Continuity of medical care has been the casualty of specialization. Surgery and Medicine have been separated for centuries. More recently Pediatrics has separated from Medicine followed by Neonatology from Pediatrics and Geriatrics from Medicine along with the formation of a multitude of specialties based on organ systems. Most recently separation has begun on specific diseases. This fractionation is now being compounded with Pediatric and Adult specialists for these specific diseases. There seems to be no limit in the fragmentation of Medicine.
Continuity of practice within these fragmented areas has become a popular topic in the published literature of medicine. "… a research group in Exeter … has been developing a theory of continuity, based partly on clinical experience and partly on published evidence …(that)… in primary care, a 'personal doctor' with accumulating knowledge of the patient's history, values, hopes and fears will provide better care than a similarly qualified doctor who lacks such knowledge; and that the benefits of such continuity will include not only greater satisfaction for the patient but also more efficient consultations, better preventive care and lower costs."(1) This Exeter theory of continuity, while desirable in many ways for both doctor and patient, is not the Epidemiological Continuity of this essay.
The Epidemiological Continuity considered here is like that mystical dream of Alexis Carroll, discussed in Man, the Unknown(2). Carroll’s continuity would connect the myriad aspects of life, the history of events medical, social, nutritional, economic, educational, ethnic, etc. from infancy on, that lead to problems for adult and geriatric patients. Such information, if available, might make it possible for "Medicine" to understand each individual’s health and disease, the contribution of risk for future disease and the suggestion of preventive measures.
Today, with super fast computers providing mega calculations per second coupled with the practically unlimited electronic memory capacity to store information, the ability to communicate using the Intranet may be combined with Epidemiology, the basic science of medicine, to accomplish Alexis Carroll’s dreams within the lifetimes of the investigators and patients participating in such a project.
Carroll’s concept is wide and immense and so is not likely to receive immediate support for widespread or universal application. But the CF Aging Project could become a pilot project to prove Carroll’s principle and so lead not only to better health for our patients growing old with this one time fatal diagnosis, but also to pioneer for broader application to all. In a sense Carroll’s vision would join the forces that believe genetics has the answers to all problems with the forces that believe environment with its entire context really has the answers.
Perhaps, as members of the Groups that will start the CF Aging Project, we could keep in mind this broader view of a potential of the future that we could help to fashion, if we are bold enough to include a well designed historical assessment along with the prospective study that the CF Aging Project will require.
(1) Gray DP et al, Towards a theory of continuity of care. J R Soc Med 2003; 96: 160-166
(2) Carroll, A. Man, the Unknown: http://www.soilandhealth.org/03sov/0303critic/030310carrel/Carrell-toc.htm
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