Research findings published in the January issue of Annals of Family Medicine add weight to a growing body of evidence that family medicine's scope of practice is being eroded.
And it's not due to a lack of clinical training.
Authors of the article,(www.annfammed.org) titled "Changes in Preparation and Practice Patterns Among New Family Physicians," noted that their study looked at the difference between preparation for practice and scope of practice among new family medicine residency graduates in 2000 and again between 2012-2014.
Specifically, researchers Amanda Weidner, M.P.H., and Frederick Chen, M.D., M.P.H., of the Family Medicine Residency Network, University of Washington Department of Family Medicine in Seattle, conducted a retrospective cross-sectional study that compared responses of two cohorts of new family physicians who completed surveys some 12-14 years apart.
- New research shows that the scope of practice in family medicine is narrowing even though residents say their training is more comprehensive.
- Women's health showed some of the most significant training versus practice changes in areas such as vaginal and cesarean delivery and colposcopy.
- Other significant swings were seen in inpatient medicine, intensive care and emergency care.
Survey questions probed graduates of the University of Washington Family Medicine Residency Network to discover how prepared they felt for practice and what sorts of skills they actually were using in practice.
"We found that the recent cohort of graduates felt more prepared for practice than their earlier counterparts, but that the recent graduates had a much narrower scope of practice than those who graduated before 2000," wrote the authors.
"This suggests that training has improved over the last decade; it also suggests that scope of practice is declining for reasons other than lack of training," they added.
A total of 293 residents from the 1996-1999 classes and 408 residents from the 2010-2013 classes of the University of Washington Family Medicine Residency Network and its affiliated programs in Washington, Wyoming, Alaska, Montana and Idaho (WWAMI)(wwaminetwork.org) responded to the surveys.
The surveys all had better than 70 percent response rates.
When it came to survey results, some of the biggest changes were seen in women's health care. For instance, prenatal care saw a 14 percent uptick in the preparation category between 1996-1999 and 2010-2013, but recorded a drop of 19 percent in the "Part of Practice" question during that time frame.
Other women's health services where training and practice patterns changed significantly were
- vaginal delivery (+20 percent in preparation, -25 percent in practice),
- cesarean-section delivery assist (+15 percent, -23 percent),
- newborn CPR (+16 percent, -8 percent),
- dilation and curettage (+4 percent, -13 percent), and
- colposcopy (+24 percent, -5 percent).
Significant swings occurred in other categories of family medicine services, as well, including
- inpatient medicine (+25 percent, -32 percent),
- emergency care (+17 percent, -26 percent),
- intensive care (+21 percent, -34 percent),
- nursing home care (+32 percent, -19 percent),
- surgery assist (+8 percent, -28 percent), and
- orthopedics (+20 percent, -18 percent).
The researchers also noted some possible explanations for their findings, including changes in clinical practice and evidence in the past 20 years -- as is the case with flexible sigmoidoscopy -- differences in practice size and type, and a trend toward practice in large multispecialty groups.
Corresponding author Weidner is a research scientist at the University of Washington and also serves as the deputy director of the Association of Departments of Family Medicine.(adfm.org) In an interview with AAFP News, she provided a more in-depth look at the study findings and discussed what they might mean for family medicine residency training in the future.
Q. Why is this an important topic for family physicians to consider?
A. If you are a family physician in training now, and you're being trained to do this really broad scope of care, it could be helpful to know that some people aren't doing many of these things anymore. It's interesting to have these reference points between two periods in history, and to see how family medicine practice has changed pretty significantly and pretty quickly.
Q. What did you find most surprising?
A. There were statistically significant differences in almost every category, and some of the change between the two cohorts in terms of services and procedures provided in practice was as much as 34 percent -- 38 percent in one case.
Q. Medical students often say they go into family medicine because they appreciate the scope of practice the specialty offers. How could these findings affect student choice?
A. That's one of things I keep thinking about. But we can't draw any conclusions about why this is actually happening from the data we have. We hypothesize that these changes are mostly on the system end of things -- meaning that the scope of practice is being restricted.
It's an open-ended question, and the answer depends, I suppose, on what kind of practice a potential future family physician is interested in -- the more traditional broad scope of care or a more narrow range of clinical offerings.
Q. What do you want readers to take away from this study?
A. If family physicians feel like they're not doing everything that they were trained for, they should know they are not alone. It's a pretty common thing that the scope seems to be decreasing across the board. But that doesn't mean they weren't trained well for a broad range of clinical services, and if that's what they want to do, we should find a way to fight for it.
Those who are in a position to do so should negotiate with their health systems to allow them to practice a broader scope of care and to get those privileges in a hospital setting.
Q. Aside from personal preferences, why is scope of practice important?
A. We know that when physicians broaden their clinical expertise, it's linked with all sorts of other positive things -- like continuity of care -- that is also associated with lower costs and higher patient satisfaction.
Q. What are the broader implications for residency training?
A. We're certainly not advocating that training programs decease their scope of training.
However, if we're not putting people into practice who are going to be using these skills, should we change our training to hone in on the skills people are actually using in practice? For instance, should we have a high-volume OB track for people who are sure they want to provide obstetrics when they practice -- versus an OB track for people who know they don't want to provide it, but it's good for them to have the exposure?
This is an idea that has been raised before.
The real question is, do you train the many for services that just a few are providing? I still think the answer is yes -- because I think there are other benefits that come with a broad spectrum of training. It helps physicians become a more prepared and competent physician overall.
Q. What are the next steps?
A. We need to know where health care systems are heading. That will determine whether residency programs need to adapt their training or whether we need to fight to ensure our family physicians are allowed to practice the full scope for which they have been prepared.
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