Factors Influencing Changing Scopes of Practice Among Contemporary Graduates of the Nation's Largest Family Medicine Residency.

Abstract

Background: John Peter Smith (JPS) Hospital Family Medicine Residency participated in both the P4 (Preparing the Personal Physician for Practice) and LOT (Length of Training) projects, and is known for its emphasis on preparing physicians for full-scope practice. Scope of practice outcomes among graduates of these programs are previously described, but how and why the scope of practice of these physicians change in their early career merits further exploration.

Methods: A structured questionnaire was sent to all JPS graduates who matriculated as interns in the years 2007 to 2016 with information on cognitive and procedural scope of practice. Graduates were asked about their scope of practice both in their initial jobs out of residency and their current jobs. They were also asked about the forces affecting their scope of practice with both structured and open-ended questions. Responses were analyzed quantitatively and through qualitative thematic analysis.

Results: A total 184 graduates provided information about practice scope. Graduates stopped providing inpatient care for children (9.2%), prenatal care (8.8%), long-acting reversible contraception (7.8%), ICU care of adults (7.8%), joint injections (7.4%), and inpatient care of adults (6.9%) at the highest rates between initial and current jobs. Scope of practice changes over time found to be statistically significant included inpatient care of children, ICU care of adults, inpatient care of adults, nursing home, substance use disorder including medication assisted therapy, and obstetric deliveries. The most common reasons for change were personal preference and work-life balance, rather than institutional and related systematic barriers.

Conclusion: In the graduates of one institution, it is common for the scope of practice to change over time, both by discontinuing and adding services. Changes seem most driven by choice and work-life balance, rather than outside pressures or a feeling of inadequate preparation for practice.