Teaching Continuity of Care: The role of teachers of family medicine

1
Teaching Continuity of Care The role of
teachers of family medicine

• Yonah Yaphe MD
• Department of Family Medicine
• Rabin Medical Centre and
• Sackler Faculty of Medicine
• Tel Aviv University, Israel

2
Objective

• Define CONTINUITY in family medicine
• Describe the role of the teacher in presenting
  this concept to learners.

3
Features of family medicine

• Continuous
• Comprehensive
• Contextual
• Coordinated
• Communication

4
Writing educational objectives

• Knowledge, skills and attitudes (Bloom)
• Write a specific objective for a specific
  audience under specified conditions.
• E.g. At the end of the course the trainee will
  list the benefits of continuity of care.

5
Principles of adult learning

• Adults learn best
• with clear objectives
• relevant topics that help them solve real
  problems
• with active, self-directed learning
• in a pleasant environment
• with effective feedback

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Objectives for teaching unit on continuity of care

• At the end of the unit the learner will
• Define continuity of care.
• List and define the types of continuity.
• Describe the advantages and costs of continuity.
• Demonstrate attention to features of continuity
  in the consultation.
• Value continuity of care in family medicine.

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Continuity Definition and Types

• The provision of care by one provider or team to
  a patient over time.
• Types
• Single provider continuity
• Team continuity
• Continuity of medical records

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Benefits of continuity - Starfield 92

• Patients keep appointments
• Fewer, shorter hospitalizations
• Better preventive care
• More immunizations
• Better care for undifferentiated illness
• Less acute illness

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Benefits of continuity - Freeman 97

• increased compliance
• saving time and tests
• patient satisfaction
• doctor satisfaction
• increased reporting of emotional complaints

10
Experience from Israel Continuity of care and
admissions to hospital from a rural
practiceFurst and Yaphe 1993

• 309 admissions over a 7 year period
• Comparison with national statistics
• Lower admission rates at all ages
• Probably due to care by a single provider over
  time

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Admissions from a rural practice with single
provider continuity
Furst and Yaphe, 1993
12
Costs of continuity Freeman 97

• Personal commitment
• Doctors time
• Late referral
• Reduced standards
• Increased waiting times
• Misdiagnosis

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Alternatives to continuity

• Group Practice
• Job sharing
• Sharing night call
• Doc-in-a-box walk-in clinics

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Encouraging personal continuity

• Make it worthwhile for patients to wait.
• Watch for doctor-shopping.
• Refer within the team.
• Negotiate rebooking with personal doctor.
• Explain the policy.

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Trainee survey on continuityComparison of the
hospital and community settings

• Where do you feel more confident?
• Where do patients trust you more?
• Where is work more interesting?
• Where do patients consult you for a wider range
  of problems?
• Trainees discussed the differences between
  hospital-based and community-based physicians

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Role play exercise on continuity

• The learner plays a locum physician who is
  filling in for the patients regular doctor for
  one week.
• The patient presents symptoms of weight loss and
  decreased general function that are suggestive of
  malignancy, depression or other serious illness.
• How does the locum physician cope?

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Debriefing the role play on continuity

• Does the temporary physician explore sensitive
  emotional issues?
• Does the physician raise the possibility of
  serious disease?
• How is the issue of further investigation
  handled?
• How would the patients regular physician handle
  the challenge?

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Conclusions

• Continuity of care remains a key component of
  general practice despite changes in medical
  services.
• Students and trainees can observe the importance
  of continuity in action and reflect on its
  importance.
• Role models and patients remain our most
  effective teachers.
• Continuity is a thread running through all other
  aspects of family medicine.