Article Figures & Data
Tables
Scope of Practice Change over Time (Initial Job out of Residency to Current Job
(% of whole cohort, number of residents)
Organized by highest rate of attrition over timePractice Scope Initially Provided Stopped over Time Added over Time Did Not Change Inpatient care of children 34.4 (63) 10.8 (20) 7.6 (14) 81.6 (151) Prenatal care 41.5 (76) 10.3 (19) 3.8 (7) 85.9 (159) ICU care of adults 23.9 (44) 9.2 (17) 6.5 (12) 84.3 (156) Inpatient care of adults 52.7 (97) 8.1 (15) 8.1 (15) 83.8 (155) Long-acting reversible contraception (ie, IUD, Nexplanon) 48.9 (90) 7.8 (17) 5.5 (12) 86.6 (156) Outpatient care of children 76.6 (141) 7.6 (14) 7.0 (13) 85.4 (158) Nursing home 16.9 (31) 7.6 (14) 3.2 (6) 89.2 (165) Joint injections 80.9 (148) 7.4 (16) 3.7 (8) 94.5 (161) Inpatient proceduresa 43.5 (80) 6.5 (12) 7.0 (13) 86.5 (160) Outpatient dermatological proceduresb 77.2 (142) 6.5 (12) 5.9 (11) 87.6 (162) Point of care ultrasound 44.6 (82) 4.9 (9) 6.5 (12) 88.6 (164) Substance use disorder including medication assisted therapy 27.7 (51) 3.8 (7) 7.6 (14) 88.6 (164) Team sideline coverage 14.7 (27) 3.8 (7) 2.7 (5) 93.5 (173) Colposcopy 24.5 (45) 3.8 (7) 2.2 (4) 94.1 (174) Deliveries (Vaginal or cesarean) 31.5 (58) 2.7 (5) 5.9 (11) 91.4 (169) HIV care including cART 19.0 (35) 2.2 (4) 3.8 (7) 94.1 (174) Endoscopy (upper or lower) 9.8 (18) 1.6 (3) 1.1 (2) 97.3 (180) Hepatitis C treatment 13.1 (24) 1.1 (2) 4.9 (9) 94.1 (174) Abbreviations: cART, Combination Antiretroviral Therapy; IUD, intrauterine device; ICU, Intensive care unit.
aAny of the following: paracentesis, thoracentesis, lumbar puncture, or central venous catheterization.
bAny of the following: skin biopsy, excision, cauterization, or cryotherapy.
3-Year
(n = 50)4-Year
(n = 85)p Personal preference 4.0 4.04 0.87 Lifestyle considerations 3.42 3.2 0.45 Organizational/Administrative support 2.84 2.48 0.15 Lack of comfort with service 1.96 2.27 0.14 Credentialing 1.94 1.95 0.95 Malpractice insurance issues 1.69 1.63 0.73 1 – Least Important; 5 – Most Important.
Emerging Themes Among Comments Regarding Factors Influencing Scope of Practice Qualitative Coding Theme Percentage of Comments with Elements of This Theme Personal preference for choosing a scope of practice with those things you most enjoy 48.3% Work-life balance concerns 33.1% Location of practice and local patient needs 31.0% Institutional Pressure for Narrower Scope of Practice 25.2% Lack of training or preparation 8.3% Insurance, reimbursement, or income concerns 5.5% Burn out/ moral injury 1.4% Emerging Themes Among Comments Regarding Factors Influencing Scope of Practice Theme Percentage of Comments with Elements of This Theme Personal preference for choosing a scope of practice with those things you most enjoy “Any limitations in my scope of practice are by my choice.” “My main driver of my scope of practice has been personal preference/desire to build a sports medicine ONLY practice within an orthopedic group.” Work-life balance concerns “To truly do full scope medicine it requires a team who are all comfortable with the same level of medicine otherwise you never get time with family.” “My desire to deliver babies diminished after the birth of my son, and we decided to prioritize living near family. This decision limited my scope of practice, as this took us to (large metropolitan area), where very few family medicine doctors have delivery privileges.” “The biggest driver for me has been lifestyle. As a single mother, it is imperative that my practice be flexible, and limited to Monday-Friday 8-5.” “It is really hard in rural practice to maintain work life balance with any additional responsibilities outside of clinic.” Location of practice and local patient needs “In the small community we found ourselves, endoscopy was needed by our surgeon to maintain volume, so it was not desirable to the hospital to seek to provide that service. Similarly, ED coverage was provided by a dedicated, contracted group which served the hospital administration's goals.” “Unanticipated external factors like the closure of L&D/inpatient after hospital sale and restructuring.” “The community typically embraces the increased scope of practice from family medicine providers, yet other specialists and hospitals are resistant to embracing the increased scope of practice.” Institutional pressure for narrower scope of practice “My residency trained me to be a doctor above and beyond what my coworkers can handle and procedures they can do.” “After some years of practice (I had) less drive/energy to struggle against administrative set up for how (the) practice is run.” "I have seen how much I love the full scope of Family Medicine and also the underestimate employers have of my abilities along with how markets effect this. Family medicine is the best specialty in the world, but unfortunately, times are changing (and) not in our favor.” “Credentialing and lack of administrative support. We have to prove our ability beyond what I consider expected training.” Lack of training or preparation “(Medication assisted treatment) would have been nice to gain more experience with as it’s a huge issue everywhere.” “(I) wouldn't be comfortable to do obstetrics or prenatal care with my level of training.” Insurance, reimbursement, or income concerns “Private practice is easy - what does this service cost me versus how much am I reimbursed? It does not make financial sense in private practice to round on inpatients or do OB without an FQHC or employment model.” “(The balance of) financial reward to risk and lifestyle.
Obstetrics pays well, but not insanely well, and you have to do a lot to make it worthwhile.”Burn out/moral injury “Lifestyle (was the) biggest issue because I was on call every M-F and every 3rd weekend, giving 6 actual days off per month. My patients valued how accessible I was, but it took a toll on (my) marriage and relationship with my kids, not to mention being burned out quickly.” “Unfortunately, there are a LOT of bad doctors out there. A LOT. And a lot of bad administrators. I saw time and again how these providers harmed patients in every town in which I traveled to. And I saw the administrators back them up because they were making money.”
