Our general linear mixed-model analyses are presented in Tables 3 to 5. Of the 14 electronic features assessed (Table 3), none had statistically significant differences according to medical school, even though up to 10-fold variation in implementation of other PCMH features existed. Three PCMH electronic features reached 50% implementation when averaged according to medical school: (1) presence of an EHR, which ranged from 33% to 100%, (2) availability of fully secured remote access (range 33%–100%), and (3) electronic scheduling system integrated into the EHR (22%–100%).
Implementation of nonelectronic features of the PCMH (Table 4) indicates that of the 12 features assessed, three (25%) were found to vary significantly among schools: (1) the availability of a credible, reliable patient satisfaction survey (range 20%–100%; P = .02), (2) the presence of clinical pharmacy support (range 0%–100%; P = .05), and (3) adequate free parking (range 7%–100%, P = .007). No significant difference existed in the other nonelectronic elements of the PCMH. By medical school, more than half of the clerkship sites had implemented 7 of the 12 non-electronic features assessed (58%) including (1) expanded hours (range 0%–100%), (2) credible, reliable patient satisfaction surveys (range 20%–100%), (3) integrated behavioral health care (range 13%–100%), (4) adequate physical space (range 60%–100%), (5) adequate free parking (range 7%–100%), (6) access to convenient public transportation (range 56%–100%), and (7) overall status of practice as patient-centered versus physician-centered (range 33%–100%).
Table 5 outlines our findings related to physicians' attitudes about how new technology in clinical practice influences medical education. Approximately 86% (n = 51) of clinics that have EHRs allow medical students to access their EHRs, whereas 14% (n = 8) do not. We found wide variation among the physician attitudes regarding both the effect of new technologies on the quality of medical education and the larger role students are playing in the patient-care team as a result of new technology—although this latter variation was not significantly different among the medical schools.
We examined several factors that we thought might be associated with high versus low PCMH-component implementation to determine the best analytic approach using our composite scores. These included being an FQHC or integrated health system. We found no associations with type of practice setting for either of these variables. We also examined the relationship between patient volume and electronic features of the PCMH to test the hypothesis that high patient volume might correlate with more electronic and nonelectronic features of the PCMH (using the composite scores). The correlation coefficient between these two variables was 0.48 (P = .66) for electronic features and −0.04 (P = .71) for nonelectronic features, indicating no significant relationship between patient volume and features of the PCMH.
Discussion and Conclusions
Health care reform is likely to generate a period of rapid change in how medicine is practiced throughout the United States, and these changes are already having a significant impact on the day-to-day work of physicians.7,14,16,19,20 Educating medical students while in this transitional mode raises questions about curricular objectives and how best to prepare students for careers in a new model of practice.
To our knowledge, our study is the first to use a national sample to examine the degree to which medical students in the United States are experiencing elements of the PCMH in their required curriculum as well as the extent to which student exposure to PCMH features varies by medical school. Because third-year internal medicine and pediatric clerkships are often based primarily in hospital settings, FM clerkships are the most likely place in the curriculum for students to first experience these new care models in the ambulatory setting. Although we found up to 10-fold differences from school to school in our analysis of clerkship training sites, only three areas reached statistically significant variation, and all three were in nonelectronic features. We found that over 50% of clerkship placement sites have EHRs, which differs from the findings of Linder and colleagues,21 who found that in 2003 and 2004 only 18% of the patients seen by physicians had EHRs as recorded on the Ambulatory Medical Care Survey. Our findings suggest that implementation of these features may be rapidly expanding or that medical school faculty may be selectively assigning students to practices with more of these features. Although other reports have shown wide variation among clinical practices in how and when elements of this new model of care arise,7,19 these did not focus on the teaching that occurs in these settings, which is the specific contribution to the literature that our study makes.
We explored several possible sources of variation including whether the practices were part of integrated health systems or FQHCs or whether high patient volume was associated with more versus fewer PCMH features. We found no such association, which leaves us to speculate other possible explanations. Some regions of the country may be implementing the PCMH model more readily than others. Or size and other features of a practice simply may not affect implementation of innovations likely to improve patient care. Also, medical school clerkship faculty members might pay varying degrees of attention to the presence of PCMH features when they select training sites.
We were surprised to learn how much variability there is regarding preceptor attitudes about the effects of practice transformation and information technology on medical education, even though these variables did not reach statistical significance when we analyzed them by medical school. Preceptors seemed to reach no overall consensus on whether emerging technologies in the care of patients will help or hinder student education. In three of the nine schools, over 65% of preceptors either agreed or strongly agreed that new technology would improve medical education, while at another six schools more than half of respondents disagreed or strongly disagreed that new technology would improve the quality of medical education. Previous work suggests that there is considerable disagreement on this point among medical students, residents, and medical educators.22–25 Peled and colleagues22 speculate that use of EHRs bypasses the need for trainees to synthesize clinical information because the EHRs do so much of this for them. They also note that EHRs can be a significant distraction for learners as they focus too heavily on the computer and not enough on patients. However, the results of another study23 showed that preceptors gave more and better feedback to third-year medical students on progress notes when the students entered the notes into an EHR.
The preceptors' responses to our survey questions regarding the influence of electronic technology on medical education may be due to factors identified in the studies cited above,22–25 or they may be due to the timing of our survey compared with when EHR use started in each practice. We conducted our survey when many practices were just beginning to use EHRs (only 37% described their EHR as mature). Transforming a practice from paper to electronic is stressful, especially at the beginning,19 and physicians may initially perceive that EHRs create barriers to patient care and complicate time management. Physicians working during such times of transition may have a hard time seeing the benefits of the EHR for patient care, let alone fathoming the benefits to medical education. This initial lack of enthusiasm is understandable in light of published research questioning whether EHRs improve ambulatory care21 or reduce cost26 at this point in their evolution. Students working in practices with newly implemented EHRs often experience an environment of chaotic change, and this is likely to affect their education in unpredictable ways. Stressed physicians are likely to be less effective teachers.
Preceptors also may not know how to best use new technology when teaching. A lack of faculty development in the area of using electronic media for medical education may leave these preceptors at a loss when confronted with the daily demands of both patients and students. Preceptors need instruction not only in using the technology clinically but also in using it educationally.
If students do not have access to the EHR, it is hard to imagine how they could review patients' history, identify and interpret lab results, write notes, or investigate consultant reports, all essential tasks for clinical learning. In 14% of the EHR-equipped practices in our study, students did not have access to the record system. Using EHRs in education requires a change in the systems of teaching, and the infrastructure for this education needs support. Excellent medical education using an EHR requires that students have a place to use the computer, a computer to use, a password to get into the system, adequate practice with the EHR system, permission to enter orders and write notes in the chart, and an understanding of the power of the EHR in quality chronic disease and population management.
We found more variability in the adoption of nonelectronic than electronic features of the medical home. These included the availability of a credible, reliable patient satisfaction survey, the support of a clinical pharmacy, and the presence of adequate free parking. Reasons for the variation we found for these items may include practice location (metropolitan versus suburban or rural settings) and the status (i.e., as an FQHC) of the health systems to which some of these practices belong. If patients are to embrace the PCMH, then this new model of care must be more immediately consumer-accessible and more user-friendly. Some have argued that such patient-centeredness is the most essential concept in the PCMH.8,20 Many of the attributes of patient-centeredness are key components of professionalism for students, and practicing these attributes will help students learn how to be available to patients while also managing appropriate boundaries between personal and professional responsibilities. It is not clear how much attention medical school faculty are paying to the principles of the PCMH when choosing practices in which to place clerkship students, but differences in this emphasis may also explain some of the variation we found from school to school.
The strength of our study is that we were able to collect detailed information about features of the PCMH from over 100 clinics that are active ambulatory care teaching sites for third-year medical students. Our study also had some limitations. One is that only nine medical schools were represented, and although these nine represent a national sampling, our results are not necessarily generalizable to all sites where medical student education occurs. In addition, though we attempted to control who completed the survey at each site, we are not confident that the lead physician was always the one who performed this task, so response bias may have influenced our findings. We chose to focus our analysis on established clerkship training sites with a clear history of taking students over time. While this choice allowed us to survey those sites that take the most students, we did not include new or part-time sites, and this exclusion might have influenced our results.
We surveyed preceptors of the practices and not the students because our primary interest was in how these teaching practices were changing, and we sought to compare our results with similar analyses in previous studies at the residency and community practice levels.7,16 An obvious follow-up approach might be to measure student experiences and attitudes before and after completing required clerkships in these practices.
In conclusion, we found that the process of transforming primary care to the PCMH is already well under way in a national sample of FM clerkship sites. Modest variability exists in specific features of the PCMH, and considerable variation exists in preceptor attitudes about the impact of new technologies on ambulatory medical education. Managing this variability will be a major challenge to FM clerkship and medical school curricular leaders for the next several years.
The authors wish to thank the departments of family medicine at the nine participating medical schools (Albert Einstein College of Medicine; Jefferson Medical College; New Jersey Medical School; Medical University of South Carolina; Southern Illinois University School of Medicine; Eastern Virginia Medical School; University of North Dakota School of Medicine & Health Sciences; University of Texas, San Antonio School of Medicine; and University of Washington School of Medicine) for their assistance in practice identification and data collection.
The authors also wish to thank Ms. LeNeva Spires for her editorial assistance with the final version of the manuscript.
The Society of Teachers of Family Medicine and the Research Program at Oregon Health & Science University's Department of Family Medicine supported this study. The Oregon Clinical and Translational Research Institute (OCTRI), grant number UL1-RR024140 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Methods Research, provided statistical expertise.
The institutional review board at Oregon Health & Science University approved the study.
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* The nine schools that provided usable surveys from the family medicine ambulatory medicine clerkship sites were Albert Einstein College of Medicine, New York; Jefferson Medical College, Pennsylvania; New Jersey Medical School; Medical University of South Carolina; Southern Illinois University School of Medicine; Eastern Virginia Medical School; University of North Dakota School of Medicine & Health Sciences; University of Texas, San Antonio School of Medicine; and University of Washington School of Medicine.© 2010 Association of American Medical Colleges