Quality of Outpatient Care With Internal Medicine Residents vs Attending Physicians in Veterans Affairs Primary Care Clinics | Medical Education and Training | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Table 1.  Characteristics of Patients Cared for by Internal Medicine Residents and Attending Physicians in VA Teaching Primary Care Clinics in 10 Medical Centers in 2014
Characteristics of Patients Cared for by Internal Medicine Residents and Attending Physicians in VA Teaching Primary Care Clinics in 10 Medical Centers in 2014
Table 2.  Probability of Patients Cared for by Internal Medicine Residents or Attending Physicians in VA Teaching Primary Care Clinics Meeting Specific Quality Measures or Using Health Care Services in 2014a
Probability of Patients Cared for by Internal Medicine Residents or Attending Physicians in VA Teaching Primary Care Clinics Meeting Specific Quality Measures or Using Health Care Services in 2014a
1.
Reilly  BM.  Don’t learn on me—are teaching hospitals patient-centered?  N Engl J Med. 2014;371(4):293-295. doi:10.1056/NEJMp1405709PubMedGoogle ScholarCrossref
2.
Elixhauser  A, Steiner  C, Harris  DR, Coffey  RM.  Comorbidity measures for use with administrative data.  Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004PubMedGoogle ScholarCrossref
3.
Fick  DM, Semla  TP, Beizer  J,  et al; American Geriatrics Society 2015 Beers Criteria Update Expert Panel.  American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults.  J Am Geriatr Soc. 2015;63(11):2227-2246. doi:10.1111/jgs.13702PubMedGoogle ScholarCrossref
4.
Charlson  ME, Karnik  J, Wong  M, McCulloch  CE, Hollenberg  JP.  Does experience matter? a comparison of the practice of attendings and residents.  J Gen Intern Med. 2005;20(6):497-503. doi:10.1111/j.1525-1497.2005.0085.xPubMedGoogle ScholarCrossref
5.
Zallman  L, Ma  J, Xiao  L, Lasser  KE.  Quality of US primary care delivered by resident and staff physicians.  J Gen Intern Med. 2010;25(11):1193-1197. doi:10.1007/s11606-010-1456-0PubMedGoogle ScholarCrossref
6.
Etz  RS, Gonzalez  MM, Brooks  EM, Stange  KC.  Less and more are needed to assess primary care.  J Am Board Fam Med. 2017;30(1):13-15. doi:10.3122/jabfm.2017.01.160209PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Research Letter
    April 1, 2019

    Quality of Outpatient Care With Internal Medicine Residents vs Attending Physicians in Veterans Affairs Primary Care Clinics

    Author Affiliations
    • 1Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon
    • 2Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
    • 3Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
    • 4Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
    • 5Oregon Health & Science University–Portland State University School of Public Health, Portland
    JAMA Intern Med. 2019;179(5):711-713. doi:10.1001/jamainternmed.2018.8624

    Concerns persist that care provided by resident physicians is of lower quality than that provided by more experienced attending physicians.1 In this study, we compared quality of outpatient care between internal medicine residents and attending physicians in US Department of Veterans Affairs (VA) primary care clinics.

    Methods

    As part of an evaluation of the Centers of Excellence in Primary Care Education, an interprofessional education initiative, we examined 10 geographically diverse VA medical centers with affiliated internal medicine residencies. This work was determined to be a quality improvement activity per Veterans Health Administration policies, with a waiver of informed consent. We identified patients seen in teaching primary care clinics at each site who were assigned to the panel of either a resident physician or attending physician (staff physician who supervised resident’s care) and who had at least 1 primary care visit in calendar year 2014. We collected demographic characteristics, comorbidity,2 and quality of care and health service utilization measures from the VA Corporate Data Warehouse in 2014. Outcomes included measures of diabetes care quality (annual glycated hemoglobin [HbA1c] testing, HbA1c poor control [>9% or unmeasured (to convert HbA1c concentration to a proportion of total hemoglobin, multiply by 0.01)], and annual renal testing [urine microalbumin to creatinine ratio or prescription of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker]), use of a high-risk medication3 in patients older than 65 years, hypertension control (blood pressure <140/90 mm Hg), emergency department visits, and hospitalizations (all-cause hospitalizations and from ambulatory care–sensitive conditions). We selected these measures because they are common primary care measures that we could extract reliably. We compared outcome measures using logistic mixed models adjusted for demographic characteristics, comorbidities, and years under VA care and included site as a random effect to control for site-level effects. We used a 2-sided P < .05 as a significance threshold.

    Results

    Of 76 392 patients, mean (SD) age was 62.3 (15.7) years, 69 677 (90.6%) were male, 55 082 (72.1%) were white, 10 986 (14.4%) were black, 2568 (3.4%) were Hispanic, and 7756 (10.1%) were of another race/ethnicity. We identified 19 324 patients cared for by resident physicians and 57 068 patients cared for by attending physicians in 2014. Residents cared for a greater proportion of younger, female, and black patients (Table 1). Patients of resident physicians had a higher mean comorbidity score (14.1 [16.1] vs 12.5 [15.1] for attending physicians; P < .001), were more commonly diagnosed as having substance use disorders (3656 [18.9%] vs 7797 [13.7%]; P < .001) and depression (4270 of 19 324 [22.1%] vs 10 212 of 57 068 [17.9%]; P < .001), and were under VA care for less time.

    Diabetes quality-of-care measures were similar (Table 2), but patients of residents were more likely to have appropriate renal testing (difference, 3.2 percentage points; P = .001). Patients of residents were less likely to have controlled hypertension (difference, 2.9 percentage points; P = .02), but older patients of residents were less likely to be prescribed high-risk medications (difference, 4.2 percentage points; P < .001). Patients of residents also were slightly more likely to have at least 1 emergency department visit in 2014 (difference, 1.3 percentage points; P < .001).

    Discussion

    Although studies have shown that primary care provided by residents is similar to that provided by attending physicians, earlier studies have been limited to small samples4 and measures based on self-reported data.5 In this large, national study using electronic health record–based measures, we found that residents provide access for new patients and play an important role in caring for vulnerable patient groups with complex care needs.

    Quality-of-care measures were similar between patients of resident physicians and patients of attending physicians, and absolute differences were small. Residents’ better performance on some measures could be a product of training in evidence-based medicine and the use of clinical guidelines, or precepting, and supervision from attending physicians.

    Limitations of this work include the VA-specific context, analysis of only VA data, and use of only 10 sites. In addition, unmeasured differences between patients of resident and attending physicians, such as differences in frailty or behavioral health history, could cause residual confounding and bias our results against clinicians who care for more complex patients.

    Current measures of primary care quality are limited and typically focus on disease-specific process measures and short-term outcomes.6 However, according to these measures, residents appear to be providing near-equivalent care to attending physicians. More investigation is needed to understand how residents perform more complex primary care functions, such as integrating and prioritizing patient needs and delivering coordinated, whole-person, relationship-based care.

    Back to top
    Article Information

    Accepted for Publication: December 18, 2019.

    Corresponding Author: Samuel T. Edwards, MD, MPH, Section of General Internal Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D199), Portland, OR 97239 (samuel.edwards@va.gov).

    Published Online: April 1, 2019. doi:10.1001/jamainternmed.2018.8624

    Author Contributions: Dr Edwards had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Edwards, Hooker, Niederhausen, Tuepker.

    Acquisition, analysis, or interpretation of data: Edwards, Kim, Shull, Hooker, Niederhausen.

    Drafting of the manuscript: Edwards.

    Critical revision of the manuscript for important intellectual content: Kim, Shull, Hooker, Niederhausen, Tuepker.

    Statistical analysis: Edwards, Kim, Hooker, Niederhausen.

    Obtained funding: Edwards, Tuepker.

    Administrative, technical, or material support: Shull, Tuepker.

    Conflict of Interest Disclosures: Dr Edwards reported receiving grants from the US Department of Veterans Affairs during the conduct of the study. No other disclosures were reported.

    Funding/Support: This work was supported by the VA Quality Enhancement Research Initiative and Office of Academic Affiliations’ Interprofessional Learning & Practice Partnered Evaluation Center grant PEC-15-247. Dr Edwards was supported by VA Health Services Research & Development grant CDA 16-152.

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The ideas expressed in this article are solely those of the authors and do not represent any official position of the US Department of Veterans Affairs.

    References
    1.
    Reilly  BM.  Don’t learn on me—are teaching hospitals patient-centered?  N Engl J Med. 2014;371(4):293-295. doi:10.1056/NEJMp1405709PubMedGoogle ScholarCrossref
    2.
    Elixhauser  A, Steiner  C, Harris  DR, Coffey  RM.  Comorbidity measures for use with administrative data.  Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004PubMedGoogle ScholarCrossref
    3.
    Fick  DM, Semla  TP, Beizer  J,  et al; American Geriatrics Society 2015 Beers Criteria Update Expert Panel.  American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults.  J Am Geriatr Soc. 2015;63(11):2227-2246. doi:10.1111/jgs.13702PubMedGoogle ScholarCrossref
    4.
    Charlson  ME, Karnik  J, Wong  M, McCulloch  CE, Hollenberg  JP.  Does experience matter? a comparison of the practice of attendings and residents.  J Gen Intern Med. 2005;20(6):497-503. doi:10.1111/j.1525-1497.2005.0085.xPubMedGoogle ScholarCrossref
    5.
    Zallman  L, Ma  J, Xiao  L, Lasser  KE.  Quality of US primary care delivered by resident and staff physicians.  J Gen Intern Med. 2010;25(11):1193-1197. doi:10.1007/s11606-010-1456-0PubMedGoogle ScholarCrossref
    6.
    Etz  RS, Gonzalez  MM, Brooks  EM, Stange  KC.  Less and more are needed to assess primary care.  J Am Board Fam Med. 2017;30(1):13-15. doi:10.3122/jabfm.2017.01.160209PubMedGoogle ScholarCrossref
    ×