This study demonstrates a pervasive decrease in the comprehensiveness of primary care in Ontario. Physicians in all age groups, of both sexes and in all practice locations showed significant levels of decline in the comprehensiveness of the care they provided from 1989/90 to 1999/2000. Decreases in comprehensiveness of care occurred even in rural areas, where GPs/FPs do not have the same latitude to shift patient care to specialists. This finding suggests that either patients are facing barriers to access, or it may be that a decreasing number of GPs/FPs who provide comprehensive care are assuming the workload of those dropping out of nonoffice settings.
Cities with teaching facilities registered the lowest levels of comprehensiveness of care. One reason may be that such areas have high concentrations of specialists, resulting in both ease of referral and greater patient expectations to be seen by a specialist. Academic centres may also have policies limiting GP/FP involvement in obstetrics, inpatient wards and emergency departments.
Although older physicians had the lowest participation in acute care settings such as emergency and inpatient wards, they remained as likely as younger, established physicians to provide nursing home coverage and do house calls. One explanation may be that older physicians tend to treat older patients,10
which may reflect a natural tendency for physicians to age in step with their patients. Currently, recent graduates are less likely to work in these environments. As older physicians retire, there is the potential that older patients requiring care in these settings will be left unserved, or that responsibility for their care will pass from GPs/FPs to geriatric specialists.
Female physicians were more likely to provide obstetric care than males, but they were less likely to work in all other nonoffice settings and more likely to have an office-only practice. This finding suggests that the dramatic rise in the proportion of GPs/FPs who are women over the past decade5
may have contributed to the overall decline in comprehensiveness of care. It must be emphasized, however, that many studies suggest that female physicians provide superior care in the office setting. Female physicians are better communicators,12
spend more time with their patients,12,13
focus more on preventive health care14
and have higher quality-of-care assessments.15
Some studies have found that patients report greater satisfaction with care offered by female physicians16,17
and express a preference for female physicians.18
This study highlights a de facto role differentiation by physician gender, and policy-makers who are trying to plan how many doctors will be needed in the future may need to consider the impact of these trends.
Physicians with a CCFP were more likely to provide emergency and inpatient coverage and were less likely to have an office-only practice. This suggests that family medicine training programs may be having a positive impact. The fact that new graduates intending to work in family practice are now required to have a CCFP may mitigate future trends toward lower comprehensiveness of care by GPs/FPs. Further research could examine which types of family practice programs best prepare physicians for comprehensive practice.
This study has several limitations. First, information about physicians who are not paid on a fee-for-service basis is unavailable. Second, data elements in the OHIP or OPHRDC datasets may be subject to coding error. However, OHIP regularly audits physicians for fraudulent claims, and OPHRDC calls each physician periodically to verify specialty and practice location information. Third, this study cannot assess the impact of declining comprehensiveness on quality of care, and further research is needed in this area. Fourth, the study does not consider whether declining comprehensiveness of primary care was a result of the relatively low remuneration for nonoffice services. For example, the fees for nursing home and hospital visits are one-third lower than for an intermediate office assessment.19,20
Although the relative proportions of fees have not changed over time, the acute condition of inpatients, and hence the workload per patient, may have increased with decreasing hospital-bed capacity. Cost-containment measures directed at physicians during the mid-1990s,21
such as fee decreases and expenditure caps, may have also discouraged physicians from providing low-paying services.
Some readers of this study may conclude that declining comprehensiveness of primary care is inevitable and, perhaps, desirable. It may be argued that the expectations of young physicians for quality family time are incompatible with a workload that spans all of the practice domains discussed in this paper. The increasing complexity of medical care demands greater specialization, and the ideal of the “super-FP” who can do everything is unrealistic. In the United States, a similar debate on the role of “hospitalists” has taken on great fervour. Hospitalists specialize in inpatient care, leaving primary care physicians to focus on ambulatory care.22,23
Opponents decry the loss of continuity of care,24,25,26
whereas supporters hail the benefits of a specialized knowledge base.26,27,28
The evidence on the impact of hospitalists on patient care is mixed29,30
The College of Family Physicians of Canada supports comprehensive primary care but proposes that one alternative could be the group family practice, or “family practice network.”31
Within such networks, individual physicians may specialize to some degree, but the group as a whole provides comprehensive care. An implicit assumption of this model, however, is that there will be a solid core of physicians who work in at least one nonoffice setting. This study, however, suggests that such a core is eroding. The proportion of “office-only” physicians has almost doubled in the past decade to its current level of one-quarter of all GPs/FPs. Proponents of these networks must consider how they will be sustainable if these trends continue.