Monday, November 7, 2011

Innovation in Physician Training

Patient-Centered Medical Homes (PCMH’s) are presented as a care delivery innovation that has had success in the realm of increasing quality of care while decreasing costs. At its core, the PCMH seeks to strengthen primary care, leading to coordinated care, improved access, and ultimately reduced costs. However, the dark irony of the success of the PCMH model is that as primary care demonstrates its ability to serve as a hub for care coordination while reducing cost, primary care physicians (PCP’s) are dwindling in proportion of the physician work force. Perversely designed fee schedules have created a dramatic income inequality among physician specialties, strongly steering medical students away from generalist careers. While many factors ultimately influence student specialty choice, medical students are hard pressed to choose generalist careers while income disparity remains so troublingly wide.

Further, essential to the success of PCMH’s are functional teams. Looking at the results of the 2006 Group Health Cooperative model, strong PCP leadership was identified as a critical factor for the success of organization transformation into a PCMH[1]. However, current undergraduate and graduate medical training does not search out these skills in its applicants, nor does it provide comprehensive education for how to develop these practice tools. Strong leadership capable of excelling at the challenges of practice management are necessary for PCMH’s to become a widespread national success story, yet medical education has not responded to the growing need for these additional physician skill sets. Biomedical science training and clinical knowledge, the current mainstay of medical education, is not enough to produce physicians competent for current health challenges. Physicians, especially PCP’s, must be taught how to work and lead within teams, manage practices, motivate members of the care team, integrate health IT, and adapt quickly to practice innovations. These competencies are critical for the success of PCMH’s and ultimately care delivery transformation.

The reported success of PCMH’s is exciting; though many details need to be ironed out to rigorously define the characteristics of successful models, the early victories among differing patient populations provide evidence that the key organizing principles of the PCMH are widely applicable across our nation. However, to achieve this dream of coordinated, high value care, it is necessary to rethink medical student training and physician payment. Large income disparities are not sustainable if we are to attract the number and quality of primary care doctors necessary to lead transformation in care delivery. Further, medical education itself must innovate in order to equip its graduates to practice within these new models.

[1] Robert J. Reid, Katie Coleman, Eric A. Johnson, Paul A. Fishman, Clarissa Hsu, Michael P. Soman, Claire E. Trescott, Michael Erikson and Eric B. Larson The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers Health Affairs, 29, no.5 (2010):835-843

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