Researchers Explore Diminishing Scope of FP Practice

Is Rising Tide of Employed Physicians Hurting the Specialty?

April 18, 2018 08:45 am Sheri Porter – Is the much-celebrated broad scope of family medicine shrinking? Family medicine researchers around the country have been having that discussion for a while now, and a policy brief published in the March/April issue of the Journal of the American Board of Family Medicine continues the conversation.

Titled "Wide Gap between Preparation and Scope of Practice of Early Career Family Physicians," the brief was written by researchers from the American Board of Family Medicine (ABFM), the Department of Family and Community Medicine at the University of Kentucky, and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

The team looked at data gleaned from the 2016 National Graduate Survey and based its findings on responses from 1,617 survey respondents -- all ABFM diplomates who completed residency in 2013.

The researchers' objective was to "investigate differences in reported preparation for practice and actual scope of practice for early career family physicians."

They discovered that "a substantial gap exists between the training and preparation family medicine residents receive and the services they deliver in practice."

With more than 50 percent of physicians now reporting they are employed, "the specialty of family medicine should address the possibility of employers influencing scope of practice," wrote the authors.

Survey Highlights

Researchers limited their sample to family physicians practicing outpatient continuity care. The survey included a series of paired "yes or no" questions asking participants whether they were trained to practice -- and were in fact practicing -- 25 specific services.

Responses showed that for specific services, the largest gaps between preparation and practice existed for

maternity care (91 percent and 27 percent respectively),
newborn hospital care (89 percent, 28 percent),
neonatal circumcision (83 percent, 22 percent), and
pediatric hospital care (77 percent, 21 percent).

Importantly, behavioral health care was the only category in which practice (92 percent) exceeded preparation (88 percent).

Story Highlights

Other services where gaps between preparation and practice were less than 10 percent included

joint aspiration and injection (89 percent and 80 percent respectively),
pediatric outpatient care (93 percent, 86 percent),
management of hepatitis C (28 percent, 24 percent),
integrative health care (24 percent, 21 percent), and
osteopathic manipulative treatment (15 percent, 12 percent).

Researcher Response

Corresponding author Lars Peterson, M.D., Ph.D., is research director for the ABFM and an associate professor in Department of Family and Community Medicine at the University of Kentucky in Lexington.

In an email conversation with AAFP News, Peterson provided additional comment about the increasing number of physicians leaving private practice for employed positions and how that trend could be influencing family physicians' scope of practice.

"We've seen a huge shift in the last few years with physicians moving into practice arrangements where they are employees of health systems instead of physician-owned practices," said Peterson.

He cited an internal ABFM analysis not yet available to the public that showed in 2017, of the 7,185 family physicians who registered for the ABFM Family Medicine Certification Examination to continue their ABFM certification, 64 percent reported they had no ownership stake in their practice.

And of the 2,475 graduating residents who registered for the ABFM exam in 2017 -- and who already had a job contract -- 79 percent reported they would have no ownership stake in their future practice.

"There are many anecdotes but few reported data on scope of practice and practice ownership," said Peterson. However, it's not hard to imagine the ways a family physician's scope could be restricted by a health system. For instance, it's likely that a health system

employs hospitalists, so a family physician could be told not to do inpatient care;
owns obstetrical practices, so no deliveries would fall to FPs;
has bought practices with dermatologists, cardiologists and other subspecialists, and may create incentives for physicians to refer care they could easily provide; and
owns urgent care centers and simply doesn't structure the family medicine practice to accommodate patients with acute needs.

Unfortunately, said Peterson, "Once kids, OB, procedures, urgent care and inpatient care are removed, many family physicians have become outpatient-only managers of adult chronic disease."

Prior research confirms that health care systems with strong primary care lower costs, enhance quality and provide better population health, said Peterson. And emerging evidence shows that a broadened scope of practice helps prevent burnout in early career physicians.

"This all points to a potential win-win-win for physicians, patients and the health system if family physicians could practice to the top of their license and training," said Peterson.

Companion Commentary Piece

Peter Carek, M.D., M.S., authored commentary titled "Potentially Alarming Trends in the Scope of Practice for Family Physicians," that complements the research brief. He serves as a professor and chair of the Department of Community Health and Family Medicine at the University of Florida College of Medicine in Gainesville.

Carek writes in his piece that the current report as well as a study led by Anastasia Coutinho, M.D., that was published in the Dec. 8, 2015 issue of JAMA: The Journal of the American Medical Association "demonstrate a decrease in the scope of care being provided by many family physicians."

However, "Potentially more alarming is the finding that many family physicians are no longer planning to or provide the basic services associated with a primary care physician," he wrote.

"Not having all, or nearly all, family physicians provide these basic services seems to contradict the premise of primary care and affects the value of family medicine in the current health care system," he added.