ECPC

Practice Patterns Among Early-Career Primary Care (ECPC) Physicians and Workforce Planning Implications: A Mixed Methods Study

Funded by:

Context

Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians. There is speculation that primary care physicians, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine. Prior to this study there was little evidence to support or refute this.

Objectives

This project used quantitative data routinely collected as part of health care delivery in British Columbia, Manitoba, Ontario, and Nova Scotia and qualitative interviews with doctors in British Columbia, Ontario, and Nova Scotia to inform primary care planning by:

Comparing practice patterns of early-career and established primary care physicians to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of physicians), or period effects (changes over time across all physicians) (quantitative).
Identifying values and preferences shaping the practice intentions and choices of family medicine residents and early-career primary care physicians (qualitative).
Integrating findings to understand implications for policy (mixed methods).

What we found

Changes in practice patterns are not unique to physicians early in practice.

Service volume and comprehensiveness are declining across all years in practice and genders.
Changes may reflect increasing complexity of care, administrative burden, or different choices about work across all family physicians.
Intergenerational blame distracts from broader issues in primary care practice. Feelings of blame are particularly damaging when layered with the fact that family medicine is already felt to be undervalued.

Early-career physicians are committed to providing care that meets community needs, but practice and payment models must be aligned to support this.

Many participants describe training to provide team-based comprehensive care but report limited opportunities to practice in this way.
Some physicians are choosing to address system and community needs through focused practice.
This points to changes needed in primary care systems, not gaps in family medicine training.

Primary care workforce planning needs to incorporate information about changing practice patterns and physician demographics.

Planning needs to consider the range of important roles family medicine physicians play in health care delivery.
Even with an increasing per-capita supply of family medicine physicians, additional human and administrative resources will be needed to ensure all patients can access comprehensive primary care, particularly as the physician workforce ages.

Team Members

Nominated Principal Investigator: Ruth Lavergne

Co-Principal Investigators: Emily Gard Marshall, David Rudoler, Agnes Grudniewicz, Laurie Goldsmith

Co-Investigators and Collaborators: Adrian MacKenzie, Alan Katz, Ali Coates, Carole Taylor, Catherine Moravac, David Snadden, David Stock, Doug Blackie, Ellen Randall, Fred Burge, Gail Tomblin Murphy, Goldis Mitra, Ian Scott, Jacalynne Hernandez-Lee, Kath Stringer, Kathleen Horrey, Kimberlyn McGrail, Lindsay Hedden, Lori Jones, Margaret Jamieson, Maria Mathews, Monisha Kabir, Rick Glazier, Rita McCracken, Sabrina Wong, Sandra Peterson, Tara Kiran, Tara Sampalli

Contact: ruth.lavergne@dal.ca

Papers & Preprints

Changing practice patterns

Lavergne, M.R., Rudoler, D., Peterson, S., Stock, D., Taylor, C., Wilton, D., Wong, S., Scott, I., McGrail, K., McCracken, R., Marshall, E., MacKenzie, A., Katz, A., Jamieson, M., Hedden, L., Grudniewicz, A., Goldsmith, L., Glazier, R., Burge, F. & Blackie, D. (2023). Declining comprehensiveness of services delivered by Canadian family physicians is not driven by early-career physicians. Annals of Family Medicine, 21(2), 151-156.

Comprehensiveness is declining among family physicians in Canada, but declines are no greater among physicians within their first 10 years of practice.
Efforts to enhance or maintain comprehensiveness of care delivered by family physicians should address the service delivery contexts in which all physicians are practicing, rather than interventions in training or early practice.

Lavergne, M. R., Rudoler, D., Peterson, S., Stock, D., Taylor, C., Wilton, A. S., Wong, S. T., Scott, I., McGrail, K. M., McCracken, R. K., Marshall, E. G., MacKenzie, A., Katz, A., Jamieson, M., Hedden, L., Grudniewicz, A., Goldsmith, L. J., Glazier, R. H., Burge, F., & Blackie, D. (2023). Changes in comprehensiveness of services delivered by Canadian family physicians: Analysis of population-based linked data in 4 provinces. Canadian family physician Medecin de famille canadien, 69(8), 550–556.

We observe that comprehensiveness, defined as number of service settings and service areas (that could be part of office-based practice), is declining among family physicians in all provinces studied (British Columbia, Manitoba, Ontario, and Nova Scotia). Declines were greater for settings than for service areas.
Changes in comprehensiveness were observed across all physician characteristics, but on average, were greater among physicians in practice 20 years or longer, male physicians, and physicians practising in urban areas.
That declining comprehensiveness was observed across all physician characteristics points to changes in the practice and policy contexts in which all family physicians work, not to gaps in training among more recent cohorts.

Lavergne, R., Peterson, S., Rudoler, D., Scott, I., Mccracken, R., Mitra, G., & Katz, A. (2023). Productivity Decline or Administrative Avalanche? Examining Factors That Shape Changing Workloads in Primary Care. Healthcare policy/Politiques de sante, 19(1), 114–129.

Findings suggest that population aging and increased complexity of care are contributing to increased coordination workload per patient visit among family physicians providing care in community-based settings.
At the same time, a larger proportion of family physicians are providing care outside of community-based settings and patient visits per family physician are falling.
Efforts to improve efficiency of coordination work, sometimes described as administrative workload, may increase supply of community-based primary care.

Rudoler, D., Peterson, S., Stock, D., Taylor, C., Wilton, D., Blackie, D., Burge, F., Glazier, R., Goldsmith, L., Grudniewicz, A., Hedden, L., Jamieson, M., Katz, A., MacKenzie, A., Marshall, E., McCracken, R., McGrail, K., Scott, I., Wong, S., & Lavergne, M. R. (2022). Changes over time in patient visits and continuity of care among graduating cohorts of family physicians in 4 Canadian provinces. Canadian Medical Association Journal.

Recent cohorts of family physicians practice similarly to predecessors in terms of practice volumes and continuity of care.
Since FPs of all career stages show declining patient contacts, system-wide solutions to recent challenges in the accessibility of primary care in Canada are needed.

Practice intentions and choices

Kabir, M., Randall, E., Mitra, G., Lavergne, M. R., Scott, I., Snadden, D., Jones, L., Goldsmith, L. J., Marshall, E. G., & Grudniewicz, A. (2022). Resident and early-career family physicians’ focused practice choices in Canada: A qualitative study. British Journal of General Practice, 72(718), e334–e341.

Focused practice is viewed by family medicine residents and early-career physicians as a way to circumvent the burnout or exhaustion with comprehensive practice in the current structure of the healthcare system.

Mathews, M., Ryan, D., Randall, E., Marshall, E. G., Goldsmith, L. J., Jones, L., Lavergne, M. R., Snadden, D., Scott, I., Wong, S. T., Stringer, K., Horrey, K., & Grudniewicz, A. (2022). “At the mercy of some of the regulations”: The impact of the residency match and return of service requirement on the early-career decisions of international medical graduates in Canada. Human Resources for Health, 20(1), 15.

Return of service agreements can restrict career choices and delay international medical graduates from their preferred scope of practice and location.

Marshall, E.G., Horrey, K., Moritz, L.R., Buote, R., Grudniewicz, A., Goldsmith, L., Randall, E., Jones, L., & Lavergne, M.R. (2022). Influences on intentions for obstetric practice among family physicians and residents in Canada: an explorative qualitative inquiry. BMC Pregnancy and Childbirth, 22, 857.

Our results demonstrate that the decision to provide obstetric care is not influenced solely by individual factors.
Family physicians’ choices to provide or not provide obstetric care are also influenced by community needs, organizational factors, and public policy.
Policymakers who want to encourage obstetric practice by family physicians should consider public policy, community, organizational, interpersonal, and individual levels of intervention.

Mitra, G., Grudniewicz, A., Lavergne, M. R., Fernandez, R., & Scott, I. (2021). Alternative payment models: A path forward. Canadian Family Physician, 67(11), 805–807.

The availability of remuneration models is an important factor shaping the practice choices of early career physicians.
In areas of the country where fee-for-service was the only payment option, some family physicians were deterred from practising comprehensive family medicine.

Lavergne, M.R., Scott, I., Mitra, G., Snadden, D., Blackie, D., Goldsmith, L., Rudoler, D., Hedden, L., Grudniewicz, A., Ahuja, M., and Marshall, E.G. (2019). Regional Differences in Where and How Family Medicine Residents Intend to Practise: A Cross-sectional Survey Analysis. CMAJ Open, 7(1), E124-E130.

Across Canada, two-thirds of family medicine reported it was somewhat or highly likely they would commit to providing comprehensive care to the same group of patients in their first three years of practice.
Over 80% of family medicine residents indicated they intended to practise in a team-based model.

Lavergne M.R., Gonzalez Patterson A., Ahuja M.A., Hedden L., McCracken R. (2019). The relationship between gender, parenthood and practice intentions among Family Medicine residents: Cross-sectional analysis of national Canadian survey data. Human Resources for Health, 17(1), 67.

Family medicine residents who are parents and who are women are more likely to report intentions to provide comprehensive care soon after entering practice
Supporting family medicine residents who are parents may positively impact the quality and availability of primary care services

Primary care policy context

Grudniewicz, A., Randall, E., Lavergne, M.R. et al. (2023). Factors influencing practice choices of early-career family physicians in Canada: a qualitative interview study. Human Resources for Health 21, 84.

We identified four practice choices by early-career physicians: 1) scope , 2) type and model, 3) location, and 4) schedule and work volume.
Practice choices were found to be influenced by three key categories of factors: 1) Training factors; 2) Professional factors; and 3) Personal factors.
Early-career physicians' decisions regarding their practice are subject to the influence of multiple interconnected factors, some of which can be addressed through policy interventions (e.g., regulations) while others are more entrenched (e.g., family obligations).

McKay M., Lavergne, M.R., Prince Lea, A., Le, M., Grudniewicz, A., Blackie, D., Goldsmith, L.J., Matthews, M., McCracken, R., McGrail, K., Wong, S., Rudoler, D. (2022). Government policies targeting primary care physician practice from 1998-2018 in three Canadian provinces: A jurisdictional scan. Health Policy, 126(6), 565-575.

Policy reforms across the three provinces (British Columbia, Ontario and Nova Scotia) were driven by physician payment.
Practice patterns of primary care physicians are changing—so too should the policies that may shape their practice choices.

Lavergne M.R., Bodner A., Peterson S., Wiedmeyer M., Rudoler D., Spencer S., Marshall E.G. (2022). Do changes in primary care service use over time differ by neighbourhood income? Population-based longitudinal study in British Columbia, Canada. International Journal for Equity in Health, 21:80

Equity in access to primary care is deteriorating.
Reforms to primary care that fail to attend to the multidimensional needs of low-income communities may entrench existing inequities.

Study Protocol

Lavergne M.R., Goldsmith, L.J., Grudniewicz, A., Rudoler, D., Marshall, E.G., Ahuja, M., Blackie, D,. Burge, F., Gibson, R., Glazier, R.H., Hawrylyshyn, S., Hedden L., Hernandez-Lee, J., Horrey, K., Joyce, M., Kiran, T., MacKenzie, A., Mathews, M., McCracken, R., McGrail ,K., McKay, M., McPherson, C., Mitra, G., Sampalli, T., Scott, I., Snadden, D., Tomblyn Murphy, G., Wong, S. (2019). Practice patterns among early-career primary care (ECPC) physicians and workforce planning implications: protocol for a mixed methods study. BMJ Open, 9(9), e030477.

Recorded Presentations

Lavergne, M.R. Working hard or hardly working? Fact-checking narratives of changing practice patterns and productivity in primary care. Canadian Association for Health Services and Policy Research Primary Care Theme Group Webinar. April 21, 2022.

Lavergne, M.R. Talking ’bout my generation: Practice patterns among early-career family physicians and implications for primary care policy and workforce planning. BRIC NS Primary Health Care Learning Series. February 9, 2022.

Marshall, E.G. The kids are alright: Influences on the intentions for obstetric practice among family physicians and residents in Canada. BRIC NS Primary Health Care Learning Series. February 9, 2022.