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We describe changes in the comprehensiveness of services delivered by family physicians in 4 Canadian provinces (British Columbia, Manitoba, Ontario, Nova Scotia) during the periods 1999-2000 and 2017-2018 and explore if changes differ by years in practice. We measured comprehensiveness using province-wide billing data across 7 settings (home, long-term care, emergency department, hospital, obstetrics, surgical assistance, anesthesiology) and 7 service areas (pre/postnatal care, Papanicolaou [Pap] testing, mental health, substance use, cancer care, minor surgery, palliative home visits). Comprehensiveness declined in all provinces, with greater changes in number of service settings than service areas. Decreases were no greater among new-to-practice physicians. Key words: comprehensive health care; scope of practice; primary care; family medicine; cohort effect; Canada https://doi.org/10.1370/afm.2945, INTRODUCTION Declining comprehensiveness of family physician practice has been documented across multiple jurisdictions, (1-8) with accompanying speculation that this is driven by lack of interest or inadequate training among more [...]

Context: It is becoming more difficult to find a family physician in Canada. This has led to speculation that new family physicians may be to blame because they are more likely to provide lower service volume and less likely to provide longitudinal primary care. Objective: To investigate the impact of graduation cohort on family physician practice volume and continuity of care over two decades. Study Design and Analysis: Retrospective-cohort of family physicians from 1997/98 to 2017/18. Median polish analysis of patient contacts and physician-level continuity was completed to isolate years in practice, period, and cohort effects. Dataset: Administrative health and physician claims data were collected in British Columbia, Manitoba, Ontario, and Nova Scotia, Canada. Databases included registry files from provincial regulatory colleges, physician billing information, and patient registration files for provincial insurers. Population Studied: All physicians registered with their respective provincial regulatory colleges with a medical specialty of family practice and/or billed the provincial health insurance system for patient care as FPs. Outcome Measures: Patient contacts (count of unique patient-physician day combinations) and physician-level continuity (proportion of total annual contacts--excluding ED visits--that all patients seen by an FP had with that FP). Results: Median patient contacts per provider fell over time in the four provinces examined. In all provinces, median contacts increased with years in practice until mid-to- late-career and declined into end-of-career. We found no relationship between graduation cohort and practice volume or FP-level continuity. Conclusions: Declines in service volume were observed in all provinces, with expected trajectories of service volume and continuity over a FP's career. We found no generational differences in FP practice. These findings are important for health workforce planning in primary care sectors across the country, and for the general discourse concerning the behaviours and preferences of recent medical graduates. Our findings highlight that intergenerational tension and blame is unfounded and only distracts from important issues in workforce planning in primary care sectors., Presenters David Rudoler, PhD, Agnes Grudniewicz, PhD, Ruth Lavergne, PhD, Emily Gard Marshall, PhD, MSc, Laurie Goldsmith, [...]

Abstract Background Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support. Methods Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience. Results Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician. Conclusions Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants’ accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery.

Context: There is growing concern that delivery of primary care is becoming less comprehensive and that new family physicians may be moving away from comprehensiveness as the cornerstone of their approach to care. However, understanding what is meant by "comprehensiveness" is key to ascertaining the current state of primary care delivery. Objective: To report on how family medicine residents and early career family physicians describe comprehensiveness in primary care. Study design and analysis: Thematic analysis of interview data from the main qualitative strand of a broader mixed-methods study exploring early career family practice patterns. Setting: Canadian family medicine in British Columbia, Ontario, and Nova Scotia. Population studied: Family medicine residents (n=31) and family physicians in their first 10 years of practice (n=63). Results: Participants described comprehensiveness in multiple, rich, and varying ways. These descriptions reflected two general views of comprehensiveness: one centred on operational dimensions of care delivery and one centred on philosophy of care. Operational descriptions focused on services offered, patient population, care settings, and delivery models. Some operational descriptions were unidimensional (e.g., services offered), while others included multiple care dimensions (e.g., services, settings, and patient population). Philosophy of care descriptions centralized the patient, viewing comprehensiveness as care that considered the "patient as a whole"--looking at a person in their entirety, rather than only their presenting conditions, and rendering care that best meets their broader needs. Cutting across these two views of comprehensiveness are considerations of context (e.g., urban/rural) and whether comprehensiveness is considered at the level of the patient, population, individual clinician, or team. Conclusions: Participants' descriptions of comprehensiveness revealed that some view it primarily in terms of care components (e.g., services, populations), while others view it as a philosophy of care. Regardless of the lens, participants' descriptions portray comprehensiveness as nuanced, variable, and sensitive to practice and patient population contexts. Understanding how residents and clinicians think about comprehensiveness is important for policymakers and educators seeking to support ongoing delivery of comprehensive primary care. [ABSTRACT FROM AUTHOR]