Continuity of Care as an Educational Goal but Failed Reality in Resident Training: Time to Innovate

Differences in reproductive health discussions in an urban Hispanic population with SLE: lessons from the field

OBJECTIVE

Management of reproductive health-related issues is crucial for patients with SLE, given this is a disease that primarily affects women of childbearing age. Little is known as to how the 2020 American College of Rheumatology (ACR) Reproductive Health in Rheumatic Disease Guideline is experienced by an underserved, primarily Hispanic population and their physicians as it relates to pregnancy planning and contraception conversations. Given this population experiences high rates of unplanned pregnancies and worse SLE outcomes compared with the non-Hispanic white population, it is crucial to understand how reproductive health is discussed in this setting.

METHODS

A survey based on the 2020 ACR Reproductive Health Guideline was created and distributed in English and Spanish in the outpatient setting to 151 patients with SLE to determine patients' beliefs, experiences and limitations with reproductive health discussions. Associations between categorical variables were evaluated using Pearson's χ2 or Fisher's exact test, as appropriate, and differences in continuous variables were assessed using Wilcoxon rank-sum test.

RESULTS

English language survey respondents were significantly more likely to report having conversations regarding contraception, pregnancy planning and peripartum medication use than the Spanish survey respondents. Two-thirds of all respondents relied on the rheumatologist as a top source of reproductive health information.

CONCLUSION

Disparities exist regarding reproductive health conversations on multiple topics between English-speaking and Spanish-speaking populations with SLE. Further understanding is needed to clarify why reproductive health conversations occur at lower frequencies in Spanish-speaking SLE populations.

Impact of Set-Day Clinic on Physician Continuity in a Family Medicine Residency Clinic

BACKGROUND AND OBJECTIVES

Continuity of care between patients and their primary care providers is associated with improved patient outcomes and experience, decreased health care costs, and improved provider well-being. Strategies to enhance continuity of care in residency programs involve electronic health record, scheduling, and panel management methods. Our study compared physician-patient continuity rates (pre and post) for one family medicine residency's implementation of a set-day clinic (SDC) scheduling model.

METHODS

In July 2019, Bethesda Clinic switched from a rotation-driven scheduling (RDS) model to SDC. Physicians were divided into two scheduling groups: Monday, Thursday, or Friday; or Tuesday, Wednesday, or Friday. We used visit data from two 6-month periods, October 2018 to March 2019 (RDS) and October 2021 to March 2022 (SDC), to calculate continuity using the continuity for physician formula. We used t tests to compare mean continuity rates between the RDS and SDC periods. In June 2022, faculty and residents were emailed a nine-question survey about SDC.

RESULTS

Adherence to the SDC model ranged from 65% to 76%. Postgraduate year (PGY) 3 residents' continuity increased significantly (P<.001) from 44% (RDS) to 56% (SDC), while PGY2 residents' continuity increased, nonsignificantly, from 38% to 43%. Among those that completed the survey, 94% of residents and 78% of faculty were in favor of SDC.

CONCLUSIONS

We demonstrated that SDC is feasible and well received by residents and faculty alike. Continuity was highest for PGY2 and PGY3 residents during the SDC period. Predictable clinic schedules have the potential to improve continuity in family medicine residency clinics and may improve physician well-being.

Integrated Behavioral Health in Primary Care Residency and Nonresidency Practices

BACKGROUND AND OBJECTIVES

Integrated behavioral health (BH) is becoming a preferred model of care for primary care because it improves patient outcomes and satisfaction. Little is known about whether residency practices are consistently modeling this preferred care model relative to real-world nonresidency practices. The study compared levels of BH integration, patient health outcomes, and satisfaction with care between residency practices and nonresidency practices with colocated BH providers.

METHODS

Baseline data were collected in 2018-2019 from 44 practices and their adult patients with chronic conditions participating in a cluster-randomized, pragmatic trial to improve BH integration. The sample included 18 (40.9%) residency and 26 (59.1%) nonresidency practices, with 1,817 (45.3%) patients from residency practices and 2,190 (54.7%) patients from nonresidency practices. Outcomes including BH integration levels (the Practice Integration Profile), patient health outcomes (the PROMIS-29), and patient satisfaction with care (the Consultation and Relational Empathy scale) were compared between residency and nonresidency practices using multivariate regression analyses.

RESULTS

No differences were found between BH integration levels, patient health outcomes, and patient satisfaction with care between residency and nonresidency practices. In a sample of primary care practices with colocated BH providers, residencies had BH integration and patient outcomes similar to real-world practices.

CONCLUSIONS

Primary care practices with residency programs reported comparable levels of BH integration, patient health outcomes, and patient satisfaction compared to practices without residency programs. Both types of practices require interventions and resources to help them overcome challenges associated with dissemination of high levels of BH integration.

Challenges in an X + Y ambulatory model

BACKGROUND

Internal medicine training requires significant exposure to ambulatory practice. Ensuring continuity of patient care is challenging, especially with intermittent ambulatory resident assignments. A popular scheduling model is an X + Y block system where residents rotate for X weeks on inpatient rotations followed by Y weeks on ambulatory clinics. Although benefits exist with the X + Y model, it has drawbacks, particularly for continuity of care: residents struggle to obtain follow-up test results and return patient calls promptly. To provide patients with seamless continuity the programme assigned two Managing Clinic Continuity Care Residents (MCCCRs) to cover all tasks. The MCCCRs were soon overwhelmed by the number of tasks and became dissatisfied with the workflow, however, resulting in a low task-completion rate.

METHOD

In our 4 + 1 model residents are divided into five cohorts, we created mini-practice groups (MPGs) consisting of one resident from each cohort. Each week the resident in the clinic is assigned to act as the Practice Clinic Continuity of Care Resident (PCCCR) for the MPG. This individual is responsible for addressing the patient tasks of the other four residents in the MPG. For optimal performance, the previous two MCCCRs are now assigned for oversight only each week. We tracked task-completion rates weekly and surveyed residents for satisfaction.

RESULTS

Following the redistribution of responsibilities, the task-completion rates improved from 75 to 97%. The MCCCR satisfaction rate for the workflow increased from zero to 63%, and the on-time note completion rates increased from 21 to 67%.

CONCLUSION

Modification of the X + Y model using the MPG structure ensured the timely completion of patient-related tasks, and improved the overall experience for both patients and providers. Modification of the X + Y model using the MPG structure ensured the timely completion of patient-related tasks, and improved the overall experience for both patients and providers.

Continuity of Care in Residency Teaching Practices: Lessons from "Bright Spots"

Continuity of care is a challenge in primary care residency teaching clinics. Resident physicians have competing inpatient and outpatient responsibilities and often spend only 1 to 2 half-days per week in the clinic. Their clinic schedules are often pieced together after the needs of inpatient and specialty rotations are met. Similarly, faculty clinicians often balance limited clinic time with teaching, research, or administrative responsibilities. Seeking approaches to improve continuity of care, we visited 23 internal medicine, family medicine, and pediatric residency clinics across the US. This article highlights strategies to optimize continuity of care pioneered by 3 "bright spot" residency teaching clinics with high-continuity performance. The strategies include adopting a strong continuity culture and patient scheduling algorithms that prioritize continuity, appointing a team continuity anchor, and/or reorganizing resident and faculty schedules to maximize continuity. We hope that these perspectives can assist residency teaching practices to improve continuity of care for their patients.

Chart stalking, list making, and physicians' efforts to track patients' outcomes after transitioning responsibility

CONTEXT

Transitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians' activities in practice as they sought follow-up information about patients.

METHODS

Using a constructivist grounded theory approach, semi-structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants' strategies when deliberately conducting follow-up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT) to explore interactions among the social, cultural and material influences related to follow-up.

RESULTS

The authors identified three themes related to follow-up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow-up. Analysis of participants' follow-up processes as an activity system highlighted key tensions in the system and participants' work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients' outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients' health information (rules) led to rule-breaking or abandoning activities of locating information. Finding time to conduct desired follow-up produced tension between this and other activity systems.

CONCLUSION

In clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow-up. The authors offer four recommendations to address the tensions identified through AT: (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians' skill development in developing and maintaining tracking systems for follow-up; (iii) dedicate time in physicians' work schedules for conducting follow-up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians' learning and respect patients' privacy.