1 9 9 2 – 2 0 0 1 Joshua Tepper

1 9 9 2 – 2 0 0 1 Joshua Tepper
The Evolving Role of
Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Joshua Tepper
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Institute for Health Information.
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The Evolving Role of Canada’s Family Physicians, 1992–2001
ISBN 1-55392-481-9 (PDF)
© 2004 Canadian Institute for Health Information
Cette publication est aussi disponible en français sous le titre :
L’évolution du rôle des médecins de famille au Canada, 1992-2001
ISBN 1-55392-501-7 (PDF)
The Evolving Role of
Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Joshua Tepper
Table of Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.1 Family Medicine in the Canadian Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.2 Time of Change and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3 More Than Head Counts . . . What Are They Doing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.4 Focus on Nine Areas of Clinical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.5 Questions Asked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1 Where the Data Come From . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2 Limitations of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3 Who Is Being Studied? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.4 Organization of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.5 Statistical Measures and Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.6 Defining Geographic Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. Changes in the Workforce, 1992 to 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4. Summary Picture of Activity Levels and Changes in Practice . . . . . . . . . . . . . . . . . 21
4.1 Overview of Participation Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.2 Overview of Workload Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.3 Four Broad Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5. The Context of Change—Policy Directions, 1992 to 2001 . . . . . . . . . . . . . . . . . . . 25
5.1 Changes in Medical Training and Licensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.2 Changes in the Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
6. Changes in Specific Clinical Practice Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
6.1 Surgical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
6.2 Office Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6.3 Advanced Procedural Skills Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.4 Anaesthesiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.5 Surgical Assistance Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
6.6 Basic Procedural Skills Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
6.7 Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
6.8 Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6.9 Hospital Inpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
7. Discussion and Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
7.1 Activity Patterns: An Important Factor in Health Human Resource Planning . . . . . . . . . . . 57
7.2 Decreasing Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.3 Increasing Intensity of Service Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7.4 Stable at the Core . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
7.5 An Area of Sustained Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
7.6 More Involvement and More Work by Older Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . 61
7.7 Gender Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7.8 Geographic Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
7.9 System in Evolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
8. Limitations and Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.1 Assessing “Quality” of Care Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.2 Additional Practice Areas and Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.3 Non-Clinical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.4 Non Fee-for-Service Family Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.5 Impact of Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.6 A Cohort Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
9. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
The Canadian Institute for Health Information
(CIHI) wishes to thank Dr. Joshua Tepper
and Mr. Steve Slade for authoring this report.
Dr. Tepper is a practising, rural family physician
and Adjunct Scientist at the Institute for Clinical Evaluative Sciences in Toronto. Mr. Slade is a
Consultant in CIHI’s Health Human Resources area. Joshua and Steve worked collaboratively to
develop the study concept and both acted as principal authors on various sections of the report.
Acknowledgements
Dr. Mamoru Watanabe, of the University of Calgary, made significant contributions to this report,
giving generously of his time in reviewing draft reports and providing helpful advice on how to
proceed with the analysis. CIHI is very grateful for Dr. Watanabe for this contribution. Special
thanks are given to Mr. Vern Hicks, Health Economics Consultant, Mr. Michael Joyce, Economist,
Nova Scotia Department of Health, Ms. Jill Strachan, CIHI, Dr. Nick Busing, Chair of Family
Medicine, University of Ottawa and Dr. Albert Heyman, Professor Emeritus, Duke University,
for their thoughtful input in developing this study and its final report.
CIHI also wishes to thank the College of Family Physicians of Canada and the Canadian Medical
Association for their review and input on this report.
It should be noted that the analyses and conclusions in this report do not necessarily reflect
those of the individual reviewers or their affiliated organizations.
The following CIHI staff made valued contributions in extracting data, reviewing drafts,
fact-checking and generally preparing this report for publication:
Mr. Robert Kyte, Consultant, Physician Databases
Ms. Francine Anne Roy, Manager, Health Human Resources
Ms. Louise Ogilvie, Director, Health Resources Information
Ms. Lori Brazeau, Senior Analyst, Physician Databases
The role of Canada’s family physician has
traditionally been characterized as providing a
breadth of knowledge and skills in settings that
range from clinics to different hospital settings,
as well as homes and nursing homes. This breadth has been a defining feature of the profession and
has helped position family physicians to provide “cradle to grave” care.
Executive Summary
In the past few years, increasing attention has been focused on family medicine and the challenges
the profession is facing. Studies and reports have examined the number and location of family
physicians, their working conditions, patient access and the popularity of family medicine as a
career choice.
Less attention has been directed to understanding what clinical activities family physicians are
engaged in and whether there have been changes in the traditional breadth of activity engaged
in by family physicians.
This report builds on smaller studies that describe changes in the patterns and scope of family
physicians’ clinical activities. It advances the literature by examining a broad range of health care
services that are delivered in a variety of settings and that demand a wide array of clinical skills.
The study looks at the participation of fee-for-service family physicians in nine clinical areas: office
assessments, inpatient hospital care, mental health care, obstetrical care, surgical services, services
that require advanced and basic procedural skills, surgical assisting and anaesthesiology. Results are
presented for the period of 1992 to 2001. This report also outlines some of the many changes that
have occurred during this time period that affect the education process and practice environment
of family physicians.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
This report addresses several questions that explore the changing nature of family practice in Canada:
! How has the family physician workforce changed in terms of age, gender and
geographic distribution?
! What areas of clinical activity have family physicians traditionally engaged in?
! What were some of the major policy directions and initiatives in the education and
practice arenas that occurred during the study time period?
! Within the nine clinical areas, how has the participation of family physicians changed
over a 10-year period and how has the intensity of service delivery changed?
! How does participation in the identified clinical areas differ between genders?
Has this changed over time?
! Are there differences in clinical activity based on geographic practice setting?
How have these differences evolved over the years?
! Across age groups, how has activity in different clinical areas changed over time?
Summary of Main Findings
Study results are based on two main measures. They are, for each clinical practice area, the percentages of
family doctors who bill for services (participation rates) and the average number of services provided per
family physician. A variety of patterns emerged across clinical areas—each with important nuances related to
the age, gender and geographic setting of family physicians. The main trends can be summarized as follows.
A) Stable: Participation in office practice remained generally stable throughout the 10-year period
of analysis. Participation rates ranged from 85% to 90%, and there was relatively little change in the
average number of services provided per family physician.
B) Increasing: Only the area of mental health care had consistent increases in both study measures
(that is, participation rates and average number of services provided per family physician). The participation
rate for mental health care services went from 82% in 1992 to 85% in 2001. The average number of
mental health care services provided per family physician increased by 12% during the same time period.
C) Decreasing: A steadily decreasing percentage of family physicians participated in hospital inpatient
care over the period, dropping from 71% in 1992 to 62% in 2001. Also, fewer services were provided
on average by those family physicians who continued to provide hospital inpatient care services. While
the percentage of family doctors who provided services requiring basic procedural skills remained stable
over the study period, the average number of basic procedures offered decreased by 33%.
D) Decreasing participation with increasing intensity: This pattern was most common and was
seen in the remaining five clinical practice areas (surgical assisting, surgery, anaesthesia, obstetrics and
advanced procedural skills services). In this pattern, the percentage of family physicians participating in
the clinical service area decreased—but there was a corresponding pattern of increased average service
delivery among those who continued to provide the service. For example, the participation rate
for obstetrical care services went from 28% in 1992 to 16% in 2001. During the same period,
the average number of obstetrical services provided per family physician increased by 33%.
4
Executive Summary
The general trends described above provide a useful overview of how family doctors’ practices changed
during the 10-year study period. However, general descriptions do not reflect the diverse changes that
have occurred across family physician age and gender groups, nor across urban and rural practice settings.
These results are detailed in the main report.
Discussion and Considerations
Canadian family physicians appear to be a heterogeneous population with a dynamic pattern of clinical
activity that varies by age, sex, location and time period. Health human resource planning efforts that
consider one family physician to be essentially the same as any other family physician will capture neither
these differences nor the implications for service delivery. The practice trends presented in this report may
help to inform physician resource planning efforts.
In almost all areas of clinical activity, there has been a consistent reduction in the participation of family
physicians. For example, family physician participation rates in surgical services, surgical assistance,
anaesthesia and obstetrical care declined by 32%, 31%, 28% and 43%, respectively, between 1992
and 2001. The finding of a general decline in the participation of family physicians in a variety of clinical
areas is congruent with past studies.
Declining participation and service delivery rates may suggest a need to further explore the causes and
catalysts of change. Efforts to address patterns of clinical practice may require a comprehensive and
integrated approach that uses a variety of strategies. Such an approach may demand attention for both
the education and practice environment. Similarly, successful efforts may hinge upon consideration not
only of family medicine, but also of other medical disciplines and the broad spectrum of health care
provider groups.
Within several clinical practice areas, participation rates declined—but at the same time, there was an
increase in the average number of services provided by those family physicians who stayed involved. While
it is beyond the scope of this study to examine cause and effect relationships, a number of explanations for
this commonly observed trend are possible. Perhaps doctors who remain involved adopt a more intensive
workload to compensate for the withdrawal of participation by other providers. Family physicians, in
response to the increasing complexity of medicine, may explore opportunities to focus their practice in
limited clinical practice areas, characterized by high levels of service that promote a sense of competency.
Alternative explanations may point to a variety of implicit or explicit incentives/disincentives to engage in
certain clinical activities.
A wide range of questions stem from the commonly observed pattern of decreased participation, coupled
with increased intensity of service provision for those family doctors who remain involved. For example,
! How high can the workload for participating physicians rise, and how long can these
physicians maintain the higher level of activity?
! What is an appropriate and realistic range of skills to expect individual family physicians
to acquire and exercise through their practice?
! What is the level of “volume” or “experience” that confers and maintains competency?
! What policy changes are needed to support family physicians in traditional
broad-based practices?
5
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Results of this study illustrate a variety of practice trends across age groups. Discussion has taken place
in health human resource forums about generational differences between physicians, and the suggestion
has been made that new physicians (starting in training programs) are trying to establish a different balance
between their clinical careers and their other professional or personal activities. Again, a variety of questions
and considerations stem from these observations:
! Will younger physicians adopt the practice patterns of established older physicians as they age?
! Are there certain clinical activities that correlate with certain stages in the career life cycle?
! In addition to a possible desire to seek a different work/personal balance, what policy or
other changes have occurred to create this apparent generational difference?
In this study, men and women generally mirrored each other in terms of broad patterns of change.
However, there were differences in their level of participation and intensity of workload in different
clinical areas. For example, female family physicians tended to provide surgical and obstetrical services
more intensively than males. On the other hand, male family physicians provided 46% more office
assessment services than female family doctors in 2001, and approximately twice as many advanced
procedural skills services throughout the study period. With women entering family medicine in numbers
significantly higher than men, the results of this study touch upon a number of possible considerations:
! How will the practice patterns of women change as they move through the “physician life cycle”?
(The current number of older female physicians may be too small to draw strong conclusions.)
! What are the factors that lead to these gender differences? Are there strategies that can be
implemented to either minimize these differences or capitalize upon them?
! What are other differences in practice between the sexes that should be considered? These might
include patient acuity, illness burden of their practice, patient satisfaction, adherence to practice
guidelines, etc.)
This study illustrates generally consistent patterns across geographic areas in terms of decreasing
participation and increasing workloads. However, rural physicians consistently had higher rates of
participation in most clinical areas. Mid-sized communities had the highest participation in surgical
assistance services and hospital inpatient care. Relative to other regions, rural areas had a larger loss
of participation in hospital-based services such as anaesthesia and surgical services. Rural regions
may be particularly impacted by the broader health care system changes that are discussed within
this report.
Future research on family physician practice across geographic areas may consider how regionalization,
amalgamation and change in hospital service delivery have influenced the scope of family practice.
Furthermore, although the trends toward decreased participation are similar across settings, the reasons
for change may vary depending on geographic setting. Further research may also look at whether the
health care system changes described above have greater implications in non-urban areas, possibly due
to the limited other physician and health professional resources that are available in those areas.
6
Executive Summary
Limitations and Future Research
This report moves beyond describing the number, location and basic demographics of the workforce to
reflect a profile of family physicians’ clinical practice. A next step would be to capture issues around the
quality of care provided by family physicians with different practice profiles. Future research may examine
a broader range of clinical practice areas, such as sports medicine, women’s health, emergency medicine,
addictions, palliative care and First Nations’ health. Alternative methodologies may also be used in future
studies, possibly tracking practice changes among specific physician cohorts through time.
This report does not address family physicians’ non-clinical professional activities (including research,
teaching and administrative work), which may impact the amount of time available for direct clinical care.
The report findings are also based exclusively on fee-for-service billing data. Thus, the extent to which
the results can be generalized to family doctors who practise exclusively as non-fee-for-service physicians
is unknown.
Conclusion
This report describes recent changes in family practice within the context of the broader health care
landscape. It looks at how differences between family practices—reflected in participation rates, intensity
of service provision, gender, age and location—might contribute to human resource planning for family
doctors. Other questions may still need to be asked: When should more traditional comprehensive family
practices be encouraged? Is it still feasible to have all family physicians provide the traditional broad range of
skills? Addressing these questions will help to define the roles of family doctors as we move into the future.
7
1. Introduction
1.1 Family Medicine in
the Canadian Health
Care System
One of the classic pictorial representations of the family physician is of a doctor, black bag in hand, standing
beside a horse-drawn carriage. The family physician is ready to travel wherever patients need to be seen,
and in the black bag is whatever equipment and medications the visit requires.
It is a powerful picture that implies some core concepts about the nature
of family medicine. If the contribution of some physicians is their mastery
of a focused area of medicine, then the hallmark of family physicians is their
complementary role as doctors whose knowledge spans a wide breadth
of clinical medicine.
This broad knowledge, and the corresponding clinical skill sets, enable the
family physician to work in diverse settings such as patients’ homes, medical
clinics, emergency rooms, operating rooms, labour and delivery suites and
hospital wards. In Canada, the family physician often serves as the main entry
point to the health care system and the hub that provides continuity of care
among many providers and throughout the life cycle. The importance of
primary care in quality of health and the value Canadian society places on
family physicians in the delivery of this care are well known.1, 2, 3, 4, 5
In 2003 there were approximately 30,000 family physicians practising
across the country in urban, mid-sized, rural and isolated settings.
! What are they doing in their clinical practice?
! Does the traditional understanding and conceptualization
of their role in the health care system still hold today?
If the contribution
of some physicians
is their mastery of
a focused area of
medicine, then the
hallmark of family
physicians is their
complementary role
as doctors whose
knowledge spans
a wide breadth of
clinical medicine.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
1.2 Time of Change and Challenges
The last decade has been a period of change and challenges for family physicians. Twenty-four percent
of medical students chose to pursue family medicine as their first-choice residency program in 2003—
a significant decline from the 32% to 35% results of the mid- to late-1990s.6, 42 Of those students electing
to pursue family medicine training, an increasing number are seeking further sub-specialization in areas such
as sports medicine and emergency medicine.7, 8 Initial research suggests that these doctors who choose to
sub-specialize do not engage in traditional broad-based family practice.9
There are a variety of changes in the health care system that could impact upon family physicians. Other
providers, such as chiropractors, nurse practitioners and pharmacists already share some areas of patient
care with family physicians and seek to further increase their role.10, 11, 12, 13 To the extent that family
physicians participate in clinical areas targeted by a variety of medical specialty groups—such as obstetrics,
anaesthesia and psychiatry—they may have a role to play in responding to health human resource demands
related to other physician specialty groups. Finally, there is currently a wide range of regional, provincial and
national efforts to alter the models of practice in which family physicians work.
These and other changes (some of which are explored in Section 5 of this report), combine to create a
context in which family physicians may feel either “pushes” or “pulls” to change their scope of clinical activity.
1.3 More Than Head Counts . . .
What Are They Doing?
In light of these events, significant health human resource research and policy
discussion has focused on family physicians, family medicine and primary
care.15, 16, 17 The focus has generally been on the number, demographic profile
and geographic location of family physicians. Other efforts have also looked at
the ability of the public to access family physicians and the opinion of the
public about family physicians and primary care.18
However, less attention has been given to the range of activity undertaken by
family physicians. The importance of doing such research has been noted and
a few reports in this area have highlighted a changing scope of work either
among all those studied or among certain groups of physicians based on age or
gender.19, 20, 21, 22, 23, 24, 25 These studies have typically focused on a specific clinical
area or geographic region.
This report builds
on previous research
by moving beyond
discussing the
number or location
of family physicians
to explore what
they are doing.
This report builds on previous research by moving beyond discussing the number or location of family
physicians to explore what they are doing. The report will document changing practice profiles of Canadian
family physicians between 1992 and 2001.
10
1. Introduction
1.4 Focus on Nine Areas of Clinical Activity
Activity in nine clinical areas, traditionally identified as potentially part of a family physician’s scope of
activity, will be studied: office assessments, obstetrical care, surgical services (such as appendectomies,
hysterectomies and tonsillectomies), surgical assisting, hospital inpatient care, basic procedural skills services
(such as suturing, joint injection/aspiration and IUD insertion), advanced procedural skills services (such as
setting fractures, performing vasectomies and intensive care/resuscitation), anaesthetic services and mental
health care services. Further details on the nine clinical areas are given in Appendix A.
These nine areas are used as representative samples of clinical practice in which family physicians engage.
They do not cover the broad spectrum of health care services offered by family doctors, such as preventive
medicine, sports medicine, elder care and palliative care. Nor do they specifically describe the many detailed
services that family doctors provide, such as bereavement counselling, working with patients to manage
asthma and low back pain and diabetes, advising when to use and when not to use antibiotic drugs,
performing a variety of therapeutic and diagnostic manoeuvres ranging from wart removal to cyst aspiration
to appendectomy. Again, the selected areas of study represent a broad sample of clinical practice and are
meant to serve as markers of family physicians’ changing scope of activity.
1.5 Questions Asked
This report will look at several key questions that explore the changing nature of family medicine in Canada:
! How has the family physician workforce changed in terms of age, gender and geographic distribution?
! What areas of clinical activity have family physicians traditionally engaged in?
! What were some of the major policy directions and initiatives in the education and practice arenas
that occurred during the study time period?
! Within the nine clinical areas, how has the participation of family physicians changed over a 10-year
period in terms of areas of activity and workload?
! How does participation in the identified clinical areas differ between genders?
Has this changed over time?
! Are there differences in clinical activity based on geographic practice setting?
How have these differences evolved over the years?
! Across age groups, how has activity in different clinical areas changed over time?
11
2. Methodology
2.1 Where the Data
Come From
The primary database for this study was
the Canadian Institute for Health Information National Physician Database (NPDB). The NPDB contains
physicians’ fee-for-service (FFS) claims data provided to the Canadian Institute for Health Information (CIHI)
by provincial/territorial medical service plan administrative systems. NPDB files are submitted to CIHI
on a quarterly basis. The files contain, for each physician within each jurisdiction, the total number of
clinical services provided and payments made for each fee service code billed. In this report, annual results
are based on aggregate data provided over four quarters, starting on April 1 of each year and ending on
March 31 of the following year. Data for the years 1992–93 to 2001–02 were included in their totality.
All fee service codes within the NPDB are mapped to a National Grouping System (NGS) category. NGS
categories describe health care services within specific clinical service areas. A detailed list of the 120 NGS
categories, to which fee service codes are mapped, is given in CIHI’s annual National Grouping System
Categories Report. NGS categories are further classified under 14 broad clinical service areas, including,
but not limited to, consultations and assessments, hospital care days, psychotherapy, major and minor
surgery, surgical assistance, anaesthesia, as well as obstetrical and other diagnostic/therapeutic services.
A detailed description of how NGS categories/strata were used to define clinical service areas in this
report is given in Appendix A.
In addition to FFS payment and service data, the NPDB contains physician characteristics information. This
study used NPDB data fields describing physicians’ medical specialty, date of birth, sex and geographic location.
A second data source used in this study is the 2001 National Family Physician Workforce Survey (NFPWS).
The NFPWS, also known as the “Janus Survey,” was carried out by the College of Family Physicians of
Canada. The 2001 NFPWS database contains a wide range of information, including family physicians’ selfreported areas of clinical service provision. NFPWS clinical practice data were used in this study to validate
NPDB data and to select provinces for inclusion/exclusion in the analysis of each clinical service area.
Comparable data elements within the NPDB and NFPWS are listed in Appendix B, along with provincial
exclusion results applied in analyzing each clinical service area.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
2.2 Limitations of the Data
The NPDB collects information only on physician activities compensated
through FFS payment programs. In recent years there has been a growth of
alternative payment models for physicians, including capitation, salary, hourly
wages and combinations of these models.26 Existing data sources describe
alternative payment and FFS payment trends for all physicians, including family
doctors and non–family medicine physicians. In 2001, an estimated 16.2% of
total clinical payments for all physicians were made through alternative (non
fee-for-service) modes. This is up from 12.6% in 2000 and 10.5% in 1999.26, 27
Furthermore, in 1990, 67.5% of physicians reported that 90% or more of
their income came from FFS activity.28 In 2002, 58.4% of physicians reported
that 90% or more of their income came from FFS activity.28
In 2001, an estimated
16.2% of total clinical
payments for all
physicians were made
through alternative
(non fee-for-service)
modes. This is up
from 12.6% in 2000
and 10.5% in 1999.
Medical service fee schedules, used by physicians, are created in each
province/territory through ongoing negotiations between medical associations and provincial/territorial
governments. They are, therefore, dynamic lists that differ across the country and over time. While fee
service codes typically cover well-defined clinical services, payment incentives and the creation of new
fee codes may impact utilization patterns across NGS categories. NGS methodologies attempt to assign
equivalent clinical service activities to like categories and to adjust for provincial/territorial variations in
billing conventions.
Also, with respect to NPDB data, while FFS codes may specify a particular act, they do not necessarily
specify the service delivery location. For example, simple suturing—whether done in the office, nursing
home, emergency room or as part of a home visit—is typically billed under the same fee code. With the
exception of office assessment and hospital inpatient services, it is difficult to identify the precise location
of service provision.
The 2001 NFPWS was carried out as a self-report mail survey. A variety of potential limitations apply
to survey data, including incomplete response, response bias and subjective interpretation of survey
questions. The 2001 NFPWS was conducted as a census survey of family physicians, and the response
rate was 51.2%. The resulting database reflects the self-reported activities of half of Canada’s family
doctors. Full methodological details of the 2001 NFPWS, including provincial/territorial response rates
and weighting techniques to adjust for non-response, are available on the College of Family Physicians
of Canada Web site (www.cfpc.ca).
2.3 Who Is Being Studied?
The focus of this report is physicians identified in NPDB as either general practitioners or family doctors.
These two groups are analyzed together and referred to as family physicians or family doctors. As a short
form, the initials “FP/GP” are used, primarily within figures. Physician specialty data within the NPDB is
based on data submissions from provincial/territorial administrative payment systems; the family/general
practitioner category may include non-certified specialists. The term “non-certified specialist” refers to
non-family medicine physicians who do not (yet) possess specialty certification credentials awarded by
the Royal College of Physicians and Surgeons of Canada or the Collège des médecins du Québec, but
who are considered as specialist physicians within their jurisdictions.
14
2. Methodology
As noted above, the NPDB contains only fee-for-service payment data. Thus, physicians were included in
the study if they received any fee-for-service payments in a given year, regardless of whether FFS payments
or alternative payments were the primary source of income. Furthermore, this study does not compare the
practices of FFS and non-FFS physicians. Therefore, the extent to which the results can be generalized to
family doctors who practise exclusively as non-FFS physicians is unknown.
2.4 Organization of the Data
This study reports family physician practice patterns between fiscal years 1992 and 2001 in each of nine
broad clinical service areas. The studied clinical service areas include:
! office practice, based on office assessment claims
! hospital inpatient care
! mental health care, based on psychotherapy and counselling claims
! services that require basic procedural skills (such as suturing, joint injection/aspiration
and IUD insertion)
! services that require advanced procedural skills (such as setting fractures, performing
vasectomies and intensive care/resuscitation)
! surgical services (such as appendectomies, hysterectomies and tonsillectomies)
! anaesthesia services
! obstetrical services
! surgical assisting
As noted above, the NGS categories and strata used to define these clinical service areas are described
in detail in Appendix A. NPDB categories and strata that were unlikely to reflect activities carried out by
family physicians at any time during the study period (such as coronary artery bypass) were not used.
Practice patterns are described in relation to physician groups based on age, sex and geographic location.
General trends for all family physicians, as well as notable trends for specific subgroups, are presented
in the main body of this report. Detailed data tables summarizing each clinical service area are presented
in Appendix C.
15
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
2.5 Statistical Measures and Definitions
Two main summary measures are used to describe family physician practice patterns in each of the nine
clinical practice areas. They are:
I)
Participation rate. This measure reports the percentage of family physicians who bill for services
within the clinical practice area in a given year. Participation rates are calculated as the number of family
physicians who bill for the service divided by the total number of family physicians within the group
being described, times one hundred.
II) The average number of services per family physician. This measure indicates how intensely
individual family physicians provide various types of health care services. It is calculated as the total
number of services within a clinical practice area divided by the number of family physicians who billed
for those services. Note that the calculation includes only those physicians who actually provide the
type of service being reported. Also, this summary measure does not tell us whether individual family
physicians provide a greater or lesser number of services over time. For instance, it is possible that in
1992 there were some family doctors who provided a high number of a particular service, while others
provided relatively few services. If the family doctors who provided relatively few services ceased
providing them altogether, and the remaining physicians continued to provide the same number of
services as they always did, the average number of services provided would have increased.
Both of these summary measures are used to describe practice patterns for all family physicians in Canada
or for a subgroup based on age groupings, sex and/or geographic location.
2.6 Defining Geographic Location
Geographic location descriptors used in this study are based on Statistics Canada definitions of census
metropolitan areas (CMAs), census agglomerations (CAs) and communities not classified as CAs or CMAs.29
CAs and CMAs are defined by Statistics Canada as “one or more adjacent municipalities centred on a large
urban area (known as the urban core).”30 CMAs have populations greater than 100,000 and CAs have
populations between 10,000 and 100,000. Non-CMA/CA communities have populations of less than 10,000.
In this study, CMAs are referred to as urban communities, CAs are called mid-sized communities and nonCMA/CA communities are referred to as rural communities.
The challenges of defining urban and rural communities are well documented.31, 32 The CA category spans a
large variety of communities—the difference between a town of 10,000 and 100,000 is significant. This
approach also does not take into account the distance of a rural community from a mid-sized or urban
community. It does not consider other geographic factors, such as average yearly snowfall, that might affect
a community’s “rurality.” Furthermore, as communities change population size over time they may change
designation. Notwithstanding its limitations, the typology of CMA, CA and non–CMA/CA has been used in
past health human resource reports.33, 34
16
3. Changes in the Workforce,
1992 to 2001
The total number of family physicians billing
FFS increased from 27,447 in 1992 to 28,493
by the end of the study period, 2001. During
this time, the gender ratio shifted, with an
increasing number of women (7,193 rising to 9,524) practising as family physicians accompanied by a
decreasing number of men (20,254 dropping to 18,969). This change is illustrated in Figure 1. At the end
of the study period, the ratio of male family physicians to female family physicians was about two to one.
1
Family Physician Counts by Gender, Canada, 1992 to 2001
30,000
FP/GP count
25,000
20,000
15,000
10,000
5,000
0
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
Source: National Physician
Database, CIHI
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, gender was not
reported for less than 1% of
family physicians.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
The changing balance between male and female family physicians is largely due to a sharp decline in
male physician numbers in the two youngest age categories. Since 1999, female family physicians have
outnumbered males in the less-than-35 age group (see Figure 2).
In the 35-to-44 age group, there appears to be an approaching parity between the two genders. In the
older age categories, the relationship between male and female family physicians is constant or even
widening (ages 55 to 64), with a greater number of male physicians relative to female. These patterns
are seen in Figures 3 to 6.
2
FP/GP count
Family Physician Counts in the Under-35 Age Group, by Gender, Canada, 1992 to 2001
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
2001
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, age was not
reported for approximately
1% of family physicians.
Total
3
Family Physician Counts in the 35-to-44 Age Group, by Gender, Canada, 1992 to 2001
12,000
FP/GP count
10,000
8,000
6,000
4,000
2,000
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Female
18
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, age was not
reported for approximately
1% of family physicians.
3. Changes in the Workforce, 1992 to 2001
4
FP/GP count
Family Physician Counts in the 45-to-54 Age Group, by Gender, Canada, 1992 to 2001
10,000
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
2001
Total
5
FP/GP count
Family Physician Counts in the 55-to-64 Age Group, by Gender, Canada, 1992 to 2001
5,000
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, age was not
reported for approximately
1% of family physicians.
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, age was not
reported for approximately
1% of family physicians.
19
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
6
Family Physician Counts in the Over-65 Age Group, by Gender, Canada, 1992 to 2001
2,500
FP/GP count
2,000
1,500
1,000
500
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
2001
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, age was not
reported for approximately
1% of family physicians.
Total
The decreasing number of male family physicians and increasing number of female family physicians is true
for urban, mid-sized and rural communities. The overall population of family physicians is also aging in all
three of these geographic regions. In regards to total numbers, Figure 7 shows a small increase in urban
settings (2%), with more significant increases in the mid-sized (8%) and rural (18%) areas.
7
FP/GP count
Family Physician Counts by Location, Canada, 1992 to 2001
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Urban
20
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes fee-for-service
family physicians only. From
1992 to 2001, location was
not reported for less than
2% of FP/GPs.
4. Summary Picture of
Activity Levels and
Changes in Practice
4.1 Overview of
Participation
Levels
While Section 6 of this report will explore specific areas of clinical practice, a broad picture of family
physician activity is illustrated in Figures 8a and 8b. Throughout the study period (1992 to 2001), most
(85% to 90%) family physicians were active in office practice, as well as providing mental health care
services and services that require basic procedural skills. The percentage of total family physicians who
provided hospital inpatient care declined from 71% in 1992 to 62% in 2001. The percentage of total
family physicians who provided services requiring advanced procedural skills declined from 77% in
1992 to 71% in 2001. Finally, participation rates in surgical care, surgical assistance, anaesthesia and
obstetrical services declined by 32%, 31%, 28% and 43%, respectively, between 1992 and 2001.
In summary, over the study period there was a convergence in family physician participation rates in
office practice, mental health care and services that require basic procedural skills. While family physician
involvement within each of the remaining areas declined, the inter-relationship between these areas
remained fairly stable, as illustrated by the approximately parallel lines shown in Figures 8a and 8b.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
8a
Percentages of Family Physicians Providing Office Assessment, Hospital Inpatient,
Mental Health, Basic Procedural Skills and Advanced Procedural Skills Services, Canada,
1992 to 2001
100
% of FP/GPs
90
80
70
Source: National Physician
Database, CIHI
60
50
1992
1993
1994
Office
1995
1996
Hospital Inpatient
1997
1998
1999
Mental Health
2000
BPS
Notes: Includes fee-for-service
family physicians only.
BPS= basic procedural skills
APS= advanced procedural skills
See Appendix A for definitions of
clinical service areas.
See Appendix B for provincial data
inclusion/exclusion criteria applied
to each clinical service area.
2001
APS
8b
Percentages of Family Physicians Providing Surgery, Surgical Assistance,
Anaesthesia and Obstetrical Services, Canada, 1992 to 2001
50
% of FP/GPs
40
30
20
Source: National Physician
Database, CIHI
10
0
1992
1993
Surgery
22
1994
1995
1996
Surgical Assistance
1997
1998
Anaesthesia
1999
2000
2001
Obstetrics
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
See Appendix B for provincial data
inclusion/exclusion criteria applied
to each clinical service area.
4. Summary Picture of Activity Levels
and Changes in Practice
4.2 Overview of Workload Intensity
Figures 9a and 9b illustrate the percentage change in the average number of services provided in each year
compared with the baseline year of 1992. Figure 9b illustrates an increase in the average number of services
for mental health, surgery, surgical assisting, anaesthesia and obstetrics. While not necessarily linear, these
increases were 12%, 88%, 57%, 35% and 33% respectively in 2001 compared with 1992. An increase of
19% in advanced procedural skills is seen in Figure 9a. Also shown in Figure 9a are small percentage
decreases in office assessments (4%) and hospital inpatient care (8%). The percentage decrease (33%) in
the average number of basic procedural skills services offered by family doctors was larger than for office
assessments and hospital inpatient care (see Figure 9a).
Percent Change in Average Number of Services per Family Physician Compared to 1992—
Office Assessment, Hospital Inpatient, Basic Procedural Skills and Advanced Procedural
Skills Services, Canada, 1992 to 2001
9a
50
% Change Compared to 1992
40
30
20
10
0
Source: National Physician
Database, CIHI
-10
-20
-30
-40
-50
1992
1993
1994
Office
1995
1996
1997
Hospital Inpatient
1998
BPS
1999
2000
APS
2001
Notes: Includes only
services provided through
fee-for-service programs.
BPS = basic procedural skills
APS = advanced procedural skills
See Appendix A for definitions of
clinical service areas.
See Appendix B for provincial
inclusion/exclusion criteria applied
to each clinical service area.
23
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Percent Change in Average Number of Services per Family Physician Compared to 1992—
Mental Health, Surgery, Surgical Assistance, Anaesthesia and Obstetrical Services, Canada,
1992 to 2001
9b
100
% Change Compared to 1992
90
80
70
60
50
40
30
Source: National Physician
Database, CIHI
20
10
0
1992
Mental Health
1993
1994
1995
Surgery
1996
Anaesthesia
1997
1998
Obstetrics
1999
2000
2001
Surgical Assistance
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
See Appendix B for provincial
inclusion/exclusion criteria applied
to each clinical service area.
4.3 Four Broad Trends
Based on the patterns illustrated above, four broad practice trends among family physicians can be
identified. They are:
A) Stable: The number of office assessment services remained generally stable throughout the 10-year
period of analysis. Although participation rates declined slightly, there was relatively little change in the
average number of services per family physician.
B) Increasing: Only the area of mental health care had consistent increases in both main outcome
measures (that is, participation rates and average number of services provided per family physician).
C) Decreasing: A steadily decreasing percentage of family physicians participated in hospital inpatient
care over the period of 1992 to 2001, and fewer services were provided on average by those family
physicians who continued to provide hospital inpatient care services. While the percentage of family
doctors who provided services requiring basic procedural skills remained stable over the study period,
the average number of basic procedures offered decreased steadily.
D) Decreasing participation with increasing intensity: This pattern was most common and was seen
in the remaining five clinical practice areas: surgical assisting, surgery, anaesthesia, obstetrics and advanced
procedural skills services. In this pattern, the percentage of family physicians participating in the clinical
service area decreased—but there was a corresponding pattern of increased average service delivery
among those who continued to provide the service.
Further details of each of these trends in relation to the specific practice areas are included in Section 6.
24
5. The Context of Change—
Policy Directions,
1992 to 2001
Shifts in physician activity occur in the broader
context of changes in the health care system.
Policy directions taken by governments,
educational institutions and other stakeholders
can impact on the number and location of family physicians as well as their practice patterns.35, 36
This report does not suggest a cause-and-effect relationship between specific policies and particular shifts
in clinical practice (or vice versa). Nor do the changes outlined below include all the changes that occurred
during the study time period. However, by highlighting some of the areas of significant policy activity that
occurred during the decade, insight can be gained into the environment in which family physicians made
their practice decisions. These changes and others are highlighted in Illustration 1.
Illustration 1:
Canada’s Family Doctors: Surrounded by Change, Such as . . .
Growth of underserviced populations
One pathway to family medicine
Other primary care providers
Health human resource concerns
across disciplines
Aging of the Canadian population
Regionalization initiatives
Post-graduate training trends
Globalization of the workforce
Early career choice for medical students
Increased length of training
Sub-specialization among specialist physicians
Aging of the physician workforce
Flexibility to change training programs
Primary Care Reform
Hospital closures and amalgamations
More specialized training for family physicians
Fluctuating approaches to physician supply
Information Technology
Rapid growth of medical knowledge
Increased patient knowledge and expectations
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
5.1 Changes in Medical Training and Licensing
a) Path to family medicine
At the beginning of the study period (1992), those finishing medical school could enter primary care
either by becoming a general practitioner after a one-year post-graduate rotating internship or by
becoming a family physician through completion of a two-year post-graduate family medicine
residency training program.
In 1993, the two-year family medicine residency program became the only option for medical students
who wanted to become family physicians.37 The impact of this change on the physician workforce has been
documented in the CIHI Report From Perceived Surplus to Perceived Shortage, authored by Dr. Ben Chan.38
b) Specialized training
There has been a steady growth of opportunities for family physicians to gain
training in areas of further specialization, such as emergency medicine, sports
medicine, obstetrics, palliative care, women’s health, geriatrics and First
Nation’s health. Third-year post-graduate positions are primarily offered to
individuals currently training to be family physicians, rather than those already
in practice. There has been increasing interest in these opportunities by family
medicine trainees. There has also been a similar trend towards more subspecialization within other disciplines of medicine, such as general internal
medicine and general surgery.39, 40, 41
There has been a
steady growth of
opportunities for
family physicians
to gain training
in areas of further
specialization
c) Training in family medicine
Statistics published by the Canadian Resident Matching Service (CaRMS) report medical students’ selection
of post-graduate medical training programs in Canada. In its 2003 Match Report, CaRMS notes that it “has
been tracking the interest of the graduating students in a career in family medicine as evidenced by family
medicine as a first choice discipline.”42 The CaRMS report indicates that, during the time period of 1994 to
2001, the percentage of medical school graduates who selected family medicine as a first-choice discipline
registered a high of 34.7% in 1997 and a low of 28.2% in 2001. The 2001 result represents an 18.7%
reduction in the proportion of medical school graduates who selected family medicine as a first-choice
training discipline compared to the high point in 1997.
The Canadian Post-M.D. Education Registry (CAPER) also reports medical
training statistics. In its annual census report, CAPER gives the proportions of
total postgraduate trainees who are exiting family medicine programs versus
non–family medicine specialty training programs. CAPER’s annual postgraduate exit statistics reflect the potential numbers of physicians who enter
medical practice just after completing post-graduate training in Canada. The
annual census report indicates that family medicine graduates declined from
44% of all exiting graduates in 1994–95 to 40% of all exiting graduates in
2001–02.43 This decreasing proportion of family medicine graduates has been
noted in research that considers Canada’s future supply of family physicians.44
26
This decreasing
proportion of
family medicine
graduates has
been noted in
research that
considers Canada’s
future supply of
family physicians
5. The Context of Change—
Policy Directions, 1992 to 2001
d) Career choice for medical students and flexibility in post-graduate training
Related to the medical training statistics noted in the previous section, are considerations of the factors
that influence medical students’ career choices. Many factors may be at play, and caution is warranted in
assuming the decision-making importance of each. Medical students’ decisions may be influenced by the
amount of family medicine taught in the undergraduate curriculum. Also, research and statements published
by the Canadian Federation of Medical Students and College of Family Physicians of Canada have suggested
that changes to the educational and training system have led to medical students making career choices
earlier than they would like.37, 45, 46, 47 Premature career choice may be complicated by a reduction in
opportunities to change training pathways after a career choice is made.
e) Length of medical education and post-graduate training
In the years preceding the study period, it was possible for
students to enter medical school following two years of
undergraduate coursework. This convention was in contrast to
reports that favoured students entering medical school with a
broader educational background.48, 49 Medical schools responded
by making completion of an undergraduate degree the usual
requirement,50 adding an additional one to two years to the
education process. The increasing role of third-year fellowships
in family medicine has increased the length of family medicine
training for many by another year.
The increasing role of
third-year fellowships
in family medicine
has increased the
length of family
medicine training for
many by another year.
f) Opportunity to re-enter specialties
There has been a steady reduction in the ability of physicians already in the workforce to return and re-train
in another discipline. This loss of opportunity may be one of the reasons behind a decreased selection of
family medicine as a training option by medical students. Another disincentive is that many of the re-entry
positions that remain available require a return of service contract following the training.36, 51, 52
5.2 Changes in the Health Care System
a) Regionalization, amalgamation and changes in hospital care
During the 10-year study period, most provinces and territories underwent a process of hospital
amalgamation, health care system regionalization or both.53, 54, 55, 56 At the same time, the approach to care
in the hospital settings changed, with shorter hospital stays, increased outpatient procedures and a greater
focus on community-based care. Changes in the hospital setting, including the impact on the role of family
physicians, have been documented by the College of Family Physicians of Canada in their recent report,
Family Physicians Caring for Hospital Inpatients.57
27
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
b) Primary care reform
By 2001 (the end of the study period) almost all provinces and territories
had committed to introducing new models of primary care delivery. Some
engaged in limited pilots, while others invested in a significant roll-out of
new approaches.15, 16, 17 Many different models were implemented.14 They
typically addressed the issues of patient access, alternative models of financial
remuneration for physicians, integration of a team of health care professionals
and enhanced use of information technology. While primary care reform
remains a focus, some reports suggest that these initiatives have created
uncertainty within the profession and medical schools about the future need
and role of family physicians.58, 59
While primary care
reform remains a
focus, some reports
suggest that these
initiatives have
created uncertainty
within the profession
c) Increasing numbers and types of health care provider groups
A variety of health care provider groups have expressed increasing interest in participating in areas of care
that are currently provided by family physicians.10, 11, 12, 13 In some cases, there has already been an increase
in the number of other health care providers, or a change in their practice scopes.36, 60, 61
d) Needs of underserviced populations
During the study period, there was growing concern about ensuring an appropriately trained number of
health professionals providing care in geographical areas with need.35, 36 A large range of measures have
been taken to encourage health care workers to serve in areas of identified need, such as rural and
remote communities, as well as some inner-city populations. These initiatives have included recruitment
and retention measures, better data collection and changes to the educational/training system.62, 63, 64, 65
e) Physician supply
As noted above, in 1993 a number of policies were implemented that had an impact on the supply of
physicians. These included, for example, a 10% reduction in the number of medical school positions and
policies related to international medical graduates’ entry into the Canadian physician workforce.66, 38
In 1999, a Canadian Medical Forum physician supply report suggested that retirement rates would
accelerate and outstrip the number of new graduates by 2008.66 In the years following this study, many
provinces have increased positions in medical schools and attention is being given to means of increasing
the role of international medical graduates in the system.36 Given the length of medical school and postgraduate training programs, the impact of these changes will not be reflected in the results of this study.
28
5. The Context of Change—
Policy Directions, 1992 to 2001
f) Societal changes
Significant demographic changes are occurring in Canada. The size of the population is growing at a
faster rate than the supply of physicians. Furthermore, the population is aging.38 Currently, those over
age 65 utilize 70% of the health care budget.66 Associated with this aging population are possible impacts
on health care utilization, with respect to both volume and complexity.
There has also been a growth in patients’ knowledge about their own health. This change has been
facilitated and supported by a significant increase in access to medical information through resources
such as patient advocacy groups, the Internet and increased media coverage. In turn, this has led to
greater expectations of their health care providers and a greater desire to be involved in the decisions
related to their own care or the care of a family member.
Changes such as those described above contribute to an environment that impacts on the day-to-day
work of health care providers, including family physicians. The following section, Changes in Specific
Clinical Practice Areas, looks at the trends in family physician practice patterns during the 10-year study
period, 1992 to 2001.
29
6. Changes in Specific
Clinical Practice Areas
A detailed description of the types of health
care services included in each clinical practice
area is provided in Appendix A.
6.1 Surgical Services
In each year of the study period (1992 to 2001), less than 13% of all family physicians provided surgical
services. In each year, the participation rate was higher for male family physicians as compared to that of
female family physicians (see Figure 10). For instance, in 1992, 14% of male family physicians provided
surgical services, compared to 9% of female family doctors. However, participation rates for both males
and females declined in a similar fashion over the study period. By 2001 the participation rates had
dropped to about 10% and 6% for males and females, respectively.
Percentages of Family Physicians Providing Surgical Services, by Sex, Canada, 1992 to 2001
10
25
% of FP/GPs
20
Source: National Physician
Database, CIHI
15
10
5
0
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Surgical service results are based
on data for all provinces, with the
exception of Newfoundland and
Labrador, Prince Edward Island
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
While male family physicians were more likely to provide surgical services, female family physicians who
provided these types of services typically provided more of them. Figure 11 shows that, throughout the
study period, female family physicians provided more surgical services on average than their male
counterparts. For instance, in 2001 female family doctors provided 62 surgical services on average,
compared to the male average of 50. For both males and females, the average number of surgical
services provided increased steadily during the study period (see Figure 11).
11
Average Number of Surgical Services per Family Physician Providing Surgical Services,
by Sex, Canada, 1992 to 2001
70
Services per FP/GP
60
50
40
Source: National Physician
Database, CIHI
30
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Surgical service results are based
on data for all provinces, with the
exception of Newfoundland and
Labrador, Prince Edward Island
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
20
10
0
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
2000
Total
Rural and mid-sized communities had higher percentages of family physicians
engaged in providing surgical services (see Figure 12). At the start of the study
period (1992), 9% of urban family doctors, 15% of family physicians in midsized communities and 21% of those in rural places provided surgical services.
Participation rates declined in all three geographic locations over the study
period. The decline was most precipitous in mid-sized and rural communities
where the participation rates dropped to 9% and 14%, respectively, in 2001.
32
2001
At the start of the
study period (1992),
9% of urban family
doctors, 15% of
family physicians
in mid-sized
communities and
21% of those in
rural places provided
surgical services.
6. Changes in Specific Clinical Practice Areas
12
Percentages of Family Physicians Providing Surgical Services,
by Geographic Location, Canada, 1992 to 2001
25
% of FP/GPs
20
15
Source: National Physician
Database, CIHI
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Surgical service results are based
on data for all provinces, with the
exception of Newfoundland and
Labrador, Prince Edward Island
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
10
5
0
1992
1993
1994
1995
1996
Urban
1997
1998
Mid-Sized
1999
2000
2001
Rural
In contrast to participation rates, the average number of surgical services provided by family physicians
was typically higher in urban communities than in rural and mid-sized communities (see Figure 13). Rural
family doctors provided fewer surgical services on average throughout the study period. The average
numbers of surgical services provided by family physicians in urban and mid-sized communities was quite
similar during the period of 1992 to 1996. However, from 1997 on, the average number of surgical
services offered was greatest for urban family physicians.
13
Average Number of Surgical Services per Family Physician Providing Surgical Services,
by Geographic Location, Canada, 1992 to 2001
70
Services per FP/GP
60
Source: National Physician
Database, CIHI
50
40
30
20
10
0
1992
1993
1994
1995
Urban
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Surgical service results are based
on data for all provinces, with
the exception of Newfoundland
and Labrador, Prince Edward Island
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
33
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
6.2 Office Practice
Figure 8a showed that, between 1992 and 2001, 85% to 90% of family physicians billed for office-based
assessments. It is important to note that throughout the study period, office-based assessments accounted
for two-thirds of all services provided by family physicians. Given the stability of office-based practice and its
predominant share of total billed services, subgroup variations in this clinical practice area are particularly
suggestive of family physician workload variations for those family doctors who are remunerated
predominantly through fee-for-service systems.
Participation in office assessments remained largely unchanged between 1992
and 1997. After that, there was a small but steady decline in participation. As
shown in Figure 14, male and female family physicians were equally likely to
participate in office practice. However, as shown in Figure 15, male family
doctors provided a significantly higher number of office assessments, on
average, than female family physicians. In 2001, male family physicians billed
for 3,960 office assessments on average, compared to an average of 2,712 for
female family doctors. In 2001, male family physicians billed for 46% more
office assessment services than female family physicians.
In 2001, male
family physicians
billed for 46% more
office assessment
services than female
family physicians.
14
Percentages of Family Physicians Providing Office Assessment Services,
by Sex, Canada, 1992 to 2001
100
% of FP/GPs
90
Source: National Physician
Database, CIHI
80
70
60
50
1992
1993
1994
1995
Female
34
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Office practice results are based
on data for all provinces, with
the exception of Prince Edward
Island, Ontario, Saskatchewan
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
6. Changes in Specific Clinical Practice Areas
15
Average Number of Office Assessment Services per Family Physician Providing
Office Assessment Services, by Sex, Canada, 1992 to 2001
4,500
Services per FP/GP
4,000
3,500
Source: National Physician
Database, CIHI
3,000
2,500
2,000
1,500
1,000
500
0
1992
1993
1994
1995
1996
1997
Female
Male
1998
1999
2000
2001
Total
Notes: Includes only services
provided through fee-forservice programs.
See Appendix A for definitions
of clinical service areas.
Office practice results are based
on data for all provinces, with
the exception of Prince Edward
Island, Ontario, Saskatchewan
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
The average number of office assessment services provided by family physicians traditionally peaked in
the 45-to-54 age group and then declined. However, at the end of the study period, this pattern moved
to the 55-to-64 age group, who then provided the highest average number of office assessment services.
Over the 10-year period, the average number of office assessment services provided increased for the
eldest age groups while declining in the younger age groups. This trend is seen in male and female family
physicians, as shown in Figures 16 and 17.
16
Services per FP/GP
Average Number of Office Assessment Services per Male Family Physician Providing
Office Assessment Services, by Age Groups, Canada, 1992, 1996 and 2001
5,000
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
1996
55–64
2001
65+
Notes: Includes only services
provided through fee-forservice programs.
See Appendix A for definitions
of clinical service areas. Office
practice results are based on
data for all provinces, with the
exception of Prince Edward
Island, Ontario, Saskatchewan
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
35
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
17
Average Number of Office Assessment Services per Female Family Physician
Providing Office Assessment Services, by Age Groups, Canada, 1992, 1996 and 2001
4,000
3,500
Services per FP/GP
3,000
Source: National Physician
Database, CIHI
2,500
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions of
clinical service areas.
Office practice results are based
on data for all provinces, with
the exception of Prince Edward
Island, Ontario, Saskatchewan
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
2,000
1,500
1,000
500
0
<35
35–44
45–54
1992
55–64
1996
65+
2001
As seen in Figure 18, there is fairly strong homogeneity among geographic settings. Rural and mid-sized
settings had slightly (2% to 3%) higher participation rates than urban settings.
18
% of FP/GPs
Percentages of Family Physicians Providing Office Assessment Services,
by Geographic Location, Canada, 1992 to 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Urban
36
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Office practice results are based
on data for all provinces, with
the exception of Prince Edward
Island, Ontario, Saskatchewan
and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
6. Changes in Specific Clinical Practice Areas
6.3 Advanced Procedural Skills Services
Throughout the study period, most family physicians provided advanced procedural skills services. This was
particularly true for family doctors in rural communities where no less than 81% of family physicians billed
for advanced procedural skills services in each year (see Figure 19). Among rural family physicians, the
participation rate in advanced procedural skills services was consistently about 20% higher than for family
physicians serving urban communities. While participation rates in advanced procedural skills services
declined only modestly, the decline became steeper after 1996 (see Figure 19). This trend was observed
not only in all geographic locations, but also among male and female family physicians in all age groups.
19
Percentages of Family Physicians Providing Advanced Procedural Skills Services,
by Geographic Location, Canada, 1992 to 2001
95
90
85
% of FP/GPs
80
75
Source: National Physician
Database, CIHI
70
65
60
55
50
1992
1993
1994
1995
Urban
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Advanced procedural skills
services results are based on
data for all provinces, with the
exception of Quebec.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
37
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Throughout the study period, advanced procedural skills services tended to be performed by family doctors
in younger age groups (see Figures 20 and 21). While participation rates were progressively lower for family
physicians in age groups older than 35 to 44, a more marked decline in participation rates across age groups
occurred among female family physicians.
20
Percentages of Male Family Physicians Providing Advanced Procedural Skills Services,
by Age Groups, Canada, 1992, 1996 and 2001
100
90
% of FP/GPs
80
70
Source: National Physician
Database, CIHI
60
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Advanced procedural skills
services results are based on
data for all provinces, with
the exception of Quebec.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
50
40
30
<35
35–44
45–54
1992
1996
55–64
65+
2001
Percentages of Female Family Physicians Providing Advanced Procedural Skills Services,
by Age Groups, Canada, 1992, 1996 and 2001
21
100
90
% of FP/GPs
80
70
Source: National Physician
Database, CIHI
60
50
40
30
<35
35–44
45–54
1992
38
1996
55–64
2001
65+
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Advanced procedural skills
services results are based on
data for all provinces, with the
exception of Quebec.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
6. Changes in Specific Clinical Practice Areas
From 1994, there was a steady increase in the average number of
advanced procedural skills services provided per family physician
(see Figure 22). This was the case for both male and female family
physicians. Throughout the study period, male family doctors
provided more than twice as many advanced procedural skills
services, on average, as female family physicians.
22
Services per FP/GP
Average Number of Advanced Procedural Skills Services per
Family Physician Providing Advanced Procedural Skills Services,
by Sex, Canada, 1992 to 2001
70
60
50
40
30
20
10
0
From 1994, there
was a steady increase
in the average
number of advanced
procedural skills
services provided
per family physician
Source: National Physician Database, CIHI
1992
1993
1994
1995
Female
1996
1997
1998
Male
1999
2000
2001
Total
Notes: Includes only services provided through
fee-for-service programs.
See Appendix A for definitions of clinical
service areas.
Advanced procedural skills services results
are based on data for all provinces, with the
exception of Quebec.
See Appendix B for details on provincial
inclusion/exclusion criteria.
From 1992 to 2001, family physicians serving urban, mid-sized and rural communities provided between
39 and 59 advanced procedural skills services on average (see Figure 23). The relative positions of rural
and urban family physicians, with respect to the average number of advanced procedural skills services
provided, gradually reversed and exhibited a widening gap during the study period. In 1992, rural family
physicians provided more advanced procedural skills services, on average, compared to urban family
physicians (48 versus 43, respectively). By 2001, urban family physicians billed for 59 advanced procedural
skills services on average, compared to an average of 39 for rural family physicians.
Average Number of Advanced Procedural Skills Services per Family Physician Providing
Advanced Procedural Skills Services, by Geographic Location, Canada, 1992 to 2001
23
70
Services per FP/GP
60
50
Source: National Physician
Database, CIHI
40
30
20
10
0
1992
1993
1994
1995
Urban
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Advanced procedural skills
services results are based
on data for all provinces,
with the exception of Quebec.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
39
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
6.4 Anaesthesiology Services
As shown in Figure 8b, family physician participation in providing anaesthesia services generally declined
over the study period. The 9% participation rate recorded in 1992 dropped to less than 6% in 1993 and
remained fairly constant from 1993 to 1999. In 2000 and 2001, the participation rate crept to just over 6%.
Figures 24 and 25 illustrate the slight increase in participation rates among both sexes and most age groups
in 2001 compared to 1996, particularly among family physicians aged less than 35. In 2001, male and female
family doctors aged less than 35 demonstrated higher participation rates in providing anaesthesia services
than their same-age group in 1992 and 1996.
24
% of FP/GPs
Percentages of Male Family Physicians Providing Anaesthesia Services, by Age Groups,
Canada, 1992, 1996 and 2001
20
18
16
14
12
10
8
6
4
2
0
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
1996
55–64
65+
2001
% of FP/GPs
Percentages of Female Family Physicians Providing Anaesthesia Services, by Age Groups,
Canada, 1992, 1996 and 2001
20
18
16
14
12
10
8
6
4
2
0
25
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
40
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Anaesthesia service results are
based on data for all provinces,
with the exception of Nova Scotia,
Alberta and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
1996
55–64
2001
65+
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Anaesthesia service results are
based on data for all provinces,
with the exception of Nova Scotia,
Alberta and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
6. Changes in Specific Clinical Practice Areas
The downward and then slightly upward trend in anaesthesia service participation rates was manifest in all
geographic settings (see Figure 26). Nevertheless, in 2001, 25%, 25% and 38% fewer family doctors were
providing anaesthesia services in urban, mid-sized and rural communities, respectively, compared to the
participation rates recorded in 1992. Throughout the study period, a greater percentage of family physicians
was involved in providing anaesthesia services in rural areas than in urban and mid-sized communities.
26
Percentages of Family Physicians Providing Anaesthesia Services,
by Geographic Location, Canada, 1992 to 2001
18
16
14
% of FP/GPs
12
10
Source: National Physician
Database, CIHI
8
6
4
2
0
1992
1993
1994
1995
1996
Urban
1997
1998
Mid-Sized
1999
2000
Rural
Overall, the average number of anaesthesia services provided per
family physician increased by 35% over the study time period;
however, the trend was variable (see Figure 27). The average
number of anaesthesia services provided increased for male and
female family physicians in the initial study years (1992 to 1995),
and then decreased until 1997. For both male and female family
physicians, the average number of anaesthesia services increased in
1998 and 1999. In the final two years of the study (2000 and 2001),
the average number of anaesthesia services provided decreased.
27
Average Number of Anaesthesia Services per Family Physician
Providing Anaesthesia Services, by Sex, Canada, 1992 to 2001
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Anaesthesia service results are
based on data for all provinces,
with the exception of Nova Scotia,
Alberta and British Columbia.
See Appendix B for
details on provincial
inclusion/exclusion criteria.
The average number
of anaesthesia
services provided
per family physician
increased by 35%
over the study
time period.
300
Services per FP/GP
250
200
150
Source: National Physician Database, CIHI
100
Notes: Includes only services provided through
fee-for-service programs.
See Appendix A for definitions of clinical
service areas.
Anaesthesia service results are based on data for
all provinces, with the exception of Nova Scotia,
Alberta and British Columbia.
See Appendix B for details on
provincial inclusion/exclusion criteria.
50
0
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
41
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
6.5 Surgical Assistance Services
Surgical assistance
by family physicians
was more common
in mid-sized
communities,
least common in
urban areas and
decreased in all three
geographic locations.
As seen in Figure 28, surgical assistance by family physicians was more
common in mid-sized communities, least common in urban areas and
decreased in all three geographic locations. Over the study period,
participation rates in surgical assistance decreased by 38%, 25% and
19% for urban, mid-sized and rural places, respectively.
28
% of FP/GPs
Percentages of Family Physicians Providing Surgical Assistance
Services, by Geographic Location, Canada, 1992 to 2001
80
70
60
50
40
30
20
10
0
Source: National Physician Database, CIHI
1992
1993
1994
1995
1996
Urban
1997 1998
1999 2000
Mid-Sized
2001
Rural
Notes: Includes fee-for-service family
physicians only.
See Appendix A for definitions of clinical
service areas.
Surgical assistance service results
are based on data for all provinces.
While a greater percentage of male family physicians than female family physicians engaged in surgical
assistance services, a decreasing trend held true for both genders across age groups. These trends are
illustrated in Figures 29 and 30.
29
Percentages of Male Family Physicians Providing Surgical Assistance Services,
by Age Groups, Canada, 1992, 1996 and 2001
80
70
% of FP/GPs
60
50
40
30
20
Source: National Physician
Database, CIHI
10
0
<35
35–44
45–54
1992
42
1996
55–64
2001
65+
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Surgical assistance service results
are based on data for all provinces.
6. Changes in Specific Clinical Practice Areas
30
Percentages of Female Family Physicians Providing Surgical Assistance Services,
by Age Groups, Canada, 1992, 1996 and 2001
80
70
% of FP/GPs
60
50
40
30
20
Source: National Physician
Database, CIHI
10
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Surgical assistance service
results are based on data
for all provinces.
0
<35
35–44
45–54
1992
55–64
1996
65+
2001
The average number of surgical assistance services provided by family physicians increased over the study
period, particularly for males (see Figure 31). The average number of services provided per family physician
increased by 42% for females and by 68% for males.
31
Average Number of Surgical Assistance Services per Family Physician Providing
Surgical Assistance Services, by Sex, Canada, 1992 to 2001
70
Services per FP/GP
60
50
40
30
Source: National Physician
Database, CIHI
20
10
0
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes only services
provided through fee-forservice programs.
See Appendix A for definitions
of clinical service areas.
Surgical assistance service
results are based on data
for all provinces.
43
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
A comparison of Figures 28 and 32 shows that while urban family physicians were less likely to provide
surgical assistance services than family physicians in mid-sized communities, urban family physicians who
did provide surgical assistance services did so more intensively than family physicians serving mid-sized
communities. In fact, over the study period, there was a marked increase in the intensity with which urban
family physicians provided surgical assistance services. The average number of surgical assistance services
provided by urban family physicians doubled during the study period.
32
Services per FP/GP
Average Number of Surgical Assistance Services per Family Physician Providing
Surgical Assistance Services, by Geographic Location, Canada, 1992 to 2001
90
80
70
60
50
40
30
20
10
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Urban
1997
1998
Mid-Sized
1999
2000
Notes: Includes only services
provided through fee-forservice programs.
See Appendix A for definitions
of clinical service areas.
Surgical assistance service
results are based on data
for all provinces.
2001
Rural
6.6 Basic Procedural Skills Services
As noted in Section 4.1, the provision of health care services that require basic procedural skills services
remained constant in terms of family physicians’ participation rate during the study period. This observation
is true for female and male family physicians, as well as family physicians serving all types of communities
(see Figures 33 and 34).
33
% of FP/GPs
Percentages of Family Physicians Providing Basic Procedural Skills Services,
by Geographic Location, Canada, 1992 to 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Urban
44
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Basic procedural skills service
results are based on data for
all provinces.
6. Changes in Specific Clinical Practice Areas
34
% of FP/GPs
Percentages of Family Physicians Providing Basic Procedural Skills Services,
by Sex, Canada, 1992 to 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
Total
While participation rates for services that require basic procedural
skills remained stable, the average number of services provided per
family physician declined steadily. The decline was steady for both
male and female family physicians, although male family doctors
continued to provide consistently more basic procedural skills
services on average than female family physicians (see Figure 35).
35
Services per FP/GP
Average Number of Basic Procedural Skills Services per
Family Physician Providing Basic Procedural Skills Services,
by Sex, Canada, 1992 to 2001
350
300
250
200
150
100
50
0
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Basic procedural skills service
results are based on data for
all provinces.
While participation
rates for services
that require basic
procedural skills
remained stable,
the average number
of services provided
per family physician
declined steadily.
Source: National Physician Database, CIHI
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes only services provided through
fee-for-service programs.
See Appendix A for definitions of clinical
service areas.
Basic procedural skills service results are based
on data for all provinces.
45
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Furthermore, the male and female patterns of decline were different. For males, the decline in the
average number of services provided was most pronounced among family doctors in the 45-to-54 age
group (see Figure 36). Average service levels declined by 33% for male family physicians aged 35 to 44
and 38% for those aged 45 to 54 between 1992 and 2001, compared to 28% and 26% for those aged
55 to 64 and less than 35, respectively. Service levels for male family doctors older than 65 remained
virtually unchanged throughout the study period. A more constant decline in average service levels,
ranging from 43 to 50%, was recorded for female family physician age groups below the age of 65
(see Figure 37). The data show that females aged 65 or up provided more basic procedural skills
services, on average, in 1996 and 2001 compared to 1992. However, it is important to note that in
1992 there were only 153 female family physicians aged 65 or older in Canada. The year-to-year
practice patterns of such a small group may be expected to vary widely.
Average Number of Basic Procedural Skills Services per Male Family Physician Providing
Basic Procedural Skills Services, by Age Groups, Canada, 1992, 1996 and 2001
36
400
350
Services per FP/GP
300
250
200
150
Source: National Physician
Database, CIHI
100
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Basic procedural skills service
results are based on data for
all provinces.
50
0
<35
35–44
45–54
1992
1996
55–64
65+
2001
Average Number of Basic Procedural Skills Services per Female Family Physician Providing
Basic Procedural Skills Services, by Age Groups, Canada, 1992, 1996 and 2001
37
300
Services per FP/GP
250
200
150
100
Source: National Physician
Database, CIHI
50
0
<35
35–44
45–54
1992
46
1996
55–64
2001
65+
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Basic procedural skills service
results are based on data for
all provinces.
6. Changes in Specific Clinical Practice Areas
6.7 Obstetrics
The percentage of family physicians involved in providing obstetrical services decreased steadily for both
genders over the period of 1992 to 2001 (see Figure 38). However, this decline was slower for women
who, after 1992, had a higher level of participation than men. In 2001, the most recent data year, 18% of
female family doctors and 15% of males billed for obstetrical services, compared with 28% for both males
and females in 1992.
38
% of FP/GPs
Percentages of Family Physicians Providing Obstetrical Services,
by Sex, Canada, 1992 to 2001
50
45
40
35
30
25
20
15
10
5
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
2001
Total
As seen in Figure 39, participation rates were very similar for family physicians serving rural and mid-sized
communities and lower for urban family physicians. This pattern was found to be the same for male and
female family physicians across geographic settings. During the study period, participation rates declined 29%
for rural family physicians, 40% for those serving mid-sized communities and 50% for urban family physicians.
39
% of FP/GPs
Percentages of Family Physicians Providing Obstetrical Services, by
Geographic Location, Canada, 1992 to 2001
50
45
40
35
30
25
20
15
10
5
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Urban
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
47
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Figures 41 shows that, throughout the study period, participation rates for obstetrical care services
decreased steadily with age for women from the youngest age category on. In 1992 and 1996, men
reached their peak level of participation between ages 35 and 44, with decreased participation among
older age groups (see Figure 40). In 2001, the pattern of decline was similar for men and women, with
steadily decreasing participation rates from the earliest age group on.
For the three years of data presented in Figures 40 and 41, participation rates dropped in each subsequent
year in each age group for both men and women. For both sexes, the decline was greatest in the 45 to 54
age group. In 1992, 32% of males and 24% of females aged 45 to 54 participated in obstetrical care. In
2001, 16% of male and female family physicians aged 45 to 54 practised obstetrics.
40
% of FP/GPs
Percentages of Male Family Physicians Providing Obstetrical Services,
by Age Group, Canada, 1992, 1996 and 2001
50
45
40
35
30
25
20
15
10
5
0
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
1996
55–64
2001
41
% of FP/GPs
Percentages of Female Family Physicians Providing Obstetrical Services,
by Age Group, Canada, 1992, 1996 and 2001
50
45
40
35
30
25
20
15
10
5
0
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
48
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
65+
1996
55–64
2001
65+
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
6. Changes in Specific Clinical Practice Areas
Figure 39 showed that urban family physicians were less likely
to provide obstetrical care services than family physicians working
outside of urban areas. As shown in Figures 42 and 43, however,
urban family physicians who did practise obstetrics tended to do
so more intensively than other family doctors. Over the study
period, this pattern of practice became most pronounced for
female family physicians working in urban places. In 1992, female
family doctors serving urban communities provided, on average,
40 obstetrical services. This number increased 60% by 2001,
when urban female family doctors provided 64 obstetrical
services, on average.
In 1992, female
family doctors serving
urban communities
provided, on average,
40 obstetrical
services. This
number increased
60% by 2001.
42
Average Number of Obstetrical Services per Male Family Physician Providing
Obstetrical Services, by Geographic Location, Canada, 1992 to 2001
70
Services per FP/GP
60
50
40
Source: National Physician
Database, CIHI
30
20
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
10
0
1992
1993
1994
1995
1996
Urban
1997
1998
Mid-Sized
1999
2000
2001
Rural
43
Services per FP/GP
Average Number of Obstetrical Services per Female Family Physician Providing
Obstetrical Services, by Geographic Location, Canada, 1992 to 2001
70
60
50
40
30
20
10
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Urban
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
49
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Figures 44 and 45 illustrate how the intensification of obstetrical service provision manifested itself in female
and male age groups over the study period. The average number of services provided by female family
physicians in most age groups increased between 1992 and 2001 (see Figure 45). For females, the increases
were particularly marked in the 35-to-44 and 55-to-64 age groups. For males, the increases were more
modest and were observed among age groups older than 44 (see Figure 44). Figures 44 and 45 also show
that, for both males and females, family physicians aged 65 or older tended to provide fewer obstetrical
services, on average, than their younger colleagues, with the exception of females in 1996.
44
Average Number of Obstetrical Services per Male Family Physician Providing
Obstetrical Services, by Age Group, Canada, 1992, 1996 and 2001
70
Services per FP/GP
60
50
40
30
Source: National Physician
Database, CIHI
20
10
0
<35
35–44
45–54
1992
1996
55–64
65+
2001
45
Services per FP/GP
Average Number of Obstetrical Services per Female Family Physician Providing
Obstetrical Services, by Age Group, Canada, 1992, 1996 and 2001
70
60
50
40
30
20
10
0
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
50
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
1996
55–64
2001
65+
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Obstetrical service results are
based on data for all provinces.
6. Changes in Specific Clinical Practice Areas
6.8 Mental Health Services
Family physician involvement in providing mental health care services remained high throughout the
study period. Between 1992 and 2001, mental health care services participation rates increased slightly
for male and female family doctors (see Figure 46) across all geographical locations (see Figure 47).
Female participation was consistently higher than male participation throughout the study period.
46
% of FP/GPs
Percentages of Family Physicians Providing Mental Health Services,
by Sex, Canada, 1992 to 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Mental health care service results
are based on data for all provinces.
2001
Total
47
Percentages of Family Physicians Providing Mental Health Services,
by Geographical Location, Canada, 1992 to 2001
% of FP/GPs
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Urban
1996
1997
Mid-Sized
1998
1999
Rural
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Mental health care service results
are based on data for all provinces.
51
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
The modest overall increase in participation rates illustrated in Figures 46 and 47 are due, primarily, to a
change in practice among older family physicians. As shown in Figures 48 and 49, mental health care services
participation rates increased most markedly for family physicians in the 55-to-64 and 65-or-older age
groups. In 1992, 71% of female family physicians aged 65 or older billed for mental health care services.
This figure increased to 81% by 2001.
48
% of FP/GPs
Percentages of Male Family Physicians Providing Mental Health Services,
by Age Group, Canada, 1992, 1996 and 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
1996
55–64
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Mental health care service results
are based on data for all provinces.
65+
2001
Mental health care services participation rates increased most markedly
for family physicians in the 55-to-64 and 65-or-older age groups.
49
% of FP/GPs
Percentages of Female Family Physicians Providing Mental Health Services,
by Age Group, Canada, 1992, 1996 and 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
<35
35–44
45–54
1992
52
1996
55–64
2001
65+
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Mental health care service results
are based on data for all provinces.
6. Changes in Specific Clinical Practice Areas
Increased participation rates in providing mental health care services were accompanied by increased levels
of service provision as measured by average number of services per family physician. Between 1992 and
2001, the average numbers of mental health care services provided by male and female family physicians
increased by 11% and 17%, respectively (see Figure 50).
50
Services per FP/GP
Average Number of Mental Health Services per Family Physician Providing
Mental Health Services, by Sex, Canada, 1992 to 2001
400
350
300
250
200
150
100
50
0
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Female
1997
1998
Male
1999
2000
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Mental health care service results
are based on data for all provinces.
2001
Total
6.9 Hospital Inpatient Care
Family physician participation rates in providing hospital inpatient care services declined overall during the
period of 1992 to 2001. This is true for male and female family physicians (see Figure 51), as well as for
family physicians working in all geographical locations (see Figure 52). In 1992, 71% of family physicians
provided hospital inpatient services, compared to 62% in 2001. As illustrated in Figures 51 and 52, the
downward trend seems to have stabilized in the last three years, at around 62%.
51
% of FP/GPs
Percentages of Family Physicians Providing Hospital Inpatient Services,
by Sex, Canada, 1992 to 2001
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Female
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Hospital inpatient service results
are based on data for all provinces.
53
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
52
Percentages of Family Physicians Providing Hospital Inpatient Services,
by Geographic Location, Canada, 1992 to 2001
% of FP/GPs
100
95
90
85
80
75
70
65
60
55
50
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996
Urban
1997
1998
Mid-Sized
1999
2000
Notes: Includes fee-for-service
family physicians only.
See Appendix A for definitions
of clinical service areas.
Hospital inpatient service results
are based on data for all provinces.
2001
Rural
While overall participation rates in hospital inpatient care services declined for females and males in all
geographic settings, mixed results were recorded for average numbers of hospital inpatient services
provided (see Figures 53 and 54). The trend in average number of services provided was predominantly
downward throughout the study period for family doctors in rural and mid-sized settings. After 1996,
however, the trend was generally upward for doctors in urban settings (see Figure 54). There also was a
steady increase in the average number of hospital inpatient services provided by female family doctors after
1996, a trend that is not so readily apparent among males (see Figure 53).
53
Services per FP/GP
Average Number of Hospital Inpatient Services per Family Physician
Providing Hospital Inpatient Services, by Sex, Canada, 1992 to 2001
1,100
1,000
900
800
700
600
500
400
300
Source: National Physician
Database, CIHI
1992
1993
1994
1995
Female
54
1996
1997
Male
1998
1999
Total
2000
2001
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Hospital inpatient service results
are based on data for all provinces.
6. Changes in Specific Clinical Practice Areas
54
Services per FP/GP
Average Number of Hospital Inpatient Services per
Family Physician Providing Hospital Inpatient Services,
by Geographic Location, Canada, 1992 to 2001
1,100
1,000
900
800
700
600
500
400
300
Source: National Physician
Database, CIHI
1992
1993
1994
1995
1996 1997
Urban
Mid-Sized
1998 1999
2000 2001
Rural
Notes: Includes only
services provided through
fee-for-service programs.
See Appendix A for definitions
of clinical service areas.
Hospital inpatient service results
are based on data for all provinces.
Figures 55 and 56 illustrate hospital inpatient care practice patterns across age/sex groups throughout
the study period. Male family doctors tended to bill for more hospital inpatient services than female family
doctors, and their average number of services provided was greatest among the 55-to-64 age group
(see Figure 55). The results shown in Figure 56 suggest that the cohort of female family physicians who
were aged 55 to 64 in 1992 may be unique among female family doctors with respect to the provision
of hospital inpatient services. In 1992, this cohort of family physicians provided more hospital inpatient
services, on average, than all other ages of female cohorts in the years shown.
55
Services per FP/GP
Average Number of Hospital Inpatient Services per
Family Physician Providing Hospital Inpatient Services,
Males, by Age Group, Canada, 1992, 1996 and 2001
1,100
1,000
900
800
700
600
500
400
300
Source: National Physician Database, CIHI
<35
35–44
1992
45–54
1996
55–64
2001
56
Services per FP/GP
Average Number of Hospital Inpatient Services per
Family Physician Providing Hospital Inpatient Services,
Females, by Age Group, Canada, 1992, 1996 and 2001
1,100
1,000
900
800
700
600
500
400
300
Notes: Includes only services provided
through fee-for-service programs.
See Appendix A for definitions of clinical
service areas.
Hospital inpatient service results are based
on data for all provinces.
65+
Source: National Physician Database, CIHI
<35
35–44
1992
45–54
1996
55–64
2001
65+
Notes: Includes only services provided
through fee-for-service programs.
See Appendix A for definitions of clinical
service areas.
Hospital inpatient service results are based
on data for all provinces.
55
7. Discussion and
Considerations
The preceding section provided a data
summary of family physicians’ practice changes
in a number of defined clinical practice areas
during the period from 1992 to 2001. Earlier,
Section 5 of this report offered a brief summary of the context of change during the same period,
focusing on the health care delivery and training environment, as well as societal changes. The
following section will discuss trends and considerations that flow from both the study results as
well as the broader context of change. It is, unfortunately, beyond the scope of this single report to
highlight the numerous observations, considerations and perspectives that are relevant to the study
results. However, the following discussion will serve to inform and possibly encourage future
research and dialogue.
7.1 Activity Patterns: An Important Factor
in Health Human Resource Planning
Canadian family physicians appear to be a heterogeneous population
with a dynamic pattern of clinical activity that varies by age, sex,
location and time period. Health human resource planning efforts
that consider one family physician as essentially the same as any
other family physician will capture neither these differences nor the
implications for service delivery.32 The practice trends presented in
this report may help to inform physician resource planning efforts.
CONSIDERATIONS
! Can the differences in service provision as reflected by
sex, age and location be used to develop better health
human resource planning?
Canadian family
physicians appear to
be a heterogeneous
population with
a dynamic pattern
of clinical activity
that varies by age,
sex, location and
time period.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
7.2 Decreasing Participation
In almost all areas of clinical activity, there has been a consistent reduction in the participation of family
physicians (that is, the percentage of family physicians who bill for service). This trend is seen on broad
analysis and also tends to hold true across age and gender groups, as well as geographic settings. These
findings are consistent with other studies that have indicated declining participation of family physicians
in a number of clinical areas.19, 20, 21, 22, 23, 24, 25
The results bring forward important questions about the core conceptualization of family physicians and
the role they play in the health care system.
A variety of complex circumstances may explain these declining trends. Declining participation rates
are possibly a reaction to some of the system changes outlined in Section 5 of this report. For example,
the decrease in hospital-based care, including hospital inpatient visits/assessments and surgical assistance
services, may be related to the emergence of new health care models, characterized by increased
community-based care. Practice changes may be influenced by remuneration models that favour a
concentration of activity within the office setting—a clinical practice area that did not see a significant
reduction in participation rates or intensity. Finally, as the breadth and complexity of medical knowledge
and care expand, family physicians may see new opportunities to provide care in specialized areas rather
than across a broad range of clinical areas. This concept is further explored below.
These possible explanations raise the question of whether having family physicians who provide the
expected traditional broad range of skills is needed and/or feasible today. If the traditional breadth is
determined to be both needed and feasible, then recent trends might be further explored to foster
an improved understanding of how family physicians may re-enter and reassume these areas of
clinical activity.
Achieving this goal may demand further analyses and an integrated set of strategies that address education
and training systems; practice models; remuneration models and emphasis; and the perception of family
medicine as held by the public, specialist physicians, physicians in-training and family physicians themselves.
Moving forward, a broad perspective may encompass a view of patient needs, the context and environment
in which care is provided, as well as the skill sets and expertise of a broad range of health care providers.
CONSIDERATIONS
! The finding of a general decline in the participation of family physicians in a
variety of clinical areas is congruent with past studies. This finding may suggest
a need to further explore the causes and catalysts of change.
! Efforts to address patterns of clinical practice may require a comprehensive
and integrated approach that uses a variety of strategies. Such an approach
may demand attention to both the education and practice environment.
Similarly, successful efforts may hinge upon consideration not only of family
medicine, but also of other medical disciplines and the broad spectrum of
health care provider groups.
58
7. Discussion and Considerations
7.3 Increasing Intensity of Service Provision
A reduction in the overall level of participation in several clinical practice areas, with an associated increase
in the average number of services provided by those family physicians who remain involved, was the most
common pattern. This was seen in five of the nine practice areas: obstetrical care, advanced procedural
skills services, anaesthesia services, surgical services and surgical assisting.
A number of explanations for this trend are possible. The first is that those who remain involved in these
clinical practice areas adopt a more intensive workload because they are compensating for the withdrawal
of participation by other family physicians or a shortage of service provision by other physicians or health
care workers. For example, the recent increased activity of family physicians providing anaesthesia may
reflect a response to a reported shortage of anaesthesiologists who are certified by the Royal College of
Physicians and Surgeons.67 Similarly, the increasing provision of mental health care services by family
physicians may reflect a response to reported geographic and overall shortages of psychiatrists.68, 69
A second possibility, alluded to above, is that family physicians, in response to the increasing complexity of
medicine, may explore opportunities to focus their practice in limited clinical practice areas, characterized
by high levels of service that promote a sense of competency. Some studies have suggested a relationship
between high volumes of activity (particularly for surgical services) or delivery by subspecialists and
improved outcomes.70, 71 Similarly, there have been some reports of better management of common clinical
conditions by specialists in specialty clinics where the focus will be primarily on just a few clinical conditions.
However, the findings have not been consistent.72, 73
A third explanation is that there may be a variety of implicit or explicit incentives/disincentives to engage
in certain clinical activities. These may relate to compensation structures, perceived prestige of certain
practice areas or infrastructure features of the health care system.
CONSIDERATIONS
If individual family physicians are increasing their workloads to compensate for the
reduced participation of other family physicians or health human resource (HHR)
shortages in other disciplines, then:
! What has led other family physicians to withdraw from these areas?
! What are the characteristics of the physicians who have stayed
involved even if doing so requires providing more services?
! How high can the workload for these remaining physicians rise?
! How long can these physicians maintain the higher level of activity?
! How can the HHR issues within family medicine or other disciplines
be addressed?
59
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
CONSIDERATIONS
7.3
CONTINUED
If this pattern is due to the increasing complexity and a desire of family physicians
to achieve greater clinical comfort by focusing their practice, then:
! What is an appropriate and realistic range of skills to expect individual
family physicians to acquire and exercise through their practice?
! Are there changes to the educational system that could assist family
physicians in attaining and maintaining a broader set of skills despite
the increasing complexity of medical practice?
! What is the level of “volume” or “experience” that confers and
maintains competency?
! Should HHR planning consider the entire population of family physicians
and the range of services they provide as a whole?
! How can the need for these increasingly focused practices be determined,
and what changes to the number and type of training programs are needed
to accommodate family physicians who are practising more narrowly, but at
higher volumes?
! When should the more traditional comprehensive family medicine practices be
encouraged, and how should they be supported in a manner to complement
the decision by some family physicians to focus their practice?
If this pattern is primarily due to incentives and disincentives created by the
system then:
! What policy changes are needed to support family physicians in traditional
broad-based practices?
As noted previously, workload increases could be a statistical artefact. Family physicians who provide
relatively fewer services may cease participation in a particular clinical area altogether, leaving behind those
physicians who always provided high levels of care. This, in turn, would produce an apparent increase in the
average number of services per physician. However, this possible explanation still warrants consideration of
how to respond to potential health service gaps. A future study to explore this issue through use of a cohort
approach is explored below.
7.4 Stable at the Core
Office assessments represent the core clinical activity of family physician activity. Over 85% of physicians
in this study provided office care, and this service represented 60% to 70% of all billings. Study summary
measures for office practice remained generally stable throughout the study period.
60
7. Discussion and Considerations
7.5 An Area of Sustained Growth
Mental health care services showed significant growth in almost every analysis. This may simply reflect fee
schedule changes that permit improved descriptions of existing practice patterns. It may also reflect
increasing education and awareness of the need for family physicians to recognize and treat mental health
illness. Regardless, further research may be required to explore the reasons for the increasing interest levels.
CONSIDERATIONS
! The apparent increasing participation in mental health could be explored to
better understand the reasons behind this increase.
7.6 More Involvement and More Work by Older Physicians
Discussion has been made in health human resource forums about generational differences between
physicians. The suggestion has been made that new physicians (starting in training programs) are trying to
establish a different balance between their clinical careers and their other professional or personal activities.74
This report suggests that there are generational differences. While the general decreasing or increasing
trends held across all age groups, older physicians were consistently more likely to continue their
participation or even increase it. In addition, older physicians were more likely to increase their average
workload as fewer doctors participated in a clinical area. This pattern was seen in office assessments
where the average workload has increased in the 55-to-64 and 65-or-older categories, while dropping
in all other age categories (see Figures 16 and 17). Male physicians in the 45-to-64 age group have
consistently seen more patients annually than those in other age groups (see Figure 16). In mental health
services, there were increases in all age groups, but particularly so for the older age categories, especially
for older female physicians (see Figures 48 and 49). The decline in average number of procedures that
require basic clinical skills might be in part due to reductions in activity of those physicians under 65 years
of age (see Figures 36 and 37).
There were some exceptions to this pattern. For example, the number of obstetrical care services
declined steadily with age (see Figures 40, 41, 44 and 45). Younger male physicians more commonly
provided anaesthetic services (see Figure 24) and younger female physicians were more likely to
provide services that require advanced procedural skills than older female physicians (see Figure 21).
CONSIDERATIONS
! Will younger physicians adopt the practice patterns of the existing
older physicians as they age?
! What is the sustainability of a pattern of service provision that relies
significantly on older physicians?
! Are there certain clinical activities that correlate with certain stages
in the career life cycle?
! In addition to a possible desire to seek a different work/personal balance,
what policy or other changes have occurred to create this apparent
generational difference?
61
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
7.7 Gender Differences
Women are entering the family physician workforce in numbers significantly higher than men, with an
approximately 30% increase in the number of female physicians during the study period (and a sharp
decline in new male graduates entering family medicine). These increases are occurring at the entry to
the workforce, and female physicians represented only 16% of the 55-to-64 age group and 10% of the
65-or-older age group in 2001. This makes it more difficult to comment on the clinical practice of women
throughout the life cycle.
In this study, men and women generally mirrored each other in terms of broad patterns of increase and
decrease. However, there were differences in their level of participation and intensity of workload in
different clinical areas.
Throughout the study period, female family physicians provided more surgical services on average than
men (see Figure 11). Since 1993, a moderately greater percentage of female physicians has been involved in
obstetrics (see Figure 38). Female physicians also provided significantly more obstetrical services on average
from the beginning of the study period in all locations (see Figures 42 and 43). Finally, a greater percent of
female physicians were engaged in mental health services, although men and women were very similar in
terms of average number of mental health care services provided (see Figures 46 and 50).
In general, however, men participate more heavily and provide more services in almost all other clinical
areas, regardless of age or geography—often significantly so. As noted earlier, in 2001, male family physicians
billed for 46% more office assessment services than female family doctors. The trend was similar for the
provision of services that require advanced procedural skills, where men provided approximately twice as
many services (see Figure 22). Even in surgical services, where women provided more services on average,
a greater percentage of men participated than women (see Figure 10).
CONSIDERATIONS
! How will the practice patterns of women change as they move through
the “physician life cycle” and their own “personal life cycle”?
! What are the factors that lead to these gender differences? Are there
strategies that can be implemented to either minimize these differences
or capitalize upon them?
! What other practice differences are related to gender?
62
7. Discussion and Considerations
7.8 Geographic Differences
Canada is defined and distinguished by its vast size and significant rural regions. Previous literature has
identified the unique health needs of northern and rural communities75 and the particular challenges that
can face health professionals working in these areas. While 22% of the Canadian population lives in
mid-sized communities, only 10% of the physician workforce is located there76—most of them family
physicians. They care for communities that often have higher rates of morbidity and mortality for
multiple health issues.77, 78, 79, 80
This study illustrates generally consistent patterns across geographic areas in terms of decreasing
participation and increasing workloads. With few exceptions, gender patterns also largely held true
across the three geographic regions studied.
However, rural physicians consistently had higher rates of participation in most clinical areas. Rural areas
had the highest percentage of physician participation for surgical services, basic procedures (only slightly
higher than mid-sized), advanced procedures and anaesthesia (see Figures 12, 33, 19 and 26, respectively).
Mid-sized communities had the highest participation in surgical assistance services and hospital inpatient
care (see Figures 28 and 52, respectively). Participation rates in obstetrical services for rural and mid-sized
communities were almost identical (see Figure 39). Rural and mid-sized communities had slightly higher
(2% to 3%) participation for office assessments and mental health delivery was similar in all settings
(see Figures 18 and 47).
The use of average workload measurement may be more limited for comparing geographical settings,
since the size of a population can influence the volume of service delivery. For example, a rural town of
5,000 people will have comparatively few babies delivered annually, regardless of the willingness of the
family physicians to provide the service. Generally, average workloads increased over time in all geographic
areas—except for basic procedures, where there was a decrease in all three areas. There was a decline in
mid-sized and rural communities in average hospital inpatient care, while urban areas saw a steady increase
after 1997 (see Figure 54). The average obstetrical workload saw significant increases in urban areas and
only small increases in mid-size and rural (see Figures 42 and 43).
Relative to other regions, rural areas had a larger loss of participation in hospital-based services such as
anaesthesia and surgical services. These regions may be particularly impacted by the broader health care
system changes discussed throughout this report.
CONSIDERATIONS
! How has regionalization, amalgamation and change in hospital service delivery
influenced the breadth of activity family physicians can offer? Has this impact
been equal across geographic regions?
! Although the trends towards decreased participation are similar across
settings, are the reasons different depending on geographic setting?
! Do the trends of decreased clinical participation presented in this paper have
greater implications in non-urban areas, possibly due to limited other physician
and health professional resources in those areas?
63
The Evolving Role of Canada’s Family Physicians
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7.9 System in Evolution
As outlined in Section 5, family physicians have faced a large number of
changes in the last decade. The pace of this change is unlikely to slow as
governments increasingly move towards reforming primary health care.
For example, the recent well-publicized reports by Commissioners
Kenneth J. Fyke, Roy J. Romanow and Senator Michael J. L. Kirby have
all stressed the need for primary care reform.
The pace of this
change is unlikely to
slow as governments
increasingly move
towards reforming
primary health care.
Despite, or perhaps related to, these changes, family physicians seem to be
facing a number of challenges. In addition to a decline in medical students
choosing to pursue a career in family medicine, several studies have reported patients having problems
accessing family physicians and high levels of frustration and low morale among physicians.81, 82 A recent
Statistics Canada report noted, “a total of 14% of Canadians, or 3.6 million people, are without an FP.
Of that number, 1.2 million have searched unsuccessfully for an FP” (“FP” is used as an abbreviation
for “family physician”).83
CONSIDERATIONS
! To what degree do evolving activity patterns of family physicians reflect other
changes in the system, such as availability of services provided by other
physician groups?
! How have policy initiatives impacted family physicians? Are the trends seen in
this paper independent of the recent changes? Are initiatives such as primary
care reform or changes to training systems seen as positive steps by current
and future family physicians, or do they introduce uncertainty and stress?
! Can greater involvement of family physicians and family physician leadership
help the profession with modulating and positively influencing change?
! Is there a role for change management or knowledge transfer strategies to
help family physicians adjust to their changing environment?
64
8. Limitations and
Future Research
8.1 Assessing “Quality”
of Care Delivery
This report moves beyond describing the number, location and basic demographics of the
workforce to reflect a profile of a family physician’s clinical practice. A next step would be to
capture issues around the quality of care provided by family physicians with different practice
profiles. Future research might include evaluating clinical outcomes and patient views.
This research may be particularly warranted, given a number of educational and practice paradigm
shifts for medicine in general and family medicine in particular. The patient-centred approaches
to care, life-long learning (including continuing medical education and continuing professional
development), transdisciplinary approaches to primary care and evidence-based medicine are
all intended to improve the quality of care patients receive. However, the impact of these new
approaches on a family physician’s practice have not been fully evaluated.
8.2 Additional Practice Areas and Settings
In addition to the nine areas covered here, there are a variety of other clinical settings that should
be studied. These include home visits, walk-in clinics and nursing homes—all areas where family
physicians have traditionally participated. There are also other clinical areas of activity that could
be studied. These areas include sports medicine, women’s health, emergency medicine, addictions,
palliative care and First Nation health.
8.3 Non-Clinical Activity
This study does not capture current or historical involvement in professional, non-clinical, areas of
activity. In addition to direct patient care, family physicians may be engaged in research, education
or administrative activities. These important professional activities may impact the amount of time
available for direct clinical care.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
8.4 Non Fee-for-Service Family Physicians
As outlined in the explanation of the methodology, this study captured only physicians working in fee-forservice models. Since the time of completion of this study, there has been increasing recruitment of family
physicians into alternate payment systems (such as salary, capitation, per diems and sessional fees).26 It is
important to know if the demographic profile and activity profile of these physicians is different. Given that
some of these new models of payment incorporate incentives to encourage
certain types of clinical activity, some differences might be expected.
Efforts to try and
8.5 Impact of Health Policy
The data illustrate significant changes in practice patterns over a 10-year
period. The report also highlights a wide range of policy initiatives that
occurred during these years. These policies may have had an impact on some
of the practice pattern changes observed over the study period. Efforts to try
and evaluate the direct impact of specific policies (such as regionalization or
certain models of primary care reform) may help better explain the trends
seen in this study.
8.6 A Cohort Analysis
evaluate the direct
impact of specific
policies (such as
regionalization or
certain models of
primary care reform)
may help better
explain the trends
seen in this study.
This study did not explore practice changes at the level of the individual family
physician. Another approach would have been to track a particular group of individuals throughout the
same time period. This would allow us to better understand whether the increasing average workload is
being shared among a number of family physicians, each focusing on a specific area, or if there are some
family physicians increasingly active across multiple areas.
66
Historically, family physicians have had a strongly
defined role in the Canadian health care system.
This role revolved around providing both a
breadth of knowledge and skills across many
clinical settings. In studying Canada’s family physician workforce, this study moves beyond a
discussion of the number and location of doctors to explore the nature of their clinical activity and
whether the traditional understanding of the broad nature of family medicine remains valid.
9. Conclusion
This study indicates that over a 10-year period there was a decline in the participation of family
physicians in a number of clinical areas. This trend generally held true across gender and age
groupings, as well as geographic settings. In parallel with this decreasing level of participation was
an increase in intensity, as measured by the average number of services provided per family
physician. This increased average workload was often most notable among older physicians.
This study will help to inform discussions of the role Canada’s family physicians play in today’s
health care system. Family physicians, governments, educators and a wide spectrum of
stakeholders may consider the range of infrastructure and constructive policy initiatives that can be
implemented to encourage family physicians to fill their role. Due consideration must be given to
the wide range of changes that have already faced family physicians over the last decade and that
might have already impacted their choices of clinical practice and led to the trends seen here.
This report has highlighted changes in family practice within the context of the broader health care
landscape. It has touched upon how differences between family practices—reflected in participation
rates, intensity of service, gender, age and location—might contribute to human resource planning
for family doctors. Other questions, such as whether it is feasible to have family physicians provide
an expected traditional broad range of skills, or when more traditional comprehensive family
practices should be encouraged, highlight the need to define the roles of family doctors as we
move into the future.
While it is tempting to view the study results negatively, this may be an unnecessary response.
The evolution of a discipline can be a natural and healthy process resulting from a variety of innate
and environmental pressures. Readers are encouraged to view the data, not as painting a negative
picture, but as presenting a window of opportunity to help redefine, reinforce and renew the
roles of family doctors in health care throughout Canada. Change and evolution can be embraced
and possibly bring new excitement to family practice.
Appendix A
National Grouping System (NGS) Strata and Categories
Used to Define Study Clinical Practice Areas
CIHI’s National Grouping System (NGS) methodology provides a means to describe provision of physician
services across provinces and time. The NGS methodology assigns all provincial/territorial fee-for-service
billing codes to 120 categories that describe medical procedures and types of clinical service. These 120
categories are further grouped to the level of broad clinical service areas or strata (for example, obstetrics,
major surgery, diagnostic and therapeutic services). Table A1 lists the NGS categories and strata that were
used to define clinical practice areas presented in this report.
In addition to mapping fee codes to NGS categories/strata, the NGS methodology adjusts for provincial
variations in service billings. In so doing, the NGS methodology standardizes fee code level data to facilitate
analysis of payment and service count data at the level of the NGS category/stratum. Detailed NGS
descriptions and methodologies, as well as payment and service statistical summaries, are published in
CIHI’s annual National Grouping System Categories Report.84
Table A1:
Definition of Study Clinical Practice Areas Based on National Grouping System Categories
Study Clinical Practice Area
NGS Category Description
NGS Category ID
Office practice
Major assessment, office
Other assessment, office
Hospital care days, up to 28–42 days
Hospital care days, greater than 28–42 days
Hospital care days, other
Hospital inpatient major assessment, newborn
Hospital inpatient major assessment, other
Hospital inpatient other assessment
Counselling
Group/family psychotherapy
Individual psychotherapy
Insertion of IUD
Biopsy
Cryotherapy
Electorcardiogram
Injection/aspiration of joint
Allergy/hyposensitization test
Excision of nail
Suture wound
Removal of foreign body
Incision, abscess, etc.
003
010
017
018
019
004
005
011
024
023
022
117
113
111
100
099
098
068
067
065
064
Hospital inpatient care
Mental health care
Basic procedural skills
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Table A1:
Definition of Study Clinical Practice Areas Based on National Grouping System Categories
Study Clinical Practice Area
NGS Category Description
NGS Category ID
Advanced procedural skills
Sigmoidoscopy
Intensive care/resuscitation
Nerve blocks
Minor fractures
Chalazion
Excision tumour
Vasectomy
Varicose veins
Rhinoplasty
Fractures
Dilatation and curettage
Cystoscopy
Colonoscopy
Laryngo/bronchoscopy
Oesophago/gastroscopy
Therapeutic abortion
Caesarean section
Sterilization
Hysterectomy
Haemorrhoidectomy
Colectomy
Inguinal/femoral hernia
Tonsillectomy
Cholecystectomy
Laparotomy
Appendectomy
Breast excision
Anesthesia services (excluding nerve blocks)
Delivery (excluding C-section)
Services at time of delivery
(e.g. laceration repair, removal of retained placenta)
Other obstetrical services (e.g. stress test, foetoscopy)
Surgical assistance
105
097
074
071
069
066
053
040
034
028
109
104
103
102
101
079
078
057
056
049
048
047
046
045
044
043
026
075
077
076
Surgery
Anaesthesia
Obstetrical care
Surgical assistance
080
073
Appendix B
Clinical Practice Area Provincial Exclusions Based on
National Physician Database and National Family Physician
Workforce Survey Data Comparisons
National Family Physician Workforce Survey (NFPWS) data was used in this study to cross-validate results
based on National Physician Database (NPDB) billing data. The proportions of family doctors who bill for
each clinical practice area according to NPDB data were compared to the proportions of family doctors who,
through the NFPWS, indicated they provide similar services. Comparisons were made at the provincial level.
Cross-validation was carried out to improve the comparability of results based on fee schedule billing information
across provinces, as well as provincial variations in service coverage through alternative payment programs.
The NFPWS data elements used for cross-validation purposes are reported along with provincial inclusion/
exclusion results in Table B1. Detailed information on the NPDB National Grouping System (NGS) categories
used for the comparative analysis is reported in Appendix A.
Office assessment fee codes are not uniquely identified in the fee schedules of Prince Edward Island,
Ontario, Saskatchewan and British Columbia. In these provinces, office assessments are remunerated using
fee codes that cover service delivery in multiple settings (such as private offices, nursing homes and group
homes). These provinces were, therefore, excluded from the analysis of office practice in this study. All
other provincial exclusions, based on NFPWS-NPDB comparisons, are reported in Table B1.
Table B1:
Clinical Practice Areas, National Family Physician Workforce Survey Data
Elements and Study Inclusion/Exclusion Results
Study Clinical Practice Area
NFPWS Data Elements
Used for Comparison
Provincial
Inclusion/Exclusion Results
Hospital inpatient care
Hospital inpatient care—respondent had to indicate
some number of hours per week spent providing hospital
inpatient care
Psychotherapy/counselling services provided to
regular and/or other patients
IUD insertion, skin biopsy, suturing
Flexible/rigid sigmoidoscopy, vasectomy/tubal ligation,
mole removal, skin lesions, lumps and bumps, cysts,
casting/splinting
Performing major surgery in hospital
(e.g. appendectomies, C-sections, hysterectomies,
D. and C. aspiration, cystoscopy, colonoscopy, gastroscopy,
bronchoscopy, C-section as primary surgeon)
Anaesthesia services provided to regular and/
or other patients
Intrapartum care
Surgical assistance services provided to regular and/
or other patients
Include all provinces
Mental health care
Basic procedural skills
Advanced procedural skills
Surgery
Anaesthesia
Obstetrics
Surgical assistance
Include all provinces
Include all provinces
Exclude Quebec; include all other provinces
Exclude Newfoundland and Labrador,
Prince Edward Island and British Columbia;
include all other provinces
Exclude Nova Scotia, Alberta and
British Columbia; Include all other provinces
Include all provinces
Include all provinces
Appendix C
Clinical Practice Area Data Summaries
Table C1:
Surgical Service Participation Rates and Average Number of Surgical Services per Family Physician,
by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
SURGICAL SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
1992
13.5
8.5
10.5
14.1
13.2
11.6
8.4
8.6
14.8
20.7
12.2
1993
12.5
7.6
9.5
12.8
11.8
11.3
8.0
7.7
13.6
22.8
11.1
1994
12.6
7.6
10.7
12.4
11.7
10.5
7.7
7.8
13.6
22.6
11.2
1995
11.8
7.5
10.6
12.0
10.6
9.4
6.6
7.6
12.3
20.9
10.5
1996
10.9
6.9
10.5
10.8
9.5
9.4
5.4
7.1
11.0
19.1
9.7
1997
10.7
6.4
10.3
10.5
9.3
8.1
5.8
7.1
10.2
17.6
9.4
1998
10.9
6.5
10.8
11.0
9.0
8.3
5.6
7.1
11.0
17.6
9.5
1999
10.5
6.0
11.1
10.4
8.3
7.8
5.0
7.1
9.8
16.0
9.0
2000
10.3
5.8
11.8
9.6
8.6
7.0
5.1
7.0
9.9
14.6
8.8
2001
9.5
5.8
10.9
9.6
7.5
7.0
4.5
6.7
8.9
13.5
8.2
AVERAGE NUMBER
OF
SEX
35–44
SURGICAL SERVICES
45–54
PER
55–64
65+
Urban
Mid-Sized
Rural
Total
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
27
34
11
22
41
51
44
30
31
20
28
1993
27
40
10
21
50
45
50
34
32
23
30
1994
29
39
8
24
50
46
52
33
35
26
31
1995
31
38
9
24
51
48
56
35
38
25
32
1996
34
47
14
28
58
51
55
41
42
28
37
1997
36
55
17
25
64
59
58
47
41
27
40
1998
37
59
21
29
61
56
69
52
38
27
42
1999
41
63
21
35
64
63
80
56
49
28
46
2000
45
61
20
37
65
75
84
59
46
32
49
2001
50
62
17
40
71
79
97
62
55
34
53
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Surgical service results are based on data for all provinces, with the
exception of Newfoundland and Labrador, Prince Edward Island
and British Columbia.
See Appendix B for details on provincial inclusion/exclusion criteria.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Table C2:
Office Practice Participation Rates and Average Number of Office Assessment Services
per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
OFFICE PRACTICE PARTICIPATION RATES (%)
SEX
Male
AGE
Female
GEOGRAPHIC SETTING
<35
35–44
45–54
55–64
Urban
Mid-Sized
Rural
Total
1992
90.1
88.4
84.5
90.3
93.0
92.1
90.5
89.0
90.5
89.6
89.6
1993
90.1
88.2
84.3
90.1
93.2
91.3
91.0
88.8
91.2
91.1
89.6
1994
89.1
88.2
82.7
89.2
92.2
91.5
90.0
87.8
89.8
91.1
88.8
1995
89.7
88.5
82.8
89.8
92.7
91.5
89.7
88.9
91.1
89.6
89.3
1996
90.1
88.8
83.3
90.0
92.9
90.9
90.2
89.2
90.6
90.7
89.7
1997
89.4
89.0
82.9
88.7
92.8
91.6
88.8
88.9
89.9
90.2
89.3
1998
88.4
87.6
81.9
87.0
92.0
90.5
86.6
87.3
90.3
89.4
88.1
1999
87.3
85.8
78.9
85.6
91.1
90.4
83.1
85.7
89.3
88.3
86.8
2000
87.0
84.9
78.0
85.0
90.4
90.0
81.7
85.0
87.9
88.6
86.2
2001
86.4
83.5
75.9
83.2
89.6
91.1
81.7
83.9
88.3
87.6
85.3
AVERAGE NUMBER
OF
SEX
OFFICE ASSESSMENT SERVICES
PER
65+
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
3,965
2,887
2,609
3,947
4,569
4,051
2,333
3,644
3,663
3,687
3,665
1993
3,900
2,878
2,515
3,806
4,501
3,998
2,428
3,588
3,606
3,718
3,609
1994
4,020
2,950
2,585
3,841
4,587
4,161
2,452
3,678
3,826
3,701
3,702
1995
3,927
2,852
2,440
3,612
4,472
4,118
2,485
3,534
3,727
3,709
3,596
1996
3,909
2,872
2,403
3,545
4,406
4,215
2,357
3,555
3,696
3,615
3,583
1997
3,987
2,891
2,431
3,476
4,342
4,321
2,615
3,623
3,707
3,602
3,625
1998
4,141
2,939
2,486
3,422
4,408
4,628
3,119
3,760
3,726
3,646
3,725
1999
4,141
2,889
2,443
3,285
4,333
4,686
3,320
3,737
3,662
3,628
3,698
2000
4,028
2,792
2,302
3,123
4,168
4,597
3,350
3,645
3,557
3,478
3,586
2001
3,960
2,712
2,146
3,021
4,032
4,503
3,389
3,563
3,435
3,433
3,509
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Office practice results are based on data for all provinces, with the exception
of Prince Edward Island, Ontario, Saskatchewan and British Columbia.
See Appendix B for details on provincial inclusion/exclusion criteria.
Appendix C: Clinical Practice Area Data Summaries
Table C3:
Advanced Procedural Skills (APS) Service Participation Rates and Average Number of APS
Services per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
APS SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
Urban
Mid-Sized
Rural
Total
1992
79.5
69.9
73.1
83.0
82.0
75.5
60.6
72.5
84.4
87.0
77.1
1993
78.8
69.2
72.1
81.6
81.9
74.7
60.1
71.3
84.0
88.7
76.3
1994
79.2
68.8
74.6
81.5
80.4
73.2
60.0
71.6
83.8
87.6
76.4
1995
79.6
68.4
75.8
80.6
80.6
73.4
59.7
72.0
83.1
87.2
76.4
1996
79.0
69.6
76.9
80.4
79.9
72.9
58.8
71.8
83.2
87.5
76.4
1997
78.5
69.1
77.7
79.4
78.7
73.1
57.5
71.7
81.8
85.3
75.8
1998
76.9
67.0
78.1
77.4
77.3
71.7
55.4
69.7
80.1
84.1
74.0
1999
76.5
66.1
75.9
76.7
76.7
70.4
54.4
69.0
79.4
83.5
73.4
2000
75.2
65.0
74.9
75.0
75.4
70.1
53.0
67.7
78.3
82.2
72.1
2001
74.7
63.8
74.5
74.3
74.2
69.8
52.3
67.0
77.4
81.0
71.3
AVERAGE NUMBER
OF
SEX
APS SERVICES
PER
65+
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
1992
51
21
31
46
53
53
1993
50
22
31
45
53
49
1994
46
19
28
42
47
1995
49
21
31
44
48
1996
51
22
33
45
1997
53
23
39
1998
53
24
44
1999
57
25
2000
60
2001
62
Urban
Mid-Sized
Rural
Total
40
43
48
48
44
36
43
46
43
43
44
32
39
42
40
40
48
32
42
42
41
42
47
52
32
44
44
41
43
46
48
50
34
46
47
41
45
46
46
49
32
47
45
40
45
49
51
48
47
40
51
47
42
48
28
54
55
50
45
48
56
47
41
51
30
53
59
52
46
45
59
47
39
53
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Office practice results are based on data for all provinces, with the exception
of Prince Edward Island, Ontario, Saskatchewan and British Columbia.
See Appendix B for details on provincial inclusion/exclusion criteria.
65+
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Table C4:
Anaesthesia Service Participation Rates and Average Number of Anaesthesia Services
per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
ANAESTHESIA SERVICE PARTICIPATION RATES (%)
SEX
AGE
Male
Female
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
1992
10.1
6.1
7.9
9.7
9.2
10.9
7.4
6.8
10.9
16.7
9.0
1993
6.4
3.2
4.8
5.7
6.2
6.8
3.7
3.5
8.4
11.4
5.5
1994
6.0
3.0
4.3
5.8
5.2
5.9
4.0
3.4
7.6
10.5
5.2
1995
6.1
3.1
5.2
5.5
5.1
5.7
4.6
3.7
7.1
10.1
5.3
1996
6.3
3.0
6.0
5.7
4.8
5.8
3.9
3.9
7.3
9.5
5.3
1997
6.3
3.3
6.9
5.9
4.6
5.5
3.4
4.0
7.1
9.7
5.4
1998
5.9
3.3
6.6
5.3
4.3
5.4
4.1
3.7
7.5
8.5
5.1
1999
6.8
3.9
7.5
6.3
5.2
5.3
4.5
4.5
7.7
9.3
5.8
2000
7.4
3.9
7.6
6.8
5.7
5.9
4.7
5.1
7.7
9.5
6.2
2001
7.6
4.2
9.3
7.2
5.7
5.2
5.0
5.1
8.2
10.3
6.5
AVERAGE NUMBER
OF
SEX
<35
GEOGRAPHIC SETTING
ANAESTHESIA SERVICES
PER
Total
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
172
101
54
109
216
341
232
132
290
120
159
1993
220
178
67
136
274
459
391
210
327
136
213
1994
234
195
78
135
311
464
418
208
374
155
228
1995
230
200
62
166
296
406
393
200
383
158
225
1996
212
176
54
134
291
393
399
173
333
166
206
1997
206
156
70
125
254
445
329
160
312
177
197
1998
213
161
104
136
225
383
390
168
284
193
202
1999
267
177
113
191
271
481
367
222
267
277
247
2000
251
156
136
161
253
366
466
194
295
262
231
2001
234
147
95
156
255
325
464
189
278
218
215
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Anaesthesia service results are based on data for all provinces, with the exception
of Nova Scotia, Alberta and British Columbia.
See Appendix B for details on provincial inclusion/exclusion criteria.
Appendix C: Clinical Practice Area Data Summaries
Table C5:
Surgical Assistance Service Participation Rates and Average Number of Surgical Assistance
Services per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
SURGICAL ASSISTANCE SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
41.4
34.1
38.3
41.1
43.1
38.5
31.1
32.2
62.4
43.1
39.5
1993
39.7
33.6
36.3
39.9
41.5
36.8
30.3
30.7
61.0
44.2
38.0
1994
39.0
33.2
36.5
39.4
39.8
35.6
29.9
30.0
61.2
43.1
37.4
1995
38.3
32.5
35.8
38.5
38.3
35.6
29.4
29.3
59.7
42.4
36.6
1996
36.7
31.3
34.8
37.0
36.2
34.0
28.3
27.8
57.8
40.6
35.1
1997
36.3
30.8
35.8
35.8
35.2
33.0
30.0
27.3
55.9
40.9
34.7
1998
34.2
29.1
33.9
33.8
33.0
32.1
28.0
25.5
53.4
38.8
32.6
1999
32.5
27.3
32.4
31.7
31.1
29.7
27.3
23.5
51.2
38.1
30.8
2000
30.7
25.4
29.7
30.1
29.1
28.1
25.9
21.7
48.4
36.6
29.0
2001
28.9
23.9
28.2
28.0
27.7
26.5
24.0
20.0
46.8
35.0
27.3
AVERAGE NUMBER
OF
SEX
SURGICAL ASSISTANCE SERVICES
PER
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
37
26
27
28
34
51
78
41
33
21
35
1993
38
24
28
28
32
52
80
41
32
19
35
1994
41
27
33
30
33
53
88
47
32
20
38
1995
47
29
48
32
33
55
95
56
32
20
42
1996
48
30
43
36
34
56
100
58
32
20
43
1997
50
31
44
35
38
55
104
61
33
19
44
1998
52
31
28
42
40
58
118
65
34
18
46
1999
56
32
23
46
42
57
133
70
34
18
49
2000
58
35
27
46
43
61
141
77
35
17
52
2001
62
37
26
48
49
62
145
83
37
17
55
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Surgical assistance service results are based on data for all provinces.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Table C6:
Basic Procedural Skills (BPS) Service Participation Rates and Average Number of BPS Services
per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
BPS SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
Urban
Mid-Sized
Rural
Total
1992
88.7
86.8
89.8
91.5
90.4
83.7
72.7
86.6
90.4
92.0
88.2
1993
88.7
87.1
90.4
91.4
90.5
83.3
72.4
86.9
90.2
92.4
88.3
1994
89.2
87.7
90.9
92.3
90.9
83.9
72.2
87.4
90.8
92.4
88.8
1995
89.2
87.9
91.0
92.4
91.0
84.6
71.7
87.4
91.0
92.5
88.8
1996
88.6
86.7
90.9
91.8
89.8
83.7
70.1
86.4
90.5
92.4
88.0
1997
89.1
87.3
92.6
91.3
90.0
84.6
72.3
87.0
90.8
92.2
88.5
1998
88.7
86.1
91.8
91.1
89.5
85.1
71.3
86.3
89.8
92.2
87.9
1999
88.5
84.9
89.9
90.3
88.9
85.1
70.3
85.9
89.1
90.9
87.3
2000
88.1
84.5
89.3
89.9
88.2
85.1
71.2
85.7
88.4
90.1
86.9
2001
87.5
83.3
88.9
88.8
87.2
85.6
70.1
84.8
87.7
89.3
86.1
Rural
Total
AVERAGE NUMBER
OF
SEX
BPS SERVICES
PER
65+
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
1992
287
174
188
270
324
300
189
263
260
250
258
1993
275
165
178
250
307
294
196
248
255
229
246
1994
261
144
167
223
285
269
204
231
231
215
229
1995
251
137
164
205
272
247
197
223
214
204
218
1996
241
135
160
197
254
245
190
216
209
191
210
1997
238
129
156
188
243
239
206
214
196
183
205
1998
227
115
145
170
219
237
224
201
182
173
192
1999
221
111
140
168
204
233
210
194
179
169
186
2000
209
104
127
159
190
219
194
182
168
160
175
2001
206
103
116
164
184
208
192
179
164
160
173
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
BPS service results are based on data for all provinces.
Mid-Sized
Appendix C: Clinical Practice Area Data Summaries
Table C7:
Obstetrical Service Participation Rates and Average Number of Obstetrical Services per
Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
OBSTETRICAL SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
27.8
27.6
28.6
31.7
31.0
21.7
9.6
19.4
43.5
40.9
27.8
1993
26.2
27.1
27.4
30.3
29.8
19.7
8.5
18.3
42.5
43.0
26.4
1994
25.5
26.7
27.7
29.9
28.0
19.0
8.2
17.6
42.1
42.0
25.8
1995
24.2
25.9
27.0
29.1
26.1
18.3
7.4
16.8
40.9
39.7
24.7
1996
22.3
24.8
26.5
26.6
24.0
17.1
7.2
15.4
38.2
37.6
23.0
1997
20.6
23.7
25.4
24.7
22.5
15.9
6.7
14.3
35.2
35.6
21.6
1998
19.2
21.8
24.6
22.9
20.9
14.6
6.3
13.0
33.0
33.8
20.0
1999
17.5
20.8
23.4
21.3
19.3
13.4
5.8
11.9
30.8
31.6
18.6
2000
16.3
19.2
22.1
20.2
17.6
12.8
5.2
10.9
29.0
29.8
17.3
2001
14.9
17.9
21.1
18.6
16.2
11.7
5.2
9.7
26.1
29.0
15.9
AVERAGE NUMBER
OF
SEX
OBSTETRICAL SERVICES
PER
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
1992
24
37
24
32
27
22
1993
25
38
25
33
27
23
1994
24
40
27
33
28
1995
24
41
28
33
28
1996
25
42
27
35
1997
25
43
29
1998
25
47
31
1999
26
47
2000
25
2001
27
Urban
Mid-Sized
Rural
Total
12
31
28
20
27
13
32
29
21
28
24
15
33
30
21
29
26
17
34
30
22
29
29
28
17
36
30
22
31
35
30
26
18
37
30
22
31
37
33
27
16
41
31
23
33
31
38
33
29
17
43
31
23
34
49
32
38
33
28
17
44
31
23
34
52
31
42
37
29
20
49
34
23
36
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Obstetrical service results are based on data for all provinces.
65+
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
Table C8:
Mental Health Service Participation Rates and Average Number of Mental Health Services
per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
MENTAL HEALTH SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
Urban
Mid-Sized
Rural
Total
1992
80.6
87.5
81.5
86.9
87.6
77.5
62.7
82.5
83.7
82.5
82.4
1993
81.2
87.9
82.3
87.6
87.3
78.2
63.6
83.0
83.6
83.1
83.0
1994
82.4
88.5
83.0
89.1
88.2
79.2
64.3
83.9
85.8
83.6
84.1
1995
83.0
89.3
84.0
89.2
88.7
81.3
65.6
84.9
85.7
84.4
84.8
1996
83.1
89.7
83.9
89.0
89.1
81.8
66.7
85.0
86.0
84.9
85.0
1997
83.9
90.3
85.2
88.7
89.1
83.4
69.7
85.9
86.5
84.9
85.8
1998
83.7
89.6
85.7
88.6
88.7
83.5
69.7
85.7
86.1
84.8
85.6
1999
83.7
89.4
84.2
88.3
88.9
83.6
69.4
85.7
86.4
84.4
85.6
2000
83.4
89.0
84.0
87.3
88.3
84.7
69.9
85.5
85.3
84.5
85.2
2001
83.4
88.8
85.2
86.4
88.3
85.5
70.1
85.4
85.2
84.7
85.2
AVERAGE NUMBER
OF
SEX
MENTAL HEALTH SERVICES
PER
65+
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
268
253
165
255
335
363
293
306
208
167
264
1993
274
257
162
266
341
359
284
309
215
162
269
1994
287
274
177
274
352
374
283
326
230
168
283
1995
305
289
190
286
369
380
299
344
246
182
300
1996
314
298
202
292
369
386
313
355
253
187
309
1997
336
314
210
304
390
415
335
378
269
203
329
1998
310
297
188
276
356
391
338
352
245
192
305
1999
308
298
171
274
348
397
338
352
244
187
304
2000
307
300
164
271
344
405
336
351
243
196
305
2001
297
295
159
260
341
368
340
339
242
190
296
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Mental health service results are based on data for all provinces.
Appendix C: Clinical Practice Area Data Summaries
Table C9:
Hospital Inpatient Service Participation Rates and Average Number of Hospital Inpatient
Services per Family Physician, by Sex, Age Group and Geographic Setting, Canada, 1992 to 2001
HOSPITAL INPATIENT SERVICE PARTICIPATION RATES (%)
SEX
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
Urban
Mid-Sized
Rural
Total
1992
72.3
65.3
68.3
73.0
74.8
69.4
59.3
63.5
85.5
81.7
70.5
1993
72.1
65.3
67.3
73.5
74.7
68.4
58.7
63.0
85.6
84.2
70.2
1994
69.9
64.3
65.9
71.2
71.9
66.9
57.1
61.3
84.6
80.0
68.3
1995
69.5
63.8
65.6
71.4
70.4
66.5
55.5
60.7
84.3
79.3
67.8
1996
68.0
62.8
66.2
69.1
68.6
65.3
54.1
59.4
83.7
77.4
66.5
1997
67.9
62.0
68.2
68.3
67.0
64.8
54.6
59.0
83.0
76.7
66.1
1998
66.2
60.3
67.4
66.5
65.1
64.4
51.2
56.6
81.9
75.8
64.3
1999
64.9
58.7
65.4
65.0
63.4
63.0
49.1
55.0
80.9
74.5
62.9
2000
63.4
57.8
65.4
63.8
62.3
60.3
47.2
53.2
79.8
74.6
61.5
2001
64.1
58.7
70.6
65.1
62.1
60.4
44.9
53.7
79.4
77.4
62.3
AVERAGE NUMBER
OF
SEX
HOSPITAL INPATIENT SERVICES
PER
65+
FAMILY PHYSICIAN
AGE
GEOGRAPHIC SETTING
Male
Female
<35
35–44
45–54
55–64
65+
Urban
Mid-Sized
Rural
Total
1992
776
348
429
638
831
958
754
533
815
918
672
1993
745
355
417
603
798
905
744
522
790
881
647
1994
724
344
399
571
759
866
728
501
762
854
624
1995
709
330
373
538
738
847
727
498
731
799
606
1996
693
331
367
524
713
829
660
491
697
784
592
1997
691
344
368
514
714
799
672
502
686
760
592
1998
711
362
391
523
706
836
701
525
699
758
608
1999
726
366
412
521
703
857
678
541
703
745
618
2000
744
376
418
525
704
887
705
565
700
739
630
2001
728
384
404
510
688
874
707
570
690
680
620
Source: National Physician Database, CIHI
Notes: Includes fee-for-service family physicians only.
Includes only services provided through fee-for-service programs.
See Section 2.5, Statistical Measures and Definitions, for detailed
descriptions of study measures.
See Appendix A for definitions of clinical service areas.
Hospital inpatient service results are based on data for all provinces.
References
1
2
3
4
5
6
7
8
9
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J. Macinko, B. Starfield, L. Shi, “The Contribution of Primary Care Systems to Health Outcomes Within Organization for Economic
Cooperation and Development (OECD) Countries, 1970–1998,” Health Services Research 38, 3 (June 2003): pp. 831–65.
AHCPR Research Activities, Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and
Research), “Lack of Same-Day Access to a Primary Care Provider Prompts Many HMO Patients to Seek More Costly Urgent Care,”
March 1999, No. 224.
B. Starfield, “Is Primary Care Essential?,” Lancet 344, 8930 (Oct. 22, 1994): pp. 1129–I33.
L. Shi, B. Starfield, B. Kennedy, I. Kawachi, “Income Inequality, Primary Care, and Health Indicators,” Journal of Family Practice
48, 4 (April 1999): pp. 275–84.
College of Family Physicians of Canada, 4.5 Million Canadians Not Able to Get a Family Physician (press release) (Montréal: College of
Family Physicians of Canada, November 7, 2002) [on-line] last modified May 16, 2003, cited August 9, 2004, from
<www.cfpc.ca/English/cfpc/communications/news%20releases/2002%2011%2007/default.asp?s=1>.
P. Sullivan, “Family Medicine Crisis? Field Attracts Smallest Ever Share of Residency Applicants,” Canadian Medical Association Journal
168, 7 (April 1, 2003): p. 881.
C. A. Woodward, M. Cohen, B. Ferrier, J. Brown, “Physicians Certified in Family Medicine. What Are They Doing 8–10 Years Later?,”
Canadian Family Physician 47 (July 2001): pp. 1404–10.
L. Chang, L. Malkin, “National Family Medicine Resident Survey 2001,” Canadian Family Physician 48 (October 2002): p. 1666.
B. Chan, “Do Family Physicians With Emergency Medicine Certification Actually Practise Family Medicine,” Canadian Medical
Association Journal 167, 8 (Oct. 15, 2002): p. 869.
Canadian Pharmacists Association, Pharmacists Tell Romanow Canada Needs Them in an Expanded Role (press release)
(Winnipeg: Canadian Pharmacists Association, May 9, 2002) cited August 9, 2004 [on-line], from
<www.pharmacists.ca/content/media/newsroom/News_Releases/current_050902.cfm>.
Canadian Nurses Association, “Position Statement. The Nurse Practitioner. CNA Position,” Position Statement #68, June 2003,
cited August 30, 2004, from <www.cna-nurses.ca/_frames/policies/policiesmainframe.htm>.
The Canadian Chiropractic Association and the Canadian Memorial Chiropractic College, “Sustaining and Improving our Health Care:
A Call to Action,” Submission to the Commission on the Future of Health Care in Canada, January 2002.
Association of Ontario Midwives, Primary Care, (fact sheet), updated January 2, 2002, cited August 9, 2004 [on-line], from
<www.aom.on.ca/facts/PrimaryCare.html>.
Hollander Analytical Services, “Assessing New Models for the Delivery of Medical Services: Inventory and Synthesis,” Summary Report
Prepared by Hollander Analytical Services Ltd. For Task Force Two: A Physician Human Resource Strategy for Canada, August 2003.
Commission on the Future of Health Care in Canada, Building on Values: The Future of Health Care in Canada—Final Report,
(Commissioner: Roy J. Romanow), November 2002, National Library of Canada Catalogue no. CP32-85/2002E-IN.
The Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians—The Federal Role: Volume Six:
Recommendations for Reform (Ottawa: Government of Canada, October 2002).
Saskatchewan Commission on Medicare, “Caring for Medicare: Sustaining a Quality System Commissioner: Kenneth J. Fyke,
Government of Saskatchewan, April 2001.
C. Sanmartin, C. Houle, J. Berthelot and K. White, Access to Health Care Services in Canada, 2001 (Ottawa: Statistics Canada, June 2002),
catalogue no. 82-575-XIE.
C. Gutkin, “Counting on One Another: National Physician Survey,” Canadian Family Physcian 50 (March 2004): p. 511.
B. Chan, “The Declining Comprehensiveness of Primary Care,” Canadian Medical Association Journal 166, 4 (February 19, 2002):
pp. 429–34.
J. T. Rourke, “Trends in Small Hospital Obstetric Services in Ontario,” Canadian Family Physician 44 (October 1998): pp. 2117–24.
M. J. Bass, I. R. McWhinney, M. Stewart, A. Grindrod, “Changing Face of Family Practice,” Canadian Family Physician 44 (October 1998):
pp. 2143–9.
J. Kaczorowski, C. Levitt, “Intrapartum Care by General Practitioners and Family Physicians. Provincial Trends From 1984–1985 to
1994–1995,” Canadian Family Physician 46 (March 2000): pp. 587–92, 595–7.
Ontario College of Family Physicians, “Where Have All Our Family Doctors Gone? #3 Hospitals Without Family Doctors,”
August 18, 1999.
D. Watson, B. Bogdanovic, P. Heppner, et al., “Supply, Availability and Use of Family Physicians in Winnipeg,” Manitoba Centre for
Health Policy, June 2003.
Canadian Institute for Health Information, Alternative Payments and the National Physician Database (NPDB). The Status of Alternative
Payment Programs for Physicians in Canada, 2001–2002 and Preliminary Information for 2002–2003 (Ottawa: CIHI, 2004).
Ibid, pg. 4.
Canadian Medical Association, “Percent Distribution of Physicians by Mode of Remuneration,” 1990 and 2002 Physician Resource
Questionnaires (on-line survey results), cited August 9, 2004, from <http://www.cma.ca//multimedia/staticContent/HTML/
N0/l2/statinfo/pdf/remuneration.pdf>.
Statistics Canada, Postal Code Conversion File September 2002 Postal Codes. Reference Guide (Ottawa: Statistics Canada, January 2003),
catalogue no. 92F-0153-G1E.
Ibid, pg. 19.
The Evolving Role of Canada’s Family Physicians
1 9 9 2 – 2 0 0 1
31 R. W. Pong, J. R. Pitblado, “Don’t Take ‘Geography’ for Granted! Some Methodological Issues in Measuring Geographic
Distribution of Physicians,” Canadian Journal of Rural Medicine 6, 2 (2001): pp. 103–12.
32 R. W. Pong, J. R. Pitblado, “Beyond Counting Heads: Some Methodological Issues in Measuring Geographic Distribution
of Physicians,” Canadian Journal of Rural Medicine 7, 1 (Winter 2002): pp. 12–20.
33 Canadian Institute for Health Information, Supply and Distribution of Registered Nurses in Rural and Small Town Canada, 2000
(Ottawa: CIHI, 2002).
34 Canadian Institute for Health Information, The Practicing Physician Community in Canada 1989/90 to 1998/99. Workforce
and Workload as Gleaned Through Billing Profiles for Physician Services (Ottawa: CIHI, 2001).
35 M. Barer, G. Stoddart, “Improving Access to Needed Medical Services in Rural and Remote Canadian Communities:
Recruitment and Retention Revisited,” discussion paper prepared for Federal/Provincial/Territorial Advisory Committee
on Health Human Resources, Centre for Health Services and Policy Research, June, 1999.
36 Canadian Labour and Business Centre, “Physician Workforce in Canada: Literature Review and Gap Analysis,” final report
prepared by the Canadian Labour and Business Centre for Task Force Two: A Physician Human Resource Strategy for
Canada, January 2003.
37 J. Gray, J. Reudy, “Undergraduate and Postgraduate Medical Education in Canada,” Canadian Medical Association Journal 158
(April 21, 1998): pp. 1047–50.
38 Canadian Institute for Health Information, From Perceived Surplus to Perceived Shortage: What Happened to Canada’s
Physician Workforce in the 1990s? (Ottawa: CIHI, 2002).
39 Canadian Post-M.D. Education Registry (CAPER), Annual Census of Post-M.D. Trainees 2000–2001 (Ottawa: CAPER, 2001).
40 G. Goldsand, D. Thurber, “The Overlapping Roles of Primary Care Physicians, General Specialists and Subpecialists—
A Canadian Perspective,” discussion paper prepared for the 7th International Medical Workforce Conference, Oxford,
United Kingdom, September, 2003.
41 R. G. Chaytors, G. R. Spooner, D. G. Moores et al., “Postgraduate Training Positions. Follow-up Survey of Third Year
Residents in Family Medicine,” Canadian Family Physician 45 (January 1999): pp. 88–91.
42 Canadian Resident Matching Service (CaRMS), PGY-1 Match Report, 2003 (Ottawa: CaRMS, 2003).
43 Canadian Post-M.D. Education Registry (CAPER), Annual Census of Post-M.D. Trainees 2003–2004 (Ottawa: CAPER, 2004).
44 A. D. Thurber, N. Busing, “Decreasing Supply of Family Physicians and General Practitioners. Serious Implications for
the Future,” Canadian Family Physician 45 (September 1999): pp. 2084–9.
45 Canadian Federation of Medical Students, “The Canadian Medical Student’s Perspective: Career Decision Making in
Today’s Medical School,” [on-line] position paper (August 14, 2003), cited August 10, 2004 from
<www.cfms.org/representation/papers_view.cfm?id=7&what_section=representation>.
46 E. Ryten, A. D. Thurber, L. Buske, “The Class of 1989 and Post-MD Training,” Canadian Medical Association Journal 158, 6
(March 24, 1998): pp. 731–737.
47 C. Gutkin, “Medical Students’ Career Choices Part 1: Pressure on Today’s Graduates,” Canadian Family Physician 47
(June 2001): p. 1352.
48 Association of American Medical Colleges, Physicians for the 21st Century: The GPEP Report (report of the Panel on the
General Professional Education of the Physician and College Preparation for Medicine) (Washington, DC: AAMC, 1984).
49 V. R. Neufeld, R. F. Maudsley, R. J. Pickering, et al., “Educating Future Physicians for Ontario,” Academic Medicine 73
(November 1998): pp. 1133–1148.
50 Personal communication with Dr. Ian Bowmer, immediate past-Dean, Memorial University of Newfoundland, August 2004.
51 Canadian Medical Association, Principles for a Reentry System in Canadian Postgraduate Medical Education (CMA: Ottawa,
February 2000).
52 Canadian Association of Interns and Residents of Canada, “Return of Service Discussion Paper,” Ottawa, June 2001.
53 Health Services Restructuring Commission, Better Hospitals, Better Health Care for the Future: Summary Report on
Hospital Restructuring, (Government of Ontario, April 1999) [on-line] cited August 10, 2004 from
<www.health.gov.on.ca/hsrc/bettere/home.html>.
54 Canadian Centre for Analysis of Regionalization and Health, “The Changing Face of Regionalization in Canada: Recent
Changes and What to Watch for,” CCARH Newsletter (September 2003).
55 J. Lomas, J. Woods, G. Veenstra, “Devolving Authority for Health Care in Canada’s Provinces: 1. An Introduction to the Issues,”
Canadian Medical Association Journal 156, 3 (February 1, 1997): pp. 371–7.
56 Canadian Institute for Health Information, Health Care in Canada 2003 (Ottawa: CIHI, 2003), p. 11.
57 College of Family Physicians of Canada, “Family Physicians Caring for Hospital Inpatients. A Discussion Paper Prepared by
The College of Family Physicians of Canada,” (October 2003).
58 Personal communication with Dr. Calvin Gutkin, Executive Director and Chief Executive Officer, College of Family Physicians
of Canada, January 2004.
59 College of Family Physicians of Canada, Disappointing Numbers of Students Choosing Family Medicine: February 2003 Canadian
Resident Matching Service (CaRMS) Results (news release) [on-line] last updated May 27, 2003, cited August 10, 2004 from
<www.cfpc.ca/English/cfpc/communications/news%20releases/2003%20carms/default.asp?s=1>.
References
60 Canadian Institute of Health Information, Canada’s Health Care Providers (Ottawa: CIHI, 2001).
61 Advisory Committee on Health Delivery and Human Resources, A Report on the Nursing Strategy for Canada (Ottawa: Health
Canada, 2003), catalogue no. H39-554/2003E.
62 College of Family Physicians of Canada, Society of Rural Physicians of Canada and Society of Obstetricians and Gynaecologists
of Canada, “Training for Rural Family Practitioners in Advanced Maternity Skills and Cesarean Section,” 1997 joint position
paper [on-line], last updated May 1, 2003, cited August 10, 2004 from <http://www.cfpc.ca/English/cfpc/programs/
patient%20care/maternity/joint%20position%20paper/default.asp?s=1>.
63 Society of Rural Physicians of Canada, College of Family Physician of Canada and Canadian Anesthesiologists Society,
“Joint Position Paper on Training for Rural Family Physicians in Anesthesia,” March 29, 2001.
64 S. Adilman, B. Chakraborty, D. Maberley, et al., “A Model for Community-Based Medical Training and Research in the Inner
City: An example From Vancouver,” (poster abstract for the First International Conference on Inner City Health, Toronto,
Canada, October 3 to 6, 2002), Journal of Urban Health 79, Supplement 1 (December 1, 2002).
65 Canadian Medical Association, The Development of a Multi-Stakeholder Framework/Index of Evaluation,
(Ottawa: CMA, February 2003).
66 L. Tyrell, D. Dauphinee, Task Force on Physician Supply in Canada, (Canadian Medical Forum Task Force One,
November 22, 1999).
67 D. Craig, R. Byrick, F. Carli, “A Physician Workforce Planning Model Applied to Canadian Anesthesiology: Planning the
Future Supply of Anesthesiologists,” Canadian Journal of Anesthesia 49, 7 (August–September 2002): pp. 671–7.
68 A. G. Walker, “Psychiatrist Shortages a Problem in Atlantic Region,” Medical Post 36, 28 (August 23, 2000).
69 N. el-Guebaly, E. Kingstone, Q. Rae-Grant, et al., “The Geographical Distribution of Psychiatrists in Canada:
Unmet Needs and Remedial Strategies,” Canadian Journal of Psychiatry 38, 3 (April 1993): pp. 212–6.
70 J. D. Birkmeyer, T. A. Stukel, A. E. Siewers, et al., “Surgeon Volume and Operative Mortality in the United States,”
The New England Journal of Medicine 349, 22 (November 27, 2003): pp. 2117–27.
71 J. B. Dimick, J. A. Cowan Jr, J. C. Stanley, et al., “Surgeon Specialty and Provider Volumes Are Related to Outcome of Intact
Abdominal Aortic Aneurysm Repair in the United States,” Journal of Vascular Surgery 38, 4 (October 2003): pp. 739–44.
72 G. P. Samsa, D. B. Matchar, L. B. Goldstein, et al., “Quality of Anticoagulation Management Among Patients With Atrial
Fibrillation: Results of a Review of Medical Records From Two Communities,” Archives of Internal Medicine 160
(April 2000): pp. 967–73.
73 R. Upshur, C. Papoushek, D. Macdonald, et al., “Short Report: Managing Anticoagulation. Comparison of Results at
Three Primary Care Centres,” Canadian Family Physician 49 (February 2003): pp. 181–4.
74 S. A. Schroeder, “How Many Hours Is Enough: An Old Profession Meets a New Generation,” Annals of Internal Medicine 140,
10 (May 18, 2004): pp. 838–839.
75 Canadian Institute for Health Information, Improving the Health of Canadians (Ottawa: CIHI, 2004).
76 Society of Rural Physicians of Canada Web site, cited August 10, 2004 from <www.srpc.ca>.
77 Statistics Canada, “The Health of Rural Canadians: A Rural-Urban Comparison of Health Indicators,” Rural and Small Town
Canada Analysis Bulletin 4, 6 (October 2003), catalogue no. 21-006-XIE.
78 Health Canada, A Second Diagnostic on the First Nation and Inuit People of Canada (Ottawa: First Nations and Inuit Health
Branch, November 1999).
79 Health Canada, Population and Public Health Branch, Farm Family Health 7, 1 (spring 1999).
80 Ministerial Advisory Council on Rural Health, Rural Health in Rural Hands: Strategic Directions for Rural Remote,
Northern and Aboriginal Communities (November 2002) [on-line], cited August 10, 2004 from
<http://www.hc-sc.gc.ca/english/pdf/rural_health/rural_hands.pdf>.
81 M. Gulens, “FP Survey: Stiff Upper Lip Is FP Battle Cry—Family Physicians Frustrated That Patients Seem Unaware of
All They Do,” Medical Post 39, 44 (December 2, 2003).
82 Ontario Medical Association, 1 in 6 Doctors: “I Am Seriously Considering Leaving the Province of Ontario:” Ontario Physicians
Rank Long Wait Times, Under-Funding of the System, and Access to Hospital Services as Immediate Priorities, (press release)
[on-line] January 27, 2004, cited August 10, 2004 from <http://www.oma.org/pcomm/pressrel/pr040127.htm>.
83 L. Gagnon, “Stats Can: 14% of Canadians Have No Family Doctor,” Canadian Medical Association Journal 171, 2 (July 20, 2004).
84 Canadian Institute for Health Information, National Grouping System Categories Report, Canada, 2001–2002
(Ottawa: CIHI, 2004).
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