Continuity of Care

Continuity of care, as ideally envisioned, involves a patient being cared for by a single provider each and every time they interact with the healthcare system, or at least every time they come for care for a specific condition.

That situation is, of course, impossible. No medical professional has enough knowledge and skills to care for a person once their medical condition becomes the least bit complicated. There's a reason we have a progressive increase in specialization and sub-specialization, one person just can't know enough. More importantly, one person can't be there 24/7. Anything that requires urgent or continual attention means bringing someone new into the care of the patient.

Despite being relatively well-accepted that we can't have a single person care for a patient, and that continuity of care has to involve more than one provider, efforts to improve continuity of care are still largely centered around minimizing the number of providers. That's not enough.

For one, it means we are still terrible at maintaining good continuity of care between providers. Handovers, whether in person or by written communication, are fraught with errors and omissions. As a medical student, I do a fair number of dictations that serve as the definitive record of a patient's stay in hospital or visit to a clinic. I have received zero formal training on how to do this appropriately or efficiently. Not yet being a true medical expert, I don't always appreciate what details are pertinent and which ones aren't, which means I alternative miss important information, or include unimportant minutiae. More than a few times, I've had to dictate discharge summaries for patients I've never met, or only met once briefly. All my dictations have to be signed off by my supervising physician, but they're busy and are often relying on me or other trainees to know the details of the patient's visit, so these reports often get submitted with no or minimal changes.

Even how we try to maintain a single provider in the care of a patient could use a good dose of extra scrutiny. Call schedules for residents are a major problem in my mind. In inpatient medicine in academic centers, teams are often comprised on a single consultant physician and multiple learners. Each learner takes a set of patients to manage during the day. To cover nights, individuals from the team take turns on 24 hour shifts. That sounds like good continuity of care, but for two giant holes. First, the learner on the team doesn't know all the patients on their team, at least not well. They cover a subset during the day, so everyone else is a stranger. Not good. Secondly, since the learner gets a post-call day, the patients they typically cover during the day have to be covered by other learners who likely haven't met their patients before.

Some programs are playing around with night float - where a person repeatedly cover a team overnight for multiple nights - which I think makes a lot more sense. The care needed at night and the care needed during the day are often very different. Having continuity from one night to the next, as well as one day to the next, is generally more valuable than continuity from day to night. However, few programs have tried this out yet, and the approach of those who have isn't always that great for the health of those on the night shifts - some have tried 16 hours on, 8 hours off, which is a recipe for inadequate sleep and through-the-roof stress. There are ways to ameliorate this (might write more on that later), but it shows where the debate currently stands when it comes to actual practice. The medical community does talk a lot about improving continuity of care, but when it comes to practical solutions, we're barely putting our toe in the water.