Introduction

Continuity of care in medicine has important benefits for patients, physicians, and the health care system as a whole.¹ Patients who have developed a strong relationship with their physician report greater satisfaction, knowledge, and compliance with selected treatment regimens.² Traditionally, for physicians, the most powerful motivator for learning has been a deep sense of commitment to patients.³ Ongoing interaction with the same patient over time can help trainees develop clinical skills, judgment, and a sense of responsibility.⁴ As noted by Hirsh et al,³ “to anchor clinical learning in caregiving, students must have relevant involvement with patients at the site and time of initial medical decision making, ideally before the diagnosis is made, and be able to follow patients for the duration of an illness episode (and beyond), ideally across care venues.”

The importance of continuity of care in training is widely recognized in the primary care literature, where it is considered a cornerstone of training and an integral part of practice.^5–7 A number of studies from the surgical literature have also examined resident continuity of care.^8–13 Mittal et al⁸ highlighted the importance of surgical residents participating in all phases of patient care to fully appreciate the impact of preoperative and intraoperative decisions on postoperative outcomes. Ledwidge et al⁹ advocated measures to increase care continuity for surgical residents after their study noted that only 23% of patients had the same admitting resident from the emergency department for all phases of care.

A broad-spectrum assessment of trainee continuity of care across all specialties has not been performed. The purpose of this study was to assess the continuity of care provided by resident and fellow trainees across all specialties for patients seen in consultation in the emergency department (ED) at a large pediatric tertiary care center during a 1-year period. A patient was considered to have continuity of care if the same trainee who performed the initial consultation in the ED treated him or her for the same condition within the following 6 months.

Methods

Results

Resident and fellow trainees participated in a total of 3400 ED consultations for 3224 patients during the 1-year period. Emergency department consultations were performed by 244 different trainees (177 residents, 67 fellows) from 33 specialties. More than 70% of ED consultations by trainees were performed by 5 specialties (table 1).

table 1 Medical Trainee Continuity of Care^a Following Pediatrics Emergency Department (ED) Consultations by Specialty

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Overall, 2.1% (70 of 3400) of patients seen in consultation by a trainee in the ED were treated by the same trainee for the same condition in the following 6 months. However, to account for patients who did not follow up at our institution and could not have continuity of care, the denominator in subsequent analyses was limited to the 1718 (51%) patients who followed up again with the consulting specialty during the next 6 months (table 1). Of these patients, 4.1% (70 of 1718) were treated for the same condition by the same trainee from their ED consultation (table 1). The specialties differed in the percentage of patients with ED consultations who followed up during the next 6 months (χ² = 1020, P < .001; table 1), and greater follow-up predicted greater continuity of care by trainees (r = 0.37, P = .03).

The percentage of continuity of care did not differ between residents (4.0%, 57 of 1412) and fellows (4.2%, 13 of 306, P = .87), but did differ between postgraduate year (PGY) for residents (χ² = 28, P < .001; table 2). PGY-5 residents had greater continuity of care (17%, 8 of 47) than all other residents combined (P < .001), while PGY-2 residents had less continuity of care (1.5%, 6 of 401, P = .001). All PGY-5 residents with continuity of care were trainees in neurology. Continuity of care was significantly greater for surgical specialties (12%, 5 of 42) than nonsurgical specialties (3.9%, 65 of 1676, P = .03). Trainees in neurology and plastic surgery had greater continuity of care than all other specialties combined (P < .001; table 1). Neurology had trainees participate in 89 ED consultations over the 1-year period, with 65% (58 of 89) following up in clinic and 21% (12 of 58) following up with the same trainee. Four to 5 residents (PGY-3 to PGY-5) rotate through neurology at a time for 2 years and conduct a resident clinic once a week for patients seen in the ED. Plastic surgery had trainees participate in 226 ED consultations during the 1-year period, with 61.9% (140 of 226) following up in clinic and 12.1% (17 of 140) following up with the same trainee. Two to 4 residents rotate through plastic surgery at a time for 2 months and conduct a resident clinic once a week for patients seen in the ED. Six specialties had resident clinics: neurology, plastic surgery, dental, psychiatry, genetics, and oncology. Specialties with a resident clinic had greater continuity of care by trainees (14.4%, 29 of 201) than specialties without a resident clinic (2.7%, 41 of 1517, P < .001).

table 2 Medical Trainee Continuity of Care^a Following Pediatrics Emergency Department (ED) Consultations by Postgraduate Year (PGY)

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Discussion

Our study demonstrates that trainee continuity of care following ED consultations is low across all programs at a large pediatric tertiary care center. Across 33 specialties, only 2.1% of patients seen by a trainee during consultation in the ED were treated by the same trainee for the same condition during the next 6 months. The highest rate of continuity of care for any specialty was 21%.

Previous studies of individual specialties suggest poor continuity of care in outpatient follow-up is not unique to our study population.^10,11,14 A study of general surgery residents identified outpatient continuity of care in only 1% of cases when a resident had been involved in the operative procedure.¹⁴ Holmboe et al¹⁵ noted that trainees' frequent rotational transitions promote a “trainee as a tourist” mentality in current medical education.

Although consistent with poor trainee continuity of care in other studies, our population is unique as it includes all pediatrics specialties within a tertiary care institution. In addition, we sought to identify the factors associated with higher trainee continuity of care. Better continuity of care among trainees in our study was noted with greater specialty ED follow-up, having a resident clinic, and being in PGY-5 of residency training. Neurology and plastic surgery had greater continuity of care than all other specialties combined (21% and 12%, respectively). Both of these specialties had greater overall follow-up for ED consultations as well as resident clinics for treating patients seen in the ED. The neurology resident clinic was a continuity clinic for general follow-up not specific to ED cases, whereas the plastic surgery resident clinic was a weekly ED follow-up clinic. Timing and duration of pediatrics subspecialty rotations varied, with neurology residents in PGY-3 to PGY-5 rotating for a 2-year period and plastic surgery residents across all PGYs on 2-month rotations approximately twice yearly. We also found that continuity of care differed by resident training level, with PGY-5 residents having the greatest continuity of care (17%). However, all PGY-5 residents with continuity of care were trainees in neurology, suggesting that this finding had less to do with resident training level and more to do with the structure of our neurology resident training program.

Reasons for poor trainee continuity of care likely are multifactorial. Trainees' low attendance in outpatient clinics may be explained by daily responsibilities managing inpatient wards, performing emergency room consultations, or assisting with procedures in the operating room.¹⁴ Physical lack of access to outpatient clinics due to multiple satellite locations and a traditional lack of emphasis by faculty and residents on outpatient clinic may also be factors.¹⁴ A number of strategies have been suggested to improve continuity of care, including resident clinics, preceptor-based rotations, and minimizing transitions that jeopardize trainees' relationships with patients and members of the multidisciplinary team.^{8,10,11,14–16} Pu et al¹⁶ suggested that resident surgery clinics provide trainees with an invaluable patient-physician interaction. Resident clinics, however, are not without shortcomings. For patient safety, medicolegal purposes, and trainee education, resident clinics are overseen by an attending physician, which requires considerable effort and scheduling coordination that is not always feasible. Furthermore, some families may be opposed to being treated by a trainee, and some patients may require more specialized care.

Holmboe et al¹⁵ stressed the need to reduce transitions that may result in unfortunate consequences in professional development, quality improvement, and patient safety. Continuity may be improved with preceptor-based rotations or outpatient rotations where ED follow-ups are routinely treated.¹⁷ Chung et al¹⁰ reported that 98% continuity of care was achieved with preceptor-based mentorship rotations compared with 42% achieved in typical in-hospital rotations. If all trainees are required to have documentation of continuity of care for a predetermined number of ED consultations, then this could be made a mandatory component of the practice-based learning and improvement competency.

Our study has limitations, which may have resulted in underestimation of overall trainee continuity of care. For ED consultations admitted as inpatients, we identified only 1 patient seen by the same resident following inpatient admission. Electronic notes signed by a resident or fellow were used as an indication that a trainee had been involved in a patient's care. In cases where patients were seen by a team and notes were written by nurse practitioners or medical students, trainee continuity of care would not have been captured. Furthermore, by focusing on ED consultations, we likely underestimated overall trainee continuity of care that may have occurred through other pathways.

Going forward, an in-depth examination of individual specialty rotations will be important to identify where opportunities exist to minimize transitions and improve trainee continuity of care. Future directions may also include multi-institutional collaboration to build on the generalizability of our outcomes.

Conclusion

Our findings suggest that trainee continuity of care following consultation in the ED is low across all medical and surgical specialties at this large pediatric institution. Changes must be implemented to address these deficiencies across all specialties, with the knowledge that the highest patient continuity of care with residents for ED follow-up was observed in specialties that have designated resident clinics.