How the medical home can spur academic research

As we’ve gone through the process of building our patient-centered medical home, we have brought along a little bit of the scientific method.

As part of the medical home rollout, we developed an expanded quality improvement curriculum for our internal medicine residents. A series of talks on key topics of the patient-centered medical home has been developed, and several faculty experts have been delivering these to the residents. As a part of this curriculum, the residents are each doing a research project on quality improvement focused on the patient-centered medical home in outpatient medicine.

As the curriculum was developed, we decided to evaluate it, essentially to do research on the research. We thought about what we wanted to teach the residents, how we wanted to teach them, and how we wanted to learn whether they had learned.

We created a series of pretests, looking at their knowledge of the concepts of the patient-centered medical home, a series of (sort of) leading questions looking at whether they thought they already had the tools necessary to provide true patient-centered care before we taught them how to.

Now that we’ve delivered the curriculum, we are planning to give them a posttest, to see if they have learned what we wanted them to learn. Then we plan to compare the pre-tests and posttests, and see if our curriculum made a difference.

The question becomes, is this sort of research really necessary? What does it add to our knowledge?

We are already beginning to work on the abstract to be presented at a regional meeting to show that our curriculum led to a change in resident’s knowledge and ability to care for patients under a patient-centered medical home model. We have been having ongoing discussions about whether this data should be presented as a scatter plot, or variation from the mean, and how much of a change in knowledge should be considered significant.

Although it is clearly important to study whether what you’re teaching your learners really makes a difference, turning it all into research sometimes seems a bit excessive.

Yet, we live in the academic world, the world of publish or perish, and clearly there is a need for us to do scholarly work to validate that what we are doing really makes a difference, and perhaps share this knowledge with others.

And sharing is certainly important. A colleague of mine had a mentor in college who was a chemist; he suffered a devastating injury as a result of an experimental protocol he was trying, which he believed no one had ever attempted before. Years after his injury, he discovered that another group of scientists at a different institution had tried the same procedure with similar catastrophic results. They had never published this information, since it was considered a “negative finding.” I’ve always wondered if he harbored ill feelings towards that group.

It seems in academic medicine we can write up everything we do, every case we see, every initiative we try, every series of patients we follow, every new tweak to our electronic health record, every new system we put into place to improve care coordination.

But with the enormous amount of information flooding at us in multiple different formats — online, at local meetings, in journals — if we spend all of our time writing up the work we do, and reading about the work others do, do we end up not having the actual time we need to take care of our patients — to do the doing?

I’m not negating the benefits of doing rigorous academic research, and publishing well-done studies, and keeping up-to-date in the literature of your chosen field. But we already know that with the wealth of information out there, the explosion of information, the endless number of new medications being released every day, new protocols for every disease possible, that keeping 100% up-to-date is impossible.

Now all of this may sound like I’m not interested in doing research in this field, or that I think it is not going to be useful, or may, in fact, be a waste of everyone’s time. This is not the case. Recently in several leading academic journals, including JAMA, there have been a number of articles about the patient-centered medical home, how it may be reinvigorating the field, and pointing to new ways of caring for our patients.

So research in the field is important. And the leadership of our hospital and medical center have offered their support to our doing it, from our efforts to create a research structure examining all of the work we are doing around the patient-centered medical home, to the resident research projects aimed at improving point-of-care testing timeliness, to retasking the registrars to build a more cohesive team structure.

And guess who they have put in charge?

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • LeoHolmMD

    Doing a pre/post analysis is almost completely scientifically invalid. If the people supporting the PCMH were serious about real research, they would set up a randomized, placebo controlled, double blind study comparing the PCMH to traditional practice and generate some real data. You are comparing residents before and after exposure to a program. It may be impossible to generate negative data given that kind of study bias.

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