UC Berkeley

Despite calls to improve Graduate Medical Education (GME), little is known about the organizational factors influencing training design, resident learning, and assessment. This dissertation examines the organizational behavior factors in primary care GME associated with time spent training in ambulatory care, resident clinical competency learning rates, and quality of care. Linked databases from medical education accreditors and policymakers, population health sources, federal cost reports, and an integrated health system were analyzed to investigate the extent to which primary care GME’s competing internal and external organizational factors influence the professional training environment and performance of primary care residents. Key findings include: 1. Experience in ambulatory care for residents varies among their ACGME-accredited programs, with more time in ambulatory care settings most strongly associated with additional faculty, receipt of federal Teaching Health Center GME funding, and accreditation warnings; 2. Improved resident learning rates in the Accreditation Council for GME (ACGME) Milestones for family medicine and internal medicine programs were more associated with external factors than internal factors. Patient care, practice-based learning and improvement, and systems-based practice learning rates were dependent on the program’s geographic setting, organizational structural characteristics, and the type of resident learning experiences; and 3. Healthcare Effectiveness Data and Information Set (HEDIS) measure reliability in ambulatory care for residents varies among ACGME-accredited primary care residency programs with potential opportunities to utilize publicly reported quality data for GME programs. Overall, these empirical studies help clarify the organizational and associated environmental factors influencing training design, resident learning, and performance in order to assist policymakers in understanding the fragmented GME learning environment and move GME toward improved accountability. As trainee experiences may have a downstream impact on patient care, the systematic study on primary care GME organizations helps improve the design of the resident learning environment and training the future primary care workforce, especially in ambulatory care, the most common delivery setting for primary care health services today.