The Proposed Project: Conceptualizations of Family Physician Scope of Practice in Ontario

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Student: Sophia Kam, HBA, MA

The Proposed Project: Conceptualizations of Family Physician Scope of Practice in Ontario

A physician’s scope of practice is perceived in various ways. Individual physicians may conceptualize and understand their scope of practice differently based on their practice realities. These understandings and conceptualizations may also differ from those held by legislators, medical regulators, and medical educators. This construct also varies drastically from one jurisdiction to another, yet, it is central to numerous elements of physician governance and practice (Norcini & Mazmanian, 2005, Health Force Ontario, 2006). The lack of clarity around scope of practice has relevance for the medical practice of both domestically and foreign trained physicians. Physician migration necessitates an enhanced understanding of scope of practice to ensure competence for specific scopes of practice (Baldwin et al., 1999; Tulloh, Clifforth, & Miller, 2001; Probst et al., 2002; Breon, Scott-Conner, & Tracy, 2003). How and why scopes of practice change also warrant investigation. Emphasis is placed on scope of practice during the front end of physician careers (i.e., education, licensure, and certification) (Melnick et al., 2002). Yet, scope of practice can change throughout physician careers. Thus, it is difficult to create assessment mechanisms to ensure that competence is maintained through the full spectrum of medical careers if we do not know what they are for or need to measure.

Despite numerous inquiries about factors affecting scope of practice, there is a lack of clarity in conceptualizations of physician scope of practice in the literature. To address this dearth in the literature, this research aims to achieve a more comprehensive understanding of the scope of practice of family physicians. It seeks to determine how different stakeholders concerned with various areas of physician governance and practice define and conceptualize family physicians’ scope of practice in Ontario. Specifically, the objective of this research is to determine the common conceptual elements of scope of practice, where the differences lie, and the implications of these nuances in conceptualization.

To address these objectives, the research questions will examine how family physicians’ scope of practice is defined from multiple perspectives: (1) How is family physician scope of practice defined by/in: (a) Ontario legislation? (b) medico-legal liability issues? (c) medical education?; and (d) professional regulations and licensing?; (2) How do individual family physicians define their scope of practice?; (3) What factors (e.g., age, education, practice size) determine how family physicians define their scope of practice?; and (4) How and why might these factors change over the course of a physician’s career?

To answer these questions, this research will employ a sequential qualitative methods design to be conducted in three phases. To answer question 1, phase I will employ textual analysis via document reviews of major federal and provincial policy statements. Similarly, phase II will employ discourse analysis and semi-structured key informant interviews with representatives from federal and provincial medical associations, regulatory bodies, certification bodies and educational bodies. To answer questions 2 through 4, phase III will employ discourse analysis and focus groups with family physicians registered with the College of Family of Physicians of Canada that have identified special or focused interests in their practices. This research will also investigate two hypotheses: (1) Scope of practice extends beyond a physician’s education and credentials. It includes the geographic locations and settings in which physicians practise medicine; and (2) Physician scope of practice will change over time, and will likely narrow as physicians grow older.

Textual materials will be analysed with a neo-institutional theoretical lens, in recognition that policy-making theories must engage with state-societal relations (Baranek, Deber, & Williams, 2004). Neo-institutional theory necessitates that the “state be understood in its historical/societal context and that the state, its institutions, and the ideas it promotes play a key role in shaping that context” (Baranek, Deber, & Williams, 2004). This research will investigate family physician scope of practice using Baranek, Deber and Williams’ (2004) concepts of policy communities, ideas, interests, and institutions.

This study will challenge current concepts of scope of practice, the findings of which will permit the identification of key aspects of scope of practice related to physician competence and quality of care. Therefore, recommendations for maintenance of physician competence and health system improvements can be made. Also, this study can address the lack of clarity regarding scope of practice and contribute to public consultations within Ontario’s medical profession. Such clarification has the potential to inform discussions pertaining to amendments to regulatory policies or the formation of new policies. This study’s findings may serve as a point of departure for regulatory authorities to devise new institutional expectations concerning scope of practice to inform their regulatory processes. Additionally, there are practical and policy implications of this research for: health policy and regulations mandated by sub-national governments and the medical profession; physician certification and licensure; medical education at various stages of training; and the practice patterns and requirements (needed) in different and specific settings/locales.