Continuity

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].