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Can Fam Physician
Vol. 53, No. 2, February 2007, pp.277 - 286
Copyright © 2007 by The College of Family Physicians of Canada
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Research

Rewards and challenges of family practice

Web-based survey using the Delphi method

Donna P. Manca, MD MClSc CCFP FCFP
Dr Manca is an Assistant Professor in the Department of Family Medicine at the University of Alberta in Edmonton and is Clinical Director of the Alberta Family Practice Research Network.

Stanley Varnhagen, MA PhD
Dr Varnhagen is Academic Director of Learning Solutions in the Faculty of Extension at the University of Alberta.

Pamela Brett-MacLean, MA
Ms Brett-MacLean is Co-Director of the Arts and Humanities in Health and Medicine Program of the Faculty of Medicine and Dentistry at the University of Alberta.

G. Michael Allan, MD CCFP
Dr Allan is an Assistant Professor in the Department of Family Medicine at the University of Alberta and a Research Fellow at the Institute of Health Economics.

Olga Szafran, MHSA
Ms Szafran is Research Coordinator in the Department of Family Medicine at the University of Alberta.

Allen Ausford, MD CCFP
Dr Ausford is an Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.

Carol Rowntree, MD CCFP
Dr Rowntree is an Associate Clinical Professor in the Department of Family Medicine at the University of Calgary in Alberta.

Ismael Rumzan, PhD
Dr Rumzan is a researcher at the University of Alberta.

Diana Turner, MD MSc CCFP
Dr Turner is a Clinical Lecturer in the Department of Family Medicine at the University of Calgary

Correspondence to: Dr Donna P. Manca, Grey Nuns Family Medicine Clinic, Cedars Professional Pk, 2927—66 St, Edmonton, AB T6K 4C1; telephone 780 461–3533; fax 780 490–0953; e–mail dmanca{at}planet.eon.net

The 2003 results from the Canadian Resident Matching Service (CaRMS) showed that fewer medical students were selecting family practice as a career.1 Reasons for this include the perception that family practice has a heavy workload and lacks the prestige and earning power of specialty programs.1 Unfortunately, the difficulties of family practice extend beyond low enrolment and are not limited to Canada. In recent years, British and Dutch family practitioners have gone on strike to protest inadequate funding and poor working conditions,2,3 while in Australia, general practice has been described as "soul-destroying."4

Several international surveys have attempted to identify and clarify why family practitioners suffer from severe stress and health problems5–9 and job dissatisfaction,7–11 and even consider ending practice.5,12 Specific areas of difficulty include heavy workload,5,8,12,13 too much paperwork and bureaucracy,11–13 lack of control,10,11 patients’ demands,9,13 lack of time to meet demands,5,12 insufficient financial compensation,5,11 and lack of balance in personal and professional life.5,7,9

To describe these concerns more accurately, some international studies have used qualitative methods.14–20 Common themes among these studies include excessive workload14–17 and difficulty balancing personal and professional life,16–20 but most focused on specific groups, such as rural16,18 or female19,20 practitioners, and none examined Canadian physicians.

While some Canadian family physicians can relate to the concerns of their international colleagues, such concerns might not represent the key issues in Canada. Only 2 studies have addressed concerns here.21,22 In surveys of the perceived effects of health care reform21 and the National Physician Workforce Survey,22,23 family physicians identified many concerns including inadequate compensation, time demands, workloads, negative effects on personal life, excessive paperwork, inadequate staffing, difficulty accessing medical services, stressful on-call schedules, and bureaucracy in medicine. Professional satisfaction was linked with intellectual stimulation and relationships with patients.23 These studies provide insight into a few issues facing Canadian family physicians, but they were not designed to identify and develop consensus on how to manage the key issues encountered in family practice.

To address issues specific to family practice, we need to understand them. With so many concerns cited in the literature, it is difficult to determine which concerns are important. There might also be key issues that have not been described in the literature. What are the concerns, how important are they, and which ones need addressing? To answer these questions, we needed to allow family physicians to generate and report these concerns and ideas without influencing their responses. To that end, we conducted a Web-based consensus study using the Delphi method to identify, describe, and rank the important rewards and challenges experienced by family physicians in Alberta.


   METHODS
TOP
 METHODS
FINDINGS
 DISCUSSION
 Footnotes
 Acknowledgments
 References
 
Study design
A qualitative approach was used to allow family physicians to convey their personal concerns and ideas on key issues. The Delphi method enables development of consensus among experts through an anonymous iterative survey method.24,25 Initial rounds are generative; subsequent rounds clarify, refine, and facilitate the emergence of consensus.25 A Web-based Delphi survey allowed for timely participation from various locations and for participants to generate ideas in their own words, rather than having researchers assume an understanding of the important factors and simply ask participants to rate them.

This study used both a respondent group and a work group. The respondent group included the family physicians who participated in the Delphi surveys. The work group comprised members of the research team who analyzed and summarized data between rounds of the Delphi survey.

Participants (respondent group)
Participants were family physicians from throughout the province of Alberta with access to computers. Maximum variation sampling26 was used to elicit a spectrum of opinion and identify important common issues from urban and rural, male and female, academic and non-academic physicians with a range of years in practice, varied volumes of practice, and many different types of patients.

Recruitment of respondents occurred in 2 ways. First, potential participants were identified by the work group and through word-of-mouth. Second, information on the study and how to participate was e–mailed to members of the Alberta College of Family Physicians and also posted on its website. Twenty-eight family physicians agreed to participate and signed consent forms. Participation in the Delphi rounds was voluntary; each respondent participated in at least 1 round. Results from previous rounds were posted to inform participants who had missed a round. Of the 28 respondents, 18 (64%) participated in all 5 rounds, and 25 (89%) participated in at least 4 rounds.

Work group
The core work group comprised the principal investigator (family physician researcher) and 2 co-investigators (an evaluation researcher and a rural researcher) with experience in Web-based Delphi surveys. The remainder of the work group consisted of 2 researchers, 3 community family physicians, 1 rural family physician, and 2 academic family physicians. They assisted with overall project direction, recruitment, development of questionnaires, and pilot testing, and (as peers) checked interpretations.

Study procedures
The study website presented a description of the project, ethical information, a dynamic calendar of events, and contact information, all of which were publicly accessible. The Delphi surveys and demographic questionnaires were password-protected; respondents could not access other participants’ responses. E–mail reminders were sent to all participants notifying them of each survey round, and 1 week before deadline to those who had not completed their surveys. Five rounds of Delphi surveys were conducted between May 27, 2004, and January 5, 2005. Table 1 outlines the purpose and details of each round.


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  		Table 1 Procedures of the 5-round Delphi survey

 
Development and analysis of surveys
The work group communicated with each other by e–mail, teleconferencing, and face-to-face meetings. For the analysis, collated results were reviewed by the work group after each round. Results were discussed, and consensus was developed on interpretations and on how to proceed with the subsequent rounds. The work group developed and pilot-tested the surveys.

Round 1 started with an open-ended question, "Describe both the significant rewards and the significant challenges you have experienced in practice." A large amount of information was generated and was collapsed into themes using thematic content analysis.27 Members of the work group reviewed the information independently and then discussed it to develop consensus on 34 themes. Themes were presented to participants in round 2.

Round 2 generated broad descriptions and 53 themes. Saturation was reached because many of the later contributions were repetitive. Based on comments from participants, the titles of 4 themes were changed. The work group divided each theme into a reward and a challenge and selected quotes from participants to capture the breadth of their comments. This information was posted in round 3.

In round 3, each participant selected 10 rewards and 10 challenges. After reviewing the results, the work group decided that a minimum of 11 of the 25 respondents needed to select a given theme for it to be considered a key reward or challenge. Eight key rewards and 6 key challenges were identified in round 3 and were posted in round 4. The work group identified 2 additional challenges.

In round 4, participants rated how well the list represented key rewards and challenges on a scale of 1 to 5 (1—not at all, 5—very well). A mean score of 4.5 was obtained. When asked if "maintaining and acquiring skills and knowledge" could be collapsed into 1 theme with challenging and rewarding aspects, 17 of 25 participants chose to keep it as 2 separate items, a reward and a challenge. "Medical legal, insurance paperwork, and motor vehicle accidents" was also kept separate from "paperwork, telephone calls, and forms" because only 13 of 25 round 4 participants suggested combining them. Participants identified 3 new challenges to be considered key challenges.

In round 4, participants suggested new wording for 2 themes. In round 5, 22 of 24 participants selected the wording "rewards of maintaining and acquiring skills and knowledge" and "challenge of maintaining and acquiring skills and knowledge" when asked which wording should be used. All 24 selected the descriptor "medical legal, insurance paperwork, and motor vehicle accidents." When asked whether the new challenge should be considered a key challenge, 17 of 21 selected yes for "respect from specialists," 14 of 23 selected yes for "the challenge of running a practice—a small business," and 17 of 21 selected yes for "overhead and income inequities."

The study received ethical approval from the Health Research Ethics Board at the University of Alberta.


   FINDINGS
TOP
 METHODS
 FINDINGS
DISCUSSION
 Footnotes
 Acknowledgments
 References
 
We used purposeful sampling to obtain a heterogeneous sample of 28 family physicians: 11 women and 17 men from 7 of the 9 Alberta health regions. Sixteen physicians practised in urban areas, 4 in small towns, and 8 in rural areas. Years in practice ranged from 2 to 34. Physicians practised in a variety of settings, including private offices, community clinics, walk-in clinics, nursing homes, hospital inpatient units, emergency departments, academic family practices, and palliative care and rehabilitation units. Types of practice included inner city; pregnancy, labour, and delivery; well-child; elderly; aboriginal; mental health; substance abuse; palliative care; sports medicine; developing world immigrant; anesthesia; and dependent adult. Methods of payment included fee-for-service, alternative payment plans, salary, and others.

In round 4, participants ranked rewards and challenges in order of importance (Table 2). Participants also rated the need to address key challenges on a scale of 1 to 5 (1—no need to 5—very strong need) (Table 3). Consensus was developed through rounds 3 to 5 on the key rewards and challenges that affect Alberta family physicians. These are illustrated with quotes aimed to capture the breadth and depth of participants’ comments (Table 4).


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  		Table 2 Overview of ranking (highest to lowest): In Delphi round 4, 8 rewards and 6 challenges were ranked according to their level of importance relative to each other on a scale of 1 to 5 (1—least important, 5—most important)

 

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  		Table 3 Ranking of the need to address challenges:Mean scores as identified in Delphi rounds 4* and 5{dagger} (1—no need to address, 5—strong need to address)

 

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  		Table 4 Rewards and challenges of family practice: Number of participants ranking rewards and challenges in Delphi rounds 3* and 5.{dagger}

 
Eight key rewards
Diversity and comprehensive care
This reflects the variety, breadth, and diversity of practice, the complex set of skills, specific technical skills, and so on: "This is the essence of family medicine and encompasses most of the reward."

Preventive care
"Most people still go to their family doc with questions ... we’re the best people to do preventive care, at least on an individual basis."

Relationships with patients and their families
"The greatest rewards come from the personal relationships I have with my patients."

Being an immersed witness to the human condition
"I get to vicariously experience the extremes of life: birth, death, catastrophe, and almost every day I am inspired by the strength and ability ordinary people have to rise to the challenge that life has thrown at them."

Continuity of care and ongoing feedback
"Privileged ongoing relationship with patients provides satisfaction through feedback."

Control, flexibility, and security
"I highly value being able to choose my hours and my scope of practice."

Rewards of maintaining and acquiring skills and knowledge
"Development and maintenance of a highly valued skill set. I feel like I contribute to my society in a meaningful way."

Teaching and sharing knowledge, experience, and mentoring
"Keeps me up to date and excited about medicine."

Nine key challenges
Workload and time pressures, meeting demands
"Not enough time to do the kind of job I would like to do."

Overhead and income inequities
"Rising overhead forces us to try to see more patients in less time, compromising the rewards of practice and magnifying the challenges."

Respect from specialists
"The issue is more of a relationship issue than a one-way lack of respect. There is also a lack of respect from family physicians toward specialists." Working conditions and our behaviour might contribute to the problem because, "If we dump our complex patients on them with sketchy referral letters and inadequate preliminary workup we lose their respect." Also,

The lack of opportunities to meet and work together distances us. Because I do only office practice, I have never met in person many of the consultants I refer to. Often specific questions I have asked in a referral letter go unanswered as the consultant generates his or her reply. Would there be a better rapport if we had different working conditions?

Availability of specialists, procedures, tests, and other resources
"[I have] difficulty accessing appropriate consults or tests in a timely fashion."

Challenge of running a practice—a small business
"We truly subsidize health care in a major way with paying for our own offices and running them very efficiently!"

Paperwork, telephone calls, and forms
"Paperwork! I rarely have a day that I don’t have at least 2 hours of work to take home."

Challenge of maintaining and acquiring skills and knowledge
"Keeping up with the ever-expanding body of knowledge is daunting."

Patient expectations
"Patients today, compared to when I started practice, seem to expectal most instant relief of their discomfort without cost, side effects, or inconvenience."

Medicolegal issues, insurance paperwork, and motor vehicle accidents
"Least enjoyed aspects of medicine related to conditions in which lawyers, adjusters, and others manipulate the ‘I am injured’ patient population to perceive themselves as victims rather than to just move on in life."

Two other key challenges
The work group identified two other key challenges: need to promote the rewards identified to those who might consider family practice as a profession and need to ensure that the rewards identified are not adversely affected by primary care reform.


   DISCUSSION
TOP
 METHODS
 FINDINGS
 DISCUSSION
Footnotes
 Acknowledgments
 References
 
We have described a unique comprehensive consensus on the key rewards and challenges encountered by Alberta family physicians. While some themes identified are new, some provide new insights and a deeper understanding of themes found in previous research. The rewards appear intrinsic to the profession; most of the challenges seem related to external forces.

As reward 1, diversity and comprehensive care was rated as the most important reward and seen as "the essence of family medicine," an important finding that reflects our vital role as generalists. Our broad range of knowledge enables us to treat the whole person rather than treating patients by fragmenting them into diseases or systems. Treating the whole person might contribute to development of relationships.

Four key rewards provide a deeper understanding of the doctor-patient relationship and its importance, reinforcing the principle of family medicine that the doctor-patient relationship is central to the practice of family medicine. These "personal," "intense," and "long-term" relationships with patients and their families (reward 3) establish trust. Through these unique trusting relationships, preventive care (reward 2) can be offered, because we know the whole person and how best to approach that person.

A new finding, being an "immersed witness to the human condition" (reward 4) recognizes the unique nature of doctor-patient relationships. We are "witness to the powerful moments of life," and while the "Church has the sacraments, we usually are involved at some stage in the actual physical expression of them." These descriptions imply a sacred or spiritual component to the relationship. This important finding needs further study.

Finally, continuity of care (reward 5) is the means by which we come to know our patients thoroughly. Surveys done in 3 different health systems also support the importance of continuity of care; researchers concluded that, "Personal continuity of care remains a core value of general practice/family medicine and should be taken [into account] by policy makers ... redesigning health care systems."28

Participants reported a strong need to address the challenge of respect from specialists. While participants thought the problem was "pervasive," they recognized that "the issue is more of a relationship issue." In the National Physician Survey,22 23% of family physicians were very satisfied and 47.9% were somewhat satisfied with their relationships with specialists, while 50.3% were very satisfied and 35.1% were somewhat satisfied with their relationships with patients. Our findings provide a possible explanation for the fact that family physicians are more satisfied with their relationships with patients than they are with their relationships with their specialist colleagues.

Duality of rewards and challenges
The apparent duality of some rewards and challenges highlights the unique and complex aspects of family medicine. Maintaining and acquiring skills and knowledge (reward 7, challenge 7) reflects a dilemma generalists face. While physicians enjoy the intellectual stimulation that results from professional development,29 our study identifies the challenges they face in keeping skills up to date.

Relationships with patients and their families have been described as positive in surveys,22 while patients’ expectations (challenge 8) can represent a negative9,13 aspect of practice. Unlike previous work,9,13,22 this study provides a deeper understanding of conflicting themes. It is the "privileged ongoing" and "personal relationships" with our patients that are the "most significant reason for continuing." Despite this, it is important to recognize that some encounters will invariably present challenges, such as patients with "lists" and patients with high expectations of "what we should or can provide for them." Clearly, once the content and descriptors are considered, these themes do not conflict, but provide a richer understanding of patient-doctor relationships.

Workloads, time pressure, and meeting demands received the highest rating in terms of "need to address." Physicians described how "quality of patient care tends to be sacrificed" and that there is "not enough time to do the kind of job I would like to do." Canadian and international research has also identified concerns with excessive workload,5,8,12,13 paperwork, and bureaucracy11–13 and with time pressures.5,12 While this study identified paperwork, telephone calls, and forms as a challenge (challenge 6), medicolegal issues, insurance paperwork, and motor vehicle accidents (challenge 9) were identified as a distinct and separate frustration. It was considered to be "the least enjoyed aspect of medicine," and concern was expressed about the negative effect on patients due to the "manipulation of patients" and the "wasting of good clinic time when one could be practising medicine."

Overhead and income inequities (challenge 2) have been reported in previous work5,11,22,23 and arise from physicians’ concern about "our ability to take the time we should with our patients." This challenge and others, like the availability of specialists, procedures, tests, and other resources (challenge 4), derive from the ultimate goal of improving quality of care for patients.

Control, flexibility, and security (reward 6) is a key reward resulting from physicians’ perception of the "freedom to set my own hours" and the ability to "exert significant control over my client load." Family physicians in some countries do not have this luxury, and international trials describe frustration with the lack of control.10,11 The National Physician Survey found flexibility and predictability to be the third most frequently identified reason for choosing a career in medicine.29 Perhaps international research could compare practices in Canada and abroad in the hope of improving this aspect of practice for our international colleagues.

Conclusion
Alberta family physicians developed consensus on 8 key rewards and 11 key challenges of family practice and rated the need to address each challenge. The most important reward, diversity and comprehensive care, relates to family physicians’ expert role as generalists. A new facet of the doctor-patient relationship unique to family medicine is being "an immersed witness to the human condition." This has not been described elsewhere and warrants further study. Participants rated workload and time pressures, meeting demands, the need to promote the rewards identified to those who might consider family practice as a profession, overhead and income inequities, and getting respect from specialists as the top 4 challenges that need to be addressed. This provides a focus from which further work can be done.



   EDITOR’S kEY POINTS
 
  • Canadian family physicians face many challenges in practice, but also experience rewards. This qualitative study identifies, describes, and ranks key challenges and rewards as reported by a group of Alberta family physicians.
  • Four of the 8 key rewards centred on physician-patient relationships, including being "an immersed witness to the human condition."
  • Workload and time pressure was ranked most important of the 11 key challenges identified.

 


   Acknowledgments
TOP
 METHODS
 FINDINGS
 DISCUSSION
 Footnotes
 Acknowledgments
References
 
I thank Ms Kay Kovithavongs for her contribution as a research assistant. This study was funded by the Alberta College of Family Physicians and by a 2004 Janus Research Grant from the College of Family Physicians of Canada.


   Footnotes
TOP
 METHODS
 FINDINGS
 DISCUSSION
 Footnotes
Acknowledgments
 References
 
This article has been peer reviewed.

Contributors

Dr Manca conceived and designed the study, developed the questionnaires, analyzed and interpreted the data, organized meetings of the investigators, and wrote the article. Dr Varnhagen, Ms Brett-MacLean, and Dr Ausford assisted with conception and design of the study, development of questionnaires, analysis and interpretation of data, and writing the article. Dr Allan assisted with conception and design of the study, the literature review, developing the questionnaires, analyzing and interpreting the data, and critically revising the article. Ms Szafran assisted with design of the study, developing questionnaires, analyzing and interpreting the data, and critically revising the article. Dr Rowntree and Dr Turner assisted with recruitment, developing the questionnaires, analyzing and interpreting the data, and writing the article. Dr Rumzan assisted with developing the questionnaires, developing the web pages, collecting data, e–mailing participants’ reminders, and writing the article. All the authors reviewed and approved the manuscript submitted.

Competing interests

None declared


   References
TOP
 METHODS
 FINDINGS
 DISCUSSION
 Footnotes
 Acknowledgments
 References
 

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D. Manca, S. Varnhagen, P. Brett-MacLean, G. M. Allan, and O. Szafran
RESPECT from specialists: Concerns of family physicians
Can Fam Physician, October 1, 2008; 54(10): 1434 - 1435.e5.
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