Proportion of Family Physicians Caring for Children is Declining

• Access to Health Care
• Child
• Family Physicians
• Pediatricians
• Primary Health Care

Family physicians (FPs) are trained to provide comprehensive care to their patients—including children of all ages—and are key to ensuring accessible care for all children.¹ However, previous studies have documented the decline in the percentage of office visits for children to FPs,² the proportion of children seeing FPs for their primary care,³ and the proportion of FPs providing care to children of any age.^4,5 Our objective was to track FP care of children over the past 5 years to assess whether the decline in pediatric care by FPs has continued since the previous study using similar data tracked pediatric care by FPs between 2000 and 2009.⁴

We used 2014 through 2018 data from the American Board of Family Medicine (ABFM) Family Medicine Certification Examination registration questionnaire, which has a 100% response rate.⁶ From 2014 until 2016, all practicing FPs seeking to continue their ABFM certification were asked whether or not they cared for children under age 5 years, ages 5 to 12 years, and ages 13 to 18 years. Starting in 2017, all FPs were asked what percentage of their patient population was under age 5 years and what percentage was between 5 and 18 years. We combined the 5-to-12-year and 13-to-18-year age categories in the 2014 to 2016 data to mirror the 2017 to 2018 categories. We dichotomized the 2017 to 2018 data to reflect any care of children in those age groups, or none, to match the yes/no structure of the 2014 to 2016 data. To capture FPs who provide continuity care across the years of available data, which had different ways of collecting practice setting, we excluded respondents in 2014 to 2016 in likely noncontinuity settings (hospitalist, emergency, etc.) and limited our sample to those stating they provided continuity care in 2017 to 2018. We performed Cochrane-Armitage tests for changes over time. The American Academy of Family Physicians Institutional Review Board approved this study.

We analyzed data from a total of 35,063 FPs over the 5-year period. The proportion of FPs caring for children under age 5 years and age 5 to 18 years declined significantly (92.5% to 87.0% and 76.4% to 69.4%, respectively), as represented in Figure 1 (both age groups, P < .001). While FPs continued to care for older children at higher rates than younger children over time, the decline was larger in the care of children under 5 (7.0%) than for 5-to-18-year-olds (5.5%).

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Figure 1.

Percentage of practicing American Board of Family Medicine Certification Examination candidates providing care to children under age 5 and aged 5 to 18 years, 2014 to 2018 (n = 35,063). Abbreviation: FP, Family physicians.

FPs are an important part of the pediatric primary care workforce, particularly for ensuring care accessibility for children in rural areas,⁵ and are uniquely positioned to provide comprehensive, continuous care for infants and young children, older children, and adolescent patients, through their transition to adult care. While our percentages are higher than those reported using a different question from 2000 to 2009,⁴ we still found a decline in the percentage of FPs caring for both younger and older children, suggesting an underlying shift away from care of children regardless of how that care is measured. The trend does not seem to be related to self reported preparation in residency training, which has been shown to be adequate,⁷ nor to the concurrent decline in prenatal care among FPs.⁸ It is possible that the decline in obstetric care by FPs is associated with the decline in pediatric care,⁵ particularly care of young children, but this association has not been well documented. While others have speculated about how to reverse this trend in pediatric care,^4,5 major gaps in evidence exist. To identify appropriate policy solutions, further research is needed to help understand reasons for the decline, whether the decline has any association with patient outcomes, and whether care of children has declined overall or has shifted to pediatricians, nurse practitioners, or physician assistants.

• Received for publication March 4, 2020.
• Revision received April 7, 2020.
• Accepted for publication April 11, 2020.