Despite medical advances and improved access to care over the last several decades, overwhelming ethnic and racial disparities in healthcare persist. The persistence of healthcare disparities demands attention and has prompted widespread efforts to address inequities in care. Unfortunately, these gaps are likely to widen further in the setting of a dwindling primary care physician (PCP) workforce and the rise of subscription-based primary care services; both are often inaccessible for those at the greatest risk of adverse health outcomes. A recent article in the Journal of General Internal Medicine reveals another disheartening blow to health equity in America1: patients of resident primary care clinics may receive a lower quality of care compared to similar patients of faculty physicians. We sought to identify disparate health outcomes across racial groups in our own Internal Medicine resident clinic when compared to our faculty practice.
Early studies of the quality of care delivered through resident clinics when compared to faculty clinics were promising2; however, Essien, et al,1 show that resident patients were less likely to achieve chronic disease management goals or meet quality metrics for cancer screening when compared to faculty patients.
We similarly investigated the effect of resident versus faculty physician type on chronic disease control at our academic-affiliated primary care practice located in the Southeast. This was done in the context of a larger evaluation of Patient Centered Medical Home (PCMH) certification’s effect on blood pressure (BP) control rates over time, with a focus on racial disparities. A previous analysis from our group revealed that while non-White patients started with a higher BP, all racial groups achieved similar BP reduction over time.3 Based on those results, we hypothesized that there would be no difference in degree of BP reduction between resident and faculty physicians or patient race.
Our inception cohort included 1,702 patients with baseline quarterly systolic BP (SBP)≥140mmHg (63% Black, 36% White, 1% Asian or other based on self-report and electronic medical record (EMR) data) and served as their own historical controls. For this analysis, individuals identifying as Black, Asian, or other were grouped into a “non-White” group. Notably, within the inception cohort, most patients of resident physicians were non-White (87%) while the majority of faculty patients were White (62%). Mean SBP was calculated for the cohort on a quarterly basis in longitudinal fashion, averaging all recorded BPs during each quarter.
When we examined the association of physician group (resident or faculty) on BP reduction with subgroup analyses according to patient race, we discovered similar findings to Essien, et al,1; yet, the results were more pronounced. First, there were notable differences in patient distribution:
- 82% of resident patients were non-White in our clinic versus 37.7% in the work by Essien, et al.
- 62% of faculty patients were White in our clinic versus 78.4% in the work by Essien, et al.
Second, we found statistically significant differences in the mean SBP reduction between the two physician groups and between the two racial groups even within each physician group:
- White patients of resident physicians sustained a significantly greater SBP reduction than their non-White peers, also treated by resident physicians (p=0.0129).
- Non-White patients experienced a greater SBP reduction if cared for by a faculty physician rather than a resident physician (p=0.0477).
Overall, this points to differential improvement in chronic disease control for patients of varying racial groups despite being managed by the same physician group.
Several factors may contribute to variability in chronic disease control among resident and faculty clinics: Variability in skills, disruption in continuity, complexity of residency continuity schedules, and resident patient-panel characteristics (containing higher proportion of underserved and complex patients) may contribute to the difference in care quality.1 Weppner, et al,4 further emphasize the role of continuity in care delivery as it relates to interpretation of value-based metrics. This is of particular concern as resident physicians are more likely than staff physicians to care for minority and publicly funded patients.2
The Role of Health Systems in Pursuit of Equitable Care
Our work suggests that disparities in chronic disease control persist and may be more pronounced in resident physician clinics. These inequities have complex origins and perpetuating factors. Previously published literature has suggested that implicit bias, therapeutic inertia, and unseen social and economic barriers all play a role. With this in mind, we must also recognize the role of systemic racism.
Like many clinics across the country, our faculty clinic was designed to promote financial sustainability through preferential selection of insured patients. An unintended consequence is the creation of resident ambulatory clinics as the primary resource for the medically complicated, underinsured, and socially vulnerable patients. The contrast in patient population seen in our clinic, in comparison to milder differences seen by Essien’s group, may be further exacerbated by lack of uniform Medicaid service coverage or expansion in our state. Reimbursement considerations will likely continue to impact the partitioning of patient populations among faculty and resident clinics.
Consequences of our current healthcare structure expand also to future generations of patients. The higher density of medical and social challenges in the resident clinic population may lead to higher levels of primary care burnout, deter residents from choosing primary care, and further compound the issue of primary care workforce shortage.5 Additionally, continued failure to meet quality metrics or disease control can lead to decreased attention and discouragement in treating chronic conditions, threatening the quality of care that already-vulnerable patients receive. Our current healthcare structure jeopardizes health equity not only through direct impact on patients but also through downstream consequences on our trainee and primary care workforce.
Risk of Perpetuation of Healthcare Disparities and Call to Action
We must pay attention to these alarming trends and appreciate the role that health policy has played in creating and perpetuating these disparities in our internal medicine residency clinics. As the U.S. healthcare system evolves, incentives for high value care may mitigate some of the effects of a fee-for-service arrangement. Together, we must address these systemic influences and fight for our patients and our future primary care workforce.