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Thursday Mar 22, 2012

Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training

During the past two years, all 12 of the residents who completed the family medicine program at the University of Nevada School of Medicine started their careers as employed physicians. They're not alone.

According to AAFP data, more than 60 percent of AAFP members are employed physicians, and more than 80 percent of new physicians -- those who completed residency within the past seven years -- are employed. Thirty years ago, employed physicians were a minority in family medicine, but a slow shift to the employed model during the past two decades has eroded our collective scope of practice.

That erosion has occurred because some employers dictate scope of practice. Many family physicians have taken jobs with hospital groups who need primary care physicians to coordinate outpatient medicine. They don't necessarily need FPs to provide obstetric or pediatric care.

A recent AAFP member survey indicates that fewer than 20 percent of AAFP members have hospital privileges for routine obstetric delivery, and fewer than 60 percent have privileges for newborn care. Those numbers are down from 25.7 percent and 64.7 percent, respectively, in 1995. According to the American Board of Family Medicine (ABFM), fewer than 10 percent of family docs are providing maternity care, and fewer than 42 percent perform in-office procedures.

These numbers likely will continue to decline as more of us take employed positions.

One of the factors that typically draws students to family medicine is the broad scope of practice. Traditionally, family medicine has offered us opportunities to do a bit of everything. We have treated and cared for entire families -- from cradle to grave. But many new physicians are finding that they can't do that.

Employers are just one factor contributing to the problem. Restrictions on duty hours have reduced residency training and experience, leaving new physicians feeling less prepared for practice than in previous generations.

Although many small towns and rural areas continue to need primary care physicians who can provide a wide range of services, the percentage of family physicians taking those kinds of jobs is small. Fewer than 20 percent of AAFP members practice in rural areas, down from 31.7 percent in 1994.

And even rural areas aren't immune to these changes. According to the ABFM, more than 70 percent of family physicians -- regardless of whether they practiced in urban areas, rural areas or areas with health care professional shortages -- were "attending to the specialized needs of women" in 2003. By 2010, the percentage of physicians in all three categories who offered those serviced had dropped to less than 50 percent.

These are troubling trends. We have advocated against expanding the scope of independent practice for nurse practitioners (NPs), but if family physicians aren't providing pediatric care or maternity care or doing procedures or inpatient care, how do we differentiate ourselves from NPs or any other health care professionals?

As more residents are becoming outpatient docs, we have to ask ourselves:

  • Where are we going with training?
  • What needs to be done with curriculum design?

I recently attended the Association of Departments of Family Medicine (ADFM) winter meeting. Half of a day of the four-day event was dedicated to scope-of-practice issues. The Council of Academic Family Medicine, which includes the ADFM, is in the process of evaluating training and curriculum. Meanwhile, the ABFM is surveying test takers about what skills are truly needed by family physicians.

The aforementioned reduction in training time coincides with an ever increasing amount of complexity in the specialty. Patients are living longer while coping with more chronic conditions. Meanwhile, physicians are expected to be more tech savvy, implementing electronic health records and transforming practices to the patient-centered medical home model. How do we teach everything in a condensed time frame?

One potential solution is expanding residency programs to four years. The extra year would make up for time lost to work restrictions and give residents a chance to develop an area of concentration. The Accreditation Council for Graduate Medical Education has announced a pilot to examine length of training, and a call for proposals(www.acgme.org) was released March 16. Up to 25 residency programs will be selected for a pilot scheduled to begin in July 2013.

The AAFP needs to be involved in these important discussions, and the Academy needs to know what members think. So I pose these questions to you:

  • Is it important to you that your Academy advocate for full scope of practice?
  • Should we instead move forward, focusing education and training on outpatient adult medicine and population management issues?

The AAFP Board of Directors is expected to discuss this issue at its May meeting. Your input here could help inform that discussion.

Daniel Spogen, M.D.of Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a professor and chairman of the Department of Family and Community Medicine and director of medical education at the University of Nevada School of Medicine.

Posted at 11:37AM Mar 22, 2012 by Daniel Spogen, M.D.

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