Journal of General Internal Medicine

, Volume 25, Issue 11, pp 1193–1197 | Cite as

Quality of US Primary Care Delivered by Resident and Staff Physicians

Original Research



Few population-based data are available on the quality of outpatient care provided by resident physicians in the US.


To assess the quality of outpatient care delivered by resident and staff physicians.


Cross-sectional analysis. We used chi-square tests to compare resident and staff physician performance on 19 quality indicators. Using multivariable logistic regression, we controlled for sex, age, race/ethnicity, insurance, and metropolitan status.


33,900 hospital-based outpatient visits from the 1997-2004 National Hospital Ambulatory Medical Care Survey (NHAMCS).


Resident and staff physician performance on 19 quality indicators.


Resident physicians were more likely to care for younger, non-white, female, urban, and Medicaid-insured patients. In both adjusted and unadjusted analyses, residents outperformed staff on four of 19 measures including angiotensin converting enzyme inhibitor use for congestive heart failure (57.0% vs. 27.6%; p = <0.001), diuretic use for hypertension (57.8% vs. 44.0%; p = <0.001), statin use for hyperlipidemia (56.3% vs. 40.4%; p = 0.001), and routine blood pressure screening (85.3% vs. 79.6%; p = 0.02). Residents and staff performed at similar levels for counseling (range 15.7 to 32.0%). Residents and staff performed similarly well on measures capturing inappropriate prescribing or overuse of diagnostic testing (range 48.6 to 100%). Residents and staff performed similarly on measures of appropriate prescribing (range from 30.9% to 69.2%).


Primary care provided by resident physicians is of similar or higher quality than that provided by staff physicians. Significant opportunity remains to improve quality of outpatient care provided by all physicians. Residency training programs should devote attention to improving outpatient quality of care delivered by residents.


resident quality of care primary care 



angiotensin converting enzyme


beta blocker


coronary artery disease


complete blood count


chronic heart failure






inhaled corticosteroid


trimethoprim sulfamethoxazole


upper respiratory tract infection


urinary tract infection



We thank Dr Stephanie Woolhandler for her editorial comments, and Meredith Manze for her assistance with manuscript preparation.

Conflict of Interest

There are no financial conflicts of interest for any of the authors.


  1. 1.
    McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.CrossRefPubMedGoogle Scholar
  2. 2.
  3. 3.
    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.CrossRefPubMedGoogle Scholar
  4. 4.
    Serwint JR, Thoma KA, Dabrow SM, et al. Comparing patients seen in pediatric resident continuity clinics and national ambulatory medical care survey practices: a study from the continuity research network. Pediatrics. 2006;118(3):e849–858.CrossRefPubMedGoogle Scholar
  5. 5.
    Kupersmith J. Quality of care in teaching hospitals: a literature review. Acad Med. 2005;80(5):458–66.CrossRefPubMedGoogle Scholar
  6. 6.
    Ayanian JZ, Weissman JS. Teaching hospitals and quality of care: a review of the literature. Milbank Q. 2002;80(3):569–93. v.CrossRefPubMedGoogle Scholar
  7. 7.
    Mladenovic J, Shea JA, Duffy FD, Lynn LA, Holmboe ES, Lipner RS. Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. J Gen Intern Med. 2008;23(7):914–20.CrossRefPubMedGoogle Scholar
  8. 8.
    Roumie CL, Halasa NB, Edwards KM, Zhu Y, Dittus RS, Griffin MR. Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians. Am J Med. 2005;118(6):641–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Tsui JI, Dodson K, Jacobson TA. Cardiovascular disease prevention counseling in residency: resident and attending physician attitudes and practices. J Natl Med Assoc. 2004;96(8):1080–3. 1088-1091.PubMedGoogle Scholar
  10. 10.
    Ma J, Stafford RS. Quality of US outpatient care: temporal changes and racial/ethnic disparities. Arch Intern Med. 2005;165(12):1354–61.CrossRefPubMedGoogle Scholar
  11. 11.
    Hurtado MPSE, Corrigan JM. Committee on the National Quality Report on Health Care Delivery, Board on Health Care Services. Envisioning the National Health Care Quality Report. Washington: National Academy Press; 2001.Google Scholar
  12. 12.
    CDC. Accessed 7/6/10.
  13. 13.
    Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006;354(11):1147–56.CrossRefPubMedGoogle Scholar
  14. 14.
    Zaslavsky AM, Hochheimer JN, Schneider EC, et al. Impact of sociodemographic case mix on the HEDIS measures of health plan quality. Med Care. 2000;38(10):981–92.CrossRefPubMedGoogle Scholar
  15. 15.
    Ma J, Stafford RS. Screening, treatment, and control of hypertension in US private physician offices, 2003-2004. Hypertension. 2008;51(5):1275–81.CrossRefPubMedGoogle Scholar
  16. 16.
    Ma J, Xiao L, Stafford RS. Adult obesity and office-based quality of care in the United States. Obesity. 2009;17(5):1077–85.CrossRefPubMedGoogle Scholar
  17. 17.
    Ma J, Sehgal NL, Ayanian JZ, Stafford RS. National trends in statin use by coronary heart disease risk category. PLoS Med. 2005;2(5):e123.CrossRefPubMedGoogle Scholar
  18. 18.
    Stafford RS, Monti V, Ma J. Underutilization of aspirin persists in US ambulatory care for the secondary and primary prevention of cardiovascular disease. PLoS Med. 2005;2(12):e353.CrossRefPubMedGoogle Scholar
  19. 19.
    Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q. 1998;76(4):517–63. 509.CrossRefPubMedGoogle Scholar
  20. 20.
    Gilchrist VJ, Stange KC, Flocke SA, McCord G, Bourguet CC. A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits. Med Care. 2004;42(3):276–80.CrossRefPubMedGoogle Scholar
  21. 21.
    Bergeson SC, Dean JD. A systems approach to patient-centered care. Jama. 2006;296(23):2848–51.CrossRefPubMedGoogle Scholar
  22. 22.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20(6):64–78.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  • Leah Zallman
    • 1
  • Jun Ma
    • 2
  • Lan Xiao
    • 2
  • Karen E. Lasser
    • 3
  1. 1.Department of Medicine, Cambridge Health Alliance and Harvard Medical SchoolCambridgeUSA
  2. 2.Palo Alto Medical Foundation Research InstitutePalo AltoUSA
  3. 3.Section of General Internal MedicineBoston Medical CenterBostonUSA

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