Article Figures & Tables
Figures
- Figure 1:
Research design and analytic framework. Note: CFPC = College of Family Physicians of Canada, COE = Care of the Elderly, FPA = Family Practice Anesthesia, PC = Palliative Care, SEM = Sports and Exercise Medicine.
Tables
Case no. Province/territory No. of physicians Geography Institution type* Affiliated with tertiary-level hospital 1 Ontario 36 Urban Academic Yes 2 Manitoba 51 Rural Academic Yes 3 New Brunswick 9 Urban Academic No 4 Yukon 20 Remote Academic No 5 British Columbia 35 Rural Academic No 6 Ontario 100 Suburban Community Yes ↵* Academic cases included practices with affiliations to postgraduate training programs.
Case no. No. of participants Gender* CAC domain Type of professional F M PC COE FPA SEM EM AM Enhanced-skill family physician Generalist family physician Resident trainee RCPSC specialist Administrative staff 1 6 4 2 1 1 0 1 0 0 2 0 1 0 0 2 15 3 12 1 0 3 0 0 1 5 2 1 0 2 3 8 7 1 1 2 0 0 0 0 0 3 2 0 0 4 5 1 4 1 0 1 1 0 0 1 1 0 0 0 5 8 4 4 0 1 0 0 1 0 3 1 1 1 0 6 6 1 5 1 1 0 1 0 0 1 1 1 0 0 Total 48 20 28 5 5 4 3 1 1 12 8 6 1 2 Note: AM = Addictions Medicine, CAC = Certificate of Added Competence, COE = Care of the Elderly, EM = Emergency Medicine, FPA = Family Practice Anesthesia, PC = Palliative Care, RCPSC = Royal College of Physicians and Surgeons of Canada, SEM = Sports and Exercise Medicine.
↵* Participants self-identified their gender.
Quote no. Quote 1 [The availability of PC holders] has kind of taken a rather large load away. … I get them [PC holders] involved at some point, because … I know a fair amount about it [palliative care], but it rolls off of them much easier than for me. (Case 4, participant 4, generalist family physician) 2 If I see a patient that I think [needs surgery], I will fast-track them to [the orthopedic surgeon]. Meaning, it doesn’t take them 9 months to see him, it takes them maybe a month to see him, because I have seen them, I have triaged the patient, and now I know … it’s time for an assessment in surgery, so they get fast-tracked. (Case 4, participant 3, SEM) 3 [CACs] provide another layer of expertise [whereby] they [CAC holders] could handle something or diagnose something in that area of expertise, and then the patient doesn’t have to go to [the urban centre] or go to a specialist, so the care can happen quicker and within the same community. (Case 2, participant 9, generalist family physician) 4 I couldn’t do what I do fee-for-service. For one thing … geriatricians have actual billing codes for what we do, family practice does not have billing codes for what I do. … We do comprehensive geriatric assessments, they take an hour to an hour and a half. … So, you couldn’t possibly bill family practice codes and do geriatric care. (Case 3, participant 2, COE) 5 You cannot do shared care and have both doctors paid at the same time in the model that we’re in. … So, if a family doctor wants to do shared care, obviously they’re going to bill for it, that’s kind of the point and the incentive, so we kind of work for free in those cases. And, I do it, to build capacity, but I’m not getting remunerated for it. (Case 6, participant 2, PC) 6 I tried to start a primary care sports medicine clinic, based out of a physiotherapy clinic, last fall … because there has never been a sports doc here before, the community doesn’t have the culture of that, so what I ended up doing was a lot of doubling up on what the family docs were already doing or on what the [emergency department] was doing. (Case 4, participant 3, SEM) 7 I’ve been able to put “PC” behind my “CCFP,” that’s it, really. … There’s no change in … I don’t think any of my colleagues even really noticed for the longest time. But they know me by the fact that I have extra training and I’ve been able to help them out of difficult situations. That’s how you make the impact. (Case 2, participant 8, PC) 8 I enjoy doing the work that I do at the care home. I don’t know if I would need or, honestly, want the extra one [certification, because I think if I did [obtain] the Care of the Elderly [certification] … there would probably be a reasonable expectation that I was going to provide extra services to the region, and I don’t know if I have time in my practice or my life to do that. (Case 2, participant 4, generalist family physician) 9 It’s not to say that I wouldn’t value having more people in those [CAC] roles, because if that improved my access, I would use some of them more. But I trained through a time and worked in a time [in which] that accessibility wasn’t always there. And so, I’ve learned how to not need them until I really need them. (Case 3, participant 7, generalist family physician) Note: CAC = Certificate of Added Competence, COE = Care of the Elderly, PC = Palliative Care, SEM = Sports and Exercise Medicine.
Organizational model Description Enhanced scope of services The enhanced-skill family physician provides an extended set of services to his/her own patients without referral or consultation
Shared care The enhanced-skill family physician works with the referring family physician but does not take over the role of primary family physician
Family-physician–aligned transfer of care The care of the patient is temporarily or permanently transferred to the enhanced-skill family physician at the request of the referring family physician
The patient is referred to the enhanced-skill family physician, who takes over the care of the patient for the specific referred issue and performs the services
In some cases, the patient will return to the referring family physician; in others, the enhanced-skill family physician will take over the care of the patient
Specialist-aligned transfer of care This model is similar to the family-physician–aligned transfer of care model insofar that it involves the enhanced-skill family physician’s providing care for the patient at the request of the referring family physician
What distinguishes this model is that the transfer of care is from a family physician to a specialist service, and the enhanced-skill family physician sees the patient because of a formal relationship within the particular specialist context
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