Continuity: middle C—a very good place to start

Continuity of patient care

Family medicine as a discipline defines itself in terms of relationships, and continuity of patient care is fundamental to the establishment of enduring relationships between patients and doctors.⁴ The benefits of continuity of care include increased efficiency of visits, improved health outcomes, enhanced trust, and increased satisfaction for both patient and physician.^5–9 Hennen first described the concept of continuity of care as having 4 domains: chronologic or longitudinal, informational, geographic, and interpersonal.¹⁰ Since then, the concept has expanded to include family and interdisciplinary dimensions.¹¹ The combination of these 6 domains of continuity contributes to the breadth and scope of family medicine. These domains are defined in Table 1.¹

Teaching continuity of care in a 2-year family medicine residency program has many challenges. A true understanding of continuity of care often requires multiple patient-physician encounters, extended time to develop relationships, and opportunities for reflection and learning. A residency program designed exclusively around 1- or 2-month rotations in various medical disciplines lacks the structure to provide experiences needed for learners to master the concept of continuity of care and its importance in family medicine. Although many programs have attempted to address this by creating a “half-day back” for learners to return to their base family medicine clinic on a weekly basis while they are on other discipline-specific rotations, this strategy has created numerous logistical challenges. In many cases, both learners and the discipline-specific program directors view the “half-day back” as a barrier rather than a facilitator for learning in family medicine.¹

Other family medicine programs have developed creative methods for increasing the development of a therapeutic relationship between the patient and resident. One such innovative method is the development of a patient panel that provides systematic means for the learner to follow the patient through all domains of care, including the patient visit to the emergency department, stay in the inpatient ward, visit to surgery, or appointment with a consulting specialist. Longitudinal relationships between learner and patient afford residents substantial advantages in learning about patients’ responses to illness over time, the natural history of disease, and the rewards of these long-term relationships. Still other programs have created a horizontal curriculum program structure whereby learners are engaged in a family medicine curriculum woven across the 2 years; learning and time spent in other specialties are considered necessary enhancements to a resident’s core learning of how to become a family physician. Providing learning that is centred in family medicine will be further discussed in an upcoming article in this series. Critical to the concept of continuity of care is the use of metrics in residency programs to measure and evaluate how effectively residents provide continuity of care to their patients. Further research in this area is needed.¹

Continuity of education

Two key elements of continuity of education are continuity of supervision and continuity of the learning environment. (The third, continuity of curriculum, is beyond the scope of this article.) These elements support the development of a meaningful role for learners in patient care, promote increased resident responsibility over time, and facilitate effective, ongoing, formative feedback and coaching.¹

Programs often set learners up for feeling incompetent every 4 to 12 weeks with each change of rotation. In most programs, a new rotation brings changes in the learning environment (who the players are, where the equipment is, what the work cycle and expectations are). Greater continuity in the educational program can lead to more satisfying and perhaps less disruptive experiences for residents.^1,12

Conclusion

Continuity of education and patient care is an important component of the Triple C Competency-based Curriculum. Look for the next installment in this series, which will discuss comprehensiveness. Have questions? Visit www.cfpc.ca/triple_C or contact triplec{at}cfpc.ca for more information.