My Journey with Continuity of Care
Ten years after qualifying as a medical doctor, I decided to specialise in Family Medicine (FM). At the time, I was working in a rural, underserved area in South Africa. In addition to my clinical duties, I served as the medical superintendent of the health district, responsible for providing primary health care services to a population exceeding 100,000 people.
The FM specialisation at the then Medical University of South Africa (MEDUNSA) allowed me to continue working in the district while attending several face-to-face contact sessions throughout the year. The required readings and small group discussions during these sessions introduced me to the importance of the doctor-patient relationship. This resonated deeply, as I realised that patients often have their own agendas when visiting the doctor. It helped me explore the patient's experience of their illness — their ideas, concerns, and expectations.
However, this realisation also led to an inner conflict. Being virtually the only doctor for about 30,000 people, how could I possibly develop individual doctor-patient relationships? Additionally, language and cultural differences posed significant barriers. I endeavoured to become more fluent in the local language and began conducting consultations without an interpreter. Yet, when delving into the deeper levels of communication regarding the patient's experience of disease, I still felt inadequate and had to revert to using an interpreter.
The clinical nurse practitioners (CNPs) were the first-contact health care providers, with the doctor acting as a consultant. Despite this, I did develop ongoing relationships with some patients. As part of our academic assignments, we had to write up patient studies. I vividly remember a young female patient who repeatedly presented with severe acute asthma attacks. Eventually, I admitted her to the clinic, which also functioned as a makeshift hospital with a few inpatient beds. During our daily ward rounds, we practised her inhaler technique until I was satisfied, she used it correctly and understood the difference between reliever and preventer inhalers. She rarely had another acute attack, and I was able to follow her up at her local clinic.
Determined to improve continuity of care between doctor and patient, we divided the district's 21 clinics into three geographical areas, allocating one doctor to each. The doctor in each area was responsible for regular clinic visits. Additionally, at the newly opened hospital, the outpatient department was organised so that patients from a specific geographical area would see the doctor assigned to that area. Even inpatients were seen by the doctor from their geographical area, rather than by doctors assigned to specific wards. This improved continuity of care but was by no means perfect. I realised that the clinical nurse practitioners at the clinic level were the true providers of continuity of care. During my clinic visits, I relied on their knowledge of the patients’ context in my assessments and management plans.
After seven years in that rural district, I relocated to a very rural community in Manitoba, Canada, where two doctors served a population of 2,000. Here, the doctor provided first-contact care, and continuity with patients was almost a given. At the end of my two-year stay, walking through the shopping mall, it felt as if I knew everyone and could recount a story about each patient.
Upon returning to South Africa, I spent the next ten years working in three different small rural towns as a private general practitioner. Again, continuity of care was inherent, with patients choosing their healthcare provider and the doctor offering first-contact care. I then relocated to Worcester in the Western Cape, taking up a family physician post at the regional hospital, coupled with a joint appointment in the Family Medicine Department at Stellenbosch University (SU). My clinical duties were at the community health centre (CHC) adjacent to the hospital, serving the local community. Both doctors and primary health care clinical nurse practitioners provided care at the CHC.
Once more, I was determined to enhance continuity of care between healthcare providers and patients. Initially, patients were seen by clinical nurse practitioners, with doctors providing the next level of care. Patients with chronic conditions also required six-monthly reviews by doctors. At the time, doctors and nurse practitioners operated in separate sections of the clinic. We restructured the clinic into two practices, each comprising two doctors and two nurse practitioners working collaboratively. Patients were allocated to these two practices, ensuring continuity of care within the practice team. Doctors were encouraged to schedule follow-up visits on days they were available, each provided with a diary for bookings. Daily, doctors prioritised seeing their booked follow-up patients.
This initiative to improve continuity of care was implemented and evaluated as an action research project through Stellenbosch University's Department of Family Medicine1. While this attempt achieved partial success, challenges arose due to differing understandings of roles and responsibilities between doctors and CNPs. Continuity of care was supported by patients and doctors, but CNPs felt more ambivalent.
In a further effort to fulfil my need for continuity of care and ongoing relationships with patients and the community, I engaged with an underserved community on the outskirts of Worcester through community health care workers (HCWs). We operated from a container and conducted home visits. Undergraduate medical students, during their family medicine rotation, accompanied me on these visits. Through Stellenbosch University, we established a facility in the Avian Park community in Worcester, serving as a health post where local patients could collect their chronic medication2. When the Ukwanda Rural Clinical School was established in 2011, selected final-year medical students from SU could complete their final year at Worcester Hospital. These students spent one afternoon a week at the Avian Park Clinic, each assigned several patients for continuous follow-up, including at least one home visit per patient. Rehabilitation services, including home visits, were also provided by undergraduate allied healthcare students. Over the 14 years I engaged with the Avian Park community, I developed several ongoing relationships with patients, some of whom I remain in contact with.
After retiring from the university, I relocated to a small coastal town about 100 kilometres from Cape Town. For several years, my only clinical contact was through consultancy work, supervising medical students in rural South Africa during their family medicine training at district hospitals. I missed the continuity of care with patients during this period. Therefore, I was thrilled when offered the opportunity to work one day a week at the local government clinic, feeling privileged to serve the community where I now live. Nurse practitioners book patients requiring a doctor's attention for me to see, and I am gradually re-establishing continuous relationships with patients.
In private practice, continuity of care is a given. In my experience within the state health services, continuity of care is seldom prioritised, with minimal efforts to provide it. As a young doctor, I found satisfaction in making new diagnoses and mastering new procedures. As my career progressed, my fulfilment increasingly stemmed from relationships with patients. These relationships energise me rather than deplete my energy.
References
1. Mash B, Mayers P, Conradie HH, Orayn A, Kuiper M, Marais J, Cornelissen B, Titus S. Challenges to creating primary care teams in a public sector health centre: A co-operative inquiry. SAFPJ 2007:49(1) 17-20.
2. Fish T, Lourens G, Meyer L, Muller J, Conradie H. When the clinic is not yet built … the Avian Park Service Learning Centre story. African Journal of Health Professions Education, [S.l.], v. 7, n.1, p. 79-80, jun. 2015. ISSN 2078-5127. Available at: http://hmpg.co.za/index.php/ajhpe/article/view/7980>. Date accessed: 27 Jun. 2015.
Written by Dr. Hoffie Conradie
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