Conceptualizations of Family Physician Scope of Practice in

Conceptualizations of Family Physician Scope of Practice in Ontario Sophia Kam, MA Elizabeth Wenghofer, Ph. D CPE Spring Meeting Winnipeg, Manitoba May 31, 2013

Problem Statement � Physician scope of practice (SOP) perceived in various ways in different jurisdictions � Individual family physicians vs. legislators, medical regulators and educators (Baldwin et al. , 1999; Tulloh et al. , 2001; Probst et al. , 2002; Breon et al. , 2003) � Geography & variations in practice patterns (Jin et al. , 2003; Veugelers et al. , 2003; Konkin et al. , 2004; Hutten-Czapski et al. , 2004; Chan & Shultz. , 2005; Peterson et al. , 2005; CIHI, 2009) � Central to numerous elements of physician governance and practice (Norcini & Mazmanian, 2005, Health Force Ontario, 2006) � We don’t really know what SOP is (CPSO, DIALOGUE, Vol. 8 Iss. 1, 2012) � Assumption that SOP is entirely consistent with specialty certification (Melnick et al. , 2002; CPSO, DIALOGUE, Vol. 8 Iss. 1, 2012) � Changes in SOP throughout careers & assessment (Baldwin et al. , 1999; Tulloh et al. , 2001; Probst et al. , 2002; Breon et al. , 2003)

Hypotheses �There are two hypotheses: �(1) SOP is more than just education. It includes where physicians practice medicine (i. e. , it changes with the needs of their patient base, and the resources they may or may not have in their practice setting) �(2) Physician SOP will change over time, and will likely narrow as physicians grow older

Objectives �Broad - determine how different stakeholders concerned with various areas of physician governance and practice define and conceptualize family physician SOP in Ontario �Specific - determine the common conceptual elements of SOP, where the differences lie, and the implications of these commonalities and differences

Research Questions �(1)How is family physician SOP defined by/in: �(a) Ontario legislation? �(b) medico-legal liability issues? �(c) medical education? ; and �(d) professional regulations and licensing? �(2) How do individual family physicians define their SOP? �(3) What factors determine how family physicians define their SOP? �(4) How and why might these factors change?

Factors �Physician (Personal Provider) �Age �Gender �# of years in medical practice �Country in which medical training was received �Specialty certification �# of years practicing in their current setting

Cont’d �Organizational (Environmental) �Type of practice �Geographic setting/location �Patient base and associated needs �Available resources �Access to professional supports outside the primary practice setting �# of hrs/week in primary practice setting �# of patient visits/week in primary practice setting �Active hospital/teaching appointment �Focused SOP

Research Rationale �(1) Different practice scopes of family physicians, despite possessing common education and similar credentials (Smith & Hays, 2004; Wong & Stewart, 2010) �(2) Perspectives of SOP: medical profession vs. individual practitioners (Melnick et al. , 2002) �(3) Potential to redefine and reconceptualise SOP based on reassertions of factors influencing this concept in the literature (Klass, 2007)

Methods, Data Collection & Procedure � Purpose: Phase I �Evaluate how scope of practice is currently defined in regulatory and liability legislation �(TEXTUAL ANALYSIS VIA DOCUMENT REVIEWS) �PHASE I �Internet search of major federal and provincial policy statements on SOP (i. e. , MA, 1991; RHPA, 1991; AIT, 2012 – Ch. 7, CPSO Policy # 1 -08) �General search of medical literature re: definitions and concepts of term “SOP” via medical journals, books, internet �Literature search for concepts and definitions of SOP in different areas of physicians governance and practice

Cont’d �Purpose: Phase II �Examine current definitions of scope of practice in medical education, and professional governance and licensing �(DISCOURSE ANALYSIS, SEMI-STRUCTURED KEY INFORMANT INTERVIEWS, FOCUS GROUPS) �PHASE II �Semi-structured key informant interviews & focus groups �Federal and provincial medical associations (i. e. , CMPA, CMA, OMA) �Regulatory bodies (i. e. , FMRAC, CPSO) �Certification bodies (i. e. , CFPC) �Education bodies (i. e. , AMFC)

Cont’d � Purpose: Phase III & Phase IV �Assess how individual family physicians conceptualize their own practice scopes �Assess what factors influence this �Assess how and why these factors might change � PHASE III �Survey designed � 2 week pilot test of survey instrument �Distributed & administered mail and online � 8 weeks from initial distribution to date of reply �Dillman’s Tailored Design Method – weeks 3 and 6 (Dillman, 2007)

Cont’d � Sample �Probability sampling (oversampling northern Ontario) � 4000 Ontario family physicians (CMA Masterfile, January 2012) �Approx. 600 responses estimated (~15%) � Inclusion Criteria �(1) Family physicians �(2) Completed the 2013 CPSO Annual Membership Renewal Survey �(3) Have a license to practice independently �(4) In independent practice for at least 5 years �(5) In “good standing” �(6) Primary practice address is in Ontario �(7) Consented to participate in this study

Cont’d �Exclusion Criteria �(1) RCPSC certified specialists not holding a license to practice family medicine �(2) Physicians who do not wish for their data to be released will be preliminarily excluded from the CPSO data feed �PHASE IV �Post-eight week period �Returned surveys examined �Rural practicing participants contacted & invited to further participate in follow-up focus groups

Data Analysis Plan – Quantitative Data �Part I �Descriptive analysis re: factors physicians use themselves (e. g. , Patients seen? Diseases treated? Practice structure, geographic location, etc? ) �SPSS – Descriptive statistics re: non-parametric items (demographic, “yes”/“no” questions). Frequencies re: most identified/popular definitions �Part II �Parametric testing, logistic regression re: perceptions of breadth of practice scopes (e. g. “above average, ” “about right/on par, ” “more focused”) – outcome variable

Study Limitations �The influence of legislation and other policies and regulations that impact physician SOP will be jurisdictionally specific �Specific practice contexts in areas not included in the study may differ. Results may have limited applicability for those areas �Defining the scope of a profession is difficult & defining SOP with any level of detail may be impossible (CPSO, DIALOGUE, Vol. 8 Iss. 1, 2012) �An attempt to define SOP may be more feasible for specialties other than family medicine (CPSO, DIALOGUE, Vol. 8 Iss. 1, 2012)

Regulator Considerations Re: Defining/Limiting SOP � Feedback from CPSO consultation with profession includes: �Potentially good for public protection �Could help with resource planning �Must account for different practice needs in northern and rural areas �Would such an endeavour make a difference? �Concern that a consequence could be to limit SOP more narrowly � (CPSO, DIALOGUE, Vol. 8 Iss. 1, 2012) � Unintended consequences of defining SOP too narrowly? � Breadth vs. depth of knowledge expected of physicians & accountability (Melnick et al. , 2002; Klass, 2007)

Relevance & Implications of Expected Results �This study will challenge current concepts of SOP �Have direct relevance for quality of care � Baldwin et al. , 1999; Tulloh et al. , 2001; Probst et al. , 2002; Breon et al. , 2003 �This study can address the lack of clarity regarding the concept of SOP �Contribute to public consultations within Ontario’s medical profession �Numerous practical and policy implications of this research

When Conducting this Research, the Following Will be Encouraged… �The methods encourage: �Physicians to personally conceptualize SOP (may differ from medical regulators and educators) �A balanced perspective of SOP with an emphasis on physician voices �The generation of a practice and evidence informed definition of SOP to be considered in legislation and medical education

References � � � Baldwin, L. M. , Rosenblatt, R. A. , Schneeweiss, R. , Lishner, D. M. , & Hart, L. G. (1999). Rural and urban physicians: Does the content of their medicare practices differ? Journal of Rural Health, 15(2): 240 -251. Breon, T. A. , Scott-Conner, C. E. , & Tracy, R. D. (2003). Spectrum of general surgery in rural Iowa. Journal of Current Surgery, 60(1): 94 -99. Canadian Institute for Health Information. (2009). Health Indicators. Ottawa, ON: CIHI, 1 -138. Canadian Medical Association. (January 2012). CMA masterfile: Number of physicians by province/territory and specialty, Canada, 2012. Ottawa: Canadian Medical Association. Retrieved from: http: //www. cma. ca/multimedia/CMA/Content_Images/Inside_cma/Statistics/01 Spec&Prov. pdf. Chan, B. T. & Shutlz, S. E. (2005). Supply and utilization of general practitioner and family physician services in Ontario: ICES Investigative Report. Toronto: Institute for Clinical and Evaluative Sciences. College of Physician and Surgeons of Ontario (2012). “Defining Scope of Practice: College Explores possible solution to “practice drift. ” Dialogue, Vol. 8, Iss. 1: 9 -12. Dillman, D. A. (2007). Mail and internet surveys: The tailored design method. Second edition. New York, New York: John Wiley & Sons, Inc. Health Force Ontario. (2006). Entry to practice requirements for health care professionals outside Ontario. Retrieved from: http: //www. healthforceontario. ca/Work/Outside. Ontario/Physicians. Outside. Ontario/Practice. Requirements. aspx. Hutten-Czapski, P. , Pitblado, R. , Slade, S. (2004). Short report: Scope of family practice in rural and urban settings. Canadian Family Physician, 50: 1548 -1550. Jin, Y. , Marrie, T. J. , Carrier, K. C. , Predy, G. , Houston, C. , Ness, K. & Johnson D. H. (2003). Variation in management of community-acquired pneumonia requiring admission to Alberta, Canada hospital. Epidemiol Infect. , 130(1): 45 -51. Klass, D. (2007). A performance-based conception of competence is changing the regulation of physicians’ professional behaviour. Academic Medicine, 82(6): 529 -535.

References � Konkin, J. , Howe, D. & Soles, T. L. (2004). Society of Rural Physicians of Canada, SRPC � � � � Policy Paper on Regionalization. Canadian Journal of Rural Medicine, 9(4): 257 -259. Melnick, D. E. , Asch, D. A. , Blackmore, D. E. , Klass, D. J. , & Norcini, J. J. (2002). Conceptual challenges in tailoring physician performance assessment to individual practice. Medical Education, 36: 931 -935. Norcini, J. J. , & Mazmanian, P. E. (2005). Physician migration, education, and health care. Journal of Continuing Education in the Health Professions, 25(1): 4 -7. Peterson, S. , Shapiro, E. & Roos, N. P. (2005). Regional variation in home care use in Manitoba. Can J Aging, 24 Suppl 1: 69 -80. Probst, J. C. , Moore, C. G. , Baxley, E. G. , & Lammie, J. J. (2002). Rural-Urban differences in visits to primary care physicians. Fam Med. , 34(8): 609 -615. Smith, J. , & Hays, R. (2004). Is rural medicine a separate discipline? Australian Journal of Rural Health, 12: 67 -72. Tulloh, B. , Clifforth, S. , & Miller, I. (2001). Caseload in rural general surgical practice and implications for training. ANZ Journal of Surgery, 71(4): 215 -217. Veugelers, P. J. , Yip, A. M. & Elliot, D. C. (2003). Geographic variation in health services use in Nova Scotia. Chronic Dis. Can. 24(4): 116 -123. Wong, E. , & Stewart, M. (2010). Predicting the scope of practice of family physicians. Canadian Family Physician, 56: e 219 -e 225.

Thank You! � Questions? �I would greatly appreciate your feedback! �skam@laurentian. ca �sophie. kam@alumni. utoronto. ca