Experiments in continuity - Rethinking residency training in ambulatory care

摘要

Like many internal medicine residents, I had a love-hate relationship with my primary care continuity clinic. On the one hand, I enjoyed the interactions with my patients. T.W. would show up wearing a colorful hat and tell stories about her roots on the Caribbean island of Dominica. B.L. always seemed one puff away from a hospital admission for chronic obstructive pulmonary disease (COPD), yet he never failed to walk in with a big smile on his face. On the other hand, the challenges were enormous. The vast majority of my clinic patients were socioeconomically dis-advantaged, and their needs extended well beyond what I could address with my stethoscope and prescription pad. M.K. had been unemployed for nearly 2 years. R.M. was paralyzed from the waist down and lived in poorly accessible public housing. Most visits were scheduled for 20 minutes, but they often stretched much longer. Too often in clinic, I felt that the opportunity to deliver high-quality health care to my patients was hindered by systemic barriers. In a 20-minute visit, I was expected to reconcile the patient's medications, refill prescriptions, review cancer screening, update health maintenance items, provide counseling on healthy lifestyle choices, review new symptoms, and perform a physical exam. Such challenges are daunting enough for a full-time primary care clinician, yet as a resident I spent only a small portion of my time caring for patients in the ambulatory care clinic. Given my patients' complex medical and social needs, I often felt powerless as an individual provider to have a true impact on their overall health. What my patients really needed was a team of pharmacists, social workers, nurses, and mental health care professionals working with me to provide coordinated care that could address each of their health needs.