4/9/2019
PITTSBURGH – Patients who receive primary care from a resident physician were more likely to be from underserved populations and less likely to meet benchmark chronic disease and preventive screening outcomes compared to patients who receive primary care from staff physicians, according to a new study published online today in the Journal of General Internal Medicine.
First author Utibe R. Essien, M.D., M.P.H., assistant professor in the University of Pittsburgh Division of General Internal Medicine, retrospectively analyzed more than 143,000 patients from 16 outpatient primary care clinics affiliated with Massachusetts General Hospital to better understand potential differences in the quality of care patients receive at academic medical centers when they are seen by a resident, who is still in training, or a staff physician who has completed his or her education.
“As internal medicine residents pursue their training, providing outpatient primary care is critical to their overall education,” said Essien, who conducted this research during his fellowship at Mass General. “These findings are not meant to discourage patients from seeking care from residents, but rather to identify areas to improve upon in their training and to address disparities that are unintentionally impacting the care patients receive.”
To assess quality of care, Essien and his team analyzed control of cholesterol (LDL) in patients with coronary artery disease (CAD) and diabetes, as well as control of blood sugar (HbA1c) in patients with diabetes, and compared their findings against established guideline-based levels for these factors. They also assessed completion of preventive cancer screenings and accounted for differences in socioeconomic factors in their results.
The study found that 60.6% of patients with CAD seen by residents had an LDL screening test performed in the past year compared to 78% of patients seen by staff physicians. When they were screened, fewer patients with CAD who were seen by residents had an LDL at goal. In patients with diabetes, 63.5% of resident patients had undergone an LDL screening test in the previous year compared to 79.1% of staff physician patients, and there was no significant difference in those patients who had their lipids at goal.
Furthermore, 52.6% of resident patients with diabetes had an HbA1c test performed compared to 64.1% of staff physician patients, and when tested, fewer resident patients had an HbA1c at goal. Eligible resident patients also were less likely to have completed preventive breast, cervical or colorectal cancer screening tests.
The researchers found a key contributor to these differences was that residents primarily care for an underserved population, treating lower-income patients, minorities and individuals who do not speak English as their first language.
“Underserved populations are more likely to have unmet health care needs and are disproportionally triaged into the care of a resident physician. This may result in an unintentional negative impact on care and challenges academic medical centers across the country to find a balance between providing exceptional training for our newest physicians while ensuring the high-quality, equitable care patients expect,” said senior author Steven J. Atlas, M.D., M.P.H., of the Division of General Internal Medicine at Mass General. “Primary care is a critical component of the health care system for all patients, and these findings highlight the need to pay more attention to how individuals from underserved populations enter into their care.”
Essien’s participation in this research was funded by the National Institutes of Health National Research Service grant T32 HP10251. Additional authors include Jonathan R. Abraham, M.P.H., Yuchiao Chang, Ph.D., Wei He, M.P.H., Alaka Ray, M.D., and Daniel E. Singer, M.D., all of Massachusetts General Hospital.