Continuity of Education

Continuity of care is an oft-discussed topic in medicine. Oversimplifying a bit, it means having the same provider or set of providers care for a single patient over time. The major upside is that the providers are fully aware of the patient's medical history and only need updates in between encounters rather than starting from scratch. Same goes for the relationship between patient and provider - rather than having to build it at each encounter, the relationship can be built and sustained over time. Implemented effectively, continuity of care should improve efficiency in medicine and quality of care.

The other facet of continuity of care is a seamless or near-seamless transition between various healthcare providers, when a transition is necessary. That is, providers should communicate well when referring patients between themselves and have a coherent plan for all aspects their care.

When it comes to education, continuity is equally important. We all have our challenges when learning a new task or skill, and medicine is no different. Overcoming those struggles is often a long-term prospect, requiring multiple different strategies before settling on an appropriate course of action. Having a single instructor or close-knit group of instructors can be enormously beneficial, as feedback can be given on new strategies with the results of previous efforts in mind. With a single instructor, a student's unique challenges, along with their strengths, don't have to be re-established at each encounter and can be incorporated into a plan for improvement moving forward. On an even more basic level, lessons can be tailored with full knowledge of gaps in previous lessons in mind.

Yet when it comes to medical education, particularly at the medical school level, continuity in education is virtually non-existent. In my third year of study, I have never been evaluated by a single person more than twice, other than maybe having the same person mark my exams (ie never an in-person evaluation, I'd just be a name to them, not a face). Where twice did happen, it was always in a single semester for a single class, typically only a few weeks or months apart. Never was there communication from one instructor to another on my strengths or weaknesses. It's a very fractured system.

If a student is generally doing well, this isn't too much of a concern - they'll pick up the little suggestions from each instructor and incorporate them as they move forward in their training. It's still not ideal, as more subtle problems often go unaddressed entirely and small issues can persist even if addressed, but the consequences aren't dire in these situations. For individuals who do struggle, lack of continuity can be a huge problem. Lack of progress isn't readily identifiable, since instructors only see a snapshot. Where progress is made, it generally goes unacknowledged - struggling students are either only recognized as being adequate (with little fanfare for the student's successful efforts), or inadequate (ignoring significant improvements the student may have made between evaluations).

In the worst situation, struggling students are passed without much feedback even if there are significant concerns. Most instructors are keen to help students improve, but they're also heavily incentivized to pass students along. When an instructor will likely never deal with a student again, they have no real reason to address problems. I see this way too often - when I ask for areas to improve upon, and I do at every evaluation, the most common answer is something along the lines of "not really, just keep doing what you're doing and reading". I'm a good student (I think), so I'm not expecting a litany of problems, but I do know that I'm far from perfect and that there are things I should be working on. I can easily see a struggling colleague getting the same treatment. When a student's problems do become too significant to ignore, it may be late in the game, in clerkship or later, and the realization of inadequacy can come without warning for the student. At this stage, opportunities for effective remediation are minimal, and high costs have already been borne by the student, who is now years into their training and tens of thousands of dollars in debt.

Medical education research has started to come to the conclusion that education isn't just the mechanical transmission of information from one person to another in the way a computer transmits data. Investment on the part of both the student and the instructor matters. As medical education evolves, we'll need to figure out a way to link students up with their evaluators over a longer period of time. A series of disconnected learning opportunities are simply not good enough to reliably ensure excellence in education, even if each individual educational event is of high quality. We need a higher focus on continuity in medical education.