Journal of General Internal Medicine

, Volume 28, Issue 6, pp 801–809 | Cite as

Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

  • Anna ChangEmail author
  • Judith L. Bowen
  • Raquel A. Buranosky
  • Richard M. Frankel
  • Nivedita Ghosh
  • Michael J. Rosenblum
  • Sara Thompson
  • Michael L. Green
Original Research



The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.


We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?


The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).


The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.


The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.


patient-centered medical home entrustable professional activities graduate medical education internal medicine primary care 




We thank Karen Hauer, H. Carrie Chen, Patricia O’Sullivan, and C. Seth Landefeld for their thoughtful reviews of the manuscript.


Josiah Macy Jr. Foundation supported the Education Summit. Additional financial support for the Summit was provided by the United Health Foundation. The American College of Physicians, Primary Care Progress, and the Veterans Health Administration office of Academic Affiliations provided in-kind support.

Prior Presentations

The paper has not been presented. The list of EPAs from this Education Summit was presented at a workshop during the 2011 Annual Meeting of the Society of General Internal Medicine

Conflict of Interest

The authors declare that they do not have a conflict of interest.


  1. 1.
    Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Heal Aff. 2008;27(3):w232–w241. May 01.CrossRefGoogle Scholar
  2. 2.
    Bodenheimer T. Primary care—will it survive? N Engl J Med. 2006;355(9):861–864. Aug 31.PubMedCrossRefGoogle Scholar
  3. 3.
    Julian K, Riegels NS, Baron RB. Perspective: creating the next generation of general internists: a call for medical education reform. Acad Med. 2011;86(11):1443–7.Google Scholar
  4. 4.
    Hauer KE, Durning SJ, Kernan WN, Fagan MJ, Mintz M, O’Sullivan PS, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154–1164. September 10.PubMedCrossRefGoogle Scholar
  5. 5.
    Schwartz MD, Durning S, Linzer M, Hauer KE. Changes in medical students’ views of internal medicine careers from 1990 to 2007. Arch Intern Med. 2011;171(8):744–749. April 25.PubMedCrossRefGoogle Scholar
  6. 6.
    Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. 2008;83(5):498–502.PubMedCrossRefGoogle Scholar
  7. 7.
    Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80(5):507–512.PubMedCrossRefGoogle Scholar
  8. 8.
    American Academy of Family Physicians. Joint principles of the patient-centered medical home. Del Med J. 2008;80(1):21–22.Google Scholar
  9. 9.
    Stange KC, Nutting PA, Miller WL, Jaen CR, Crabtree BF, Flocke SA, et al. Defining and measuring the patient-centered medical home. J Gen Intern Med. 2010;25(6):601–612.PubMedCrossRefGoogle Scholar
  10. 10.
    Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med. 2010;25(6):584–592.PubMedCrossRefGoogle Scholar
  11. 11.
    Jaen CR, Ferrer RL, Miller WL, Palmer RF, Wood R, Davila M, et al. Patient outcomes at 26 months in the patient-centered medical home national demonstration project. Ann Fam Med. 2010;8 Suppl 1:S57,67; S92.Google Scholar
  12. 12.
    Maeng DD, Graf TR, Davis DE, Tomcavage J, Bloom FJ, Jr. Can a patient-centered medical home lead to better patient outcomes? The quality implications of geisinger’s ProvenHealth navigator. Am J Med Qual. 27(3):210–6.Google Scholar
  13. 13.
    Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaen C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood). 2011;30(3):439–445.CrossRefGoogle Scholar
  14. 14.
    Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835–843.CrossRefGoogle Scholar
  15. 15.
    Association of Program Directors in Internal Medicine, Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC. Redesigning residency education in internal medicine: a position paper from the association of program directors in internal medicine. Ann Intern Med. 2006;144(12):920–926. Jun 20.PubMedCrossRefGoogle Scholar
  16. 16.
    Bowen JL, Salerno SM, Chamberlain JK, Eckstrom E, Chen HL, Brandenburg S. Changing habits of practice. Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med. 2005;20(12):1181–1187.PubMedCrossRefGoogle Scholar
  17. 17.
    Holmboe ES, Bowen JL, Green M, Gregg J, DiFrancesco L, Reynolds E, et al. Reforming internal medicine residency training. A report from the society of general internal medicine’s task force for residency reform. J Gen Intern Med. 2005;20(12):1165–1172.PubMedCrossRefGoogle Scholar
  18. 18.
    Huddle TS, Heudebert GR. Internal medicine training in the 21st century. Acad Med. 2008;83(10):910–915.PubMedCrossRefGoogle Scholar
  19. 19.
    Meyers FJ, Weinberger SE, Fitzgibbons JP, Glassroth J, Duffy FD, Clayton CP, et al. Redesigning residency training in internal medicine: the consensus report of the alliance for academic internal medicine education redesign task force. Acad Med. 2007;82(12):1211–1219.PubMedCrossRefGoogle Scholar
  20. 20.
    Nadkarni M, Reddy S, Bates CK, Fosburgh B, Babbott S, Holmboe E. Ambulatory-based education in internal medicine: current organization and implications for transformation. results of a national survey of resident continuity clinic directors. J Gen Intern Med. 2011;26(1):16–20.PubMedCrossRefGoogle Scholar
  21. 21.
    Stevens DP, Bowen JL, Johnson JK, Woods DM, Provost LP, Holman HR, et al. A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices. J Gen Intern Med. 2010;25(Suppl 4):S574–S580.PubMedCrossRefGoogle Scholar
  22. 22.
    Stevens DP, Wagner EH. Transform residency training in chronic illness care—now. Acad Med. 2006;81(8):685–687.PubMedCrossRefGoogle Scholar
  23. 23.
    Health Resources and Services Administration Primary Care Residency Expansion Initiative, (HRSA-10-277, 2010).Google Scholar
  24. 24.
    VA centers of excellence in primary care education [Internet]. 810 Vermont Avenue, NW - Washington, DC 20420: U.S. Department of Veterans Affairs. Available from: Accessed June 22, 2012.
  25. 25.
    Babbott SF, Beasley BW, Reddy S, Duffy FD, Nadkarni M, Holmboe ES. Ambulatory office organization for internal medicine resident medical education. Acad Med. 2010;85(12):1880–1887.PubMedCrossRefGoogle Scholar
  26. 26.
    American college of physicians medical home builder [Internet]. 190 North Independence Mall West, Philadelphia, PA 19106–1572: American College of Physicians; 2011. Available from: Accessed June 22, 2012.
  27. 27.
    ACGME outcomes project [Internet]. 515 N. State Street Suite 2000 Chicago, Il 60654: ACGME; 2011. Available from: Accessed June 22, 2012.
  28. 28.
    Royal College of Physicians and Surgeons of Canada CanMEDS [Internet]: Royal College of Physicians and Surgeons of Canada; 2011. Available from: Accessed June 22, 2012.
  29. 29.
    Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the flexner report. N Engl J Med. 2006;355(13):1339–1344. Sep 28.PubMedCrossRefGoogle Scholar
  30. 30.
    Green ML, Aagaard EM, Caverzagie KJ, Chick DA, Holmboe E, Kane G, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1(1):5–20.PubMedCrossRefGoogle Scholar
  31. 31.
    ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176–1177.PubMedCrossRefGoogle Scholar
  32. 32.
    Carraccio C, Burke AE. Beyond competencies and milestones: adding meaning through context. J Grad Med Educ. 2010;2(3):419–422.PubMedGoogle Scholar
  33. 33.
    Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638–645. 08/01; 2011/10.PubMedCrossRefGoogle Scholar
  34. 34.
    ten Cate TJO, Snell L, Carraccio C. Medical competence: the interplay between individual ability and the health care environment. Med Teach. 2010;32(8):669–675. 08/01; 2011/10.PubMedCrossRefGoogle Scholar
  35. 35.
    Jones MD Jr, Rosenberg AA, Gilhooly JT, Carraccio CL. Perspective: competencies, outcomes, and controversy–linking professional activities to competencies to improve resident education and practice. Acad Med. 2011;86(2):161–165.PubMedCrossRefGoogle Scholar
  36. 36.
    ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542–547.PubMedCrossRefGoogle Scholar
  37. 37.
    Mulder H, Cate OT, Daalder R, Berkvens J. Building a competency-based workplace curriculum around entrustable professional activities: the case of physician assistant training. Med Teach. 2010;32(10):e453–e459. 10/01; 2011/10.PubMedCrossRefGoogle Scholar
  38. 38.
    National committee for quality assurance patient centered medical home 2011 [Internet]. 1100 13th Street, NW, Suite 1000, Washington, DC 20005: National Committee for Quality Assurance; 2011. Available from: Accessed June 22, 2012.
  39. 39.
    Joint principles for the medical education of physicians as preparation for practice in the patient-centered medical home. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA); 2010. Available at
  40. 40.
    Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408–1417.PubMedCrossRefGoogle Scholar
  41. 41.
    Scheele F, Teunissen P, Luijk SV, Heineman E, Fluit L, Mulder H, et al. Introducing competency-based postgraduate medical education in the Netherlands. Med Teach. 2008;30(3):248–253. 01/01; 2011/10.PubMedCrossRefGoogle Scholar
  42. 42.
    Hammick M, Olckers L, Campion-Smith C. Learning in interprofessional teams: AMEE guide no 38. Med Teach. 2009;31(1):1–12.PubMedCrossRefGoogle Scholar
  43. 43.
    Parmelee DX, Michaelsen LK. Twelve tips for doing effective team-based learning (TBL). Med Teach. 2010;32(2):118–122.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Anna Chang
    • 1
    Email author
  • Judith L. Bowen
    • 2
    • 3
  • Raquel A. Buranosky
    • 4
  • Richard M. Frankel
    • 5
  • Nivedita Ghosh
    • 6
  • Michael J. Rosenblum
    • 7
  • Sara Thompson
    • 8
  • Michael L. Green
    • 9
  1. 1.University of California San Francisco, San Francisco Veterans Affairs Medical CenterSan FranciscoUSA
  2. 2.Oregon Health and Science UniversityPortlandUSA
  3. 3.Veterans Health Administration Office of Academic AffiliationsWashingtonUSA
  4. 4.University of Pittsburgh Medical CenterPittsburghUSA
  5. 5.Richard L. Roudebush Veterans Affairs Medical CenterIndiana University School of MedicineIndianapolisUSA
  6. 6.Brigham and Women’s Advanced Primary Care AssociatesHarvard Medical SchoolBostonUSA
  7. 7.Baystate Medical CenterTufts University School of MedicineSpringfieldUSA
  8. 8.Group Health Family Medicine ResidencyUniversity of Washington School of MedicineSeattleUSA
  9. 9.Yale University School of MedicineNew HavenUSA

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