Practice volume has not changed significantly for newer Canadian family physicians, compared with previous generations of physicians, a new study suggests.
In Canada, limited patient access to family physicians is a nationwide concern. Observers have raised questions about the role of recent physician graduates in this problem.
David Rudoler, PhD
But a retrospective cohort study of family physician practice volume and continuity of care suggests that “focusing on generational differences is a distraction,” study author David Rudoler, PhD, assistant professor of health sciences at Ontario Tech University, Oshawa, Ontario, Canada, told Medscape Medical News.
The study was published online December 12 in the Canadian Medical Association Journal.
No Generational Differences
The investigators examined trends in family physician practices from 1997-98 to 2017-18, based on administrative health and physician claims data from the Canadian provinces of British Columbia, Manitoba, Ontario, and Nova Scotia. Study outcomes were the number of annual patient contacts and annual physician-level continuity of care, per physician billing records.
The median number of annual patient contacts per provider declined by between 515 and 1736 contacts in each province between the start and end of the study. Although the decline was consistent in all provinces, it was significant only in Manitoba and was more pronounced in rural practices.
In all provinces, inverted U-shaped curves showed the median number of contacts peaking at 27-29 years in practice (between 2340 and 2566 more contacts at the median than at 0-2 years in practice) and median physician-level continuity of care increasing until 30 or more years of practice.
Family physicians who started practice in the late 1940s and early 1950s had lower median patient contacts than those who started practice in 1991-93 in the three provinces where data were available. Data for Manitoba were incomplete. No association was seen, however, between graduation cohort and patient contacts or physician-level continuity of care.
The proportion of family physicians using shadow billing increased in all provinces concurrently with the increase in the proportion of physicians compensated through alternative payment models.
Study limitations include the use of billing data that did not fully capture the scope or complexity of the services provided, the types of services patients received, the complexity of the patient populations, or the impact of alternative payment plans on patient contacts.
Systemwide Changes Needed?
“Some have argued that recently trained physicians think more about work/life balance, are less career motivated, and are less likely to engage in comprehensive and continuous family practice,” Rudoler and colleagues wrote. “The implication is that younger family physicians work less and are less likely to be providing accessible, comprehensive care than their older colleagues.”
The lack of evidence of changes specific to doctors starting practice more recently was a surprise to the team, said Rudoler. However, three points helped the investigators understand this observation.
“It is true that doctors starting out in practice work differently than doctors who have been in practice longer, but this has been true of preceding generations,” said Rudoler. Physicians reach a peak in service volume and continuity of care around mid-career.
“It is also true that new entrants to the workforce are practicing differently than previous generations did at the same point in their careers, but this is the case for physicians at all career stages,” Rudoler added.
Moreover, practice is changing for everyone. “Anecdotally, we’ve heard examples of people in established practice scaling back or changing how they work. That helps us understand the fact that we do see changes, just not for early career physicians specifically.
“This study is a reminder that changes in the broader systems and structures in which people work are going to have a big impact on everyone, regardless of generation or when you started work,” said Rudoler.
Team-Based Care
Lee A. Green, MD, PhD, professor emeritus of family medicine at the University of Michigan, Ann Arbor, and professor and immediate past chair of family medicine at the University of Alberta, Edmonton, Alberta, Canada, was not involved in the study, but agreed with the results. “I’m not in the least surprised by the findings,” he told Medscape.
Dr Lee A. Green
In their investigation of practice patterns in Alberta and Ontario, Green and his colleagues are finding “a very similar pattern, even though Alberta is almost entirely fee-for-service, whereas Ontario has a lot of non–fee-for-service payments,” he said. “The real difference in capacity now is that we have fewer people coming into family medicine and a big cohort that’s approaching retirement.”
Physicians’ task has changed markedly, he said. “Over the past 20 to 30 years, our patient population has gotten older, more complex, higher need. You can’t do as many visits per day the way you used to be able to. I’ve been in practice over 40 years. When I was in training, taking care of heart failure, for example, was very simple. We basically gave two drugs, and people didn’t live very long with it.
“Now, people survive many, many years with heart failure as a chronic disease, and care is so complex,” he said. “The practice guideline is almost impossible to lift. Each patient nowadays requires so much more work than in the past.”
The solution, he said, “is to redesign the system.” The current system is designed for the “old days,” when people came in for simple, episodic problems. “We have a whole payment system that is structured around perverse incentives to see large numbers of patients for short visits and to have the physician doing pretty much everything. We need to redesign the system completely to prioritize team-based, comprehensive care, with different payment mechanisms.”
Dr William Orovan
William Orovan, MD, vice dean of clinical service and commercial enterprises at McMaster University, Hamilton, Ontario, Canada, expressed reservations about the study. He believes there are “both systemic problems and behavioral problems that may be generational.” Orovan did not participate in the study.
“I do think that there is a change over time in the approach and in the practice style of newer physicians vs older physicians,” he told Medscape. That change might emerge more clearly if the study looked over a longer period than 20 years, he noted, and requires “further analysis.”
The move to alternate payments “is a behavioral change that needs to be properly measured” as a separate variable, he said. “In this study, it did not reach statistical significance, except in one jurisdiction, but it is consistent throughout. So again, I think there’s a need for further investigation.
“Clearly, we need to graduate more primary care physicians,” he said. Like Green, he noted, “We need to look to provide incentives for them to care for more and potentially more complex patients. We need to look at other primary care providers such as nurse practitioners and look to do team-based care. The solitary family physician who used to work very hard night and day doesn’t fit with the current genre of physicians. So, we need to bulk up the numbers of people that are available to see patients in a primary care capacity.”
Tara Kiran, MD, Fidani chair of improvement and innovation in family medicine at the University of Toronto, Toronto, Ontario, Canada, concluded in an accompanying editorial, “Primary care should be considered a right and a necessity, similar to public education. When families move to a new neighborhood, children are guaranteed a spot in a local school. Likewise, when people move to a new neighborhood, they should be guaranteed a spot in a local primary care practice.”
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. Rudoler reported receiving funding from the Canadian Institutes of Health Research (CIHR) for this research and support from CIHR to attend scientific meetings where the results of this research were presented. Kiran has received grants from organizations such as St. Michael’s Hospital Foundation, the University of Toronto, Health Quality Ontario, the Canadian Institutes of Health Research, and the Ontario Ministry of Health. She also has received grants from Gilead Sciences. Green and Orovan reported no relevant disclosures.
CMAJ. Published online December 12, 2022. Full text.
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