Small family practices interested in becoming patient-centered medical homes (PCMH) should first examine the relationships between their physicians and medical assistants, says one UC researcher.
They should help build a relationship that is marked by a high degree of trust but still requires that proper medical procedures are verified by physicians so patient care remains exemplary, says Nancy Elder, professor of family and community medicine.
Elder says medical assistants have become an important part of the medical staff in small family practices, replacing nurses in most of these offices. However, training to become a medical assistant (MA) varies, with some starting with little or no medical background.
"If we are thinking about transforming to a new model of PCMH, it is important to know our current model, especially locally or regionally.” says Elder. "For this study, we were not interested in the great big practices where there are 25 doctors working within a large health system. Even though there are fewer of them, there are still hundreds of smaller primary care practices.”
"Our question was, ‘How do doctors and medical assistants work together to care for patients? What is their relationship status, which you would think would be very straightforward, but most of the existing research looks at doctors and nurses in hospitals, not office based relationships.”
Elder says the patient-centered medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety. She says it has become a widely accepted model for how primary care should be organized and delivered throughout the health care system.
"Over the last 20 to 30 years, there has been a decrease in nurses in medical offices,” says Elder. "Medical assistants do not have the same clinical training that a nurse does. You can become a medical assistant with no training whatsoever and just start working in a doctor’s office or you could go to school for two years or as long as an LPN (licensed practical nurse) does to become a certified MA. Training is all over the place.”
"We have made this shift from nurses to medical assistants without really knowing what that change entails,” she says.
Elder and a team of researchers conducted an ethnographic study of five small family medical offices in the Cincinnati area that included interviews, surveys and observations of 19 medical assistants and their supervisors and 11 clinicians—nine family physicians and two nurse practitioners—while observing 15 medical assistants in practice.
The study’s findings were published recently in the Annals of Family Medicine with Elder as the article’s corresponding author.
Other co-authors included: C. Jeffrey Jacobson, PhD, associate professor and interim head of the Department of Anthropology in UC’s McMicken College of Arts and Sciences and assistant professor of family and community medicine; Shannon Bolon, MD; Joseph Fixler, a second-year UC medical student; Harini Pallerla, senior research assistant in the Department of Family and Community Medicine; Christina Busick; Erica Gerrety; Dee Kinney, associate professor at UC Clermont; Saundra Regan, PhD research scientist in the Department of Family and Community Medicine; and Michael Pugnale.
"Our takeaway was that there were some highly functional offices that worked very well and then there were other offices with many more challenges,” says Elder. "We found that the old Russian saying, ‘trust but verify,’ used by President Reagan in 1987, to be an appropriate way to look at the offices. There were various levels of trust between the physician and the medical assistants and various levels how the physicians were verifying what the medical assistants are doing.”
"You would think that if you had a lot of trust maybe you didn’t need to verify as much and if you did not have a lot of trust you needed to verify a lot,” says Elder. "The reality is that we didn’t always find that. We found physicians that had no trust in their medical assistants but who also never bothered to verify what their medical assistants were doing.”
"Those practices had a hands-off approach with poor teamwork and a lot of staff turnover,” says Elder. "They were not in a place where they could make the transition to a patient-centered medical home.”
"We also saw other practices that had high trust and did a high amount of verification. ‘Yes, I trust my medical assistant a lot, but this is my responsibility to verify what they are doing and what is going on.’ These practices were on their way to becoming PCMHs,” says Elder.
Some of the problem is rooted in who hires the medical assistant, says Elder. In some offices, the hiring was handled by a system administrator with little to no input from an office physician. In other offices, physicians actively hired and managed their medical assistants, she says.
"If a practice wants to look at becoming a patient-centered medical home, if they want to look to transforming to new levels of care for their patients, they need to look seriously at where their relationship is right now,” says Elder.
"We propose a model of looking at the level of trust and the level of verification. This model is informed by how well the physicians and the nurses interact socially in the office as well as what level of responsibility the physicians have with the medical assistants,” says Elder.