Private equity’s growing footprint in emergency medicine has drawn scrutiny for its effects on staffing, billing and patient care. A new study, published in Jama Network Open Nov. 10, turns to a less examined question: what happens to physician training when faculty work for PE-backed groups.
Researchers from Brown University Health and the Brown University School of Public Health, both in Providence, R.I., analyzed 267 U.S. emergency medicine residency programs with board examination results from 2021 to 2023. The research letter, led by Emily Shearer, MD, compared programs where faculty at any training site were employed by a PE-backed physician group with programs where they were not.
At first glance, the gap is clear. Residents at PE-backed programs passed the American Board of Emergency Medicine’s written qualifying exam at a rate of 81.6%, compared with 89.6% at other programs, a difference of 8 percentage points. Pass rates on the oral certification exam were similar, at 94% and 95.1%.
But the programs themselves look very different. Of the PE-backed programs, 85.7% were community-based, compared with 38.8% of programs without PE ties. About three-quarters, 75.7%, were established after 2015, compared with 25.9%. And just 31.4% were based at level 1 trauma centers, compared with 65.5% of their counterparts.
Once researchers accounted for those differences, along with emergency department volume, most of the gap disappeared. The adjusted written exam pass rate was 87.1% at PE-backed programs and 88.6% at others, a 1.5-percentage-point difference that was not statistically significant. The oral exam difference also fell away.
Program age proved a far stronger signal than ownership. In the adjusted model, programs established after 2015 had written exam pass rates 11.6 percentage points lower than older programs and oral exam pass rates 2.7 points lower, both statistically significant.
The authors wrote that worse board outcomes at PE-backed programs “may be associated with program maturity or other structural features of the clinical environment that impact educational rigor.”
A sensitivity analysis that counted only programs with current PE backing, rather than any history of PE investment, found a slightly wider written exam gap of 3.1 percentage points. That difference also did not reach statistical significance.
The footprint of PE in emergency medicine education is substantial and uneven. Seventy programs, or 26.2%, had faculty employed by PE-backed groups, and those programs trained 17.1% of graduating residents. Exposure was concentrated in the South. In Florida, 70.7% of emergency medicine graduates trained at programs with PE-backed faculty, while 27 states had none.
The researchers noted limitations, including the observational design and “the inadequacy of using board examination outcomes as a proxy for educational quality.” Board pass rates, in other words, capture only one slice of how well a program prepares physicians.
Still, the findings raise a strategic question for health systems and graduate medical education leaders as new residency programs open at community sites, often staffed through outside physician groups. If the structural features of a training site matter more than who employs its faculty, then where programs are built carries as much weight as who backs them.
The authors wrote that “there may be a tension between expanding PE-associated residency programs and ensuring these sites have the clinical features” needed for rigorous training, pointing specifically to patient volume and trauma capabilities.
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