Drivers of Scope of Practice in Family Medicine: A Conceptual Model

This qualitative study on the drivers of scope of practice in family medicine makes an important contribution by exploring factors that affect family physicians’ scope of care. This adds to previous reports that residency graduates’ actual practice scope was narrow compared with the scope they felt prepared to provide.1
The evidence that there is a gap between what family physicians are trained to do and want to do, and what they actually do, is well-established and cited in the article. Most family medicine residency program directors are familiar with this phenomenon as well. This problem merits attention as it affects the recruitment of students into family medicine, the professional satisfaction and well-being of practicing family physicians, and the cost of health care.
This discussion is timely, given that the Accreditation Council for Graduate Medical Education (ACGME) review of requirements for family medicine residency training is underway. Given the volume of knowledge and breadth of practice required by primary care physicians, one could argue that there is no point spending precious time training in skills the resident will not have the opportunity to practice. I hope that is not the case because the public needs comprehensive, broad-scoped care for which family physicians are uniquely trained.
To ensure a scope of care that is both broad and cost-effective, family medicine residents should be trained to provide comprehensive care rather than reflexively referring to subspecialists and manage patients with complex medical conditions, all of which should be enhanced by the provision of individual and practice-level data on quality metrics.2 These experiences are critical as the resident training environment has a lasting impact on the care physicians deliver for at least two decades after residency completion.3 The next step is to ensure the opportunity to practice these clinical skills.
The recently released report Implementing High-Quality Primary Care – Rebuilding the Foundation of Health Care describes excellent primary care as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”4 Narrowing the scope of practice is another one of the trends that is moving in the wrong direction if we are to encourage medical students to choose family medicine and reverse the shrinking primary care physician workforce. We must ensure that family medicine is attractive to medical students. Though family physicians know the ethos of family medicine and the rich training provided, if medical students perceive it as nothing but adult outpatient medicine, many will see no reason to enter the specialty over internal medicine or med/peds.
I am pleased that the authors have identified the potentially modifiable stressors and the needed support to align scope of practice with family physicians’ willingness and desire to practice as they are trained. This is critical to create a sensible, viable and sustainable health care system.

1. Carek PJ, Mims L, Kirkpatrick S, et al. Does community- or university-based residency sponsorship affect graduate perceived preparation or performance? J Grad Med Educ. 2020;12(5):583-590. doi:10.4300/JGME-D-19-00907.1
2. Neutze D, Hodge B, Steinbacher E, Carter C, Donahue KE, Carek PJ. The Practice is the Curriculum. [published online ahead of print May 10, 2021]. Fam Med. https://doi.org/10.22454/FamMed.2021.154874.
3. Phillips RL, Holmboe ES, Bazemore AW, George BC. Purposeful Imprinting in Graduate Medical Education: Opportunities for Partnership. [published online ahead of print May 10, 2021]. Fam Med. https://doi.org/10.22454/FamMed.2021.264013.
4. National Academies of Sciences, Engineering, and Medicine. 2021. Implementing high-quality primary care: Rebuilding the foundation of health care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25983.