Comprehensive practice

DISCUSSION

Of our respondents, 71.7% identified as comprehensive family physicians. In the most recent National Physician Survey,²⁶ 67.6% of family physician respondents described themselves as family physicians and 32.4% described themselves as family physicians with a specialty focus (eg, emergency medicine, sport and exercise medicine).

There is no generally agreed-upon definition of what constitutes comprehensive family practice, resulting in great difficulty in measuring this dimension of primary care.⁸ For this study we did not provide a definition of comprehensive practice, but asked practising family physicians who saw themselves as comprehensive practitioners what services they provided to their patients, thus providing a normative definition of the term. That definition included in-office care, housecalls, palliative care, after-hours care, and minor surgery. Fewer than half of the respondents provided in-hospital care, nursing home care, intrapartum obstetrics, ED care, or sport medicine. It is important to note that this normative definition varied by location, with rural, remote, or isolated practitioners reporting a longer list of services available to their patients. Further, this definition varied across the generations studied, with housecalls, palliative care, and nursing home care provided by less than 50% of more recent graduates.

Overall, we found a decline in the number of services provided by newer graduates compared with earlier graduates. Others^11,15,27,28 have noted a decline in the scope of practice provided by family physicians and general practitioners. We found, as Chan¹¹ did more than a decade ago, that housecalls are more characteristic of older family physicians than younger ones. Our finding points to potential differences in activities of graduates based on the year of graduation. There might be a number of reasons for these observed differences. Practice type, practice location, and training site might all play a part in determining the range of services that physicians offer their patients. As Starfield points out, although comprehensiveness implies a broad range of services, “What is optimal, or even acceptable, changes over time, expanding as new knowledge and improved technology widen the range of possibilities.”²⁹ Nevertheless, Wong argues persuasively that comprehensive care “must be defined by the context under which it is examined”¹⁰ and points out that office-based family practice is the first criterion for a definition, as it is the setting for a defined population for which a practitioner is responsible. Yet, not all of our self-identified comprehensive practitioners provided in-office care, adding a further layer of complexity to the meaning of the term. Grierson et al³⁰ examined residents’ intention to practise comprehensive family medicine and the influence of attitude, perception of subjective norms, and perception of behavioural control. The perception of subjective norms—norms perceived by the individual to be the beliefs of most other people that he or she should or should not engage in given behaviour—was found to have the strongest influence on the stated intention to practise comprehensively. They raise the importance of ensuring the community of practice (preceptors, peers, family, etc) that surrounds residents during training is perceived as supporting comprehensive continuing care. For this study, this raises the question of whether, across the 3 alumni groups, there might have been changes in the program or social environment that influenced attitudes toward the provision of the services about which we inquired. Coutinho et al³¹ found that newly certified family physicians (in the last year of training or first year of practice) reported intentions to provide a wider scope of practice than those family physicians undergoing recertification. They raise the possibility that narrow scope of practice might be associated with post-training work environment. Our finding that those in rural practices report a wider range of services compared with those in urban practices might support this interpretation. Scope of practice might be influenced by local hospital policies and availability of other medical and health professionals and these likely differ between rural and urban settings.

We found that the older physician group reported offering a broader range of services to their patients. Others have commented on potential generational differences in practice activities and potential influences on HIV care³² and health work force planning.³³ We found that the older alumni group were more likely to be in FHO or FHN arrangements. Others have found that older physicians were more likely to select capitated models.³⁴ There is some evidence that payment models influence the behaviour of primary care physicians.³⁵ We found that those in FHO or FHN models were more likely to report offering more services, raising the question of whether these models attracted those already doing comprehensive care or whether they were the motivation for broader scope of practice.

We found significant decreases in those who offered housecalls, palliative care, and nursing home care between the older and younger alumni generations. In a study of graduates of another family medicine program, using health administration data, it was found that more recent graduates were more likely to do hospital visits and ED care but less likely to do housecalls.³⁶ One qualitative study found that rotations in palliative care during training might actually discourage further engagement in that work.³⁷ This once again raised alarm bells for the future of family medicine.¹⁷ On the other hand, we found that the well-documented decline in provision of intrapartum obstetric care has stopped, if not reversed, at least in this group of respondents. Among newer graduates, 12.1% provide this service. In the National Physician Survey of 2010,³⁸ 10.5% of respondents indicated that they continued doing obstetric deliveries; however, that survey did not differentiate comprehensive from focused practitioners. Had it done so, the proportion of comprehensive family physicians providing obstetric care might have been higher.

Beaulieu et al²² found differences in how comprehensive care was defined in a qualitative study of family physicians, family physician educators, family medicine residents, and other specialists. Some family physicians and most other specialists defined scope of practice based on functions, principally first response to patients’ problems and coordination and integration of care. Others defined scope of practice based on practice settings—on whether they practised in the office, the ED, the hospital, the delivery room, and so on. This viewpoint was held only by family physician educators and, not surprisingly, is the view most often reflected in the literature. There continues to be a fundamental tension between those who define comprehensiveness by function and those who emphasize a range of locations. More nuance is suggested by McGrail et al,³⁹ who divided general practitioners into high, low, and mixed responsibility based on the degree to which they assumed responsibility for referrals, starting long-term medications, oversight, screening, and repeat visits.

Changes in practice styles and team-based care might mean that comprehensiveness, when understood to be scope of practice, should be seen as a team function rather than the function of one person.¹⁶ Further, and related to this point, it has been suggested that definitions of comprehensiveness go beyond a strict medical model and address fundamental social determinants of health.⁴⁰ In a survey of family medicine residents’ intentions to practise a broad definition of comprehensive care, it was suggested that consideration must be given to residents’ understanding of newer team-based models of care.³⁰

Recent curricular changes to residency training in Canada emphasize training family physicians who are capable of providing comprehensive and continuous care that is responsive to community needs.²¹ The dimensions of comprehensive care defined in the standards for the Triple C curriculum include care of patients across the life cycle (children, adolescents, and adults, including women’s health care, maternity care, men’s health care, care of the elderly, end-of-life care, and palliative care), care across clinical settings (ambulatory or office practice, hospital settings, long-term care, emergency settings, home care), care across the spectrum of clinical responsibilities (disease prevention and health promotion, diagnosis and management of presenting problems [acute, subacute, and chronic], chronic disease management, rehabilitation, supportive care, palliation), care of underserved patients (including but not limited to Aboriginal patients, patients with mental illness or addiction, and recent immigrants), and procedural skills (College of Family Physicians of Canada core procedures).⁴¹ The effect of these curricular changes on practice style remains to be determined.

If the benefits of comprehensive care that have been demonstrated by others are to be preserved and enhanced, there is a need for better understanding of when and why family medicine residents choose a particular practice style.³⁰ Further analysis of our data will describe the background and activity of those graduates not engaged in comprehensive care, including the influence of 3-year residency training programs.

It is important to recognize that comprehensiveness, regardless of the definition used, is only one of the components of primary care, the others being first contact, continuity, and coordination.²⁸ Whatever definition of comprehensiveness is used should support the remaining dimensions of primary care. Offering a range of services is more comprehensive if those services are provided to a practitioner’s patient population where continuity of care is more likely. Studies that look only at scope or range of services need to also examine these other components of primary care. McWhinney⁴² recommended distinguishing between services such as home visits, hospital visits, nursing home visits, full or shared obstetric care, and provision of after-hours care, which are provided to one’s own patients, and services such as ED shifts, anesthetic lists, and occupational medicine sessions, which are provided to individuals outside of one’s practice. The latter provide important support for the broader system, but he considered it an error to use them as criteria for a universal definition of comprehensiveness. A scoring system for comprehensiveness could list the services offered in a hierarchical manner such that those that most clearly provide continuity of care to a practice population are graded higher.