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

Kelly L Graham; Elizabeth Norian; Jonathan Li; Maelys Amat; Roger B Davis

doi:10.1097/ACM.0000000000005663

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

Acad Med. 2024 Feb 14. doi: 10.1097/ACM.0000000000005663. Online ahead of print.

Authors

Kelly L Graham¹, Elizabeth Norian², Jonathan Li³, Maelys Amat⁴, Roger B Davis⁵

Affiliations

¹ K.L. Graham is director of ambulatory training and the primary care track for the internal medicine residency program, Department of Medicine, and codirector, Faculty Scholarship for the Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
² E. Norian is associate medical director of the resident continuity clinic, Healthcare Associates, Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
³ J. Li is director of population health management, Healthcare Associates, Division of General Medicine Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
⁴ M. Amat is director of social justice for graduate medical education, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
⁵ R.B. Davis is associate director of biostatistics, Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

PMID: 38358939
DOI: 10.1097/ACM.0000000000005663

Abstract

Purpose: Prior studies report disparities in outcomes for patients cared for by trainees vs faculty physicians at academic medical centers. This study examined the effect of having a trainee as the primary care physician vs 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% 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.