Joel Morgenlander, MD and
Cheryl Bushnell, MD, MHS
From Duke University Medical Center (J.M.), Durham, NC; and Wake Forest University Health Sciences (C.B.), Winston-Salem, NC.
Address correspondence and reprint requests to Dr. Joel Morgenlander, Professor of Medicine (Neurology), Box 3394, Duke University Medical Center, Durham, NC
The Neurology Review Committee (RC) mandates continuity clinicfor adult neurology residency training programs. Most neurologicpatients, however, are seen in return every few months and emergenciesare not seen in continuity clinic. Residents on inpatient rotationsleave their rotation to go to clinic, resulting in discontinuityof inpatient care, extra handoffs, and additional distractionsin clinic.
Our objective was to compare the traditional weekly schedulefor the neurology resident continuity clinic to a new schedulefavoring more clinic time during outpatient rotations and lesstime in clinic during inpatient rotations.
With the permission of the Neurology RC, we devised a pilotstudy. Duke Institutional Review Board waiver was obtained.In the first 6-month block, three of the first-year neurologyresidents attended weekly continuity clinic (standard track),and the other two attended two clinics/week on outpatient rotations,one clinic/week on ward rotations, and no clinics on Neurology–intensivecare unit and inpatient consult rotations (study track). Theresidents switched to the opposite track during the subsequent6-month block. Numbers of new and return patients seen werecompared between blocks. The vast majority of return patientshad been seen initially by the same resident. Patients knownto the practice who need to be seen urgently or who have beenseen by residents who have graduated were seen as returns. Residentsand faculty completed a questionnaire to assess their satisfactionwith the new schedule (see appendix e-1 on the Neurology®Web site at www.neurology.org).
Table New and return patients seen during continuity clinic
Resident and faculty satisfaction.
The new schedule was favored by 3 of 5 residents (2 residentswere neutral) and 13 of 15 faculty.
Questionnaire comments.
Advantages noted on the questionnaires of the new schedule includedbetter care of inpatients, less disruption of schedules forresidents pulled to cover consults, and fewer disruptive pagesin the clinic when the residents are more outpatient based.
The major disadvantage of the new system was difficulty in schedulingpatients due to more variability in the resident clinic schedule.
Our pilot study showed that the total number of new and returnpatients seen by neurology residents in continuity clinic canbe kept stable while allowing more flexibility in clinic sessionscheduling. Residents and faculty favored the new schedule forcontinuity clinic over the traditional schedule.
Patient satisfaction scores may be lower when residents aremore distracted due to fatigue or having to answer additionalpages such as on an inpatient service.1 Our residents’satisfaction with their ability to attend to their patients,whether on the ward or in clinic, was improved with the newschedule.
With the development of more flexible residencies such as theR25 pathway, more programs will want to develop flexibilityin scheduling for the continuity experience. While we have noplans for further study, other programs should be encouragedto develop alternative schedules and share their experience.
We recommend that the Neurology RC allow neurology programsto submit alternative schedules for resident continuity clinicas long the total number of clinics each year is held constantand the plan supports continuity in patient care.
Hoellein AR, Feddock CA, Griffith CH, et al. Are continuity clinic patients less satisfied when the resident is postcall? J Gen Intern Med 2004;19:562–565.[Medline]
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