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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 Academic Medicine, Vol. 94, No. 10 / October 2019 1561 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. Research Report 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
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