Med schools start picturing their place in a medical home world
■ Medical schools and residency programs seek to teach teamwork, quality improvement and community-based care to prepare students for practicing in a patient-centered medical home.
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As the health care system shifts toward a more patient-centered and outcomes-based approach, more medical schools and residency programs are exploring how to train the next generation of physicians to practice in the medical home model.
For many programs, the shift is causing them to rethink traditional medical education, including decisions about how, where and with whom they train students. Several schools either are testing new instructional models or are revamping their curricula to educate trainees on the medical home concept.
“Everybody is starting to look at this,” said Joanne Conroy, MD, chief health care officer with the Assn. of American Medical Colleges. “We believe this is a great vehicle to train medical students in a different way, and to really attract more students who are interested in primary care.”
Education on the medical home model needs to address several core principles, according to a 2010 report by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Assn. Students need to understand patient-centered care, teamwork, performance improvement and population-based care. They also must think about maximizing access through nontraditional care methods, the report said.
“It’s about understanding systems of care and how components of care relate to one other to create the most effective care for the patient,” said Stan Kozakowski, MD, director of the AAFP Division of Medical Education.
In Ohio, Boonshoft School of Medicine at Wright State University in Dayton is one of four schools teaming up with 44 medical practices on a statewide patient-centered medical home education project led by the Ohio Dept. of Health. The goal is to transform the practices into medical homes and educate medical students and residents on the model, said Phil Whitecar, MD, a professor of family medicine at Boonshoft and regional coordinator for the Ohio Patient-Centered Medical Home Education Pilot Project.
“We don’t really have a health care system as much as we have a lot of people providing health care. We’re not really doing it in a coordinated fashion,” Dr. Whitecar said. “If you want the model to grow fast, you want to recruit practices, but you also want to teach students.”
Level of school overhauls may vary
Training students and residents in the medical home model will require different levels of adjustment for different institutions. For some, it might mean minor changes while for others, it could be more radical, said Renee M. Turchi, MD, MPH, associate professor at Drexel University School of Public Health in Philadelphia.
Dr. Turchi directs the Pennsylvania Medical Home Program and is involved with the National Center for Medical Home Implementation, an initiative by the AAP and the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. The national center has been working for more than a year to develop a model curriculum for residency programs on the medical home concept, with the hope of beginning to pilot the curriculum at multiple sites within the next six to nine months, she said.
“We will always be playing catch-up if we don’t change the culture in how we train our trainees,” Dr. Turchi said.
Ten pediatric residency programs already are testing one aspect of that model curriculum — focusing on involving family members in patient care, said Aditee Narayan, MD, MPH, who also is working with the center to design the new curriculum.
“Eliciting family feedback is a key component of the medical home,” said Dr. Narayan, an assistant professor and associate program director of the pediatric residency program at Duke University School of Medicine in Durham, N.C. “We want to change the way that residents practice medicine from the get-go. We want them to begin clinical practice with a patient- and family-centered approach.”
When A.T. Still University School of Osteopathic Medicine in Arizona was founded six years ago, one of its primary goals was to train students in the medical home model. To do that, the school is experimenting with a new education model, said Frederic N. Schwartz, DO, a professor and chair of family and community medicine at the school.
Students spend their first year at the school’s campus in Mesa, Ariz. After that, they move to one of 11 community health centers or affiliated sites with which the school partners in states as far as New York and Hawaii. At those sites, students spend the next three years taking courses through distance learning while obtaining firsthand experience working in medical homes, Dr. Schwartz said.
“Traditional medical education is built on the idea that you have two years of education in a big building and then spend two years in the big building next door, which is the academic medical center,” Dr. Schwartz said. “We have turned that upside down.”
New strategies for teaching key skills
To be successful in a medical home world, medical students and residents need to learn how to be leaders of a health care team, Dr. Kozakowski said. They need to understand how to evaluate their practices continually and implement changes to improve patient care.
The medical home model requires physicians to think broadly and for the long term, Dr. Conroy said. For example, some schools are beginning to alter their clinical training so that students follow panels of patients throughout the year, or for multiple years, rather than jumping from patient to patient through traditional clinical block rotations.
“They really learn about disease processes and continuity of care,” she said.
Another area that’s not traditionally taught in schools is the care of larger populations, said Stephen Shannon, DO, MPH, president and CEO of the American Assn. of Colleges of Osteopathic Medicine. Physicians need to be able to think beyond their regular patients to the community at large. For example, doctors may explore ways to reduce diabetes rates in communities through programs that teach about nutrition and weight control, he said.
“It’s a perfect example of how the medical home model can target and prevent some of the problems that patients have, but save money in the long run,” Dr. Shannon said.
In 2009, Western University of Health Sciences and its College of Osteopathic Medicine of the Pacific in Pomona, Calif., began a required interprofessional training program for students from each of its nine colleges. Students from the different colleges work in small groups on patient case scenarios throughout their first three years of training, said Sheree J. Aston, OD, PhD, chair of the university’s Interprofessional Education Committee and vice provost for academic affairs. The goal is to expose students to other professions with which they will partner in medical practice.
“The whole idea is to not have the silos be created,” Aston said. “We want them to know what the other profession does, and we want them to have the knowledge and skills to practice collaborative care.”
Barre, Mass., is a small community with a population of about 5,000. The Barre Family Health Center is one of 46 sites nationwide involved in a medical home pilot project through the federal Dept. of Health and Human Services.
Part of that effort involves having the center’s 12 medical residents actively involved in quality improvement initiatives at the facility, said Stephen Earls, MD, medical director of the center and associate professor of family medicine at the University of Massachusetts Medical School. For example, the center recently began holding huddles with members of the medical staff before they start seeing patients. Residents meet with nurses, medical assistants and others to discuss patients’ care and plan the upcoming visits for that day.
“One of the major reasons we wanted to get involved in the project was because we are a training site, and we wanted to expose residents to the changing face of medicine,” Dr. Earls said.
Integrating the medical home model into medical education does present some challenges. For many schools, significant faculty development will be required for instructors who were educated under the traditional model and don’t have experience with a medical home, the AAFP’s Dr. Kozakowski said.
“The faculty themselves grew up in an era in which they were not taught these skills,” he said. “In many cases, it’s necessary for faculty and learners to learn simultaneously.”