Residency Program Characteristics and Individual Physician Practice Characteristics Associated with Family Physician Scope of Practice Anastasia J

Research Report

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice Anastasia J. Coutinho, MD, MHS, Zachary Levin, Stephen Petterson, PhD, Robert L. Phillips Jr, MD, MSPH, and Lars E. Peterson, MD, PhD

Abstract Purpose first recertification examination with SCoP (0.26 increase in SP4PC); those A family physician’s ability to provide the American Board of Family Medicine from major teaching hospitals had lower continuous, comprehensive care begins (2013–2016)—7 to 10 years after SCoP (0.18 decrease in SP4PC). in residency. Previous studies show that completing residency. The authors used patterns developed during residency may linear regression analyses to examine the Conclusions be imprinted upon physicians, guiding relationship between individual physician Residency program characteristics future practice. The objective was to SCoP (measured by the SCoP for primary may influence family physicians’ determine family medicine residency care [SP4PC] score [scale of 0–30; low SCoP, although less than individual characteristics associated with graduates’ = small scope]) and individual, practice, characteristics do. Broad SCoP may imply scope of practice (SCoP). and residency program characteristics. more comprehensive care, which is the foundation of a strong primary care Method Results system to increase quality, decrease cost, The authors used (1) residency program The authors sampled 8,261 physicians and reduce physician burnout. Some data from the 2012 Accreditation from 423 residencies. The average SP4PC residency program characteristics can Council for Graduate Medicine Education score was 15.4 (standard deviation, 3.2). be altered so that programs graduate Accreditation Data System and (2) Models showed that SCoP broadened physicians with broader SCoP, thereby self-reported data supplied by family with increasing rurality. Physicians from meeting patient needs and improving the physicians when they registered for the unopposed (single) programs had higher health system.

Family physicians are trained to residency; thus, residency training has the cost differences were not associated with provide continuous, comprehensive potential to influence the scope of skills any discernible differences in quality health care for individuals and families obtained and used in later practice. measures.11 across all ages, genders, and various care settings. Although the scope of practice Growing evidence suggests that practice Prior research has shown that rural of family physicians is narrowing,1–3 patterns developed during residency physicians have a broader scope strong primary care systems include training may be imprinted upon of practice than those in urban comprehensiveness as a core pillar,4 and physicians, guiding future practice areas,12 but little is known about health systems with a robust number of long after they complete the residency scope of practice beyond these basic primary care providers have better health program. Asch and colleagues were geographical differences. Based on the outcomes.5,6 Additionally, a study in able to rank obstetrics–gynecology Accreditation Council for Graduate the United States found that patients of residencies by examining the correlation Medicine Education (ACGME) Program physicians with broader scope of practice between complication rates of vaginal Requirements for Family Medicine, experience lower overall costs and fewer and cesarean deliveries and graduates’ trainees should be able to attend any hospitalizations.7 A recent study also previous residency program.9 The residency program and obtain skills shows an association between a broader clustering of complication rates by for a broad scope of practice.13 Yet, it scope of practice and lower levels of residency was unassociated with is unknown to what extent residency physician burnout.8 The ability to provide residents’ board scores, with residency training may influence physician comprehensive care begins within selection of trainees, or with location of scope of practice. Our objective was to determine whether any residency-specific Please see the end of this article for information current practice. Additionally, Chen and about the authors. colleagues found that physicians who characteristics were associated with trained in regions with lower Medicare the future scope of practice of family Correspondence should be addressed to Anastasia physicians. J. Coutinho, Santa Rosa Family Medicine Residency, spending per beneficiary, compared with 3569 Round Barn Circle, Suite 200, Santa Rosa, those trained in regions with higher California 95403; telephone: (859) 538-7180; email: Medicare spending, had lower total [email protected]; Twitter: @TheABFM. Method spending—even if they moved to practice Acad Med. 2019;94:1561–1566. regions in a different spending category Sample First published online June 11, 2019 from that of their residency training.10 We used (1) residency program data doi: 10.1097/ACM.0000000000002838 Copyright © 2019 by the Association of American A subsequent study supported this from the 2012 ACGME Accreditation Medical Colleges finding and further showed that these Data System (ADS) and (2) self-reported

data supplied by family physicians During the study period, family and individual, practice, and residency when they registered for the American physicians wishing to continue their program characteristics. Our first model Board of Family Medicine (ABFM) ABFM board certification completed the included current practice characteristics Family Medicine Certification (FMC) FMC examination every 7 to 10 years. and individual characteristics. Our examination from 2013 to 2016. To As part of the examination application, second model assessed the association of better match the training environment individuals were required to complete scope with individual, current practice, represented by the ACGME ADS data, a practice demographic questionnaire; and residency characteristics. We we further restricted our sample to thus, we have a 100% completion rate for compared R2 in the models to determine physicians who were completing their the physicians in our sample. Questions the percentage of variation explained at first recertification during our study asked for information about practice the individual and residency levels. We period (2013–2016). These physicians characteristics, such as geographic performed all analyses using Stata 14.0 would have completed residency training location and practice type (e.g., private/ (StataCorp, College Station, Texas). The 7 to 10 years before recertification; during group, hospital affiliated, integrated American Academy of Family Physicians the study period, the ABFM altered the practice, public, solo, or urgent/emergent and the George Washington University recertification period from 7 to 10 years, care). The FMC questionnaire included institutional review boards provided and physicians were able to choose their a list of separate clinical activities or ethical approval for this study. own recertification timing during this services that represent the broad scope transition. All ACGME and ABFM data of practice possible by family physicians. are confidential, and no programs or Physicians indicated whether they Results sponsoring institutions were identified. provided each service via a “yes/no” Sample characteristics question. Data The study sample included 8,261 physicians applying for ABFM We linked the residency experience of Finally, we collected individual physician demographic characteristics from ABFM recertification between 2013 and 2016. physicians in our sample to their practice The 2012 ACGME ADS database included information using data from the ACGME databases to determine additional measures that may influence scope of a total of 456 family medicine residencies, and ABFM. The ACGME collects of which 423 could be matched to ABFM program information including details practice (age, gender, degree type, and location of medical school). All ABFM diplomates in our sample. Because of the on faculty, enrollment, and practice flux of residency programs, we excluded site exposures (e.g., rural or urban). and FMC data are self-reported by physicians. residents from programs that existed Programs are required to update their during the initial certification period data annually. We used ACGME-collected Analysis but which subsequently closed and from program data from 2012 to determine programs that opened after the initial To represent the scope of practice for the following family medicine residency certification period. program characteristics: a given individual, we calculated the Scope of Practice for Primary Care Among the diplomates included in our • geographic region (classified as South, (SP4PC) score, which is based on the study sample, the average age was 43.3 Northeast, Midwest, and West, per U.S. sum of the number of clinical activities years (standard deviation [SD], 5.3 census regions), reported.14 This score ranges from 0 to years), 52.7% were female, and 12.8% 30 points, with a lower total indicating • program size, as determined by the graduated from an osteopathic medical a narrower scope of practice. Physicians number of residents per year (classified school (i.e., DO). International medical not performing direct patient care were into groups of 1–6, 7–9, and 10 or graduates (IMGs) were 25.8% of the not asked practice characteristic questions more), population (see Table 1). The average and were excluded from the study. SP4PC score was 15.4 (SD, 3.2). Among • whether the residency program was If a physician registered for multiple the family medicine residency programs opposed or unopposed (i.e., single examinations, we retained the data from in our sample, 42.3% graduated 1 to 6 programs with no additional competing the initial test because that information residents per year, 40.4% graduated 7 to residency training programs), was more proximate to residency training. 9 residents, and 17.3% graduated more • whether the hospital where a majority than 10 residents (see Table 2). Of the of rotations occurred was classified as We merged the ACGME ADS data for family medicine residency programs with 423 residency programs, 12.3% included a major academic teaching hospital rotations in rural sites (and 6.4% (defined as any hospital with a ratio of the ABFM demographic and practice data by matching last residency training site. provided greater than 50% of training interns and residents to beds of 0.25 or time in such a site), 41.8% of residencies greater), and Using our merged data, we assessed the need for a multilevel model, as physicians were based in a major teaching hospital, • rural training exposure (determined were clustered within residency and 45.6% were unopposed. by what percentage of time residents programs. The intraclass correlation for Residency characteristics associated spent rotating in rural sites, which the SP4PC score was only 9%; we chose with scope of practice were determined by linking each site’s not to use a multilevel model. mailing address to the Rural–Urban We ran linear regression models to Commuting Area and classifying it into Using linear regression models, we layer individual, practice, and residency 1 of 4 categories: urban, large rural, examined the relationship between the characteristics onto scope of practice. small rural, and frontier). SP4PC score of individual physicians Physician scope varied across several

scope (coefficient = 0.23 in Model 1). Table 1 Being female, older, and having a DO Table 2 Characteristics of American Board of degree were all associated with narrower Characteristics of ACGME-Accredited Family Medicine First-Time Recertifiers scope (coefficient =− 0.29, −0.03, and Family Medicine Residency Programs (2013–2016) Who Have Matching 0.23, respectively, in both Model 1 and in 2012 ACGME-Accredited Family Medicine − Residency Program Data From the Model 2). Being an IMG had the largest Characteristic No. (% of 423) Accreditation Data System in 2012a contribution among individual physician Number of graduating characteristics and was associated with residents per year No. (% of a lower scope of practice (coefficient = Characteristic 8,261) 1–6 179 (42.3) −0.95 in Model 1). Female 4,354 (52.7) 7–9 171 (40.4) Medical degree (MD) 7,204 (87.2) Adding in residency program 10+ 73 (17.3) International medical 2,131 (25.8) characteristics (Model 2) further Region graduate emphasized the influence of geography. Northeast 75 (17.7) Practice organization type To illustrate, compared with those who South 141 (33.3) Group practice 3,074 (37.2) trained in the South (reference group), Midwest 121 (28.6) Hospital affiliated 1,561 (18.9) those who trained in the West had a West 86 (20.3) broader scope of practice (0.53 points on Integrated practice 917 (11.1) Associated with a 177 (41.8) the SP4PC score), and those with rural major teaching hospital Other 570 (6.9) exposure had greater scope than those Rural training Public 900 (10.9) without (0.34 and 0.61 points on the Solo practice 644 (7.8) SP4PC score for, respectively, greater than No rural exposure 371 (87.7) Urgent/emergent care 595 (7.2) 50% of time during training exposed to 1%–50% rural exposure 25 (6.0) Practice location rural training and 1% to 50% of time 51%+ rural exposure 27 (6.3) Urban 7,080 (85.7) exposed to rural training). Graduates of Unopposed program 193 (45.6) residency programs centered in a major Large rural 471 (5.7) Abbreviation: ACGME indicates Accreditation teaching hospital had a narrower scope of Small rural 603 (7.3) Council for Graduate Medical Education. practice (coefficient =− 0.18), and those Frontier 107 (1.3) from unopposed programs had a broader Our main findings—that residency Abbreviation: ACGME indicates Accreditation scope of practice (coefficient = 0.26). Council for Graduate Medical Education. We detected no association between geographic location in the West or a The mean age of the 8,261 recertifiers at the program size in 2012 and scope of Midwest and exposure to rural settings recertification was 43.3 (standard deviation [SD] = during residency broaden scope of 5.3). Their mean Scope of Practice for Primary Care practice. score was 15.4 (SD = 3.2). practice—are consistent with other studies showing that rural family physicians Discussion often have a broader scope of practice.16 individual and residency characteristics Our study of over 8,000 family physicians Studies show that family physicians often (Table 3). Model 1 included individual stay within 50 miles of residency after 2 seeking initial recertification with the and practice characteristics with an R of 17 ABFM from 2013 to 2016 showed that graduating and that those who train in 0.178, whereas Model 2 added residency individual, practice, and residency rural programs are more likely to stay in characteristics and increased the R2 to 18 characteristics were all associated with rural areas. Importantly, our findings 0.184. The R2 for a model including family physicians’ scope of practice. show that associations with program residency characteristics alone was 0.037 However, models with individual training geography are maintained even (results not shown). and practice variables explained 14% when controlling for individual and more variation than those with only practice characteristics that may differ Both models indicate that geographic residency variables. Specific to residency from residency characteristics, such as region of practice and rurality of characteristics, location in the West geographic and rural location. This new practice both influence scope of practice. or Midwest, rural rotations, and an finding raises important questions: Physicians practicing in the Midwest unopposed nature of the residency and West have a greater scope than those 1. Does the training provided by program increased scope of practice these types of residencies (Western/ practicing in the South and Northeast. of family physicians—even after Midwestern, rural, unopposed) Compared with urban practices, being controlling for the physicians’ current include a broader scope of practice? in a frontier practice was associated practice geography and organization. with 2.23 or 2.37 more points on the These findings are important since a 2. Does the training deliver a greater SP4PC score (Model 2 and Model 1, broader scope of practice implies more level of preparedness? and respectively). Practice type influenced comprehensive care. More comprehensive 3. Do the residents attending these SP4PC score to varying degrees; to care is the foundation of a strong primary programs vary in some way that we illustrate, compared with the reference care system, which increases quality, did not measure? group of a private/group practice, reduces hospitalizations, decreases cost, a public practice had a lower scope and lowers physician burnout6–8—all of Additional questions include whether the (coefficient = −2.31 in Model 1), whereas which are, in turn, essential for achieving residency’s primary clinic site represents a solo practice had a slightly higher the Quadruple Aim.15 different practice organization types,

whether insurance and malpractice Table 3 mechanisms located in these geographic Adjusted Associations Between SP4PC Score and Individual, Practice, and areas vary, and whether cultural Residency Characteristics Among American Board of Family Medicine First- acceptance of family physicians providing Time Recertifiers (2013–2016) Who Have Matching ACGME-Accredited Family certain types of services differs by Medicine Residency Program Data from the Accreditation Data System in 2012 (n = 8,261)a geographic area. Given that family physicians provide the majority of care Model 1 Model 2 in rural areas (despite less than 10% of Category Characteristic or measure coefficientb (SD) coefficientb (SD) training occurring in these locations19), Residency Geographic location maintaining a broad scope of practice South — Ref within residency programs is crucial Northeast — 0.02 (0.12) for meeting the needs of patients once Midwest — 0.29 (0.12)c graduates distribute widely, especially to geographic locations where practice West — 0.53 (0.12)d settings may be very different from the Amount of rural exposure training environment. provided None — Ref We found that those family physicians 1%–50% — 0.61 (0.14)d who trained at a major teaching hospital > 50% — 0.34 (0.18)e had a smaller scope of practice and Number of residents graduating that those from unopposed programs per year had a broader scope—even after 1–6 — Ref controlling for their current practice 7–9 — −0.06 (0.08) characteristics. While these patterns may 10+ — −0.05 (0.09) be the results of the training received at each type of institution, they may Major teaching hospital — −0.18 (0.07)c d also reflect the desired career choices Unopposed — 0.26 (0.07) of the individuals who attended these Practice Geographic location programs. For example, physicians who South Ref Ref choose a residency program at a major Northeast 0.48 (0.11)d 0.52 (0.13)d teaching hospital may want a career Midwest 1.11 (0.09)d 0.88 (0.12)d more heavily involved in teaching, West 0.93 (0.08)d 0.63 (0.11)d research, or additional nonclinical duties. Conversely, those who choose an Rurality unopposed program may do so with the Urban Ref Ref intent of practicing broadly, or they may Large rural 1.00 (0.14)d 0.90 (0.14)d feel an increased level of preparedness Small rural 1.95 (0.13)d 1.83 (0.13)d to perform certain clinical activities Frontier 2.37 (0.29)d 2.23 (0.29)d and, in turn, incorporate these activities Type into their practice at a greater level than Private/group Ref Ref those who completed a residency with multiple programs. Medical school Hospital affiliated 0.11 (0.09) 0.11 (0.09) d d students often choose residency programs Integrated practice −1.22 (0.11) −1.21 (0.11) based on the dichotomy of community- d d Public −2.31 (0.13) −2.32 (0.13) based or university-based programs,20 Solo 0.23 (0.11)c 0.25 (0.11)c which often correlate to, respectively, Urgent/emergent care −0.70 (0.13)d −0.69 (0.13)d unopposed programs or major teaching Other −2.13 (0.13)d −2.13 (0.13)d hospitals, and differences in their desired Individual Female −0.29 (0.06)d −0.29 (0.06) future careers may influence this choice. Despite these possibilities, educational Age (per 1-year increase) −0.03 (0.006)d −0.03 (0.006)d opportunities at all family residency c c Doctor of osteopathy (DO) −0.23 (0.10) −0.23 (0.10) programs should allow for residents to International medical graduate −0.95 (0.08)d −0.91 (0.08)d be sufficiently trained in a broad scope Abbreviations: SP4PC indicates Scope of Practice for Primary Care; ACGME, Accreditation Council for Graduate of practice, as future career desires may Medical Education; SD, standard deviation. change and family physicians should be aThe R2 score was 0.178 for Model 1 and 0.184 for Model 2. responsive to the needs of their patient bThe coefficient represents the change in SP4PC score based on each of the variable brackets compared with the reference category. population. cP < .05. dP < .01. Importantly, residency size had no e P < .1. significant effect on determining

graduates’ scope of practice. We practices, rather than family physicians’ means not only for creating a workforce hypothesized that graduates of small scope of practice. Alternatively, the able to more comprehensively care for the programs would more likely have a difference may be that certain types of population in proximity to these training greater scope of practice as a result employers, health insurance providers, or institutions but also for graduating of more exposure and experience for malpractice insurance providers do not physicians with a greater scope of practice residents—similar to an unopposed understand the power of primary care and who choose to work elsewhere. training environment. However, the lack comprehensiveness to improve outcomes of association may reflect that residency and lower overall costs.11 Our results show programs are increasing their class size that physicians working in hospital-based Conclusions only to meet patient population needs, practices actually have a scope of practice The importance of residency training that greater exposure to repetitive similar to those working in private and should be emphasized. Training provides experiences does not broaden scope of group practices, and broader scope than physicians with the skills needed for their practice, and/or that smaller residency public clinics, such as federally qualified initial scope of practice. Research shows programs have fewer faculty to role health centers. Thus, more research is that as physicians continue in their careers, model all the different activities that needed to elucidate the underpinnings of scope of practice declines (likely based might increase scope. these differences. Emphasizing the value of on a number of individual and practice a broad scope of care and its effectiveness characteristics).23 Physicians beginning With regard to individual characteristics, for improving health outcomes and their career with the most comprehensive we found that female physicians, DOs, decreasing physician burnout may be scope of practice possible may be important and IMGs had a smaller scope of practice, a mechanism to retain providers and for meeting the needs of any patient which is consistent with other studies improve patient satisfaction. population. Although training program using similar data.12 These findings are characteristics may not be as closely important. DOs and IMGs provide This study had some limitations. We associated with scope of practice as other a large amount of primary care in used ACGME program characteristics types of characteristics (e.g., practice rural settings,21 and female physicians from 2012, although physicians initially type, geography), their influence is easily constitute an increasingly larger certified between 2003 and 2009. observable, and manipulating aspects of percentage of the overall workforce; Programs may have changed slightly; training—specifically, increasing exposure thus, for these family physicians to however, the likelihood of large program to rural locations and/or emphasizing maintain a scope of practice that reflects characteristics changing (e.g., association unopposed training experiences—may population needs is crucial. Further with an academic medical center or increase the likelihood of producing a research to examine these subsets of geographic location/rurality) is low. physician with a wide scope of practice who physicians is important to ensure that Second, the SP4PC score is a cumulative can better serve the patient population. a majority of a patient’s health care score reflecting the number of distinct needs are met. Combining the ACGME clinical activities performed (measured Funding/Support: None reported. and American Osteopathic Association with yes/no questions) rather than a Other disclosures: None reported. residency programs by 2020 may be one measure of the frequency with which a mechanism to meet this need. physician provides any of the activities. Ethical approval: Reported as not applicable. Additionally, this is a cross-sectional Previous presentations: Peterson LE, Levin Z, Finally, we found that geographic location study that cannot address causality. Coutinho AJ. Residency program characteristics and practice organization type influenced Finally, numerous variables determine and individual resident characteristics scope of practice. Rural family physicians scope of practice, and we have not influence family physician scope of practice. often maintain a broad scope of practice identified or included all of them in our AcademyHealth Annual Research Meeting, out of necessity; fewer subspecialists study. As a result, we acknowledge a level Seattle, Washington, June 2018. practice in rural areas.12 Previous studies of unmeasured confounding. have also reported differences in scope A.J. Coutinho was, when this research occurred, a third-year family medicine resident, Santa Rosa based on geographic region, likely due to Our study offers insight into residency Family Medicine Residency Program, Santa Rosa, cultural acceptance. However, influences program characteristics that may California.

of practice organization may be more influence scope of practice for family Z. Levin was, when this research occurred, research nuanced. Type of practice organization physicians. We believe that maintaining assistant, Robert Graham Center, Washington, DC. is often associated with the availability a broad scope of training for residents S. Petterson is research director, Robert Graham of specialty or procedural resources is vital—even for programs within Center, Washington, DC. both within and outside the clinic, the communities where certain skills may R.L. Phillips Jr is executive director, Center business model for throughput, and seem unnecessary—since residency for Professionalism and Value in Health Care, specific patient populations and patient training may influence future practice Washington, DC. resources—each of which, in turn, affects abilities. The imprinting of residency L.E. Peterson is vice president of research, American provider scope. Recent studies have shown could be considered when establishing Board of Family Medicine, Lexington, Kentucky. that hospital-based practices provide new programs and/or when reforming more low-value care and make more the curricula of standing programs. References specialty referrals than community-based Increasing training opportunities in the 22 1 Bazemore AW, Petterson S, Johnson N, et al. practices. This difference may reflect West and Midwest, increasing exposure What services do family physicians provide ideals of increasing throughput and to rural locations, and/or emphasizing in a time of primary care transition? J Am reimbursement in these hospital-based unopposed training experiences may be Board Fam Med. 2011;24:635–636.

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