• Robert Graham Center Research

    Should Fewer FPs Providing Hospital Care Cause Concern?                                  

    November 19, 2019, 04:13 pm Sheri Porter – New research from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care shows the provision of inpatient care by family physicians dropped by 26% between 2013 through 2017.

    young physician and older patient

    The policy brief, titled "The Declining Presence of Family Physicians in Hospital-Based Care," was published in the November-December issue of the Journal of the American Board of Family Medicine.

    Key Findings

    Researchers used data collected for the American Board of Family Medicine Certification Examination application questionnaire to analyze hospital trends.

    Specifically, they found that of the 46,762 physicians who responded to questions about specific services provided during that five-year period, the percentage of family physicians who reported providing inpatient care decreased from 34.1% in 2013 to 25.2% in 2017.

    In a Nov. 12 press release, about the study, corresponding author Anuradha Jetty, M.P.H., said, "Policymakers, payers and leaders in medical education should closely track the impact of these trends, given previous evidence associating better cost and utilization outcomes with broader scope of practice."

    The researchers said the study adds to a growing body of evidence that scope of practice is contracting across what once were traditional family medicine domains, including prenatal care, home visits, nursing home care and obstetrics.


    "Theoretically, continuity of care across settings translates to better health outcomes for patients," wrote the authors. "As the proportion of family physicians providing inpatient and outpatient services shrinks, we need better research on the impact that practicing across settings may have on patients and health systems."

    Companion Commentary

    Peter Carek, M.D., M.S., a professor and chair of the Department of Community Health and Family Medicine at the University of Florida College of Medicine in Gainesville, authored a companion commentary titled "Declining Presence of Family Physicians in Hospital-Based Care: A Major Concern or Totally Makes Sense?"

    In his piece, Carek discusses possible factors associated with the decline.

    "The potential forces behind this change are most likely numerous and multifactorial, considering the complexity of our health care system and evolving needs of patients, communities and physicians," he wrote.

    Carek detailed residency training factors, health system influences, individual family physician preferences, and community and population needs.

    Notably, he wrote, the Accreditation Council for Graduate Medical Education Review Committee for Family Medicine guidelines have been consistent between 2014 and 2019 in requiring that residents have at least six months of inpatient care experience and maintain continuity of patients across care settings, including hospitals.

    But even though the amount of time residents spend in the hospital setting has remained stable, other factors have not, said Carek. For instance, fewer patients may be available for care, and limits on duty hours may affect the continuity of care residents provide.

    Also, a greater emphasis on outpatient care may be influencing residency program graduates' overall experience with inpatient care "in such a manner as to decrease their ability or willingness to provide hospital care," he added.

    Carek said previous research found that declining inpatient care from generalists is not a case of hospitalists keeping generalists from providing inpatient care so much as it is one of an increasing number of generalists -- and declines in both the number of patient hospitalizations and hospital lengths of stay.

    Those factors combined "reduced the volume of, and probably the incentives for, generalist inpatient activity over the year just before the rapid growth of hospitalists," he said.

    Furthermore, Carek noted that 54% of family physicians are using hospitalist services, and many FPs now focus only on providing outpatient care.

    He pointed to recent CDC data that shows that the volume of patient visits to physicians' offices (883,725,000 in 2016) overwhelmingly outnumbers hospital admissions (35,061,000 in 2015). "Due to the scale of these differing numbers and a host of other factors, … the community may be requiring the FP to spend more time addressing ambulatory medicine and, as a consequence, less focus on inpatient care."

    Thus, Carek surmised, the trend in FPs providing only outpatient care "is logical and reasoned."

    Next Steps

    In an interview with AAFP News, Carek explained that the factors used to measure the comprehensiveness of the care provided by a family physician may change, "but the underlying need for a family physician to provide comprehensive primary care does not."

    More research is needed to determine which factors primary influence the decline of hospital-based care among family physicians, as well as what services patients need their physicians to provide, he said.

    Carek also identified the tipping point in this shifting landscape that, if reached, would be cause for alarm.

    "Family physicians need to be trained in inpatient care and they need to be involved, in some manner, when their patients are hospitalized in order to ensure the best overall care is provided.

    "When the shift away from inpatient care affects either of these activities, then this trend will have evolved into a major issue for the specialty," he said.