The document summarizes research examining changing primary care patterns in Canada using administrative health data. The key findings are: 1. Primary care practice patterns are changing over time, with family doctors seeing fewer patients and working in fewer settings. However, these changes are not unique to early career physicians. 2. Factors driving the changes point more to issues with primary care systems rather than gaps in family medicine training. While early career physicians are committed to community care, practice and payment models must better support this. 3. Understanding changing practice patterns combined with population needs can help plan future primary care capacity, as workload and administrative duties are increasing per physician. Additional resources may be needed to ensure all

1. Data NB seminar
December 14, 2022
If there are more family doctors than
ever before, why can’t I find one?
Using linked administrative data to
study changing primary care in
Canada
Ruth Lavergne, Dalhousie University
Associate Professor, Department of
Family Medicine
Tier II Canada Research Chair in
Primary Care
1

2. Land
Acknowledgemen
t
Dalhousie University is located in
Mi’kma’ki, the ancestral, unceded,
present, and future territory of the
Mi’kmaq.
We are all Treaty people.
This research was also conducted on
the unceded Traditional Coast Salish
Lands including the Tsleil-Waututh
(səl̓ilw̓ətaʔɬ), Kwikwetlem (kʷikʷəƛ
̓ əm),
Squamish (Sḵwx̱wú7mesh Úxwumixw)
and Musqueam

3. FUNDING AND DISCLOSURES
 The research I’ll present today is
supported by grants from the Canadian
Institutes of Health Research
 I hold a Tier II Canada Research Chair
in Primary Care
 I have no conflict(s) of interest to
declare
Access to data provided by the Data
Steward(s) is subject to approval, but can be
requested for research projects through the
Data Steward(s) or their designated service
providers.
All inferences, opinions, and conclusions
drawn in this publication are those of the
author(s), and do not reflect the opinions or
policies of the Data Steward(s).

4. PLAN
FOR TODAY
1. Key findings
2. Context
3. How are practice patterns of family physicians
changing over time? (completed research)
 Are different choices among early career family physicians
driving changes over time?
4. What other factors may be driving changing primary
care capacity? (work in progress)
5. Next steps – and possible opportunities for NB
collaboration
6. Questions and discussion of implications
 Thoughts on medical education, primary care policy, and
workforce planning
4

5. STUDY TEAM
Team BC ON NS MB*
Principal
Applicants
Ruth Lavergne,
Laurie Goldsmith
Agnes Grudniewicz,
David Rudoler
Emily Gard Marshall Alan Katz
Co-Applicants
(primary care
physicians)
Ian Scott, Dave Snadden,
Rita McCracken, Goldis
Mitra, Laura McKinnon
Rick Glazier, Tara Kiran,
Steve Hawylyshyn
Fred Burge, Rick Gibson,
Kathleen Horrey, Jacalynne
Hernandez-Lee
Research staff,
trainees and
co-Applicants/
collaborators
Lindsay Hedden,
Ellen Randall, Sandra
Peterson, Sabrina Wong,
Kim McGrail, Doug
Blackie
Maria Matthews,
Monisha Kabir, Alison
Coates, Lori Jones
Tara Sampalli, Charmaine
McPherson, Adrian MacKenzie,
Mike Joyce, Gail Tomblin
Murphy, Catherine Moravac,
Katherine Stringer
Leane
Kosowan
*Quantitative study
arm 5

6. 6
KEY
FINDINGS

7. 1. Primary care
practice patterns
are changing.
 Family doctors are seeing fewer patients over
time and working in fewer settings.
 Some physicians are responding to system
and community needs through focused
practice.
 Changes in practice patterns are not unique to
physicians early in practice.
7

8. 2. Findings point to
changes needed in
primary care
systems, not gaps
in family medicine
training.
 Early-career physicians are committed to
providing care that meets community needs,
but practice and payment models must be
aligned to support this.
 There is no evidence that declining
comprehensiveness is driven by inadequate
preparation or training.
 Many participants describe training to provide
team-based comprehensive care but report
limited opportunities to practice in this way.
8

9. 3. Information on
changing practice
patterns and
population need
can help plan for
future primary
care capacity.
 Population aging combined with increasing complexity
of patient needs mean workload per visit is likely
increasing.
 Administrative workload and time spent on coordination
of care in the community may be increasing.
 A growing proportion of family physicians are filling
health system roles outside of community-based
primary care.
 Even with an increasing per-capita supply of family
medicine physicians, additional resources will likely be
needed to ensure all patients can access comprehensive
primary care, particularly as the physician workforce
ages.
9

10. CONTEXT
10

11. Source: Canadian Institute for Health Information, Supply, Distribution and Migration of Physicians in Canada, 2021
60
70
80
90
100
110
120
130
140
150
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Canada
Family medicine physicians per 100,000 people in Canada

12. Source: Canadian Institute for Health Information, Supply, Distribution and Migration of Physicians in Canada, 2021
60
70
80
90
100
110
120
130
140
150
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
NB NS ON MB BC Canada
Family medicine physicians per 100,000 people in Canada

13. 13
Concern about
family
physician
shortages are
receiving
national media
attention

14. Access to primary care
is falling.
According to Canadian
Community Health Survey
Data, the percentage of
people with a regular
medical provider or place
of care declined between
2007/8 and 2017/8.
Inequities in who has
a regular provider or
place of care are
growing wider.
14

15. Use of primary care over time by income
quintile in British Columbia
Annual primary care care visits by income
quintile
% of people with no ambulatory primary care
visits by income quintile
0.00
1.00
2.00
3.00
4.00
5.00
6.00
SES1_Lowest SES2 SES3 SES4 SES5_Highest
.0
5.0
10.0
15.0
20.0
25.0
30.0
p_SES1_Lowest p_SES2 p_SES3 p_SES4 p_SES5_Highest
Lavergne, M., Bodner, A., Peterson, S. et al. Do changes in primary care service use over time differ by neighbourhood income? Population-based longitudinal
study in British Columbia, Canada. Int J Equity Health 21, 80 (2022). https://doi.org/10.1186/s12939-022-01679-4

16. Emergency department visits and referrals to
specialists by income quintile in British Columbia
ED visits by income quintile Specialist referrals by income quintile
0.00
0.10
0.20
0.30
0.40
0.50
0.60
SES1_Lowest SES2 SES3 SES4 SES5_Highest
0.00
0.05
0.10
0.15
0.20
0.25
SES1_Lowest SES2 SES3 SES4 SES5_Highest

17. “Finding steady, full-time work is a
well-documented struggle for many
young adults today, but there is an
ironic flipside to the trend: younger
professionals, such as doctors, are
seeking greater work-life balance
than their forebears, including
carrying the burden of running a
business.”
“Entrepreneurship, the 71-year-old
says, is no longer attractive or
appealing to a generation of doctors.”
“A lot of people don’t want to go
into family practice now and they
want to go work in walk-in clinics
where the hours are much better
and the time off is much better,
and it’s better for their lifestyle”
“The new generation is being
mostly trained in urban areas,
by people who are working in
smaller and smaller niches of
family medicine”
“Generational” explanations for changing physician practice are
common

19. PROJECT
OVERVIEW
The overarching
goal of this study is
to provide new
information about
the family
physician
workforce, with a
focus on early-
career family
physicians.
(<10 years in
practice)
19

20. OBJECTIVES
20
1. Compare practice patterns of early-career and
established family physicians to determine if changes
over time reflect cohort effects (attributes unique to
the most recent cohort of family physicians), or period
effects (changes over time across all family physicians)
(quantitative)
2. Identify values and preferences shaping the practice
intentions and choices of family medicine residents
and early career family physicians (qualitative)
Understanding factors shaping practice intentions
and choices among early-career family physicians
is important to shape future supply of primary care
services.

21. DATA
Qualitative: semi-structured
interviews in NS, ON, BC:
• 31 family medicine
residents
• 63 family medicine
physicians in first 10 years
of practice
Inductive coding and
framework analysis
Quantitative: analysis of
province-wide linked
administrative data tracking:
• Number of visits
• Continuity of care
• Comprehensiveness of
services
Between 1997/8 and 2017/8
In NS, ON, MB and BC
21

22. For more information . .
Study protocol
 Lavergne M.R., Goldsmith, L.J., Grudniewicz, A.,
Rudoler, D., Marshall, E.G., Ahuja, M., Blackie, D,.
Burge, F., Gibson, R., Glazier, R.H., Hawrylyshyn,
S., Hedden L., Hernandez-Lee, J., Horrey, K.,
Joyce, M., Kiran, T., MacKenzie, A., Mathews, M.,
McCracken, R., McGrail ,K., McKay, M.,
McPherson, C., Mitra, G., Sampali, T., Scott, I.,
Snadden, D., Tomblyn Murphy, G., Wong, S.
(2019). Practice patterns among early-career
primary care (ECPC) physicians and
workforce planning implications: protocol
for a mixed methods study. BMJ Open, 9(9),
e030477.
https://www.healthsystemsresearch.ca/ecpc
22

23. How are practice
patterns of family
physicians
changing over
time?
Are different
choices among
early career family
physicians driving
changes over time?
23
CHANGING
PRACTICE
PATTERNS

24. Aim
Changes specific to more recent cohorts of
physicians
(cohort effects)
Indicates need for targeted intervention
during the formative stages of physician
training and early practice.
Changes over the course of physicians’
careers
(age effects)
Indicates need to consider aging and
career stage in workforce planning.
Changes over time in work and policy
contexts that impact all physicians
(period effects)
Indicates need for broad policy responses
addressing contexts in which all physicians
practice.
Family practice is changing.
We aimed to determine if this was because of:
24

25. Analysis
• To disentangle the relative effects of age, period and
cohort on measures of service volume (patient contacts)
and continuity of care.
Purpose
• Median polish analysis to separate age, period and cohort
effects, and plot these in graphs.
Approach
25

26. AVERAGE NUMBER OF
PATIENT CONTACTS,
PER PHYSICIAN,
19997/8 AND 2017/8
 Patient contacts fell
between 1997/8 and
2017/8 in all four
provinces.
 Over this time period,
the population has
aged, the
management of
common chronic
conditions has
changed, and the
health system has
grown more complex.
26

27. Other measure of family physician practice volume are
changing
27

28. Period effects on median
patient contacts
(changes over time across
all family physicians)
 Compared to 1997-
1999, the median
number of patient visits
per physician per year
observed in
administrative data fell
in all four provinces
examined (NS, ON, MB,
BC).
28

29. Effect of years in practice
on patient contacts
(changes over the course
of physicians’ careers)
 For the median
physician, the number
of patient contacts
increases in early
practice and then fell in
later practice.
 This was observed
across physician
cohorts.
29

30. Illustration of cohort
effects
(not real data)
 If recent cohorts are
having fewer patient
contacts each year,
relative to previous
cohorts at the same stage,
the figures showing
cohort effects would look
something like this.
 Note the bars would drop
below 0 at the end.
The reference in this plot is
physicians entering practice
between 1991 and 1993.
30
EXAMPLE cohort effects

31. Cohort effects on median
patient contacts
(generational effects)
 We did not observe
changes in patient
contacts that are
unique to the most
recent cohort of
physicians.
The reference in this plot
is physicians entering
practice between 1991
and 1993.
31

32. CHANGES IN
CONTINUITY OF CARE
OVER TIME
 Physician continuity: of
all the patients a
physician saw within a
year, this is the
proportion of all those
patients’ contacts that
were with the individual
physician
 Continuity fell slightly
in ON – this may be
because this measure
doesn’t factor in a
transition to team-
based care.
32

33. COHORT EFFECTS
ON CONTINUITY
 We did not observe
changes in continuity that
are unique to the most
recent cohort of
physicians.
 Continuity increases with
years in practice as
physicians establish
patient panels, but there
is no evidence of cohort
effects.
The reference in this plot is
physicians entering practice
between 1991 and 1993.
33

34. • Service volume and comprehensiveness
are declining across all years in practice
and genders
• Changes in practice patterns are not
unique to physicians early in practice.
• Changes may reflect increasing
complexity of care, administrative
burden, or different choices about work
across all family physicians.
• Intergenerational blame distracts from
broader issues in primary care practice.
• Feelings of blame are particularly
damaging when layered with the fact
that family medicine is already felt to be
undervalued.
34
KEY FINDINGS

35. 35
For more
information:
Rudoler, D., Peterson, S., Stock,
D., Taylor, C., Wilton, D., Blackie,
D., Burge, F., Glazier, R.,
Goldsmith, L., Grudniewicz, A.,
Hedden, L., Jamieson, M., Katz,
A., MacKenzie, A., Marshall, E.,
McCracken, R., McGrail, K., Scott,
I., Wong, S., & Lavergne, M. R.
(2022). Changes over time in
patient visits and continuity of
care among graduating cohorts
of family physicians in 4 Canadian
provinces. Canadian Medical
Association Journal.
https://www.cmaj.ca/content/194
/48/E1639
https://www.healthsystemsresear
ch.ca/ecpc

36. COMPREHENSIVENESS
36
 Declining comprehensiveness of family
physician practice has been widely observed.
 Some speculate this reflects lack of interest
or inadequate training among more recent
cohorts of family physicians.
 Some data show that physicians who have
recently entered practice participate in a
narrower range of services than those in
established practice.
Whether comprehensiveness is changing more
rapidly among early-career physicians relative
to physicians in established practice is not
clear.

37. Measuring comprehensiveness
Service settings
(or aspects of care delivered out-of-
office)
 home
 long-term
 emergency department
 hospital
 obstetrics
 surgical assistance
 anesthesiology
Service areas
(consistent with office-based
practice)
 pre/post-natal care
 pap testing
 mental health
 substance use
 cancer care
 minor surgery
 palliative home visits
37
These measures:
• Could be consistently tracked over time in each of the four study provinces
• Align with settings and domains of care in the College of Family Physicians of Canada’s Family
Medicine Profile and Residency Training Profile
• Build on previous work using administrative data, grouping billing codes into activity areas, and
selecting a minimum threshold of 7 activity areas to define comprehensive primary care (Schultz et
al. 2017)

38. Analysis
38
Outcome: Number of service settings and service areas in which physicians
had 5 or more patient contacts (count variable ranging from 0-7)
Models: generalized estimating equations (GEE), Poisson distribution and log
link
Adjustment variables: physician administrative sex, urban/rural practice
location, practice volume, location of MD (Canada, international, unknown)
Hypothesis: there is a significant interaction between year and years in
practice

39. EXCLUSION
CRITERIA
The number of
physicians
excluded based
on focused
practice setting
increased
between the
study years
39
11.2
8.9 8.6 7.3
2.5 2
10.2
8.1
4.2
14.7
4.5 6.5
7.6
15.3
7.9 13.2
1.2
1.7
9.7 9.5
3.5
3.1 0
0.7
1999/20002017/20181999/20002017/20181999/20002017/20181999/20002017/2018
BRITISH COLUMBIA MANITOBA ONTARIO NOVA SCOTIA
% physicians excluded by province
Focused practice areas - more than 80% of contacts in a single practice area
Focused practice setting - more than 80% of contacts in non-office
locations
Low service volume

40. EXCLUSION
CRITERIA
The percentage of
excluded physicians
within their first 10
years of practice fell
between study
years
Put differently,
focused/low volume
practice is NOT
increasing more
rapidly among early
career physicians.
40
35.8
30.4
76.6
59.9
31.8 30.4
31.6
28.8
20.9
21.1
13.4
17.1
24.6
22.1
21
18
14.2
24.7
10
23
15.7 20.9
17.1
23.2
15.9
23.5
27.9 26.7
17.1
25.8
1999/20002017/20181999/20002017/20181999/20002017/20181999/20002017/2018
BRITISH COLUMBIA MANITOBA ONTARIO NOVA SCOTIA
% OF PHYSICIANS EXCLUDED BY YEARS IN
PRACTICE
0-10 10-19 20-29 (MB 20+) 30+

41. COMPREHENSIVENESS
- SERVICE SETTINGS
• The average
number of service
settings per family
physician has fallen
over time.
• It has fallen among
physicians at all
career stages.
41
-3
-2
-1
0
1
2
3
4
5
6
7
1999/2000
2017/2018
Change
1999/2000
2017/2018
Change
1999/2000
2017/2018
Change
1999/2000
2017/2018
Change
British Columbia Manitoba Ontario Nova Scotia
Service settings
<10 years in practice 10-19 years in practice
20-29 years in practice* 30+ years in practice

42. COMPREHENSIVENESS - SERVICE SETTINGS
42
Adjusted models include administrative sex, urban/rual, number of contacts/year, location of MD (Canadian, International,

43. COMPREHENSIVENESS
- SERVICE AREAS
• The average
number of service
areas per family
physician has fallen
slightly over time.
• Changes are similar
across all career
stages.
43
-1
0
1
2
3
4
5
6
7
1999/2000
2017/2018
Change
1999/2000
2017/2018
Change
1999/2000
2017/2018
Change
1999/2000
2017/2018
Change
British Columbia Manitoba Ontario Nova Scotia
Service areas
<10 years in practice 10-19 years in practice
20-29 years in practice* 30+ years in practice

44. COMPREHENSIVENESS - SERVICE AREAS
44
Adjusted models include administrative sex, urban/rual, number of contacts/year, location of MD (Canadian, International,

45. KEY FINDINGS
Paper in press at
Annals of Family Medicine,
Expected publication January 2023
• On average, family physicians practiced in
fewer settings in 2017/8 compared to
1999/2000.
• Findings are remarkably consistent across
the four provinces examined, given varied
models of primary care delivery and
physician payment within provincial
systems.
• There is no evidence that
comprehensiveness declined faster
among physicians within their first 10
years of practice.
• Efforts to influence comprehensiveness of
care should consider the service delivery
contexts in which all physicians are
practicing, rather than interventions in
training or early practice.
45

46. POLICY AND PRACTICE IMPLICATIONS
• Broadly-targeted, system-wide
strategies are needed if the goal is to
maintain or increase supply of primary
care services.
Changes in primary care practice are observed
across physicians at all career stages, not just those
entering practice recently (period effects).
• It is important to pay attention to the
age distribution of the physician
workforce in planning.
Since practice patterns differ over the course of
physicians’ careers (age effects), physician workforce
with more physicians early or late in their careers will
have lower volume.
• Understanding practice intentions and
choices can still support recruitment
and retention in longitudinal,
comprehensive primary care.
Though there is no evidence that changes in primary
care are driven by early-career physicians (cohort
effects). 46

47. Qualitative
research
What do
primary care
physicians
entering
practice want?
47
 We conducted interviews with 90+ family medicine
residents and early career physicians in three
provinces (British Columbia, Ontario, Nova Scotia)
about factors shaping practice intentions and
choices. Many highly value:
 Opportunities to deliver comprehensive care in
team-based models (consistent with how they
trained)
 Alternatives to fee-for-service, with fair
compensation
 The ability to take time off, with coverage for
patients
 The ability to focus on medicine, not running a
business
 Fulfilling work that responds to community
needs

48. For more on qualitative study findings
Kabir, M., Randall, E., Mitra, G., Lavergne, M.
R., Scott, I., Snadden, D., Jones, L.,
Goldsmith, L. J., Marshall, E. G., &
Grudniewicz, A. (2022). Resident and
early-career family physicians’ focused
practice choices in Canada: A qualitative
study. British Journal of General Practice,
72(718), e334–e341.
→ Focused practice is viewed by family
medicine residents and early-career
physicians as a way to circumvent the
burnout or exhaustion with comprehensive
Mitra, G., Grudniewicz, A., Lavergne, M. R.,
Fernandez, R., & Scott, I.
(2021). Alternative payment models: A
path forward. Canadian Family Physician,
67(11), 805–807.
→ The availability of remuneration
models is an important factor shaping the
practice choices of early career physicians.
→ In areas of the country where fee-for-
service was the only payment option,
some family physicians were deterred
from practising comprehensive family
Marshall, E.G., Horrey, K., Moritz, L.R., Buote, R.,
Grudniewicz, A., Goldsmith, L., Randall, E.,
Jones, L., & Lavergne, M.R. (2022). Influences
on intentions for obstetric practice among
family physicians and residents in Canada:
an explorative qualitative inquiry. BMC
Pregnancy and Childbirth
→ Individual-level factors alone do not
account for the decrease in obstetric care
offered by FPs.
→ Choices to provide or not provide obstetric
care are by community, organizational, and

49. For more on practice intentions of family medicine residents . . .
 Lavergne, M.R., Scott, I., Mitra, G.,
Snadden, D., Blackie, D., Goldsmith,
L., Rudoler, D., Hedden, L.,
Grudniewicz, A., Ahuja, M., and
Marshall, E.G. (2019). Regional
Differences in Where and How
Family Medicine Residents Intend to
Practise: A Cross-sectional Survey
Analysis. Canadian Medical
Association Journal Open, 7(1), E124-
E130.
 Across Canada, two-thirds of family
medicine reported it was somewhat
or highly likely they would commit to
providing comprehensive care to the
same group of patients in their first
three years of practice.
 Over 80% of family medicine
residents indicated they intended to
practise in a team-based model.
 Lavergne M.R., Gonzalez
Patterson A., Ahuja M.A.,
Hedden L., McCracken R.
(2019). The relationship
between gender, parenthood
and practice intentions among
Family Medicine residents:
Cross-sectional analysis of
national Canadian survey data.
Human Resources for Health,
17(1), 67.
 Family medicine residents who
are parents and who are
women are more likely to
report intentions to provide
comprehensive care soon after
entering practice
 Supporting family medicine
residents who are parents may
positively impact the quality
and availability of primary care
services
49
https://www.healthsystemsresearch.ca/ecpc

50. Capacity for family medicine training
 While these findings don’t point to gaps in training, reforms to
family medicine training are underway, with implications for
capacity.
 The College of Family Physicians of Canada has announced plans
to increase the length of family medicine residency from 2 to 3
years, starting in 2027. This may have substantial workforce
implications:
 ”Double cohort” year with no graduating family physicians
 Limited capacity to expand the number of residency spaces
 Limited capacity to offer Practice-Ready Assessment (PRA)
programs for internationally educated physicians who have
completed residency
 Changes in choice of family medicine among specialties
50
https://www.cfpc.ca/CFPC/media/Res
ources/Education/AFM-OTP-
Report.pdf

51. What other factors
may be driving
changing primary
care capacity?
(work in progress)
51
PRIMARY
CARE
CAPACITY

52. SOME
PRELIMINARY
DATA
 Findings from British Columbia only,
over the period from 1999/2000 to
2017/8
 More national research needed!
52

53. The population is aging and health needs are increasingly
complex.
53
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
0-19 20-39 40-59 60-79 80+
Population registered for health
insurance in British Columbia by age
group
1999/2000 2017/2018
-30%
-20%
-10%
0%
10%
20%
30%
40%
50%
60%
70%
0-19 20-39 40-59 60-79 80+
% change in the number of
comorbidities (Charlson) treated
between 1999/2000 and 2017/2018
by age group

54. The volume of services requiring coordination in
primary care has increased dramatically, especially
among older age groups.
54
-40%
-20%
0%
20%
40%
60%
80%
100%
Medical
specialist visits
Surgical
specialist visits
Day surgeries Prescriptions Diagnostic
radiology
Diagnostic
ultrasound
Lab tests
% change in outpatient service use between 1999/2000 and 2017/2018 by age group in British Columbia
0-19 20-39 40-59 60-79 80+

55. Family physicians are playing new roles within health systems
 The total number of
family physicians
per capita is
increasing.
 The increase is
almost entirely
taken up by doctors
with 80% or more
of their services in a
specific service
location (hospital,
emergency
department) or
focused practice
area.
55
0
2
4
6
8
10
12
1999/2000 2017/2018
Number of family physicians per 10,000 people in British Columbia
Emergency department
Hospitalist/mix of locations
Mental health and/or substance use
Other focused practice (sports medicine, surgical
assistance, anesthesiology, perinatal services, cancer
care)
Community-based physicians in comprehensive
practice (includes walk-in clinics)

56. Coordination workload per visit with family physicians
in comprehensive practice is increasing substantially
 The volume of services requiring family
physician coordination has increased
substantially per visit with a community-
based physician in comprehensive practice
 This ranges from a 35% increase for
prescriptions dispensed to a 122% increase
for lab tests
56
0
0.5
1
1.5
2
2.5
Medical
specialist visits
Surgical
specialist visits
Prescriptions Lab tests
Number of services requiring primary care
coordination per volume per community-based
family physician visit in British Columbia

57. What factors are driving changing primary care capacity?
(Or, if there are more family doctors than ever before, why can’t I find
one?)
The work
family doctors
do is changing.
Population
needs for
primary care
are changing.
The systems in
which family
doctors work
are changing.
57

58. The work
family
doctors do is
changing.
58
 Average visits are falling across all family
physicians
 Much of the increase in family doctors
per person is accounted for by family
doctors working in different (and needed)
roles within the health system.
 More family physicians are working in
focused practice settings and, to a lesser
extent, focused practice areas.

59. Population
needs for
primary care
are changing.
59
 The population is aging, but this doesn’t
tell the whole story.
 People are being treated for more
conditions at older ages.
 People, and especially older people at
older ages are getting more
prescriptions, imaging, and laboratory
tests.

60. The systems
in which
family
doctors work
are changing.
60
 More health care is being done in the community.
 People at older ages are spending fewer days in hospital,
and receiving more day surgeries.
 This means more coordination work for family physicians
working in the community.
 The time it takes to do coordination work may be
changing
 Referral processes are complicated, and family doctors
spend a lot of time coordinating care in advance of visits
with other specialists.
 Finding other specialists who will take referrals and
navigating different forms and processes for these is also
time consuming.
 Electronic health records can mean family doctors do more
coordination work that might previously have been done
by other team members.

61. Papercuts project:
Understanding and
addressing
changing
administrative
workload in
primary care
Rethinking Primary
Care Capacity in
Canada
(ReCap):Will more
of the same be
enough?
61
NEXT
STEPS

62. Papercuts Project
 Increases in administrative workload within primary
care have been casually called “death by a thousand
papercuts,” but we do not have good information
about the extent of this problem and what we can do
to fix it.
 This project will use a combination of administrative
data, and semi-structured interviews with family
physicians, nurse practitioners, and administrative
team members to collect new information about
administrative workload, toward the overarching goal
of more efficient coordination and delivery of care
Funded by Research Nova Scotia December 2022
Data collection will begin in Spring 2023
Interviews planned in both NS and NB – ideas for
recruitment or collaboration welcome!
Objectives
1. Determine how the volume of services requiring
primary care coordination has changed over time
2. Understand how workload associated with
coordination has changed, from the perspective of
primary care providers in Nova Scotia and New
Brunswick
3. Identify practical strategies to make coordination
more efficient, with attention to opportunities to
reduce volume, improve process efficiency, and
optimize distribution of workload within teams
62

63. Rethinking Primary Care Capacity in Canada (ReCap):
 The overarching aim of this project is to support
more rigorous workforce planning by providing new
information about changes shaping primary care
capacity and patient need.
 National study, but interviews and administrative data
in a subset of provinces
Planned CIHR Project Grant in Spring 2023
Data collection will begin in Fall 2023
NB collaboration or partnership welcome!
Objectives
1. Understand current workload from the perspective of
primary care providers, and whether and how
workload has changed over time (Qualitative
interviews)
2. Quantify demand-side factors shaping population
primary care need, including demographics,
complexity, and service intensity, and estimate the
degree to which current use differs from real demand
given growing inequities in access. (Administrative
data)
3. Quantify supply-side factors shaping primary care
capacity, including provider demographics, service
volume, roles played by family physicians outside of
community primary care, and participation of non-
physician clinicians in community-based primary care.
(Administrative data)
4. Integrate information to generate simple projection
models of primary care capacity and need, under a
range of scenarios. (Operations research simulation
models)
63

64. Implications
Medical education
Findings point to
system responses,
not gaps in training
Need to consider
implications of
longer family
medicine residency
Primary care
planning
Need for strategies
that expand capacity
for longitudinal
primary care in the
community
Workforce
Need for proactive
and coordinated
planning
Your thoughts
or questions?
64

65. THANK YOU!
65
More information at
https://www.healthsystemsresearch.ca/ecpc
Drop me a note at ruth.lavergne@dal.ca

66. MEDIAN AGE OF FAMILY MEDICINE PHYSICIANS
66
35
40
45
50
55
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
NB NS ON MB BC Canada
Source: Canadian Institute for Health Information, Supply, Distribution and Migration of Physicians in Canada, 2021