Unmasking a Vulnerable Patient Care Process: A Qualitative Study Describing the Current State of Resident Continuity Clinic in a Nationwide Cohort of Internal Medicine Residency Programs



      Residents serve as access points to the health care system for the most vulnerable patients in the United States. Two large academic medical centers have identified performance gaps between resident and faculty physicians. Our intent in this study was to measure the scope of resident-faculty performance gaps in a nationwide sample and identify potential targets for intervention.


      This is a qualitative study of 12 residency programs representing 4 out of 5 US regions. Main measures include perceptions of population health performance in resident versus faculty populations, description of precepting model employed, perceptions of differences between resident and faculty patients, and handoff processes at the time of graduation.


      Of the 8 programs that routinely compare resident and faculty performance, half had confirmed the presence of outcome disparities on routine population health metrics. Seven out of 12 programs employ a 1:1 preceptor:resident comanagement structure. Ten of the 12 programs perceived that resident panels were more psychosocially complex; 2 had a formal process to measure this. Four of the 12 programs had a process to monitor patient loss to follow-up after resident transition.


      Resident-faculty performance disparities may be a widespread problem nationally. Potential targets for intervention include increased preceptor engagement, improving access for empanelment in the faculty practice for vulnerable patient populations, and employing more robust handoff practices. Integrating a culture of quality improvement to continuously monitor important educational metrics such as outcome disparities, panel demographics, educational continuity, and patient loss in the resident panel should be a routine practice for academic health centers.


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        • Essien UR
        • He W
        • Ray A
        • et al.
        Disparities in quality of primary care by resident and staff physicians: is there a conflict between training and equity?.
        J Gen Intern Med. 2019; 34: 1184-1191
        • Amat M
        • Glassman R
        • Basu N
        • et al.
        Defining the resident continuity clinic panel along patient outcomes: a health equity opportunity.
        J Gen Intern Med. 2021; 36: 2615-2621
        • 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: 497-503
        • Scheid D
        • Logue E
        • Gilchrist VJ
        • et al.
        Do we practice what we preach? Comparing the patients of faculty and residents.
        Fam Med. 1995; 27: 519-524
        • 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: 1193-1197
        • Bodenheimer T
        • Gupta R
        • Dube K
        • et al.
        High-functioning primary care residency clinics, building blocks for providing excellent care and training.
        UCSF Center for Excellence in Primary Care & AAMC, Washington, DC2016
        • Gupta R
        • Dubé K
        • Bodenheimer T
        The road to excellence for primary care resident teaching clinics.
        Acad Med. 2016; 91: 458-461
        • Bates CK
        • Yang J
        • Huang G
        • et al.
        Separating residents' inpatient and outpatient responsibilities: improving patient safety, learning environments, and relationships with continuity patients.
        Acad Med. 2016; 91: 60-64
        • Young JQ
        • Wachter RM.
        Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.
        JAMA. 2009; 302: 1327-1329
        • Pincavage AT
        • Ratner S
        • Prochaska ML
        • et al.
        Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs.
        J Gen Intern Med. 2012; 27: 1438-1444
        • Caines LC
        • Brockmeyer DM
        • Tess AV
        • Kim H
        • Kriegel G
        • Bates CK.
        The revolving door of resident continuity practice: identifying gaps in transitions of care.
        J Gen Intern Med. 2011; 26: 995-998