Continuity of Care: Now More Than Ever

I’ve been conducting virtual clinic visits for almost a full year now.  At first, mostly telephone, then gradually transitioning to video encounters; it was helpful to be able to “lay eyes” on my patient.  Actually, I have been pleasantly surprised by how much we can accomplish during a virtual visit. And not just reviewing blood pressure medication or diabetes regimens, but also making de novo diagnoses as well.  I’ve been able to visualize things such as skin rashes and ankle swelling which helped inform a diagnosis and treatment plan.

Interestingly, I found that staffing patients in a virtual resident’s clinic was a different story.  Our internal medicine residents, although extremely bright and capable, seemed less comfortable in this mode, despite being millennials raised on technology.  One of my residents wanted to send a patient to the ER for abdominal pain, which is probably the last place you want to be during a viral pandemic.  Instead, we treated presumptively for diverticulitis, since after digging more into the chart, we could see he’d had an occurrence of this in the past. 

At first, I thought the discomfort was related to the inability to perform a physical exam, or potentially a lack of clinical experience.  But as time went on, I started to realize it was more related to continuity of care.  The patients they were following as primary MD (as opposed to a random appointment) had much better developed assessments and plans.  They tended to rely more on careful history taking, and also on knowing the patient’s previous experience in terms of symptoms or response to different therapies.  They also tended to schedule close follow up, in case our diagnosis was incorrect, because a patient is much more likely to come back if they have known you as their doctor over time.

This phenomenon is something supported by the medical literature all along: continuity of care really, truly matters.  It positively impacts almost all measures of health care outcomes, such as rates of screening colonoscopies or diabetic control as evidenced by A1c.  It also improves both patient and doctor satisfaction, a win-win in this era of physician burnout, which has been exacerbated by the pandemic.  What I see in resident clinic is that they have fewer continuity patients and more “urgent care” type appointments compared to a faculty member’s schedule.  So unfortunately, they don’t get to experience these benefits on a consistent basis. 

Still, I see valuable lessons learned as we will continue some portion of virtual care for the foreseeable future.  Perhaps now more than ever, we should emphasize to the patients (and the schedulers and of course everyone involved) that continuity matters.  Many seem to truly enjoy virtual visits with the convenience and efficiency of not having to leave their home and travel to the clinic.  And, since I am not tethered in time and space by the availability of clinic exam rooms, I can more easily accommodate both their schedule and my own.  It is far easier to “add on” or “overbook” a patient if it’s a video call.

Levering technology to benefit patients was a recurring theme throughout my two books; I find it very interesting that four years later, it takes a global pandemic to finally bring that about.  Hopefully continuity of care will be the glue that binds it all together, and can help promote safe, effective, and high quality medical care.  

Even virtually.

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