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Some participants noted favorable reactions to the metaphor of the home, where, as Robert Frost penned, "they have to take you in." The national alignment of purchasers and payers with primary care clinicians to develop the medical home was seen as creating newsworthy, positive movement toward enhanced primary care, something quite different from "business as usual." The potential transformative effects of becoming patient centered were emphasized, including: elevating this notion to the national policy scene; involving families, teams, and communities in caring for patients who are actively involved in their own care; and tapping into consumerism with patients sharing decisions and making choices. Learning how to fully incorporate all the elements of the PCMH was seen as a rich academic opportunity to use multiple scientific methods to understand effects and to teach learners how to work together on behalf of all the people through/in the PCMH.
There was apprehension that the PCMH remains "in the belly of the beast"—not radical enough to escape from old "medical" models and provider-centeredness into the concepts of health and community linkage. Transforming primary care practice is very hard; it involves more than doing a few quality improvement cycles. Underlying genuine practice transformation are hidden assumptions and fears about primary care, physicians, values, and expectations that have not been sufficiently exposed; these threaten progress, possibly resulting in the PCMH becoming another passing fad. There is much ignorance—about how to actually achieve the attributes and functions of the PCMH and about how to measure the existence and performance of the PCMH—making sweeping claims and over-promising inadvisable. Balancing legitimate professional prerogatives, commercial interests, use of new technologies, and roles among patients and teams is very challenging. Mis-positioning the PCMH as a miracle that will solve conflicting interests could condemn the PCMH to not succeeding sufficiently to please anyone. Broader system changes, particularly financing arrangements, are necessary for the PCMH to work properly, and these are beyond the control of primary care, threaten powerful interests, and, thus, there is no guarantee that such changes will occur.
Not surprisingly for a group of investigators, many important issues were quickly identified, ranging from very specific questions to much broader topics representing possible programs of research:
The discussion was arbitrarily limited to 70 minutes and concluded with participants having further ideas and suggestions not expressed. Thus, this recounting is only a partial listing of what was an invigorating moment of sharing hopes, concerns, and investigative opportunities by a forthcoming convenience sample of the 2008 NAPCRG attendees.
ACKNOWLEDGMENTS
Richard Deyo, Ron Epstein, Rebecca Etz, Marji Gold, Carlos Jaen, Mark Johnson, Ardis Olson, Jim Puffer, and Diane Rittenhouse volunteered to initiate this discussion with brief personal remarks. Robert Graham, Will Miller, and Kurt Stange manned the flip charts and uttered not a word. Larry Green organized and lightly facilitated the discussion.
This article has been cited by other articles:
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  L. I Solberg and P. Van Royen The medical home: is it a blind men and elephant tale? Fam. Pract., December 1, 2009; 26(6): 425 - 427. [Full Text] [PDF]
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