Abstract
BACKGROUND
The Patient-centered Medical Home (PCMH) is an important model of primary care with a promise of improving quality, reducing costs, and improving patient satisfaction. Many primary care residency programs have PCMH initiatives but it is unclear if residents are interested in learning more about the PCMH.
OBJECTIVES
To examine primary care residents’ attitudes and knowledge about the PCMH model and how it relates to them.
METHODS
A total of 82 first- through third-year family medicine and internal medicine residents participated in a survey with 25 questions. Descriptive statistics were performed to describe the responses.
RESULTS
The survey response rate was 91%. Sixty-one percent of residents thought they had “poor” or “fair” knowledge of the PCMH and 84% thought it was important to be knowledgeable about the PCMH. Thirty-four percent rated their ability to describe the PCMH as “well” or “very well”. Eighty-six percent thought they learned “too little” or “way too little” about the PCMH during medical school. The majority (88%) of residents were interested in learning more about the PCMH.
CONCLUSIONS
Family and internal medicine residents are interested in learning more about the PCMH during residency. Residents may benefit from experiential learning that focuses on the PCMH.
Keywords: Graduate medical education, patient centered medical home, organizational change, leadership
Introduction
The Patient-centered Medical Home (PCMH) is an important model of primary care with a promise of improving quality, reducing costs, and enhancing patient satisfaction.1,2 Family medicine residency programs may have PCMH initiatives but it is unclear if family medicine residents are actively participating in these important experiential learning opportunities. Medical schools and residency programs will need to both teach the scientific foundations of PCMH system performance and provide opportunities for trainees to participate in team-based improvement of their real-world health systems.
The ACGME requires resident competencies in practice based learning and improvement. Residency programs including family medicine residencies may be struggling with how to introduce residents to concepts of the PCMH within the context of current residency requirements.3, 4 Responding to the need for rapid implementation of a PCMH curriculum in our traditional residency programs, we performed a resident needs assessment to gauge resident baseline knowledge of PCMH principles and to guide our curriculum development.
Because it is unclear if students are learning about the PCMH during medical school, we were interested in learning whether residents were interested in learning about curricular opportunities during residency.5–7 The objective of this study was to describe family medicine residents’ baseline attitudes and knowledge about the PCMH model and how it relates to their learning.
Methods
A total of 82 first- through third-year primary care residents completed a 10 minute survey with 25 questions. Participants were from two family medicine and one internal medicine residency programs located in California. The programs were from two different teaching medical systems. Programs A and B included four cohorts, and programs C included three cohorts of residents. We adapted some questions from the literature5 and designed the survey as part of the initial step of a needs assessment for the development of a PCMH curriculum for family medicine residents. The survey questions assessed residents’ attitudes, perceived skills, and knowledge of the PCMH, in addition to interests in learning about the PCMH during residency. In program A, the survey was launched in January 2013 through electronic mail. Potential participants received up to three weekly email reminders about the survey participation. In programs B and C, the survey was administered during the first 10 minutes of didactic sessions and was collected by non-research staff. The programs did not have any PCMH curricula at baseline. Descriptive statistics were performed to describe the responses. The study was given human subjects exempt status by the UCLA department for protection of human subjects.
Results
The overall survey response rate was 91% (range 77% to 96%). Missing responses were < 5% for those items with incomplete data. Sixty-three percent of residents thought they had “poor” or “fair” knowledge of the PCMH and 87% thought it was important for them to be knowledgeable about the PCMH. Thirty-two percent rated their ability to describe the PCMH as “well” or “very well”. Twenty-five percent of respondents were “well” or “very well” aware of interdisciplinary models of team-based primary care. When asked “How well are you able to describe a Plan Do Study Act (PDSA) rapid cycle?”, 21% responded “well” or “very well” on a four point response scale. Eighty-eight percent thought they learned “too little” or “way too little” about the PCMH during medical school. Eighty-one percent of respondents also indicated that they had “not at all” or “slightly” read books, journals, or other materials about the PCMH. The majority (86%) of residents were interested in learning more about the PCMH. Responses did not vary by survey administration mode or by specialty.
Discussion
This is the first study that we are aware of that assess primary care residents’ attitudes and knowledge about the PCMH. Our results indicate that primary care residents are interested in learning more about the PCMH during residency. Residents perceive that they did not learn enough during medical school and that they may benefit from learning experiences that focus on the PCMH during residency.
Our findings are important because they provide preliminary but important evidence to family medicine educators that residents are interested in learning about the PCMH and that they may often start residency with little knowledge about the PCMH. Our results validate a similar study of students from two medical schools on the East Coast.5
There are several potential next steps. First, family medicine and primary care residencies should consider a knowledge assessment to inform their PCMH curricular designs. Residencies should also consider formal PCMH curricula and perhaps integrating them during practice management curriculum components or community medicine rotations. Many residency programs are likely to already have practice improvement efforts and patient-centered initiatives to enhance patient experiences with care. These clinical activities provide excellent opportunities for resident learning and possibly to enhance recruitment.8 Because of healthcare reform and the current redesign of primary care, residency programs are well positioned to organically involve residents in quality improvement efforts, committee work, and practice re-design efforts consistent with PCMH principles.9
This study has limitations. It is cross-sectional and relies on self reports that are subject to bias and socially desirable answers. The study was conducted in California and has a small sample size and cannot be generalized to other trainees or to other family medicine or internal medicine residency programs.
The practice of primary care demands scholarly inquiry, faculty training in practice improvement, analysis and innovation.10–12 Primary care physicians are uniquely positioned to lead and implement healthcare delivery transformation consistent with the Patient Centered Medical Home model. Family medicine and internal medicine residencies are still evolving in teaching these skills to residents. The results of this study have the capacity to inform the development of longitudinal PCMH curricula for family medicine and internal medicine residents.
Supplementary Material
Table 1.
Participant characteristics
| Characteristic | Percent (%) | Frequency (n) |
|---|---|---|
| Program | ||
| A | 43.9% | 36 |
| B | 28.0% | 23 |
| C | 28.0% | 23 |
| Post graduate year | ||
| First | 36.6% | 30 |
| Second | 31.7% | 26 |
| Third | 31.7% | 26 |
Table 2.
Resident attitudes and knowledge of the PCMH
| Questions and response options | Percent (%) | Frequency (n) |
|---|---|---|
| Attitudes about PCMH | ||
| Resident physicians have the responsibility to learn about the PCMH model | ||
| Strongly disagree | 2.4% | 2 |
| Disagree | 1.2% | 1 |
| Uncertain | 15.9% | 13 |
| Agree | 51.2% | 42 |
| Strongly agree | 29.3% | 24 |
| Resident physicians should be aware of the key principles of the PCMH model | ||
| Strongly disagree | 1.2% | 1 |
| Disagree | 0.0% | 0 |
| Uncertain | 6.1% | 5 |
| Agree | 61.0% | 50 |
| Strongly agree | 31.7% | 26 |
| Do you feel knowledge of the PCMH is important to you as a resident? | ||
| Not important at all | 1.2% | 1 |
| Somewhat unimportant | 4.9% | 4 |
| Neither important nor unimportant | 4.9% | 4 |
| Somewhat important | 32.8% | 31 |
| Very important | 51.2% | 42 |
| Do you feel knowledge of the PCMH will be important to you post residency? | ||
| Not important at all | 0.0% | 0 |
| Somewhat unimportant | 4.9% | 4 |
| Neither important nor unimportant | 2.4% | 2 |
| Somewhat important | 35.4% | 29 |
| Very important | 57.3% | 47 |
| Knowledge about PCMH | ||
| How well are you able to describe the PCMH? | ||
| Not at all | 18.3% | 15 |
| Not well | 47.6% | 39 |
| Well | 31.7% | 26 |
| Very well | 2.4% | 2 |
| How would you assess your knowledge of a Patient Centered Medical Home (PCMH)? | ||
| Poor | 29.3% | 21 |
| Fair | 31.3% | 28 |
| Good | 22.4% | 18 |
| Very Good | 11.9% | 10 |
| Excellent | 3.0% | 2 |
Table 3.
Resident self-rated level of confidence in skills to perform selected PCMH activities
| Not confident (%) | Uncertain (%) | Somewhat confident (%) | Totally confident (%) | |
|---|---|---|---|---|
| Coordinating care for patients with chronic conditions | 6.3% | 16.3% | 71.3% | 6.3% |
| Ability to lead primary care team | 6.3% | 31.3% | 54.9% | 7.5% |
| Leading a clinic team huddle | 8.9% | 34.2% | 50.6% | 6.3% |
| Leading a group visit for patients with diabetes or other chronic conditions | 12.5% | 25.0% | 56.2% | 6.3% |
| Using patient registries | 21.5% | 39.2% | 36.8% | 2.5% |
| Your ability to design quality improvement project | 23.8% | 33.8% | 38.6% | 3.8% |
| Conducting a PDSA rapid cycle | 40.0% | 31.8% | 24.4% | 3.8% |
| Putting together a team to conduct a PDSA rapid cycle | 38.8% | 37.5% | 19.9% | 3.8% |
Table 4.
Resident interests in learning more about PCMH
| Questions and response options | Percent (%) | Frequency (n) |
|---|---|---|
| I learned about the PCMH model during medical school? | ||
| Way to little | 50.0% | 39 |
| Too little | 35.9% | 28 |
| About right | 12.8% | 10 |
| Too much | 0.0% | 0 |
| Way too much | 1.3% | 1 |
| I have read journal articles, books, or other materials on the PCMH? | ||
| Not at all | 41.8% | 33 |
| Slightly | 35.4% | 28 |
| Moderately | 15.2% | 12 |
| Very | 5.1% | 4 |
| Extremely | 2.5% | 2 |
| I am interested in learning more about the PCMH model during residency | ||
| Not at all | 1.3% | 1 |
| Slightly | 10.1% | 8 |
| Moderately | 35.4% | 28 |
| Very | 27.8% | 22 |
| Extremely | 25.3% | 20 |
Acknowledgments
Financial Support: Dr. Moreno received support from an NIA (K23 AG042961-01) Paul B. Beeson Career Development Award, the American Federation for Aging Research, and the University of California, Los Angeles, Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684.
Footnotes
Presentations: Preliminary results of this study were presented during the 46th STFM Annual Spring Conference on May 2013 in Baltimore, MD.
Conflict Disclosures: none
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