PCMH Gets Off to Slow Start in Nation's Medical Schools

Some Projects Afoot in Clerkship Programs

February 17, 2009 03:45 pm Barbara Bein

A growing number of family medicine residencies are integrating the principles of the patient-centered medical home, or PCMH, into their programs, but the nation's medical schools remain reluctant to teach students about the PCMH model of care. They are waiting and watching to see how the model is incorporated into established physician practices, say teachers of family medicine and others.

It should come as no surprise that the PCMH model is not yet a standard part of most medical schools' curricula, says James Gill, M.D., who chairs the research committee of the Society of Teachers of Family Medicine, or STFM. "This is so new, how could it be in the curriculum?" he asks. "People haven't had time to think about it."

Amy McGaha, M.D., assistant director of AAFP's Division of Medical Education, agrees, noting that it will take time for PCMH concepts to move from "real-world" practice to academia. "It's currently being tested in established practices, and it's being piloted in residency training," she says.

University of South Carolina

That's what is happening at the University of South Carolina School of Medicine in Columbia. Elizabeth Baxley, M.D., chair of the school's Department of Family and Preventive Medicine, says that efforts to incorporate the PCMH into medical training at her institution have primarily targeted residents.

"We've not done this explicitly with medical students," she says. "The focus has been on getting it into the resident curriculum; they are the audience who needs it most quickly, because they will be going out into practice" relatively soon.

However, Baxley says she would like to see more emphasis on the PCMH in medical schools so students can understand the comprehensiveness of primary care and care coordination.

"The rationale for introducing PCMH principles to medical students is to formalize the curriculum around the patient," she says. "What we want them to learn is that, regardless of their specialty choice, medical practice is about the patient."

STFM PCMH Curriculum Modules

The Society of Teachers of Family Medicine(www.stfm.org) has developed four competency-based curriculum modules that cover specific aspects of the patient-centered medical home. They are posted in its Family Medicine Digital Resources Library(www.fmdrl.org).

The modules are on:

A new module on evidence-based medicine also is in the works.

One step that has been introduced at the school is to have preclinical medical students enrolled in a prevention and practice module select a specific clinical guideline from the U.S. Preventive Services Task Force and then visit a primary care practice to "see how the practice is doing with respect to that particular guideline," says Baxley. The students look for activities, such as use of patient reminder systems, collaboration between physician and nonphysician members of the care team, and use of electronic health records. They then discuss their findings in the classroom.

Baylor College of Medicine

John Rogers, M.D., interim chair of the Department of Family and Community Medicine at Baylor College of Medicine in Houston and immediate past president of STFM, says his department is taking steps to introduce the PCMH as an effective system for delivering health care.

The department has received a grant from the Health Resources and Services Administration, or HRSA, that will be used to help the 20 to 30 family medicine clerkship sites where Baylor's medical students train achieve PCMH recognition from the National Committee for Quality Assurance, or NCQA, says Rogers. When Baylor students visit one of these sites, they complete a module of the Medical Home Implementation Quotient(www.transformed.com), which was developed by TransforMED LLC, the Academy's practice redesign subsidiary.

"It is essential that family medicine clerkships provide students with clinical experiences in patient-centered medical homes so the students can appreciate this model of practice and make informed choices about specialty selection," says Rogers.

Other objectives of the three-year HRSA grant include developing a PCMH seminar curriculum and helping ambulatory teaching sites where students complete a specific first-year course also gain NCQA recognition as medical homes.

"My belief is that it's not what you tell students in a classroom, it's what they're working with so they learn this model of care," says Rogers. "Students can see that primary care is changing and it's interesting and exciting."

STFM Clerkship Medical Home Initiative

STFM recently sponsored a survey of 104 family medicine clerkship sites affiliated with nine medical schools across the country. Part of STFM's Clerkship Medical Home Initiative, the survey was designed to assess the teaching practices' progress in adopting the PCMH model.

Gill calls preliminary results of the survey "encouraging" for medical student training. "The places where (students are) training are pretty far along in the PCMH principles," he says. "This will be our model of care, so we need to be teaching it, and we need to teach it in settings that we already have."

Most clinics surveyed -- more than 57 percent -- said they use an electronic health record, or EHR, system in the practice, with slightly more than 55 percent reporting their practice has fully secured remote access. Forty-nine percent said they have electronic scheduling systems integrated into their EHR and offer advanced-access, or open-access, scheduling.

But fewer clinics had instituted the more sophisticated electronic components of the PCMH, such as population-based quality assessments (about 32 percent), EHR-based preventive services registries (about 30 percent) and asynchronous communication with patients (less than 28 percent).

When it came to the nonelectronic features of the PCMH, 68 percent of the clinics surveyed reported using patient satisfaction surveys, and almost 60 percent said they offered expanded hours. Nearly half of the clinics surveyed also have integrated behavioral health services.

But fewer clinics reported using teams to manage patient care (less than 42 percent), clinical pharmacy support (41 percent), integrated case management and social services (less than 39 percent), and group visits (about 20 percent).

Still, it's a start, according to Gill. Fully incorporating PCMH principles into the nation's medical schools "could take years," he says. "This will be a critical challenge."