Impact of Set-Day Clinic on Physician Continuity in a Family Medicine Residency Clinic

Continuity of care between patients and their primary care providers is strongly associated with improved patient outcomes, decreased health care costs, improved patient experience, and provider well-being. ^1-4 While high-performing, nonteaching primary care clinics achieve 75% to 85% continuity, ⁵ primary care residents experience continuity less than 50% of the time. ^6- 8 Residents expect the relationship building that comes from patient-physician continuity, and they risk burnout and dissatisfaction when frequently caring for patients they do not know. ^{1, 9, 10} Moreover, continuity of care is a fundamental component and requirement of family medicine residency training. ¹¹

Strategies to enhance continuity of care in residency programs involve electronic health record, scheduling, and panel management methods. ^{6, 10, 12} Barriers to continuity largely include inpatient demands and rotational learning schedules. ^{13, 14} Observational evidence from a pediatric residency suggests that scheduling residents for their outpatient continuity clinic on a set day improves their continuity. ¹⁵ Whether set-day clinic (SDC) improves continuity for family medicine residents is unknown. In an effort to improve both resident and faculty physician-patient continuity, a SDC scheduling model was implemented in 2019 within Bethesda Family Medicine Clinic. Our study compared Bethesda Clinic’s physician-patient continuity rates before and after implementation of a SDC scheduling model.

Since 2019, Bethesda Clinic has participated in Clinic as Curriculum, a multiyear, multifaceted intervention to improve continuity of care and residency clinic functionality through scheduling innovation. ¹⁶ Bethesda Clinic serves as the continuity clinic for the University of Minnesota Woodwinds residency program of 10 faculty and 24 residents, and averages 18,000 visits per year.

Prior to July 2019, the program director scheduled residents’ continuity clinics according to their rotation (rotation-driven scheduling [RDS]). To create SDC, faculty and residents were divided into two groups: those scheduled on Monday, Thursday, or Friday; and those scheduled on Tuesday, Wednesday, or Friday. One rotation was unable to accommodate SDC and was discontinued. Clinic shifts scheduled outside of SDC-assigned days were templated as acute-care shifts with same-day visit slots. The program director prioritized scheduling residents for all-day clinic rather than just half days.

We analyzed clinic visits for two 6-month periods: October 1, 2018, to March 31, 2019 (RDS); and October 1, 2021, to March 31, 2022 (SDC). We chose October through March to avoid the 3 months before and after July—key residency transition periods. We excluded faculty who were not present during both periods from the analysis.

We used visit-level data to determine continuity. We used the continuity for physician formula (PHY), defined as a physician visit with a patient from that physician’s continuity panel, as the primary outcome of interest. ¹⁷ We calculated continuity individually for each physician. We excluded virtual visits (less than 5% in 2022) from the analysis.

In June 2022, we emailed a nine-question survey to faculty and residents from the post-intervention group. We asked them to indicate their level of agreement with a series of prompts on a 4-point scale, from “strongly disagree” to “strongly agree.” Prompts included how SDC affected their experience in clinic, patient care, rotational learning (residents only), and teaching and scholarly activities (faculty only). Faculty also were asked which type of scheduling model they preferred.

We analyzed patient visit data for four different physician roles (PGY1, PGY2, PGY3, and faculty) and during two different periods (2018-2019 RDS, and 2021-2022 SDC). Each patient visit during the SDC period was coded as either adherent if it occurred on a physician’s SDC day, or nonadherent if it occurred on a day other than their SDC day. We calculated adherence rates for SDC scheduling for each physician at the day and visit level, and then averaged for each role.

For each physician role, we used independent sample t tests (residents) and paired t tests (faculty) to compare mean PHY continuity rates between the RDS and SDC periods. The RDC versus SDC comparison included both SDC adherent and nonadherent visits. We summarized survey data using proportions, with “strongly agree” and “agree” responses collapsed into one category and “strongly disagree” and “disagree” responses into another. We conducted data analysis with SPSS version 28 (IBM Corp). The University of Minnesota Institutional Review Board deemed this project not human subject research.

Nine faculty were included in the continuity analysis. Pre- and postsamples included 23 and 24 residents, respectively. During the SDC period, mean adherence, the rate at which residents and faculty were scheduled for clinic visits on their set day, ranged from 65 to 76% (Table 1). PGY3 adherence was the highest and least variable. PGY3 residents’ PHY continuity also increased significantly from 44% during RDS to 56% with SDC scheduling (P<.001; Table 2). PGY2 residents had a nonsignificant increase of 5% in PHY continuity (RDS, 38%; SDC, 43%), while faculty and PGY1 had a nonsignificant decrease.

Sixteen residents (67%) and nine faculty (90%) completed the survey. Ninety-four percent of residents and 78% of faculty respondents were in favor of SDC, noting that it improved their clinic experience and their ability to schedule continuity patients’ follow-up visits. All faculty (100%) and the majority of residents (81%) also agreed that SDC helped their continuity patients know which days they would be in clinic. Few residents (12%) and faculty (33%) reported that SDC interfered with their rotational learning and academic activities, respectively. Most faculty (67%) preferred SDC over RDS.

Compared to RDS, SDC scheduling improved PHY continuity rates for PGY3 residents. The larger impact on PGY3 continuity may be due to more robust continuity patient panels. Faculty continuity rates were higher than residents at baseline and did not improve with SDC. This may be due to their patients’ established skills navigating their primary care provider’s clinic availability.

Most liked SDC scheduling, and faculty preferred it over RDS. Both faculty and residents reported easier return visit scheduling and increased patient awareness of their schedules, which might explain why continuity improved.

Scheduling residents predictably in their continuity clinic is difficult and complex because programs balance many competing educational experiences. ¹⁸ A 2019 survey found that despite 89% of program directors endorsing the importance of clinic first, only 31% prioritized the clinic in scheduling. ¹⁹ To our knowledge, this study is the first in family medicine showing that set-day scheduling is possible with a greater than 65% SDC adherence rate.

This study had several limitations. It focused on one residency program, and SDC may not be generalizable to other family medicine residencies. The study also lacked a control group and instead used a retrospective sample. Between 2018 and 2022, myriad changes occurred within the broader health care environment that could not be controlled for, including a health care system merger and the COVID-19 pandemic. However, because clinic operations were overall the same, the changes in PHY continuity were likely associated with SDC implementation.

Family medicine residencies embrace the value of continuity of care and relationships but struggle actualizing these values amidst competing priorities. ¹⁸ In family medicine residency clinics, predictable clinic schedules have the potential to improve continuity of care, which may improve physician well-being. ^{9, 20, 21} While our positive findings are limited to one institution, they align with another single-institution study. ¹⁵ Larger scale research in other settings is needed to determine whether SDC improves continuity of care. In the meantime, we have demonstrated that SDC is feasible and well-received by residents and faculty alike.

Poster presentation on research in progress. NAPCRG Annual Conference, November 18-22, 2022, Phoenix, AZ.