Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?

J Gen Intern Med. 2019 Jul;34(7):1184-1191. doi: 10.1007/s11606-019-04960-5. Epub 2019 Apr 8.


Background: Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers.

Objective: To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs.

Design: A retrospective cohort study with a propensity-matched analysis.

Participants: 143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center.

Main measures: Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience.

Key results: At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI 0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses.

Conclusion: After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed.

Keywords: medical education; primary care; quality; racial and ethnic disparities; resident.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Cohort Studies
  • Female
  • Health Equity / standards*
  • Humans
  • Internship and Residency / methods
  • Internship and Residency / standards*
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Patient Reported Outcome Measures*
  • Physicians, Primary Care / standards*
  • Primary Health Care / methods
  • Primary Health Care / standards*
  • Quality of Health Care / standards*
  • Retrospective Studies