Early career family physician perspectives on their residency experience and practice choices in Canada: a qualitative study

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DOI:

https://doi.org/10.36834/cmej.78363

Abstract

Background: Though there are more family physicians in Canada than ever before, and residency programs are expanding, gaps in access to comprehensive care remain. This study aimed to describe and understand the role residency training experiences played in shaping practice choices, including the provision of comprehensive community-based care, among early career family physicians.

Methods: A secondary analysis of sixty-three (63) qualitative interviews was conducted on data from a larger mixed method study on practice patterns and choices of early career Canadian family physicians. We utilized Braun and Clarke’s six phases of reflexive thematic analysis on portions of transcripts concerning residency training experiences.

Results: Participants described positive residency training experiences that shaped practice choice with respect to preceptors and mentorship, experiences of longitudinal care, breadth of exposure, and preparedness for comprehensive clinical practice. Woven through these four domains were “points of tension” and “hidden truths”.  Points of tension included: i) the promotion of an idealized professional identity and practice that was difficult to uphold, ii) lack of representation among faculty/preceptors with respect to age and gender, at some sites, and iii) frustration about the lack of opportunities for interprofessional collaborative practices that reflected training experiences. Hidden truths included: i) lack of preparation to run a business, ii) high administrative workload, iii) realities of payment models, and iv) the range of roles available for family physicians beyond the provision of comprehensive care. 

Conclusions: Findings highlight opportunities for educational reform supporting the transition from residency to practice alongside the importance of addressing systemic factors beyond training which impact physicians’ choices regarding comprehensive care.

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References

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Millbank Quarterly. 2005;83(3):457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x DOI: https://doi.org/10.1111/j.1468-0009.2005.00409.x

Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Services Res. 2003;38:831-65. https://doi.org/10.1111/1475-6773.00149 DOI: https://doi.org/10.1111/1475-6773.00149

Kringos D. The strength of primary care in Europe [thesis]. Utrecht (The Netherlands): Nivel; 2012. Available from www.nivel.nl/sites/default/files/bestanden/Proefschrift-Dionne-Kringos-The-strength-of-primary-care.pdf [Accessed May 1, 2022].

Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gaceta Sanitaria. 2012;26(S):20–26. https://doi.org/10.1016/j.gaceta.2011.10.009 DOI: https://doi.org/10.1016/j.gaceta.2011.10.009

Peckham A, Ho J, Marchildon GP. Policy innovations in primary care across Canada. Toronto: North American observatory on health systems and policies. Rapid review (No. 1), 2018. https://www.researchgate.net/publication/326210991

Aggarwal M, Hutchison B. Toward a primary care strategy for Canada. CFHI. 2012. Available at www.cfhi-fcass.ca [Accessed Oct 18, 2022].

Federal/Provincial/Territorial advisory committee on health delivery and human resources a framework for collaborative pan-Canadian human health resources planning. 2007.

Strumpf E, Levesque JF, Coyle N, Hutchinson B, Barnes M, Wedel RJ. Innovative and diverse strategies toward primary health care reform: lessons learned from the Canadian experience. J Amer Board Fam Med. 2012;25:S27-31. https://doi.og/10.3122/jabfm.2012.02.110215 DOI: https://doi.org/10.3122/jabfm.2012.02.110215

College of Family Physicians of Canada. Family medicine interest groups. Strengthening the future of family medicine. 2017. Available from https://www.cfpc.ca/CFPC/media/Resources/Membership/FMIG-Future-fam-medicine-booklet-ENG.PDF. [Accessed Oct 18, 2022].

Phillips JP, Wendling AL, Prunuske J, et al. Medical school characteristics, policies, and practices that support primary care specialty choice: a scoping review of five decades of research. Fam Med. 2022;54(7):542-54. https://doi.org/10.22454/FamMed.2022.440132 DOI: https://doi.org/10.22454/FamMed.2022.440132

McKee ND, McKague MA. Ramsden VR, Poole RE. Cultivating interest in family medicine. Family medicine interest group reaches undergraduate medical students. Can Fam Phys. 2007;53:661-5.

Pham T-N, Kiran T. More than 6.5 million adults in Canada lack access to primary care. Healthy Debate. Mar 14, 2023. https://healthydebate.ca/2023/01/topic/ourcare-survey-primary-care/.

Kiran T. Keeping the front door open: ensuring access to primary care for all in Canada. CMAJ. 2022;194(48):E1655-E1656. https://doi.org/10.1503/cmaj.221563 DOI: https://doi.org/10.1503/cmaj.221563

Aggarwal M, Oandasan I, eds. Scope of practice of family physicians in Canada: an outcomes of training project evidence summary. Mississauga, ON: College of Family Physicians of Canada. 2022. https://www.cfpc.ca/CFPC/media/Resources/Education/AFM-OTP-Summary7-Scope-of-Practice.pdf

Hedden L, Banihosseini S, Strydom N, McCracken R. Modern work patterns of “classic” versus millennial family doctors and their effect on workforce planning for community-based primary care: a cross-sectional survey. Human Resources for Health, 2020;18:67. https://doi.org/10.1186/s12960-020-00508-5 DOI: https://doi.org/10.1186/s12960-020-00508-5

Kabir M, Randall E, Mitra G, et al. Factors influencing focused practice: A qualitative study of resident and early-career family physician practice choices. Brit J Gen Pract. 2022; BJGP.2021.0512. https://doi.org/10.3399/BJGP.2021.051 DOI: https://doi.org/10.1101/2021.06.24.21259486

Peterson LE, Fang, B, Puffer, JC, Bazemore, AW. Wide gap between preparation and scope of practice of early career family physicians. J Amer Board Fam Med. 2018;31(2):181-182. https://doi.org/10.3122/jabfm.2018.02.170359 DOI: https://doi.org/10.3122/jabfm.2018.02.170359

Coutinho AJ, Cochrane A, Stelter K, Phillips RL Jr., Peterson LE. Comparison of intended scope of practice for family medicine residents with reported scope of practice among practicing family physicians. JAMA. 2015;314(22):2364- 2372. https://doi.org/10.1001/jama.2015.13734 DOI: https://doi.org/10.1001/jama.2015.13734

Ringdahl, E, Delzell, JE Jr., Kruse, RL. Changing practice patterns of family medicine graduates: a comparison of alumni surveys from 1998 to 2004. J Am Board Fam Med. 2006;19(4):404-412. https://doi.org/10.3122/jabfm.19.4.404 DOI: https://doi.org/10.3122/jabfm.19.4.404

Fowler, N, Oandasan, I, Wyman, R, eds. Preparing our future family physicians. An educational prescription for strengthening health care in changing times. A final report and recommendations of the Outcomes in Training Project. Mississauga, Ontario. College of Family Physicians of Canada. 2022. https://www.cfpc.ca/CFPC/media/Resources/Education/AFM-OTP-Report.pdf

Aggarwal M, Holtby A, Slade S. Comparing Practice Intentions and Patterns of Family Physicians in Canada. Fam Med. 2023;55(9):591-597. https://doi.org/10.22454/FamMed.2023.996183 DOI: https://doi.org/10.22454/FamMed.2023.996183

Lavergne MR, Goldsmith LJ, Grudniewicz A, et al. Practice patterns among early-career primary care (ECPC) physicians and workforce planning implications: protocol for a mixed methods study. BMJ Open, 2019;9(9):e030477. https://doi.org/10.1136/bmjopen-2019-030477 DOI: https://doi.org/10.1136/bmjopen-2019-030477

Rudoler D, Peterson S, Stock D, et al. Do recent family physician graduates practice differently? A longitudinal study of primary care visits and continuity in four Canadian provinces. CMAJ. 2022;194:E1639-46. https://doi.org/10.1503/cmaj.220439 DOI: https://doi.org/10.1101/2022.03.11.22272161

Grudniewicz A, Randall E, Lavergne MR, et al. Factors influencing practice choices of early-career family physicians in Canada: a qualitative interview study. Human Res Health, 2023;21(84). https://doi.org/10.1186/s12960-023-00867-9 DOI: https://doi.org/10.1186/s12960-023-00867-9

Boyland, JR. A social constructivist approach to the gathering of empirical data. Austral Counselling Res J 2019;13(2). ISSN1832-1135 www.acrjournal.com.au

Mann K, MacLeod A. Constructivism: learning theories and approaches to research in researching medical education, (eds.) Jennifer Cleland, Steven J. Durning. 2015. https://doi.org/10.1002/9781118838983 DOI: https://doi.org/10.1002/9781118838983.ch6

Braun V, Clarke V. Thematic analysis - A practical guide. SAGE Publications Ltd. 2022. DOI: https://doi.org/10.1007/978-3-319-69909-7_3470-2

Barnhoorn PC, Nierkens V, Numas ME, Steinert Y, Kramer AWM, van Mook WNKA. General practice residents’ perspectives on their professional identity formation: a qualitative study. BMJ Open. 2022;12:e059691. https://doi.org/10.1136/bmjopen-2021-059691 DOI: https://doi.org/10.1136/bmjopen-2021-059691

Beaulieu M-D, Dory V, Pestiaux D, et al. General practice as seen through the eyes of general practice trainees: a qualitative study. Scand J Prim Health Care 2006;24:174–180. http://doi.org/10.1080/02813430600795498 DOI: https://doi.org/10.1080/02813430600795498

Beaulieu M-D, Rioux M, Rocher G, Sampson L, Boucher L. Family practice: professional identity in transition. A case study of family medicine in Canada. Soc Sci Med. 2008;67:1153-1163. https://doi.org/10.1016/j.socscimed.2008.06.019 DOI: https://doi.org/10.1016/j.socscimed.2008.06.019

Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69(11):861–871.https://doi.org/10.1097/00001888-199411000-00001 DOI: https://doi.org/10.1097/00001888-199411000-00001

Hafferty FW. Beyond curricular reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403-7. https://doi.org/10.1097/00001888-199804000-00013 DOI: https://doi.org/10.1097/00001888-199804000-00013

Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: a cross-sectional qualitative study. Med Teach 2016;38(4):410–8. https://doi.org/10.3109/0142159x.2015.1073241 DOI: https://doi.org/10.3109/0142159X.2015.1073241

Philibert I, Elsey E, Fleming S, Razack S. Learning and professional acculturation through work: examining the clinical learning environment through the sociocultural lens. Med Teach. 2019;41(4):398-402. https://doi.org/10.1080/0142159X.2019.1567912 DOI: https://doi.org/10.1080/0142159X.2019.1567912

Mulder H, ter Braak E, Chen HC, ten Cate O. Addressing the hidden curriculum in the clinical workplace: a practical tool for trainees and faculty. Med Teach. 2019;41(1):36-43. https://doi.org/10.1080/0142159X.2018.1436760 DOI: https://doi.org/10.1080/0142159X.2018.1436760

Pourbairamia G, Bigdeli S, Kamran S, et al. Hidden curriculum in residency programs: a scoping review. J Advan Med Educ Profess. 2022;10(2):69-82.https://doi.org/10.30476/JAMP.2021.92478.1486

Murakami M, Kawabata H, Maezawa M. The perception of the hidden curriculum on medical education: an exploratory study. Asia Pacific Med. 2009;8(1):9. https://doi.org/10.1186/1447-056X-8-9 DOI: https://doi.org/10.1186/1447-056X-8-9

Rothlind E, Fors U, Salminen H, Wändell P, Ekblad S. The informal curriculum of family medicine – what does it entail and how is it taught to residents? A systematic review. BMC Fam Pract. 2020;21(1):49. https://doi.org/10.1186/s12875-020-01120-1 DOI: https://doi.org/10.1186/s12875-020-01120-1

Mahood, SC. Medical education. Beware the hidden curriculum. Commentary. Can Fam Phys. 2011;57(983-5).

Beaulieu M, Dory V, Pestiaux D, et al. What does it mean to be a family physician? Exploratory study with family medicine residents from 3 countries. Can Fam Phys 2009;55:e14-20. http://www.cfp.ca/content/cfp/55/8/e14.full.pdf

Philipott, J, Sanfilipop, T, Schultz, K. What are we really telling our medical students? The story of the hidden curriculum. Dean’s blog. Queen’s University, Faculty of Health Sciences. March 11, 2021. https://healthsci.queensu.ca/stories/blog/what-are-we-really-telling-our-medical-students-story-hidden-curriculum

Woloschuk W, Wright B, McLaughlin K. Debiasing the hidden curriculum. Academic equality among medical specialties. Can Fam Phys. 2011;57(e26-30).

Holmes D, Tumiel-Berhalter LM, Zayas LE, Watkins R. “Bashing” of medical specialties: students’ experiences and recommendations. Fam Med. 2008;40(6):400-6.

Hearst N, Shore WB, Hudes ES, French L. Family practice bashing as perceived by students at a university medical center. Fam Med. 1995;27(6):366-70.

Campos-Outcalt D, Senf J, Kutob R. Comments heard by US medical students about family practice. Fam Med 2003;35(8):573-8. PMID: 12947520

Alston M, Cawse-Lucas J, Hughes LS, Wheeler T, Kost A. The persistence of specialty disrespect: student perspectives. PRiMER. 2019;3:1. https://doi.org/10.22454/PRiMER.2019.983128 DOI: https://doi.org/10.22454/PRiMER.2019.983128

Manor, S, Holland, R. Ageism and intergenerational gaps between senior physicians and young residents in the health care system. J Intergenerational Rel. 2023. https://doi.org/10.1080/15350770.2023.2166639 DOI: https://doi.org/10.1080/15350770.2023.2166639

Bogler T, Lazare K, Rambihar V. Female family physicians and the first five years. In pursuit of gender equity, work-life integration, and wellness. Can Fam Phys. Aug 2019;585-88.

First five years family practice committee (website). College of Family Physicians of Canada. 2024. https://firstfiveyears.ca

Jewell K, Newton C, Dharamsi S. Length of family medicine training and readiness for independent practice: residents’ perspectives at one Canadian university. UBC Med J. 2015;15-19. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2015/02/ubcmj_6_2_2015_15-19.pdf

Resident Doctors of Canada. 2018 National resident survey. 2018. https://residentdoctors.ca/areas-of-focus/career-planning/career-intention-and-practice-management/

Grudniewicz A, Randall E, Lavergne MR, et al. Factors influencing practice choices of early-career family physicians in Canada: a qualitative interview study. MedRxiv preprint https://doi.org/10.1101/2023.05.07.23289626. DOI: https://doi.org/10.1101/2023.05.07.23289626

EQUIP Health Centre, University of British Columbia, Western University, University of Northern British Columbia. Equity Health Care Action Kit. 2023. https://equiphealthcare.ca/equity-action-kit/

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Published

2024-06-26

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Moravac C, Grudniewicz A, Scott I, Randall E, Goldsmith L, Marshall EG, Jones L, Lavergne MR. Early career family physician perspectives on their residency experience and practice choices in Canada: a qualitative study. Can. Med. Ed. J [Internet]. 2024 Jun. 26 [cited 2024 Oct. 7];. Available from: https://journalhosting.ucalgary.ca/index.php/cmej/article/view/78363

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