The Patient-Centered Medical Home as a Curricular Model: Medical Students Need an “Educational Home”

This is the authors' abstract. We don't add key points for this paper.

In the centennial year of the Flexner Report that radically changed medical education, the Carnegie Foundation issued a new call for major medical education reform. In a summary of their 2010 report Educating Physicians: A Call for Reform of Medical School and Residency,1 the authors argue that huge increases in medical knowledge, technology and specialization in recent decades have interacted with a now near-chaotic system of health care delivery, magnifying the challenges facing medical education.… Those who teach medical students and residents must choose whether to continue in the direction established over a hundred years ago or take a fundamentally different course, guided by contemporary innovation and new understanding about how people learn.2 At the same time that the Carnegie Foundation was calling for reform, a group of primary care medical societies representing over 350,000 practicing physicians was issuing a challenge to U.S. medical schools to incorporate the Patient-Centered Medical Home (PCMH) model into their curricula.3 The PCMH is “a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.”3 Many related pilot projects are underway, and some initial outcome studies show encouraging results. However, to date, no U.S. medical school has fully incorporated the PCMH model into its educational paradigm. A PCMH-based educational model embodies many of the Carnegie Foundation's 2010 recommendations.1 A four-year longitudinal student experience rooted in the PCMH would provide early clinical exposures to drive inquiry and provide the necessary experiences for adult learners as they interact with basic scientific material. The PCMH model would be an anchor for horizontal and vertical integration of a curriculum across all four years with a focus on real-world applications. The PCMH model would provide a vehicle for continuity in which each student would work for four years with a core group of educators, patients, and peers, ensuring high quality 360-degree longitudinal evaluations of the core competencies. The PCMH model incorporates one of the most important recent developments in medical care through the use of Internet resources for decision support and meaningful use of the electronic health record; it focuses on team-based care and interdisciplinary collaboration; it emphasizes health outcomes measurement; and it stresses continuous learning and quality improvement. Leveraging recent advances in health care IT would allow centralized data gathering and study of health outcomes for students' patients in the PCMH. If each student followed a mere eight patients over four years of study, and each class had 160 students, a PCMH-based curriculum would create a pool of 5,000 patients or more for outcome analysis with just four classes. Finally, the longitudinal patient relationships that are the core of a PCMH would provide a meaningful way for students to understand the complex social determinants of disease, and the Wagner chronic care model. Incorporating the PCMH model into medical education could be an important first step towards meaningful education reform in the Internet age. Recent IT advances allow our students to track patient progress beyond the clinic walls. Medical schools need to create an educational home that empowers our students to take ownership from an early phase and measure their outcomes. How are we ever going to educate students to improve population health if we cannot effectively measure their performance? We can no longer promote a system in which the longest continuity of patient care is a four-week inpatient clerkship, and in which students never find out whether their patients get better. We should not teach “primary care” in a four-week clerkship setting where students rarely see a patient for a follow-up visit. We cannot teach lifestyle counseling without “closing the loop” and seeing whether our students affect patient outcomes. We should not endorse an educational system in which students' clinical outcomes are never measured.4 The PCMH-based educational model emphasizes all of these missing curricular issues and is a promising foundation on which to build the medical curriculum of the next century. Medical education in the United States is once again at a crossroads. Major forces are converging to promote changes in the way we train our future physicians. Massive changes in the practice of medicine, the ever-increasing pace of scientific discovery, the increasing use of technology for quality improvement, and the needs of an aging population living longer with more chronic conditions all require an updated framework for training our students. The PCMH model can provide a framework for the future of health care.