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In his plenary address at the 2007 Annual Spring Conference, Terry McGeeney repeatedly said "Houston, we have a problem." He described the disheartening state of family medicine clinical practice revealed by the TransforMED project. Jim Mold, in his plenary presentation, presented an optimistic picture of a statewide learning community that can lead to practice improvement, but his data showed far from optimal performance. While family medicine may still have a problem, there is a solution. By assembling patient-centered medical homes, family medicine can strengthen the provision of its core clinical services and stimulate progress toward optimal high quality care.
The AAFP is promoting the patient-centered medical home (PCMH) through the TransforMED project, the Patient-Centered Primary Care Collaborative (PCPCC), and advocacy in Congress. The American Board of Family Medicine (ABFM) and the Association of Family Medicine Residency Directors (AFMRD) are fostering the PCMH vision in residencies in the Preparing the Personal Physician for Practice (P4) Project. STFM seeks to spread the PCMH model to all teaching practices—medical school faculty, residency program, and community preceptor practices—by promoting a teaching practice learning community to help remodel the hundreds of teaching practices in family medicine educational programs.
STFM joined the PCPCC3 to advocate for this model of care. The Institute for Family-Centered Care4 and the New Health Partnerships5 also advocate for patient- and family-centered care. Attention to linkages around patient care is consistent with STFM’s mission statement and its responsibilities for the Future of Family Medicine strategic priorities.
STFM is "dedicated to improving the health of all people through education, research, patient care, and advocacy." Being involved in improving patient care by joining the PCPCC and partnering with other organizations that advocate for patient- and family-centered care is very consistent with STFM’s mission.
STFM is charged with taking the lead on the Future of Family Medicine strategic priority about recruiting and training a family physician workforce that will meet the needs of the US population by practicing within the personal or patient-centered medical home.6
For recruitment, STFM has started FutureFamilyDocs.org and regular stories in The STFM Messenger about efforts to recruit premedical students into medicine who are likely to share the values we hold. The literature supports this strategy, and also indicates that a required 3rd-year family medicine clinical experience is directly related to the rate of recruitment of students into family medicine.7 One expected benefit of developing patient-centered medical homes in family medicine is that this positive practice model would be attractive to clerkship students. This strategy depends entirely on whether teaching practices for students are patient-centered medical homes. Students rotate in medical school faculty practices, residency programs, and community volunteer faculty practices, so all of these teaching practices need to become patient-centered medical homes.
For training, family medicine teachers need to prepare students and residents for the PCMH practice model. A key step is to articulate the competencies necessary for functioning well in a patient-centered medical home and to develop curricula for providing learners with the knowledge-base required for that environment. The STFM Special Task Force on the Future of Family Medicine is developing competency-based curricula for the PCMH. The group visit module is described as "a dynamic longitudinal way of teaching, whereby the student learns by actively planning, conducting, and debriefing about each visit with team members."8
This approach to education fits with the educational philosophy that students learn what they do.9 The importance of the clinical experience is supported by the experiential learning cycle of abstract conceptualization, active experimentation, concrete experience, and reflective observation.10 Abstract conceptualization and reflective observation, which are typical classroom instruction activities, are important, but are incomplete without concrete experience and active experimentation in clinical settings. Students and residents continually note how the clinical experience compares with classroom didactic instruction. Messages taught about medical home topics in class settings will not stick unless learners experience the concepts in action in clinical sites. Students must work in teaching practices with medical home features or there is a risk that the PCMH initiative will be marginalized and lose credibility.
Putting learners in teaching practices that are patient-centered medical homes is a primary responsibility of family medicine educators. This implies that educational leaders help remodel these teaching practices. This is a rather ambitious agenda. There are over 100 medical school practices and over 450 residency program practices that need to become PCMH teaching practices. In addition, estimating that each medical school has approximately 30 to 50 community practices in which it places students, there are roughly 3,000 to 5,000 community teaching practices that need to be remodeled into PCMHs.
Teachers of family medicine must be concerned about the types of clinical practices where they place learners. The models of patient care that students and residents experience in clinical settings exemplify Marshall McLuhan’s adage "The medium is the message."9 The structure and process of patient care provide the message of clinical education. This medium must model the message of patient-centered care in medical homes. STFM’s 2008 Annual Conference theme underscores this fundamental point.
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