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Some older physicians have been known to be, shall we say, change-resistant. Chances are some of the operational practices they learned fresh out of medical school are what they're still using today. Who needs electronic medical records when you've got 5x7 note cards, a unique flair for penmanship, and a sturdy manila folder?

The problem is that the way medical care is delivered has to change quickly to adapt both to a shortage of physicians and an aging and chronically sicker demographic. This is particularly true in rural America.

A big catalyst for changing healthcare delivery in the future will be in the hands of the residents being trained today. Understanding the difficulty of teaching old docs new tricks, the University of Kansas School of Medicine has opened a new medical home program at its Smoky Hills Family Medicine Residency Program in Salina, 90 miles north of Wichita. The hope is that three years of residency under a medical home model will ingrain lessons that include the proactive coordinated care for chronic illnesses, with patients taking a role in their treatment plan; managing staff, building teams, and delegating responsibilities within the doctor's office; and cultivating technophilia, especially for electronic medical records and other areas of health information technology and linkage.

"The adoption of the medical home model at the residency level is particularly important because the office practices physicians learn in residency—good or bad—tend to translate into their 'real life' practice upon graduation," says Rick Kellerman, MD, professor and chair of the Department of Family and Community Medicine at the KU School of Medicine-Wichita.

"We're integrating all of the different components of the medical home. There are a lot of different practices that do certain elements, but to put them all together has never been done," he says.

The Smoky Hill medical home will steer 12 family practice residents—four residents per annual class—away from the traditional mindset of providing acute care and toward proactive management of chronic illnesses. "One of the big pushes in the medical home concept is not just waiting until the patient shows up in the office, but to identify those who are at risk or out of control and reaching out to them," says Terry McGeeney, MD, president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians, which is coordinating Smoky Hill's move toward the medical home model. "That is a very different model from what most of us have trained in, where we wait for the patients to show up with a problem and you take care of them and then wait until they show up the next time."

Smoky Hill residency teaches the young doctors to avoid micromanaging and encourages delegating responsibility to staff, which is crucial to the success of the medical home. McGeeney says a competent physician assistant can increase per-physician capacity by at least 20 patients a day, but only under a team concept. If the physician is checking temperatures and blood pressure and doing the paperwork instead of delegating to a physician assistant or an office administrator, that reduces the number of patients who can be seen, reduces patients' face time with their physician, and defeats the purpose of the medical home.

"When I trained in the '70s it was more 'captain of the ship' mentality," McGeeney says. "Now we need physicians to be more comfortable working with nurse practitioners and physician assistants and allowing them to do what they go to school for. We're urging physicians to practice in an environment where the patients participate in the decisions, so you work with patients and not just talk at them."

McGeeney and Kellerman carry a missionary's zeal for medical homes, particularly in the age of medical subspecialties, where the product of medical schools isn't meeting the needs of the greater society. "It's probably healthcare in America's only hope at this point," McGeeney says. "I do strongly believe the healthcare system in this country needs a strong primary care base. We know specialty care by itself is costly and fragmented and we absolutely need it but one of the big concepts of medical home is somebody coordinating the care."

Kellerman says he believes the medical home is here to stay because it's the only model that addresses the pressures facing healthcare delivery now and in the foreseeable future, particularly access. "In 20 years we are going to look at the way we've been treating patients now and we are going to disbelieve that we did it this way," he says. "No EMR, no registries, no emphasis on taking care of chronic illness and preventive care, with group visits and working as a team. I don't think it's going to be a flash in the pan."