Table 1.

Teaching strategies for each of the 6 components of the continuity of care

Chronologic or longitudinal5
  Care provided over timeSees intervention outcomes
  1. Have residents see the same patients in follow-ups. Try to make this process independent of the nurses or receptionists.

    • If using an EMR, teach residents how to book their own patients.

    • If the EMR is capable, link residents with their patients electronically, so anyone booking patients knows to book them with their residents.

    • “Assign” patients to particular columns (eg, columns 1 or 2) in the booking program. Then assign new residents to see patients in columns 1 or 2. Because patients are always assigned to the same column, residents would automatically see the same patients again. If some patients prefer male or female residents, make sure to consistently assign one column to male and one column to female residents and schedule patients appropriately.

    • Have appointment cards in the examining rooms; residents can fill out the cards with their names and the length of time for the next appointments. When receptionists receive these cards from the patients, they will know to book the patients with the right residents.

  2. Ask receptionists not to book follow-up visits in clinics when residents are either away or on holidays.

  3. Monitor and explicitly give feedback about the number of repeat visits at midrotation feedback sessions.

Learns to deal with difficult situations instead of deferring
Informational 5
  Providers have access to information about patients’ previous health care encounters (ie, medical records and laboratory and x-ray results)5,6Improves efficiency and safety of the encounterRecords might be incomplete, particularly with respect to future management plans7
  1. Direct laboratory work for residents’ patients to the residents as well as the faculties and have residents decide the initial management plans. It is ideal to automate this as much as possible: If using an EMR and laboratory results arrive at the office electronically, have an electronic link between residents and patients, so laboratory results automatically enter residents’ and faculties’ electronic mailboxes. If this is not feasible, laboratory results for residents’ patients would need to be manually directed to them by receptionists, nurses, or preceptors.

  2. If possible and appropriate, set up general assessments early in residents’ rotations to quickly increase their knowledge of patients, particularly complex patients.

  3. Provide residents with patients’ background information for first encounters.

  4. Ask residents to write off-service notes on patients for whom continuity of care is particularly important. This has 2 benefits: Residents going off service can think about continuity issues; incoming residents are informed about the patients.

Increases patients’ satisfaction because residents have knowledge of their histories
  Care provided in a variety of settings (office, home, hospital, etc)Increases insight to understanding patient through environmental cluesTime
  1. Have residents provide their patients with any required housecalls or nursing home visits. As it is unlikely patients will start to need housecalls or enter nursing homes during rotations, assign residents to patients who already require such visits.

  2. As opportunities for hospital visits vary, assign residents to patients who are already in hospital. If there is a discharge planning session, ask the charge nurse or social worker to involve the resident in the session, by teleconference if not in person. Ensure the resident sees that patient on discharge.

  3. Have the resident follow a patient to an outpatient procedure or appointment (eg, stroke rehabilitation, cardiac rehabilitation, preoperative clinic, outpatient surgical procedure [colposcopy, colonoscopy, etc], outpatient investigation [DEXA, CT, etc], diabetes or asthma education centre, dietitian). To facilitate this type of opportunity, book residents out of clinic so they can go to these appointments, which should not be a problem because such procedures are booked in advance. Ideally, these procedures should be booked as first-of-the-day clinic appointments, minimizing residents’ time away from clinics.

Enhances therapeutic relationship (eg, appreciation of patients for hospital and home visits)
Interdisciplinary 5
  Alternately defined as care provided by 1 practitioner across disciplines (eg, obstetrics, ED shifts, surgical procedures) or care coordinated as patients are followed across disciplines
  1. Ensure residents either do or assist with the procedures that are within the scope of family medicine for their patients.

  2. Provide residents with all consultant reports on their patients.

Family or community*
  Care provided to various family members, or care provided to various members of the same community (particularly relevant in small-town settings)Provides additional insight about patientsConfidentiality issues
  1. Follow the booking practice listed for individual patients in the chronologic or longitudinal section (ie, book all family members in 1 column or link family members together in EMR with 1 resident), and have the resident see all family members.

  2. Have residents attend patients’ family counseling appointments (marital, parenting, etc).

Co-option into issues family members or community members have with the patient
Interpersonal 5
  Establishment of the doctor-patient relationshipImproves job efficiency1,2,4Complacency (slotting patients into predetermined patterns)2
  1. Deliberately place residents in situations in which either the continuity of care is very important for patients or there is increased likelihood of quickly developing a significant therapeutic relationship with patients (eg, prenatal, delivery, or postpartum, delivering bad news, palliative care, hospital visits, housecalls, chronic disease management).2,4,8

  2. Be a role model. Discuss explicitly what you do when it comes to working on interpersonal continuity with your patients, both the positive and negative aspects, and how you cope with the negative aspects.

  3. Encourage residents to care for some difficult patients; this will further enhance their understanding of the challenging aspects of continuity of care. Make sure there is time for residents to debrief with you regarding their difficult patients.

Increases job satisfaction1,2,4Increases worry and anxiety about patients’ health, medical management, and friction between work and personal life2
Improves patient outcomes (therapeutic benefits)4
Decreases medicolegal risk4Increases sense of conflict when duties to inform arise (driving, criminal, CAS, etc)*
Provides feedback regarding effectiveness as a physician, resulting in greater confidence2Causes grief when patients die or become disabled*
Causes patient dependency1,2
Creates boundary issues*
  • CAS—Children’s Aid Society, CT—computed tomography, DEXA—dual-energy x-ray absorptiometry, ED—emergency department, EMR—electronic medical record.

  • * Data from K.S. and J. Kerr, unpublished data, 2009.