The focused FP

When Dr. Alan Kaplan started out as a family physician, he did a lot of time in the ER. There, he saw a lot of acute asthma. “It frustrated me that people were getting that sick, life-threateningly, with seemingly no plan,” said Dr. Kaplan, who works in Richmond Hill, Ont. Out of “interest and necessity,” he became involved in educational programs related to asthma, and soon began focusing on all respiratory issues. Later, after attending lectures on pain management, a strong interest in that area developed too, and it became a second area of focus. “There was such a need,” he said. “Patients started to find their way to me and then a referral base occurred.” Today, he acts as a consultant on pain and respirology, while maintaining a small comprehensive practice. Read: Practice management: Staff job-sharing tips Dr. Kaplan is one of the thousands of family physicians who chose a narrowed focus for their practice. Some do it alongside a family practice, some exclusively. Some gather knowledge, education and experience independently and move into a focused practice, while others, especially residents, seek out Certificates of Added Competence in Family Medicine after a third year of focused residency. The College of Family Physicians of Canada (CFPC) confers certificates in emergency medicine, addiction medicine, care of the elderly, enhanced surgical skills, family practice anesthesia, obstetrical surgical skills, palliative care and sport and exercise medicine. Medical schools offer third-year training for some or all of these areas for residents to get the accreditations. It’s a trend that is growing, and one that has both its proponents and its detractors. These focused FPs combined with FPs who otherwise work outside of comprehensive family practice (such as working in the ER, virtual care and episodic medical care), many say, are contributing to the crisis in family medicine that has left 3.6 million Canadians without a family physician. At the same time, there are gaps in areas like palliative care and addiction medicine that are well-filled by these “sub-specialists.” BY THE NUMBERS The CFPC’s Family Medicine Longitudinal Survey (FMLS) data show that only about 50% of early-career family physicians report providing comprehensive care in two or more clinical settings (e.g., office, hospital, other). Fewer than 50% report providing intrapartum care, in-hospital procedures, and/or care to marginalized and disadvantaged populations. Just over 25% report working in a focused practice. Findings from the FMLS indicate that approximately 30% of medical students entering family medicine residency are intent on focused practice. Based on Canadian Medical Protective Association data, the proportion of physicians working in family medicine or general practice who include obstetrics, anesthesia, surgery and work in emergency departments, has been decreasing over the past 12 years. Read: Live longer, retire longer B.C. PERSPECTIVE According to the College of Physicians and Surgeons of B.C., there are about 6,800 family doctors licensed to practice in the province, and 3,500 who are doing community-based longitudinal family medicine. “Rather than there being a shortage of family doctors in B.C, we really need to think about it as a shortage of family doctors doing longitudinal family medicine,” said Dr. Renee Fernandez, executive director of BC Family Doctors, noting that the rest are in focused practice, emergency medicine, walk-in clinics, virtual care or assisting in other places. The question, says Dr. Fernandez, is, why? Some focused practitioners are truly filling a need in the community and have a passion for areas like addiction medicine, palliative care, mental health, obstetrics, etc. Others, she said, see the lack of support for longitudinal practice and steer clear. “There’s good survey data about this and it has to do less with their training and what they are taught to do and more around the lack of system supports to truly be a longitudinal family doctor in B.C.,” she said, adding that setting up a practice is analogous to asking teachers who graduate to find and lease a space, fund a school, hire all staff and purchase all the equipment to run the school. “Those newer-to-practice physicians are telling us they want to focus on taking care of patients, but that they don’t believe that should come at the exclusion of having a family life,” Dr. Fernandez continued. “They want to be able to take parental leave, take a vacation, or stay home when they or their family members are sick—while knowing their patients will continue to have needed care. Currently in B.C., none of those basic employment conditions exist for family doctors.” In addition, she said, B.C.’s fee-forservice model is an issue—as is the administrative burdens of paperwork, which can be lighter in a narrowed practice. The CFPCs most recent report on the outcomes of training project entitled, “Preparing our Future Family Physicians: an educational prescription for strengthening healthcare in changed times,” suggests that the reasons for decreasing comprehensiveness of care in early-career family physicians is mostly related to educational exposure, lack of self-confidence and personal interest, rather than the state of family practice. Read: Five clinical pearls: Hair beware “While our graduates are deemed competent to practice comprehensive family medicine (i.e., FM in more than one context—namely clinic, in-patient care, ER, obstetrics, long-term care, etc.—many do not feel ready for this broad style of practice after two years of training,” said Dr. Kath Stringer, head of the department of family medicine at Dalhousie University, which offers training related to four of the CFPC Certificates of Competencies, plus “Category 2” focused programs, which are adapted for recognized local community need. “They do also face barriers because of the lack of opportunities to work in well-supported team-based community clinics, so they may be choosing teambased options of in-patient care instead,” said Dr. Stringer. “Family physicians in community-based clinics are managing more patients with an increasing number and complexity of concerns in the context of an aging population and pressures placed on the healthcare system by the pandemic. Community clinic-based family physicians are often left alone without the support of a team to manage these patients.” Dr. Stringer said that development of well-supported community-based primary care teams with everyone working to their maximum scope of practice is needed to entice early career physicians back to comprehensive practice. “At present, many family physicians may feel unsupported and burned out, which is not a good environment for trainees to be exposed to. Where these teams do exist, they help to create positive learning environments and are more likely to positively influence career choices in this area,” she said. ONTARIO PERSPECTIVE Dr. Kamila Premji is a family physician practising in Ottawa, who is also a PhD candidate in the family medicine department at Western University, researching access to primary care and the family physician workforce. “We know that right now of all of our (Ontario) family physicians, only about 70% are practicing in comprehensive family practice.” Dr. Premji pointed to research that found that compared to 2008, over two times more of the younger cohort in Ontario are choosing other options than comprehensive family care; more than three times of the older FP cohort are making that choice today, compared to 2008. “It’s definitely a trend,” she said. “So what it means is that when we’re planning for our workforce, we have to keep in mind that not everybody we train to be a family physician is going to be going into family medicine. We need to figure out why and address that problem, because it’s clearly worsening over time . . . there’s something not attractive about family medicine, and we actually see this shift away from comprehensive, cradle-to-grave family medicine. Dr. Premji said that combined with fewer Canadian medical students choosing a family medicine residency (from about 37% in 2015 to 30% now, according to CaRMS), and the large swath of doctors nearing retirement age, it is an issue that urgently needs addressing. “We know that the foundation of any high-performing healthcare system is primary care, and the type of primary care is that longitudinal physician-patient relationship. So we know that that relates to better health outcomes for patients, including fewer hospitalizations, fewer deaths,” she said. Dr. Fernandez agreed: “We’re certainly hearing from our specialist colleagues that the lack of family physicians providing that longitudinal continuous care to patients is resulting in worse health outcomes. NEED BEING FILLED While concerns grow about narrowed practices, there is a positive side. “For a lot of these family physicians who are choosing to do this, it’s because the need exists that’s not being filled,” said Dr. Roy Wyman, director of Certificates of Added Competence (CAC) at the CFPC. “So, a perfect example would be enhanced surgical skills, or C-sections, or family practice anesthesia, these roles can’t be filled or aren’t being filled in rural environments,” he said. “Also there is clearly a need for palliative medicine across the country. And a lot (of FPs) will try to balance comprehensive with CAC or focuseddomain practice.” Dr. Wyman works as a comprehensive FP in a family team practice in Toronto, where focused physicians (or partially focused) support one another where needed. “That kind of patient medical home model is the ideal vision and what we’re hoping for with CACs.” Dr. Kaplan agreed. “In other parts of the world, like the U.K., there are ‘GPSIs,’ that is, GPs with special interest, and they help colleagues with certain issues, which subsequently lessens the load on consultants.” A patient might need a rheumatologist for a complex inflammatory joint disease—but not for a joint injection. At the same time, Dr. Kaplan cautions young physicians who might think the focused route is necessarily easier or better than comprehensive care. “Do it if you love it, not because you think it is a shortcut. The pay is not better. The work is not easier, just different . . . and more goal-oriented. Doctors are frustrated by the endless paperwork. Frankly, doing specialized care actually increased my paperwork,” he said. “It is quite a lot of work to become ‘specialized,’ but it is a nice option for those who are burned out of daily practice woes, as long as they have a passion for the special interest.” HUMAN BEINGS, TOO To ensure that new graduates feel comprehensive family practice is a viable, sustainable career option, advocates like Dr. Premji and Dr. Fernandez say the model needs to change and supports need to be added. What we’re saying is the system needs to recognize that family doctors are not only healthcare providers—we’re human beings. We need the same human supports and working conditions that others do, too,” said Dr. Fernandez. “Many of the physicians who are doing things other than communitybased longitudinal family medicine have said that their heart remains with that type of care. And, while certainly not all of those physicians will return to longitudinal family medicine if the supports were to improve, there is a proportion who would,” she said. “We want to support those family doctors to be doing the things that they do best, which is providing longitudinal relationship-based care to patients.”

The focused FP

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