I met Diego (names in this article have been changed to protect patient privacy) for the first time in my primary care clinic at Boston Medical Center when he was 3 days old. When I entered the room, both he and his mother, Esmerelda, were crying. Esmerelda had fled an abusive relationship in the Dominican Republic and arrived in Boston alone, just in time to deliver her first son. She knew no one in the city. I was an intern at the time, just 1 month into my career as a doctor, and felt like crying too.
Since that first day, I have seen Diego and Esmerelda many times for checkups, urgent care visits, behavioral health visits, and a memorable house call. I have watched Diego grow into a robust and headstrong 3-year-old and Esmerelda into a confident single mother who has obtained her own apartment, enrolled Diego in Early Head Start, and started taking English classes. Now a senior resident, the reality of saying goodbye to Diego and Esmerelda, among my other primary care patients, is devastating. I’m concerned that the next doctor caring for Diego will not understand him and Esmerelda in the same way that I have come to. Despite the emphasis on inpatient handoffs in my residency program, there is no structured communication in place for residents leaving their primary care clinic.
During my 3 years in the Boston Combined Residency Program in Pediatrics, I have spent ∼950 hours doing inpatient verbal sign-out with my colleagues. Additional countless hours have been spent updating written sign-out documents on the various inpatient services. I have signed out patients who I have known anywhere from 30 minutes to 30 days. Over the course of my residency, sign-outs have morphed from somewhat clueless intern-to-intern relays of information, to highly structured team-based events using a standard format.
During those same 3 years, I have spent 450 hours as the primary care doctor for 75 children. Yet as I started to prepare to graduate and leave my patients to a new resident doctor, I found there was no sign-out process in place for my clinic. Previously, graduating residents indicated if their patients should be transferred to an attending, current resident, or new intern, but no physician-to-physician communication occurred. When I started in my primary care clinic as an intern, a group of existing patients had been transferred to me, but I had no idea who they were and did not receive a list of my patient panel until 6 months into intern year. Without any knowledge of my existing patients, I mostly ended up bonding with newborns and their families given the frequency of their visits. This resulted in a patient panel consisting primarily of children aged <3 years. It was not a good experience to discover a patient on my schedule whom I had never met but for whom I was listed as the primary care physician and who had active issues that I had not known to follow-up on. Although our clinic preceptors provide continuity, often I was not scheduled for clinic on my assigned day and frequently missed utilizing that connection.
It is estimated that up to 1.92 million patients experience transfer of primary care annually when residents graduate.1 However, in searching the literature for references on primary care handoffs, I found few studies in the adult medicine literature2–5 and almost none in pediatric primary care clinics. There is 1 published survey of pediatric resident opinions improving year-end transfers out of the University of California at Los Angeles.6 Despite the overall paucity of information, especially in pediatrics, the adult medicine studies I found indicate that when primary care handoffs are performed, patients are more likely to follow-up with their new primary care provider5 and residents are more likely to complete important clinical care tasks.3
In January of my senior year, I started envisioning what a good primary care handoff would look like. Each graduating senior would be paired with a new intern, who would inherit the majority of the senior’s patient panel. The senior would identify complex patients on their panel who warranted a written and verbal sign-out. Patients such as Diego, with his behavioral and social challenges, or another patient of mine who was recently intubated for a severe asthma attack, are among my “complex” patients. For these medically or socially complex patients, the graduating resident will write a note in the medical record. A template for this sign-out note would include a brief summary statement, active medical list, problem list with additional detail as needed, and any upcoming to-dos. Additionally an in-person meeting with the intern will highlight patients with active issues and pass on tips to help the new doctor to understand their patients and families as people. This will not only give the graduating resident an opportunity to pass on their knowledge of the patients they have arguably come to know best during residency ensuring better safety and continuity of care, but will also empower the new interns to start off the year with some degree of understanding and ownership over their panel of primary care patients.
At my last visit with Diego, I told him and Esmerelda that our time together was coming to an end. We almost re-created our first visit together with tears in all directions. I was comforted, however, because I will be handing off Diego as well as my other patients to a new intern this June and passing on the knowledge I have accumulated of them over the past 3 years.
- Accepted June 27, 2013.
- Address correspondence to Juniper Lyra Burch, MD, 515 Putnam Ave #6, Cambridge, MA 02139. E-mail:
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
- Copyright © 2013 by the American Academy of Pediatrics