Published online October 1, 2004
PEDIATRICS
Vol. 114
No. 4
October 2004, pp.
1082
(doi:10.1542/peds.2004-0608)
On Continuity of Care in Pediatric Training
Barbara Starfield, MD, MPH
Department of Health Policy
Johns Hopkins School of Public Health
Baltimore, MD 21205
McBurney et al1 report on an unusual approach to measuring continuity in a "continuity clinic," in which residents follow assigned patients, primarily for well-child care. Their method assesses the proportion of all visits made by patients who are members of the residents’ panels. In primary care practice, in contrast, continuity would be the extent to which patients see their doctor for both well- and sick-child care, which is a very different measure.
Primary care practitioners are expected to provide first-contact access (within reasonable bounds), long-term person-focused (not disease-focused) care, reasonably comprehensive services (at least to meet the common health-related needs of the population), and coordinated care when patients have to be seen elsewhere. These should be part of pediatric training. It is a distortion of primary care to view "continuity" in the context of wellness. Primary care includes sick-child care; a physician cannot appreciate the needs and responses of families by seeing them primarily as well children. Importantly, the authors found that increased time in the clinic enhanced the exposure of residents to their patients who were sick at the time of their appointed visit.
More time providing both well- and sick-child care would reduce time available for specialty and inpatient rotations. Would this detract from primary care training? It’s not likely. Future primary care practitioners do not learn how to manage specialty problems in primary care by exposure to specialty practice. Because of the higher probability of illnesses in specialty practice as compared with primary care practice, trainees get a distorted view of how specialty diagnoses present.2 The same is the case for inpatient care. It is far more appropriate for trainees to be exposed to possible specialty diagnoses as they occur in primary care situations, with appropriate consultation from specialists in those settings.
Assessing the adequacy of training for primary care, including continuity, should reflect the requirements of high-quality pediatric practice. Wilson et al3 led the way 15 years ago with their evaluation of the primary care experiences of pediatric trainees. Continuity needs to be evaluated in the context of what it means in practice, not from the viewpoint of the physician but from the viewpoint of the population for whom the trainee bears responsibility.
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FOOTNOTES
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Accepted Mar 22, 2004.
Address correspondence to Barbara Starfield, MD, MPH, Department of Health Policy, Johns Hopkins School of Public Health, 624 N Broadway, Room 452, Baltimore, MD 21205. E-mail: bstarfie{at}jhsph.edu
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REFERENCES
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- McBurney P, Moran C, Ector W, Quattelbaum T, Darden P. Time in continuity clinic as a predictor of continuity of care for pediatric residents.
Pediatrics. 2004;114
:1023–1027
- Hashem A, Chi MT, Friedman CP. Medical errors as a result of specialization.
J Biomed Inform. 2003;36(1–2)
:61
–69
- Wilson ME, Weiner JP, Bender JC, Bergstrom SK, Starfield BH. Does a residents’ continuity clinic provide primary care?
Am J Dis Child. 1989;143
:809
–812[Abstract]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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