Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession

Abstract

ImportancePhysicians’ knowledge about each other’s quality is central to clinical decision-making, but such information is not well understood and is rarely harnessed to identify exemplars for disseminating best practices or quality improvement. One exception is chief medical resident selection, which is typically based on interpersonal, teaching, and clinical skills.ObjectiveTo compare care for patients of primary care physicians (PCPs) who were former chiefs with care for patients of nonchief PCPs.Design, Setting, and ParticipantsUsing 2010 to 2018 Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data (response rate, 47.6%), Medicare claims for random 20% samples of fee-for-service beneficiaries, and medical board data from 4 large US states, we compared care for patients of former chief PCPs with care for patients of nonchief PCPs in the same practice using linear regression. Data were analyzed from August 2020 to January 2023.ExposuresReceiving the plurality of primary care office visits from a former chief PCP.Main Outcomes and MeasuresComposite of 12 patient experience items as primary outcome and 4 spending and utilization measures as secondary outcomes.ResultsThe CAHPS samples included 4493 patients with former chief PCPs and 41 278 patients with nonchief PCPs. The 2 groups were similar in age (mean [SD], 73.1 [10.3] years vs 73.2 [10.3] years), sex (56.8% vs 56.8% female), race and ethnicity (1.2% vs 1.0% American Indian or Alaska Native, 1.3% vs 1.9% Asian or Pacific Islander, 4.8% vs. 5.6% Hispanic, 7.3% vs 6.6% non-Hispanic Black, and 81.5% vs. 80.0% non-Hispanic White), and other characteristics. The Medicare claims for random 20% samples included 289 728 patients with former chief PCPs and 2 954 120 patients with nonchief PCPs. Patients of former chief PCPs rated their care experiences significantly better than patients of nonchief PCPs (adjusted difference in composite, 1.6 percentage points; 95% CI, 0.4-2.8; effect size of 0.30 standard deviations (SD) of the physician-level distribution of performance; P = .01), including markedly higher ratings of physician-specific communication and interpersonal skills typically emphasized in chief selection. Differences were large for patients of racial and ethnic minority groups (1.16 SD), dual-eligible patients (0.81 SD), and those with less education (0.44 SD) but did not vary significantly across groups. Differences in spending and utilization were minimal overall.Conclusions and RelevanceIn this study, patients of PCPs who were former chief medical residents reported better care experiences than patients of other PCPs in the same practice, especially for physician-specific items. The study results suggest that the profession possesses information about physician quality, motivating the development and study of strategies for harnessing such information to select and repurpose exemplars for quality improvement.

Chief Residency—More Than Just Teaching and Scheduling—Reply

“…In Reply We agree with Drs Silverstein, Stroud, and Zipursky that a chief residency itself could improve the “ability to communicate, collaborate, and maintain relationships.” We noted in our article that…”

“…In addition to potentially contributing to our patient experience findings, a chief year may also affect practice patterns. As we noted when discussing our utilization results (minimal differences between former chief and nonchief PCPs), chiefs may not be selected based on competency in evidence-based medicine. Another explanation may be that spending a year teaching about rare cases (ie, zebras) with long differential diagnoses may be associated with more aggressive testing later in practice owing to the availability heuristic .…”

“…A chief residency is demanding and has substantial responsibilities, as noted by Drs Silverstein, Stroud, and Zipursky, and chiefs hit the ground running on day 1. If our study findings entirely reflected a treatment effect, we would have to believe that the selection process fails to identify skilled residents or that nonchiefs do not catch up as they practice. Importantly, the counterfactual of a chief residency is likely becoming an attending physician a year earlier, which surely contributes to the physician’s development.…”

Chief Residency—More Than Just Teaching and Scheduling

“…These experiences likely improve chief residents’ ability to communicate, collaborate, and maintain relationships—all of which are germane to excellent patient care. Thus, the skills that the authors described as intrinsic may have been cultivated during the chief resident year.…”

“…To the Editor As 3 former chief medical residents, we read the study by Chen and McWilliams with interest. The analysis studied experiences of patients cared for by primary care practitioners and found that patients of former chief residents expressed greater satisfaction and higher composite scores regarding communication and interpersonal skills.…”