Abstract
Objective To explore perceptions of early-career family physicians on the personal, educational, organizational, community, and system factors that had influenced their scope-of-practice decisions and to compare the similarities and differences among these factors across all 13 Canadian jurisdictions.
Design Qualitative descriptive study.
Setting Canada.
Participants Fifty-nine early-career family physicians who were 2 to 5 years into independent practice.
Methods Data were collected using focus groups and were analyzed using deductive and inductive analysis techniques to identify patterns in the data within and across jurisdictions.
Main findings Participants across all jurisdictions highlighted that personal factors (ie, interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were most influential on scope-of-practice decisions. Educational (ie, exposure during training, mentorship), organizational (ie, collegial support), community (ie, needs), and system (ie, payment models, funding for team-based care, governance) factors also influenced decisions about scope of practice. Experiences were similar across all jurisdictions for personal factors. Differences in experiences were reported across jurisdictions for educational, organizational, community, and system factors.
Conclusion Decisions about scope of practice by early-career family physicians are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals’ interest in providing comprehensive care in Canada. Educators should cultivate interest in comprehensive care among learners, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the scopes of practice of family physicians and their capacity to deliver accessible and comprehensive care to Canadians.
Family physicians are trained to provide comprehensive and continuous care to patients and populations.1,2 A comprehensive practice has been defined as the delivery of a broad scope of practice (SOP) throughout the life cycle of a patient in multiple care settings.3 Canada is facing a primary care crisis, in which approximately 14.5% of Canadians are without a regular health care provider.4 There are growing concerns that fewer FPs work in full-service comprehensive practices,3,5,6 which is not considered in workforce planning. These trends raise important questions for educators and policy-makers about the factors influencing SOP decisions of early-career FPs in Canada. Jurisdiction-specific studies indicate various personal, organizational, system, educational, and community factors influence FPs’ decisions about providing a broader SOP7,8 (Table 1).8,9
Factors that influence scope-of-practice decisions as reported in the literature
To date, Canadian studies have focused on single7 or specific jurisdictions9 and have not represented national perspectives of FPs on factors that influence SOP decisions and how these factors are similar or different across jurisdictions, which vary in the design and delivery of primary care services. Thus, this study explores the similarities and differences in personal, educational, organizational, community, and system factors that influence the SOP decisions of early-career FPs across the 13 Canadian jurisdictions.
METHODS
A qualitative descriptive study design was selected to describe a phenomenon from the perspectives of those with lived experience.10,11 We report our findings using the COREQ (Consolidated Criteria for Reporting Qualitative Research).12 Research ethics approval was obtained from the University of Toronto Health Sciences Research Ethics Board.
Participants and recruitment
Purposive and convenience sampling were used. Eligible participants were early-career FPs who had completed family medicine (FM) residency training in Canada and had been in independent practice for 2 to 5 years. Recruitment methods included posting study information on social media, contacting physician working groups, and using snowball sampling.13 A maximum variability technique was used to ensure diversity in participant characteristics such as sex; training university; practice location, model, and type; and involvement in different practice and academic activities.14 A research assistant (R.A.) screened participants for eligibility and obtained written informed consent before data collection.
Data collection
Data collection took place between November 2020 and June 2021. Each participant received an information letter, signed a consent form via email, and completed a demographic characteristic questionnaire. Twelve virtual focus groups were conducted using a semistructured guide (provided as supplementary material, available from CFPlus*). Building on our methodologic approach, participants were provided with the Family Medicine Professional Profile15 before engaging in focus group discussions, ensuring a contextually informed dialogue on the SOP construct. The focus groups explored factors related to preparedness for practice, practice intentions, and practice choices. Each jurisdiction was involved in at least 1 focus group. Alberta, British Columbia, Manitoba, Newfoundland and Labrador, and Saskatchewan had 1 focus group each. Ontario, Quebec, and the territories (Yukon, Northwest Territories, and Nunavut) had 2 focus groups each. Participants from New Brunswick, Nova Scotia, and Prince Edward Island were combined into 1 focus group (Maritimes). Each focus group had 6 to 8 FPs. Videoconferencing systems were used for 90- to 110-minute focus group sessions facilitated by the principal investigator (M.A.), a qualitative woman researcher with a PhD; field notes were taken by the research assistant (R.A.). The research team had no prior relationships with participants. Data collection ended when no new relevant information was identified.16 Research team debriefings occurred after each focus group.17 The focus group discussions were audiorecorded, professionally transcribed, and reviewed for accuracy.
Analysis
Data collection and analysis were conducted iteratively and concurrently, aligning with established models in qualitative analysis applied post hoc to interpret participant responses.18 NVivo software, version 12, was used to organize data.19 Data were analyzed thematically using a directed content-analysis approach.20-24 Upon data review, we deliberately applied a deductive analytic approach, selecting a framework that encompassed personal, educational, organizational, community, and system factors.25 This framework was derived from participant responses and guided our analysis. Thus, after reading each transcript and discussing initial thoughts with the research team, we employed deductive (ie, using the previously identified personal, educational, organizational, community, and system factors) and inductive approaches (ie, using content that was identified from the data).25 Data were coded independently by the principal investigator (M.A.) and research assistants (R.A. and K.K.). We started the analysis by reading the transcripts several times to understand the whole data set. Sentences and phrases with content relevant to the aim, known as meaning units, were highlighted. The meaning units were organized under codes.22,24 The team iteratively added codes through a series of meetings and then grouped similar contexts to form categories. Through a series of meetings, the team identified the most salient emerging themes and subthemes20 and similarities and differences among comments based on the provinces and territories of participants. Alternative interpretations of the data were also discussed.24 Memos were written throughout the analysis.17,26 Member checking was done with 2 female participants who were 3 and 4 years into independent practice and had academic affiliations. For member checking we selected individuals who provided diverse perspectives on their experiences and those of colleagues (anecdotally) on the factors that had shaped their SOPs. We provided participants with a summary of findings and an opportunity to provide feedback on the results and to comment on whether the themes aligned with their experiences.27,28
RESULTS
Fifty-nine early-career FPs participated in the study. Participants were from 10 provinces (n=53) and 3 territories (n=6) across Canada. Sixteen people who had initially responded ended up not participating due to pandemic response duties or personal responsibilities. The mean age of participants across the provinces and territories ranged from 32.1 to 35.0 years. Most participants were female (44 of 59; 75%) and had been in independent practice for 2 to 3 years (37 of 59; 63%) (Table 2).
Participant characteristics across jurisdictions
Below we identify the personal, educational, organizational, community, and system factors (themes) that had influenced SOP decisions and highlight the subthemes that were similar or different across jurisdictions as derived from our analysis. In Table 3 we present illustrative quotes related to each subtheme.
Illustrative comments related to factors that had influenced scope-of-practice decisions
Personal factors
Personal factors (ie, personal interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were described by participants as being highly influential factors affecting SOP decisions across all jurisdictions.
Personal interest. The personal interests of FPs represent a major theme that appeared in the data in the context of pursuing a full-service comprehensive care practice with a broader SOP. Family physicians indicated their desire to have ongoing patient-provider relationships and to deliver care across an individual’s lifespan influenced their interest in comprehensive care. One participant from British Columbia shared, “I just really wanted those relationships. And I felt like as a locum, I couldn’t develop those long-term relationships.” As such, these FPs ensured that they obtained the exposure and experience needed to work in a full-service practice, including working in rural settings to broaden their skills, knowledge, and capabilities.
Work-life balance and family life. Across all jurisdictions, work-life balance was mentioned by participants, particularly among those with partners and children. Consequently, when FPs decided to narrow their SOPs to office-based or focused practices it was related to the lack of desire to work around the clock or concerns about the burnout experienced in a full-service comprehensive care practice.
Financial considerations. A desire to obtain a certain income level influenced decisions in all jurisdictions. Some FPs had chosen to work in full-service comprehensive rural settings or focused practices (eg, hospitals or emergency departments) due to higher compensation.
Perceived self-competence and confidence. The possession of competence and self-confidence to practise independently was a major point of discussion among participants from all jurisdictions. Participants from all jurisdictions noted that they were more likely to select and practise in areas they felt more confident in and to avoid areas in which they felt less experienced. This included emergency medicine, obstetrics, hospital care, and rural practice. One participant from Alberta noted,
I think for me, the thing I felt least comfortable with was probably emergency care. I didn’t realize that I wasn’t ready for emergency care. That was actually what I planned on my entire practice being until I tried it. I did electives and extra rotations in [the intensive care unit] and emergency [department]. And then as soon as the support is taken away and you’re on your own, it feels very different. And I didn’t feel comfortable managing that.
Educational factors
Exposure during FM training and mentorship were identified across all jurisdictions as factors that had influenced SOP decisions. Family physicians in Manitoba, Ontario, Quebec, and Saskatchewan highlighted specific experiences with their FM programs.
Exposure during FM training. Family physicians from across all jurisdictions commented on how the lack of exposure to specific practice areas (eg, emergency medicine, obstetrics, hospital care), types of practice (eg, comprehensive practice), or practice locations negatively impacted their preparedness for independent practice. In contrast, early-career FPs who had spent more extensive time in rural settings reported feeling more prepared, which broadened their SOP.
Participants from Manitoba and Saskatchewan indicated their training experience had sometimes been driven by the needs of the community and less by their learning needs. Participants described doing “grunt work” or running errands for supervisors since no one else had been available to assume these duties. Participants from Ontario and Quebec indicated their training experiences had been based on the context (ie, within specific practice models or urban areas).
Mentorship. Family physicians from all jurisdictions described experiences where mentors had positively influenced decisions to pursue broader SOPs, while others described experiences where lack of mentorship had reduced their interest in specific clinical practice areas.
Organizational factors
Collegial support was identified as having broadened SOPs by participants in Alberta, British Columbia, Ontario, and the territories. In Alberta and Ontario, it was noted that access to team-based models and sharing work with colleagues had allowed FPs to provide a comprehensive array of services and to work in different settings (see system factors below).
Community factors
Community needs were identified as a factor that had influenced the SOP decisions of FPs. We found similar perspectives among participants in Manitoba, the Maritimes, Newfoundland and Labrador, Quebec, Saskatchewan, and the territories. In some cases, this factor had broadened SOP. In other cases it had led to SOP narrowing, with FPs choosing hospital care or focused practice (eg, addiction medicine). In these jurisdictions there were challenges with health human resource shortages. Some participants described how the abundance of obstetricians in Ontario had reduced the need for FPs to participate in this area of care. On the other hand, the lack of specialists was reported to have resulted in SOP broadening in Alberta, the Maritimes, Newfoundland and Labrador, and the territories.
System factors
System factors (ie, funding and payment models, investment in team-based care, and governance and policies for the FP workforce) were commonly identified factors in SOP decisions. We found differences in perspectives in Alberta, Manitoba, Ontario, Quebec, and Saskatchewan, compared with other jurisdictions.
Funding and payment models. Early-career FPs indicated that the type of remuneration model available was crucial in deciding SOP. In Ontario, FPs indicated that access to salaried or blended capitation models allowed them to participate in comprehensive practice. Participants in Alberta, Manitoba, the Maritimes, and Saskatchewan said they believed models other than fee-for-service would foster work-life balance and comprehensive care: “The salaried positions that I worked with … all had good work-life balance and good self-care.” (Maritimes)
Investments in team-based care. Participants in Alberta and Ontario indicated that government investments in implementing team-based models allowed them to provide comprehensive care. In Ontario, participants had access to family health teams and community health centres; in Alberta, physicians had access to primary care networks. However, participants in Ontario noted there were barriers to joining models: “[O]pportunities to join those multidisciplinary practices are few and far between.”
Governance and policies for the FP workforce. Quebec’s approach to regional workforce planning contrasts with jurisdictions across Canada and influences SOP decisions. In Quebec, policies on workforce planning and recruitment were described as the most important factor determining FPs’ SOP choices. The regional physician resource plans (plans régionaux d’effectifs médicaux) of each regional department of general medicine (département régional de médecine générale) in 18 administrative regions require physicians to apply for positions based on their preferences. As such, these placements had narrowed or broadened their SOPs, as the government determined the number of available positions for FPs. Quebec was described as unique, as regional physician resource plans use a centralized system for physician resource allocation whereas no other jurisdictions have this model.
DISCUSSION
This study builds on existing literature by identifying and comparing the factors that shape SOP decisions of FPs across 13 jurisdictions in Canada. Our study extends the existing literature by finding that personal factors are highly influential on practice decisions made by early-career FPs. These perspectives were similar across all Canadian jurisdictions. In alignment with the literature, we also found that educational, organizational, community, and system factors influence SOP decisions of FPs.7,8 However, these findings contrast with a US study that found workplace, environmental, and population factors were most influential on the actual SOP.8 Differences in results may be due to the substantial differences between the 2 countries’ funding, organization, and delivery of health care.
At the personal level, interest, work-life balance and family, financial considerations, and self-confidence were key factors in SOP decisions across all jurisdictions. A novel finding from this research is that the self-perceived competence and confidence of FPs influenced SOP decisions. Similar to the literature, we found early-career FPs with broad SOPs were often motivated by wanting to have more patient contact, to treat patients with diverse profiles and problems, and to have more prevention responsibilities than others with different SOPs.29 These findings highlight the crucial role of educators in medical schools and in residency programs in promoting a genuine interest in comprehensive practice. Medical schools and FM training programs should also consider establishing a method of assessment during entry that recruits individuals with personal interests in comprehensive care.30,31 Since self-confidence influences SOP decisions, training programs should also assess trainees’ self-confidence at the individual and program levels throughout and at the end of training.
At the educational level, we found potential differences among FM programs in adequately preparing residents for a comprehensive SOP. These findings suggest that further research is needed to identify strategies that may better prepare FPs for comprehensive care. Strategies for preparing FM residents for a broad SOP could include greater exposure to different clinical and nonclinical domains, exposure to rural environments, and access to a diverse range of faculty and preceptors.32-34 In addition, existing literature emphasizes that a third year of enhanced skills training can direct career paths toward more specialized practice areas.35,36 Thus, future education innovations must consider the impact on SOP and its implications for the primary care workforce.35,36
At the organizational and community levels, FPs make SOP decisions based on collegial support and community needs. Programs should also consider pairing early-career FPs with later-career FPs.37-39 Further research is needed to understand jurisdictional differences. At the system level, provinces with team-based models enabled a broader SOP. Effective interprofessional and group models can alleviate financial strain and burnout and increase individuals’ willingness to provide comprehensive care.40 New graduates tend to prefer working in group or team practice settings.41 Financial remuneration models that support team-based care can help increase engagement in comprehensive care.40 Interestingly, Quebec’s family medicine groups were not identified as a reason for pursuing a broader SOP, possibly due to legislative requirements and location factors influencing SOP decisions.
Limitations
While our study identified varying perspectives related to SOP in specific regions, it is imperative to acknowledge the limited participant representation from particular regions and educational programs, which may not comprehensively represent the diversity of training experiences across the identified jurisdictions. Most of our study participants were female and had been in academic practice for 2 to 5 years, limiting the representation of FPs with different experience levels. Gender disparities in medical education,42 FM practice,43,44 and academic FM45 highlight nuanced differences in career trajectories, patient interactions, and approaches to comprehensive care, underscoring the importance of future research to understanding how diverse gender perspectives are shaping practice. We were unable to expand member checking to include more participants due to time constraints affecting participants during the height of the COVID-19 pandemic. Additionally, our findings capture a single point in time and lack longitudinal perspective, thus limiting their applicability to experiences over time. Social desirability and recall methodology are limitations of focus group methodology.46
Conclusion
Scope-of-practice decisions by early-career FPs are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals’ interest in practising with a broad scope in Canada. Educators should cultivate learners’ interest in comprehensive care, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of the training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the SOPs of FPs and their collective capacity to deliver accessible and comprehensive care to Canadians.
Acknowledgment
We acknowledge Dr Ivy Oandasan for reviewing the study protocol and manuscript and Lorelei Nardi for reviewing the study protocol. We recognize the College of Family Physicians of Canada (CFPC) for sponsoring the study. We acknowledge colleagues, participants, and the CFPC’s First Five Years in Family Practice Committee for assisting us with recruiting participants. Finally, we appreciate all those who took the time during the COVID-19 pandemic to participate in this study. The analyses, conclusions, opinions, recommendations, and statements expressed herein are those of the authors and are not necessarily those of their respective employers or affiliated institutions.
Footnotes
↵* Supplementary Material is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
Dr Monica Aggarwal contributed to conceptualizing and designing the study; collecting, analyzing, and interpreting the data; and preparing the manuscript for submission. Dr Kristina Kokorelias contributed to analyzing and interpreting the data and preparing the manuscript for submission. Dr Reham Abdelhalim contributed to collecting, analyzing, and interpreting the data and reviewing the manuscript.
Competing interests
Dr Monica Aggarwal was partially compensated for her time on this project by the CFPC.
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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