May 25, 2018, 08:59 am Michael Devitt – Scope of practice has been an area of concern for family physicians for some time. This is especially true for FPs who practice in rural settings -- where full-spectrum physicians are needed most, but where limited resources, low reimbursement rates and shifting patient demographics can create undue stress and present formidable challenges to serving a community's needs.
Despite overwhelming demand for health care professionals who possess the skills to treat a wide range of patients and conditions, survey results indicate considerable differences between the services family physicians can provide and the services they actually do provide. But why? What causes some rural FPs to limit their scope of practice and others to maintain a broad scope?
Those questions were the subject of a qualitative study published in the May 2018 issue of Family Medicine. The purpose of the study was to determine what factors lead family physicians to practice in rural settings in the first place, and what factors contribute to the decision to limit what they practice.
In the study, researchers posited a series of questions about scope of practice to 21 "key informants" in eight states who had indicated their intention to practice full-spectrum rural family medicine when they first entered residency. Eight participants were still in their third year of residency, while the remaining 13 were practicing physicians at least four years out of residency. At the time of the interviews, 18 participants were practicing in rural or semirural areas; the other three practiced in urban areas.
Researchers identified two broad categories of factors that shaped a family physician's choice and maintenance of scope over the course of his or her career. Developmental factors pertained to points in the trajectory of a physician's career, and included the scope envisioned at the start of residency, the scope currently being practiced and the scope the physician would ideally practice in the future. Contextual factors were external elements that influenced a physician's practice considerations, and included the national health care landscape, practice setting and personal concerns.
With regard to developmental factors, before entering residency, the participants envisioned themselves performing a very broad scope of practice. This scope narrowed as the participants reached their current position, and they anticipated it would continue to do as they advanced toward retirement.
Contextual influences on scope of practice occurred at the national/regional, local and personal levels.
Randall Reitz, Ph.D., the study's corresponding author, told AAFP News that the participants' responses both reinforced and challenged his group's assumptions about rural FPs.
"We expected to hear from a large percentage of family physicians who described dissatisfaction from external pressures and reduced scopes of practice. While we found that family physicians typically reduced scope over time, none of them reported a sense of enduring loss in job satisfaction as a result," he said.
In general, the interviews indicated that scope of practice narrowed as a family physician moved away from working in hospitals and emergency departments, and progressed toward clinical medicine and working in larger health systems. However, most physicians also remained active in at least one area outside ambulatory medicine.
Most of those interviewed said they were satisfied with choosing family medicine as their specialty and were happy with their current scope of practice, although a number of participants reported experiencing "seemingly unsustainable demands on their time and expertise" that could affect the range of their future scope. Reitz explained that some physicians chose to reduce their scope because the services and knowledge associated with the multiple areas of a full-spectrum scope often competed with one another for the FP's time and attention.
"For example, a physician who limited her practice to clinical medicine would have a more manageable schedule and fund of knowledge than a physician who needed to carve out time and study to maintain obstetrical and inpatient services. Over time, some concluded that reducing scope of practice was the sustainable path of least resistance," Reitz said.
The participants reported having only limited opportunities to reclaim an area within their scope of practice once they relinquished it. However, taking on new projects or leadership roles within the health system or community seemed to offset this issue by opening other areas for personal and professional growth. Reitz described this as "a natural process" of FPs choosing to align their careers in keeping with the desire for work/life balance and the needs of their communities.
Professional autonomy also seemed to help some physicians. Although many experienced large shifts in scope during their career, they reported some satisfaction by being able to adjust to these changes at their pace and as they were ready.
So what do the data say about the state of family medicine in general, and rural family medicine in particular? It depends.
"The good news from our data is that our participants described a high level of satisfaction with their career choice and with their autonomy to shape their careers to fit their preferred lifestyle," Reitz said.
On the other hand, the comments also support research indicating that physicians are transitioning away from owning and operating independent practices to working in larger health care systems as part of a care team. Reitz told AAFP News this same trend was observed in rural settings, and often was described as a positive development that supported rural FPs through increased resources and less isolation. "This evolution tended to come with a reduced scope of practice, but none of the physicians we interviewed expressed dismay about this development," he said.
But the choice to limit one's scope could result in other consequences that were not addressed in the study. For example, patients in rural areas with no primary care physician may have reduced access to some types of services and may not receive the same quality of care as those living in urban areas. Similarly, family physicians who transition from rural settings may not have the same feeling of connection with their community, and may not experience the same variety and professional challenges associated with a broader scope of practice.
Based on the results, Reitz predicted that internal and external forces would continue to influence family physicians to reduce their scope of practice in the future. These included desired lifestyle, maintenance of manageable boundaries, desire for leadership opportunities outside of clinical practice, expansion of team-based practice models, reduced isolation and increased patient access to subspecialists.
One concern was the small number of physicians interviewed. With eight participants identified as residents, this meant that the researchers were able to communicate with just 13 practicing physicians who could make direct decisions about their scope of practice. Even then, some of the factors that drive a physician's decision to provide full-spectrum care or to limit scope (such as hospital policies or health trends) may not be of their own choosing or within their control.
Because of the small number of FPs and residents interviewed, the researchers admitted it was virtually impossible to know if their comments represented the views of all family physicians who imagined working in a rural setting while also offering a full-spectrum practice. They concluded that additional research would be useful in replicating their findings. They suggested conducting similar interviews with larger groups of FPs and noted that the study results could be useful as an advocacy tool for those promoting full-spectrum and rural family medicine services.