Three key and three minor themes of influential factors that helped explain participants’ decisions to pursue focused practice were identified. Key themes were prominent across both resident and early-career FP datasets, while minor themes were less salient in the data.
Self-preservation within the current structure of the healthcare system
Both participant groups described issues within the healthcare system that influenced their choices of focused practice, specifically with regards to remuneration and workload. Certain physician remuneration models, such as fee-for-service, deterred participants from practising comprehensive family medicine. Fee-for-service was seen as inadequate compensation for the long hours, workload, and overhead costs associated with longitudinal care for increasingly complex patients. One resident FP elaborated:
‘It’s a bit of a crisis. I feel like a lot of physicians are burnt out … And, you know, documentation also takes up time with forms and everything. And I feel like … that’s not really being considered. And when it comes to the fee-for-service model, that’s why I don’t think it would work for me just because patients are a bit more complex than they used to be … Like I don’t think you should be rushing through your patients or just having single issue appointments … So I think when they’re [the government] making their policies and doing the compensation and payment plans, I’d like to see them sort of consider that …’
(R14, Nova Scotia)
In contrast, focused practice was seen as more attractive and sustainable because of better compensation and fewer administrative costs. The early-career FPs in this study described policies governing primary care delivery in all three provinces as contributing to heavy workloads and concerns about burnout. Similarly, resident FPs relayed observations of FP mentors being overworked, inadequately remunerated, and having difficulty securing time off in comprehensive family medicine practice. In contrast, both participant groups felt that focused practice offered better remuneration and flexibility to choose hours worked, allowing more time for family commitments, hobbies, or parental leave. A resident FP highlighted the advantages to focused practice:
‘Overhead is not something that you have when you work as a hospitalist … So you definitely make more money than you would in a clinic setting in a big city … the main thing about hospitalist work is that again it doesn’t come attached with you taking care of an office, of a staff … And then once you’re done your week of work, you don’t have the patients to follow after that.’
(R2, British Columbia)
Resident and early-career FPs also saw parental leave as incompatible with comprehensive family medicine practice. An early-career FP summarised the obstacles presented by parental leave:
‘If I were to take something like maternity leave … you don’t want to have 2000 patients [in a comprehensive family medicine practice] and then have to go off for a year … or however long you’re on maternity leave. And so that would make me … kind of think like do I actually want to take on patients? Or is that something I’d want to do after, you know, in ten years when I feel like I’ve had a family and I’m back to working full time? Or is it something that I just don’t want to do because as soon as you have a roster of patients, it makes it very difficult to leave or to move or to change your mind as much … Like I would like to have more flexibility in terms of taking time off … And finding locums is a little challenging …’
(FP26, British Columbia)
Other challenges described by both participant groups in reference to parental leave in comprehensive family medicine practice included perceived resentment from patients for time off and interruptions in patient continuity of care.
Further, early-career FPs with focused practices described feeling pressured during their training to work in what they considered an antiquated FP role. They shared that instructors put emphasis on a traditional paradigm of comprehensive family medicine practice that involved working around the clock to serve patients and that this was the best way to practise. An early-career FP explained this further:
‘There’s such a huge generational gap in medicine. And you know, the generation that by and large is training us just doesn’t see another way to be … But they truly think … that people doing focused practices are providing inferior care … This generation of doctors, we’re not lazy and we don’t not care about patients. We’re just not willing to ruin the rest of our lives for the career. And it’s self-preservation. We care about people too. We [are] also not willing to lay down our lives for the system.’
(FP4, British Columbia)
Early-career FP participants perceived these traditional comprehensive FP roles as unachievable for current and future levels of patient complexity and need, and detrimental to their wellbeing and families. Resident and early-career FPs alike expressed an unwillingness to sacrifice work–life balance, believing that policy reform was necessary for them to consider a broader scope of practice. Both participant groups were unanimously dissatisfied with provincial government policies and considered their governments to be unresponsive to their needs and undervaluing FPs.
Access to a support system
Resident and early-career FPs felt focused practice offered greater access to a support system compared with comprehensive family medicine practice. Both participant groups viewed call groups and team-based care environments within focused practice areas (for example, hospitalist medicine) as support systems that improved quality of care, facilitated knowledge sharing, and decreased isolation. One resident FP elaborated:
‘Working in hospitals, I think it’s a huge advantage over working in clinics in terms of multidisciplinary work. You know, in hospital, you basically have all the different specialties … Which is awesome and I kind of like that teamwork. Whereas clinics, when you work in a family practice office, unless it’s a big clinic and they have the multidisciplinary team, I find most clinics will have maybe one nurse or two … So yes, of course, I really like working with other specialists. I think it makes your life much easier and it helps us to provide better care. And it’s one of the reasons why hospitalist, for example, is more attractive to me.’
(R2, British Columbia)
These support systems facilitated self-preservation in the current health care system. Early-career FPs also described their peers as role models who demonstrated the feasibility of incorporating focused areas into their overall practices.
Training experiences
Both participant groups reported training experiences that increased their comfort with focused areas of practice and created recognition that the workload in comprehensive family medicine was not an ideal match for their desired lifestyle. An early-career FP illustrated this:
‘It felt most of the doctors that I followed [in medical school] , you know, would see thirty to forty patients a day. They were mostly older white men … the physician I followed would see up to fifty patients a day … And it was exhausting. And I don’t think I saw myself in a model like that. And so even though I chose family, I think in my mind I knew I wasn’t going to practice in that manner.’
(FP19, Ontario)
This belief was reinforced by resident and early-career FP perceptions that their mentors were exhausted in comprehensive family medicine practice environments.