Newly Trained Family Physicians Want Broader Scope

Marcia Frellick

December 08, 2015

Graduating family medicine residents say they want a broader scope of practice than that reported by current physicians.

Lars E. Peterson, MD, PhD, from the American Board of Family Medicine in Lexington, Kentucky, and colleagues collected data from those applying to take the 2014 American Board of Family Medicine (ABFM) Maintenance of Certification for Family Physicians examination.

The researchers compared answers on a questionnaire about intended scope of practice among those certifying for the first time (3038) and physicians recertifying (10,846). The questionnaire is a requirement of the certification process, so the response rate was 100%.

The Scope of Practice for Primary Care score (scope score), which ranges from 0 to 30, with higher numbers representing broader scope, was significantly higher for new physicians than for those recertifying (17.7 vs 15.5; difference, 2.2 [95% confidence interval (CI), 2.1 - 2.3]; P < .001).

First-timers were more likely than recertifiers to report that they intended to provide obstetric care (23.7% vs 7.7% [difference, 16.0%; 95% CI, 14.4% - 17.6%]; P < .001), inpatient care (54.9% vs 33.5% [difference, 21.4%; 95% CI, 19.4% - 23.4%]; P < .001), and prenatal care (50.2% vs 9.9% [difference, 40.3%; 95% CI, 38.5% - 42.2%]; P < .001). Similar differences were present when the researchers limited comparisons to recertifiers who had been in practice for only 1 to 10 years.

The researchers reported their findings online December 8 in JAMA.

Despite known benefits of comprehensive care by family physicians, the scope has been narrowing in recent years. For example, from 2000 to 2010, the percentage of family physicians providing maternity care, pediatric care, and women's health services declined at least 10%, the authors write.

American Academy of Family Physicians President Wanda Filer, MD, told Medscape Medical News these findings are encouraging because they show that students feel fully prepared for a broader scope when they graduate.

"They know they're comprehensively trained and they're passionate to go out and do it," she said. "I graduated about 30 years ago, and I would have exactly the same perspective as these residents."

What has happened in the current climate is that there are forces, including poor payment to family physicians, credentialing issues, and fragmentation of care, that have narrowed scope, she said.

Practices also shift over time as to what care is practical for physicians to offer financially and desired by their patients. Sometimes physicians are very capable of performing a procedure, but the clinic cannot afford the equipment, she said.

"Often, your practices ages with you," she said. "The practice group I see now requires much less [obstetrician] services than they did 30 years ago. But I might need to do more toenail removals."

She also hopes that the shift to value-based care will help the new graduates practice in a scope more closely aligned with their intentions.

"My hope is that we'll see a shift to more comprehensiveness, because that's an amazing value for the healthcare system.... But that will require paying differently for primary care and recognizing the value of that comprehensiveness."

The authors conclude that future research should follow the first-time certifiers to see whether their intentions hold true in practice over time.

"Tracking these intentions may make it possible to correlate them with health system reforms or alterations in family medicine residency training requirements," they write.

Dr Peterson and a coauthor are employees of the ABFM. Another coauthor was an employee of the ABFM during the study. Another coauthor's work at the ABFM was sponsored by the ABFM Foundation. Dr Filer has disclosed no relevant financial relationships.

JAMA. Published online December 8, 2015.

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