The reality of urban FPs

Dear Colleagues,

Recently, an FP friend of mine who had spent his initial first 5 years practising in a rural town described his current practice in a large city. He is in a group practice and, along with his colleagues, looks after a diverse population (large multiethnic immigrant population) of patients of all ages; the practice provides after-hours and weekend coverage (ie, the clinic is open every evening and from 10:00 am to 10:00 pm on Saturdays); and the FPs do house-calls for terminally ill and frail elderly patients. However, none of the physicians in the practice provides intrapartum care or hospital care. Although my friend did emergency department shifts at the beginning of his practice, he stopped doing so upon moving to the city. Geography is a more important predictor of scope of practice than physician factors are.¹ What does it mean to be active in the provision of continuing care in a large city in 2018?

I have had to substantiate my reading by resorting to the oldest professional development technique: speaking to some of my urban colleagues. Here is a summary of what they have shared with me, of my reading, and of my personal experience.

• The great thing about practising in a large city is the number and variety of resources available; the challenging thing about practising in a large city is the number and variety of available resources. Although the resources are there, learning about them and how to access them is often a challenge; this is a reality for both providers and patients. In certain areas of care, such as cancer care for example, the availability of specialist colleagues sometimes changes the nature of the continuing care relationship. Although not unique to urban practice, clarity of roles, communication, and coordination of care become particularly important in supporting continuity.^2,3

• Many urban GPs are active in the provision of continuing care “in a focused way.” They welcome vulnerable populations in their practices; over time, they acquire specific expertise in those areas, and, often through word of mouth, find themselves providing continuing comprehensive care mostly to such populations.

• Many urban patients work in the city and live in the suburbs (those agglomerations are also often urban); they might choose a walk-in clinic or an urgent care clinic for quick, emergent health issues, and reserve their contact with the provider they identify as their FP for the more serious problems. Improvements in virtual, asynchronous communication between patients and providers might present an opportunity to improve on this disconnect. The reality remains that this influences the interactions urban FPs have with their patients.

• The same phenomenon influences the referral-consultation process. An urban FP might develop good relationships with a select number of trusted specialist colleagues to refer to. This generally happens over time (longer than in a small town or rural area, in my experience) and is influenced by many factors (ease of reach by telephone or e-mail; face-to-face interactions, if they exist at all; promptness in getting a consultation report; etc). However, this might be of no use for commuter patients, who might prefer to be seen by consultants closer to their homes, whom the referring FPs might not have relationships with.

Add to all this the many different referral forms for services; the increased travel distances (and traffic) for house-calls; and, often, the higher overhead costs of running a practice. Indeed, we do end up with a complex situation.

A considerable proportion (70.8%) of FPs work in large cities (population > 100 000)⁴; 45% of urban FPs are in a fee-for-service model of care and 39% are in a blended payment model, as compared with 36% and 44%, respectively, for rural FPs.⁵ The reality of the urban FP is different than that of the rural FP. Yet they are both driven by a calling, and a wish to do a good job in continuing comprehensive care. The College believes that the concept of the Patient’s Medical Home offers an opportunity to recognize the variety of contexts in which FPs practise, and to adapt the practice and funding models to support FPs and family practices in best meeting the needs of their patients. Based on extensive input and feedback, we are doing a refresh of the Patient’s Medical Home, to be released in the fall. Stay tuned.

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