Residents & New Physicians

RESIDENTS & NEW PHYSICIANS

By: Ryan Paulus, DO PGY3 and Molly Duffy, MD PGY3 UNC Family Medicine Residency Program

CAREER DEVELOPMENT

I Trained at a Full-Scope Family Medicine Residency, Now What?

So, you’ve graduated from a full scope Family Medicine Residency. You spent three years providing holistic care to people of all ages and backgrounds. You worked throughout the hospital, on the wards, the ICU, labor and delivery, and the Emergency department. You explored your interests in the outpatient setting, learning ways to best serve your continuity panel by becoming proficient in point-of-care ultrasound, addiction medicine, end-of-life care, hepatitis C treatment, and prenatal care. You worked in federally-qualified health centers, community hospitals, public health departments, large tertiary care centers, and academic clinics. Now that these three years are coming to a close, you finally have to address the one question that hasn’t been answered, what’s next?

If you are like us, the answer to that question seems obvious. We want to continue to use our full spectrum training to provide comprehensive care to people in our communities. When reflecting on our time in residency, a few patient encounters stand out.

Just recently a patient came in to establish care at one of the clinics in our Rural Health Track. She was a 38-year-old woman presenting after she was found to have high blood pressure at a work physical and was told she needs to start a medication to lower her blood pressure. Throughout the visit, she gradually shared the rest of her story. She has a history of opiate and alcohol use disorder. She takes methadone but has been struggling to get to her methadone clinic because it is over 45 minutes away from her home. She shares that she has also been dealing with lifelong depression and anxiety, and in addition, needs a referral to an OB-GYN because her IUD is expired.

In a 30-minute visit, we were able to start treatment for her hypertension, connect her to our on-site behavioral health counselor to discuss her mood disorder, get her scheduled for IUD replacement, and

discuss possible transition to suboxone to make it easier for her to remain in remission from opiates.

At the end of the visit, the patient shared that she couldn’t believe she could come to one clinic to have all of her needs addressed, especially one that was only 10 minutes from her home.

This is the type of medicine we trained to practice.

However, in our graduating class of 12 residents, we have seen multiple people turned away from jobs in North Carolina because they desired “too large” of a scope of practice or were told “we don’t do that here” when asking about opportunities to treat hepatitis C or use medication-assisted therapy. Nationally, the trend has been similar. Despite the perception of improved training in Family Medicine programs, the scope of practice of current physicians continues to narrow1 . Additionally, there continues to be significant differences between the intended scope of practice amongst graduates when compared to the reported scopeof-practice amongst practicing family physicians2 .

Looking specifically at North Carolina, the NCAFP has conducted resident and practicing physician surveys to evaluate this trend. In 2017, 53% of residents had an interest in practicing inpatient medicine, 36% were interested in obstetric deliveries, and 64% had an interest in providing prenatal care. Most residents also planned on providing pediatric care (88%). In 2021, almost 40% of residents still wanted to practice inpatient medicine, 27% wanted to perform obstetric deliveries, and the number wanting to do prenatal care and pediatric care remained similar (63% and 86%, respectively) (Figure 1).

Resident Interest vs Practicing Physician

70%

60%

50%

40%

30%

70% 20%

60% 10%

50% 0%

40%

30%

20% Resident Interest vs Practicing Physician

Inpatient Medicine Obstetric Delivery Sports Medicine

Resident 2017 Resident 2021 Practicing Physician 2017 Practicing Physician 2021

Figure 10% 1: Percentage of current family medicine residents interested in inpatient medicine, obstetrics, and sports medicine compared to the actual reported percentage of practicing physicians doing inpatient medicine, obstetrics, and sports medicine. Figure 2: Percentage of current family medicine residents interested in listed opportunities.

Figure 1: 0% Percentage of current Family Medicine residents interested in inpatient medicine, obstetrics, and sports medicine compared to the actual Outpatient Interest Among Residents Inpatient Medicine Obstetric Delivery Sports Medicine reported percentage of practicing physicians doing inpatient medicine, Resident 2017 Resident 2021 Practicing Physician 2017 Practicing Physician 2021 obstetrics, and sports medicine. LARC Placement (IUD/Nexplanon) Figure 2: Percentage of current Family Medicine residents interested in listed opportunities.

90%

Figure 1: Percentage of current family medicine Home Visitsresidents interested in inpatient 24% medicine, obstetrics, and sports medicine Transgender Care (Hormone Replacement Therapy)compared to the actual reported percentage of practicing physicians doing inpatient medicine, 49% obstetrics, and sports medicine. Figure 2: Percentage of current family medicine residents interested in listed opportunities.

Nuring Home Care

12%

27%Hospice and Palliative Care Outpatient Interest Among Residents

Obesity MedicineLARC Placement (IUD/Nexplanon) Medication Assisted Therapy Home Visits

Hepatitis C TreatmentTransgender Care (Hormone Replacement Therapy) ColposcopyNuring Home Care ColonoscopyHospice and Palliative Care EGDObesity Medicine Dermatologic ProceduresMedication Assisted Therapy Joint InjectionsHepatitis C Treatment

24%

12% 0% 3%

27% 49% 41% 51% 63% 75%

90%

51% 63% 75%

90% 95%

Office-Based POC Ultrasound Colposcopy

41% 75%

Colonoscopy EGD

0%10%20%30%40%50%60%70%80%90%100%0%

3%

Dermatologic Procedures Joint Injections Office-Based POC Ultrasound

75% 90% 95%

0%10%20%30%40%50%60%70%80%90%100%

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As outpatient opportunities for family doctors continue to expand, residents were asked about the outpatient scope. In the 2021 survey, 95% of the residents are interested in joint injections, 90% want to continue to do dermatologic procedures and LARC placement, and 75% plan on using point-of-care ultrasound in their practice (Figure 2). Residents also expressed interest in working in the urgent care and emergency room settings (40% and 12%, respectively).

Similar surveys were sent to practicing physicians in 2017 and 2021. The results support the claim that residents’ desires are larger than the scope practiced. Only 18% of practicing physicians did inpatient work (both in 2017 and 2021), 52% did child/maternal health in 2017 that reduced to 50% in 2021, and obstetric care saw an increase from 11% to 12% (Figure 1). When asking the residents if they would leave North Carolina if the desired career opportunities didn’t exist here, 74% said yes or maybe in 2017 with the number increasing to 83% in 2021.

Similar to national trends, there continues to be a difference between the intended scope-of-practice for residents versus the current scope of practicing physicians. This is despite the fact that research has shown that family physicians who perform a greater variety of procedures or work in more clinical areas are significantly less likely to report feeling burned out. This finding was particularly notable amongst physicians practicing inpatient medicine or obstetrics.3 While further investigation is required, we are concerned about the downward trend in resident interest in practicing inpatient medicine and obstetrics from 2017 to 2021. We question whether residents are choosing to limit their scope because they feel they will be unable to find jobs that allow them to continue to utilize all aspects of their training. In response to the question, “If your practice plans have changed over time, please indicate why,” one 2021 survey respondent wrote, “I am having trouble finding a job that will allow me to practice prenatal and OB deliveries, so I may have to move out of the state or take a job that doesn’t allow me to do those things.”

Finally, despite more than half of residents indicating that they plan to continue MAT, hepatitis C treatment, pediatric and prenatal care, and office-based point-ofcare ultrasound, anecdotally residents report that finding full spectrum outpatient jobs in North Carolina has been difficult. These findings highlight a need to advocate for further employer support for new graduates interested in maintaining a full-scope outpatient practice, in order to retain residents in the state and continue to provide high quality, holistic Family Medicine.

The NCAFP is committed to helping you find your ideal job here in the state of North Carolina. The NCAFP does have a career search engine on the website (jobs.ncafp.com). We have also found 3RNET (www.3rnet.org), a resource for rural and underserved jobs, helpful in finding jobs that may not have the resources to broadcast their openings across the state.

In addition, the Family Practice Management journal recently released an article that provides guidance and tips on finding the career path that is right for you4 . Please reach out to the NCAFP if you are struggling to find the job you are looking for. If there are ways you think the NCAFP can help advocate for you and your career desires, please reach out to Ryan Paulus, a resident member of the NCAFP Board at ryan_paulus@ med.unc.edu.

REFERENCES

1 Weidner AKH, Chen FM. Changes in preparation and practice patterns among new family physicians. Ann Fam Med. 2019;17(1):46–48.

2 Coutinho AJ, Cochrane A, Stelter K, Phillips RL Jr, Peterson LE. Comparison of Intended Scope of Practice for Family Medicine Residents With Reported Scope of Practice Among Practicing Family Physicians. JAMA. 2015 Dec 8;314(22)

3 Weidner AKH, Phillips RL Jr, Fang B, Peterson LE. Burnout and scope of practice in new family physicians. Ann Fam Med. 2018;16(3):200–205.

4 Thomas H, Jensena C, and Andrea M. Life After Residency: Exploring Practice Options in Family Medicine. Fam Pract Manag. 2021 Sep-Oct;28(5):30-35.

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