Training Tomorrow's Comprehensive Primary Care Internists: A Way Forward for Internal Medicine Education

Developing the Next Generation of Physicians

To improve health care, the USA needs to create a longitudinal medical education system that will develop physicians able to lead the transformation of health care toward a focus on the promotion of healthy behaviors aimed at preventing disease. The development of patient-centered care has been an important step in promoting healthy behaviors. However, to truly develop a meaningful relationship with a patient, a physician must first see them as a person, not as a list of diseases. Medical education should develop physicians able to provide person-centered care - moving beyond patient-centered care to focus more broadly on the entirety of the person, for whom being a patient is merely one aspect of their personhood. Restructuring medical education begins with the admission process itself, followed by longitudinal changes at the undergraduate, graduate, and continuing professional development levels that will reinforce the attributes critical for future physicians. The authors view this longitudinal approach through the theoretical framework of situated cognition, exploring personal, environmental, and social factors leading to success; outline several key stages of medical education from matriculation through continuing professional development; and identify potential areas that merit longitudinal efforts to develop future physicians able to promote positive health behaviors.

Internal Medicine Resident Experiences With a 5-Month Ambulatory Panel Management Curriculum

BACKGROUND

Panel management is emphasized as a subcompetency in internal medicine graduate medical education. Despite its importance, there are few published curricula on population medicine in internal medicine residency programs.

OBJECTIVE

We explored resident experiences and clinical outcomes of a 5-month diabetes and obesity ambulatory panel management curriculum.

METHODS

From August through December 2016, internal medicine residents at the University of Vermont Medical Center reviewed registries of their patients with diabetes, prediabetes, and obesity; completed learning modules; coordinated patient outreach; and updated gaps in care. Resident worksheets, surveys, and reflections were analyzed using descriptive and thematic analyses. Before and after mean hemoglobin A1c results were obtained for patients in the diabetic group.

RESULTS

Most residents completed the worksheet, survey, and reflection (93%-98%, N = 42). The worksheets showed 70% of participants in the diabetic group had appointments scheduled after outreach, 42% were offered referrals to the Community Health Team, and 69% had overdue laboratory tests ordered. Residents reported they worked well with staff (95%), were successful in coordinating outreach (67%), and increased their sense of patient care ownership (66%). In reflections, identified successes were improved patient care, teamwork, and relationship with patients, while barriers included difficulty ensuring follow-up, competing patient priorities, and difficulty with patient engagement. Precurricular mean hemoglobin A1c was 7.7%, and postcurricular was 7.6% (P = .41).

CONCLUSIONS

The curriculum offered a feasible, longitudinal model to introduce residents to population health skills and interdisciplinary care coordination. Although mean hemoglobin A1c did not change, residents reported improved patient care. Identified barriers present opportunities for resident education in patient engagement.

REDUCING ER USE THROUGH A TRAINEE-DESIGNED, INTERPROFESSIONAL CARE GROUP FOR HIGH-UTILIZING CHRONICALLY ILL PATIENTS: A PILOT PROGRAM

BACKGROUND

Healthcare utilization is skewed to a subset of high-need, high-use patients, but optimal models of care are not known.

PURPOSE

To reduce emergency room (ER) use and hospital readmissions, trainees designed an innovative model of care delivery for chronically ill, high-utilizing adult patients.

METHODS

Enrolled patients (N = 65) joined an interprofessional care program (nutrition, behavioral health, pharmacy, and care coordination), located in a single ambulatory clinic with extended hours.

RESULTS

Evaluated by generalized linear mixed-effects models, the primary outcome of all-cause ER visits showed a significant decreasing trend after enrollment, from an increasing odds of ER visits (OR 1.07) in the 12-months prior to the program, compared to a decreasing trend post-enrollment (OR 0.88). Implementation and completion of the program was cost neutral.

DISCUSSION AND CONCLUSIONS

This pilot supports team-based ambulatory care models that address the diverse needs of chronically ill patients, with a focus on improving select health services utilization.

Do medical residents perform patient-centered medical home tasks? A mixed-methods study

BACKGROUND

Increasingly, residents are being trained in Patient-centered Medical Home (PCMH) settings. A set of PCMH entrustable professional activities (EPAs) for residents has been defined but not evaluated in practice.

OBJECTIVE

To understand whether residents trained at PCMH sites reported higher likelihood of engaging in PCMH tasks than those training in non-PCMH sites.

DESIGN

Survey and nominal group data from post-graduate trainees at three residency programs.

RESULTS

A total of 179 residents responded (80% response). Over half (52%) cared for patients at PCMH sites. Residents at PCMH sites were more likely to report engaging in tasks in the NCQA domains of enhancing access and continuity (p < 0.01 for 4/11 tasks), planning and managing care (p < 0.01 for 3/4 tasks), providing self-care and community support (p < 0.01 for 3/5 tasks), and identifying and managing patient populations (p < 0.01 for 1/6 tasks), but were not more likely to report tracking and coordinating care or measuring and improving performance. Residents at PCMH sites were more likely to report working with medical assistants (p < 0.01), but not other healthcare professionals. Qualitative data showed staff teamwork and continuity of care as facilitators of patient-centered care, and technological problems and office inefficiencies as barriers to care.

CONCLUSIONS

Residents trained at PCMH sites were more likely to engage in tasks in several NCQA domains, but not care coordination and quality assessment. Similar facilitators and barriers to trainee provision of patient-centered care were cited regardless of PCMH status. Curricula on PCMH principles and workflows that foster continuity and communication may help to inform residents on PCMH tenets and incorporate residents into team-based care.

ABBREVIATIONS

EPA: Entrustable professional activity; GIM: General Internal Medicine; NCQA: National Center for Quality Assurance; PCMH: Patient-centered medical home.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind

BACKGROUND

Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species.

OBJECTIVE

We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care.

INTERVENTION

We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations.

ANTICIPATED OUTCOMES

New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities.

CONCLUSIONS

The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.