Written by Dr William Maish
Healthcare systems continue to operate on an assumption that is increasingly untrue: that continuity of care exists by default. For much of modern medical history, this assumption was reasonable. Patients were seen by a small number of clinicians over long periods of time. Medical decisions accumulated context organically. Responsibility for risk, follow-up, and judgement was distributed longitudinally across repeated encounters. In this environment, much of medicine could safely rely on what had already been “covered off”. That world no longer reliably exists.
Across high-income health systems, care has quietly shifted toward episodic, fragmented encounters. Patients move between providers, platforms, and locations. Telehealth, after-hours services, workforce shortages, short-term contracts, and digital prescribing have transformed many clinical interactions into isolated events. Even when care is labelled as “repeat” or “follow-up”, it is often delivered by a clinician with no prior relationship to the patient and incomplete access to their history.
Yet the systems governing healthcare delivery still behave as though continuity is present. Clinical workflows, legal standards, and digital platforms continue to assume that someone else, somewhere, has already addressed key risks. This assumption is rarely stated explicitly, but it shapes practice. It allows histories to be abbreviated, medication decisions to be inherited without reconstruction, and responsibility to diffuse across time rather than attach to a specific encounter. This mismatch is no longer benign, and the elephant in the room needs to come out: this is a safety issue.
When continuity is assumed but absent, risk is not eliminated. It is transferred. It is transferred from systems to clinicians, from clinicians to patients, and from explicit processes to implicit trust. The result is not careless medicine, but unexamined medicine. Decisions appear efficient precisely because the work of verification has been silently skipped. This is particularly visible in the treatment of “simple” clinical interactions.
Repeat prescriptions, stable chronic medications, low-acuity complaints, and administrative requests are often framed as trivial extensions of prior care. In reality, many of these interactions are first-contact medicine in disguise. The clinician may be the first to reassess indication, tolerance, contraindications, interactions, or interval change since the original decision was made. Treating these encounters as anything else is a category error.
The problem is not that clinicians are negligent. It is that systems are asking them to act as if continuity exists when it clearly does not. Telehealth has amplified this tension (but did not create it). It merely made the absence of continuity harder to ignore. A digital consult cannot rely on tacit knowledge, hallway conversations, or paper notes. What is not asked, structured, or recorded does not exist. In that environment, the informal shortcuts of traditional practice are exposed as design assumptions rather than clinical necessities.
Unsurprisingly, the dominant response to this exposure has been discomfort. Clinicians often describe structured digital intake, explicit safety checks, or decision-bounded workflows as “too much” for ostensibly simple care. This reaction is understandable. Systems that make implicit work visible feel heavier to those accustomed to carrying it silently, and those who skip it. But this discomfort should not be mistaken for evidence of excess. It is evidence of misalignment between how care is designed and how it is now delivered.
The alternative is not to retreat to informality, but to redesign for honesty. Designing honestly for episodic care means accepting that many encounters begin without context and must therefore reconstruct it. It means acknowledging that a “repeat” prescription still requires a defensible decision in the present. It means replacing assumptions with explicit checks, and implicit trust with auditable judgement.
And, importantly, this does not require exhaustive interrogation. It requires intentional structure. Well-designed systems do not ask more questions than necessary; they ask the right questions early, and they adapt once safety is established. They distinguish between baseline reconstruction and interval change. They make clear which assumptions are being made, on what basis, and with whose declaration. They allow depth to contract when risk is low and expand when uncertainty appears.
This approach mirrors how good clinicians already think. In face-to-face practice, a patient who has had a recent review is not subjected to a full re-history, but nor are they waved through without verification. The clinician performs a delta check: what has changed, what has not, and what still matters. Digital systems should do the same, rather than oscillating between rigidity and permissiveness.
The ethical implications of this shift declare that when continuity is absent, pretending it exists advantages systems at the expense of patients. It obscures responsibility and makes harm harder to trace. By contrast, first-contact design makes responsibility visible. It clarifies where decisions are made, who made them, and what information they were based on. This transparency benefits not only patients, but clinicians and regulators as well.
More broadly, and looking at the financial impact, much of the cost inflation in primary care is driven not by complexity, but by inefficiency. Time is consumed reconstructing context that could have been structured once, or avoided through better pre-consult design. When decision-making is bounded and preparatory work is done upfront, consults can be shorter without being rushed. Cost can fall without quality being sacrificed. The idea that affordability requires lower standards is itself a relic of continuity-based thinking.
None of this is an argument against continuity of care. Longitudinal relationships remain valuable and should be protected where they exist. But designing systems as if continuity is universal when it is not is no longer defensible. Continuity should be treated as a modifier rather than a default.
Healthcare has already changed, yet fascinatingly, its systems have not. As episodic care becomes more common, the choice is not between structure and trust, or safety and efficiency. The choice is between honest design that reflects reality, and nostalgic design that quietly transfers risk. The myth of continuity has outlived its usefulness. Replacing it with explicit, first-contact-aware systems is not overengineering. It is simply catching up.
If you want to understand how this informs what we do at Medly and why we do it, check out Medly, my publications & my current research.
Written by Dr William Maish
MD MBA MPH FHEA JD (in prog.)
Found of Medly & Medly Health
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