a doctor, and the two can point in opposite directions.

Why it would work

The mechanism is not mysterious to anyone who has sat in an appointment with a stranger.

A doctor who knows someone notices change. Not an abnormal number, but the fact that this particular person is more breathless than they were, or thinner, or less themselves. That comparison is unavailable to a clinician meeting them for the first time, however good they are.

Continuity also carries the accumulated context that never quite fits in the record: what they are like when they are well, what they will and will not put up with, which symptoms they underplay, who is at home.

Reviews of continuity in aged care similarly associate it with fewer hospital admissions and emergency presentations for conditions common in older people.

What to do with this

• • When booking, ask for the clinician who knows them, and be willing to wait a little for it. That is a clinically defensible preference, not fussiness.
• • If continuity is genuinely unavailable, compensate deliberately: bring the history, the medication list and the recent numbers, because you are now the carrier of the context.
• • Say what has changed, not just what is wrong. "He is not himself compared with three months ago" is the observation continuity normally supplies.
• • Weigh it in the tradeoff. Waiting two days for the doctor who knows them is often better than seeing anyone today, though not always, and not in an emergency.

Why we build around this

This evidence is the reason Dr.life matches a patient to a provider and keeps them there, rather than routing each question to whoever is free.

The convenience model of telehealth, a stranger with four minutes and a chart they are skimming as they speak, discards exactly the thing this review associates with lower mortality. That trade might be worth it for a repeat prescription. For an older person with several conditions, it is giving up something the evidence suggests is valuable.

We will not pretend the person who knows you is always free, and we would rather show that tradeoff honestly than hide it. But the default should be continuity, with speed as the exception, and not the other way round.