An Analysis of Trainee Status of the Primary Care Physician and Ambulatory Care Outcomes.

PURPOSE: Prior studies report disparities in outcomes for patients cared for by trainees versus faculty physicians at academic medical centers. This study examined the effect of having a trainee as the primary care physician versus a faculty member on routine population health outcomes after adjusting for differences in social determinants of health and primary care retention. METHOD: This cohort study assessed 38,404 patients receiving primary care at an academic hospital-affiliated practice by 60 faculty and 110 internal medicine trainees during academic year 2019. The effect of primary care practitioner trainee status on routine ambulatory care metrics was modeled using log-binomial regression with generalized estimating equation methods to account for physician-level clustering. Risk estimates before and after adjusting for social determinants of health and loss to follow-up are presented. RESULTS: Trainee and faculty cohorts had similar distributions of acute illness burden; however, patients in the trainee cohort were significantly more likely to identify as a race other than White (2,476 [52.6%] vs 14,785 [38.5%], P < .001), live in a zip code associated with poverty (1,688 [35.9%] vs 9,122 [23.8%], P < .001), use public health insurance (1,021 [21.7%] vs 6,108 [15.9%], P < .001), and have limited English proficiency (1,415 [30.1%] vs 5,203 [13.6%], P < .001). In adjusted analyses, trainee status of primary care physician was not associated with lack of breast cancer screening but was associated with missed opportunities to screen for colorectal cancer (relative risk [RR], 0.77; 95% confidence interval [CI], 0.68-0.88), control type 2 diabetes mellitus (RR, 0.78; 95% CI, 0.64-0.94), and control hypertension (RR, 0.80; 95% CI, 0.69-0.94). CONCLUSIONS: Primary care physician trainee status was associated with poorer quality of care in the ambulatory setting after adjusting for differences in socioeconomic factors and loss to follow-up, highlighting a potential ambulatory training gap.

Unmasking a Vulnerable Patient Care Process: A Qualitative Study Describing the Current State of Resident Continuity Clinic in a Nationwide Cohort of Internal Medicine Residency Programs.

BACKGROUND: Residents serve as access points to the health care system for the most vulnerable patients in the United States. Two large academic medical centers have identified performance gaps between resident and faculty physicians. Our intent in this study was to measure the scope of resident-faculty performance gaps in a nationwide sample and identify potential targets for intervention. METHODS: This is a qualitative study of 12 residency programs representing 4 out of 5 US regions. Main measures include perceptions of population health performance in resident versus faculty populations, description of precepting model employed, perceptions of differences between resident and faculty patients, and handoff processes at the time of graduation. RESULTS: Of the 8 programs that routinely compare resident and faculty performance, half had confirmed the presence of outcome disparities on routine population health metrics. Seven out of 12 programs employ a 1:1 preceptor:resident comanagement structure. Ten of the 12 programs perceived that resident panels were more psychosocially complex; 2 had a formal process to measure this. Four of the 12 programs had a process to monitor patient loss to follow-up after resident transition. CONCLUSIONS: Resident-faculty performance disparities may be a widespread problem nationally. Potential targets for intervention include increased preceptor engagement, improving access for empanelment in the faculty practice for vulnerable patient populations, and employing more robust handoff practices. Integrating a culture of quality improvement to continuously monitor important educational metrics such as outcome disparities, panel demographics, educational continuity, and patient loss in the resident panel should be a routine practice for academic health centers.