By: Dr. Nathan Turner
Spring has sprung and many family medicine residents are finishing their exams and considering where they would like to practise come July. There may also be others in their first five years who are considering a change or considering settling down into a long-term practice. Whatever your situation, the decision can be a tough one. While there are many personal factors that you’ll have to consider, we’d like to help give some insight into the pros and cons of different practice styles within family medicine. We polled some friends and colleagues of the First Five Years in Family Practice committee for their insights into different practice types available in Alberta. Here are their thoughts and advice:
Community Fee-for-Service (FFS) or Primary Care Physician Compensation Model (PCPCM)
Pros:
- Flexibility to work as much or as little as you want to, and to choose your own hours
- Variety of patient presentations every day
- Ability to follow up with patients over time
- Ability to build relationships with patients and work with them towards their goals and health outcomes
- Team-based environment
- Opportunity to work with learners
- Freedom to implement innovations (e.g., AI Scribe)
Cons:
- Lack of administrative support
- Lots of paperwork (e.g., AI Scribe, disability, insurance, tax credit, etc.)
- Sometimes difficulty in finding coverage when away
Alternate Relationship Plan
Pros:
- Paid for both direct and indirect patient care, allowing for more complex case management and administrative work including filling out forms
- I do not have to worry about task coverage or finding a locum for leaves and vacations
- I know that my patient’s care needs will be met while I am away
- Allows me to provide comprehensive care for a biopsychosocially complex patient population
- I feel like I really just get to focus on taking care of the patient, not billing
- Ability to have longer appointment times for unique patient populations (e.g., Refugees, immigrants with language barriers, socially complex children/elderly)
Cons:
- Patient complexity can be difficult
- Because there is a component of group practice (colleagues seeing your patients, covering your tasks), it is important that everyone is on the same page
- Give and take, you must be willing to see your colleague’s patients and cover their tasks
- Because you spend more time with patients, some can have unrealistic expectations of what can be accomplished in a visit
- Remuneration is a bit less transparent, depending on how the clinic organizes itself, because reporting requirements to the government are based on FTEs (full-time equivalents) rather than just an hourly basis. Sometimes it is hard to compare whether you are making more or less compared to other practice types, so you have to educate yourself and be proactive. Unlike FFS, you are not in control of your own billing in the same way
Community Blended Capitation
Pros:
- Consistent pay and income over the year, you still get paid if you are away
- No whites of the eyes rule for billing so you can have a whole team to care for your panel, and they can all work to full scope (this also improves access for your patients)
- It is the best model to serve a large panel of patients. You are not on a treadmill to see a lot of patients every day so there is a much better lifestyle balance. You can manage much more by email/phone and through allied health care teams
Cons:
- Lots of start-up admin work and ongoing admin burden for your managerial staff. You must have a strong admin team
- Choosing the best way for your clinic to make sure everyone is compensated fairly takes a lot of work initially
- Patients are required to sign an affiliation form and it must be a wet signature on paper. There is also negation if they see other family physicians. Unfortunately, the negation system is not set up for the current climate of family docs working in specialty settings. We are working to reform it but it is slow and the government is not making the changes we are requesting to reflect the current climate. Currently, rather than fixing the issues, they are offering negation forgiveness paid quarterly
Locum Work
Pros:
- Lots of flexibility to take vacation/do other life things – patients aren’t constantly relying on you
- Exposure to a variety of patient panels and practice styles
Cons:
- Harder because you don’t know the patients
- Each clinic has a slightly different system/process
Academic Clinic
Pros:
- Lots of teaching
- Minimal practice management (billing, overhead)
Con:
- Less autonomy
Special Interest
Pros:
Hospitalist/Addictions Medicine Consults
- I finish all my charts at work, I don’t need to worry about checking labs after hours, all forms are done at work
- I also like working in a multidisciplinary setting in a hospital
- I really like that there are no set appointment times
Long Term Care
- Can care for a stable group of patients within a fairly supportive setting where nursing staff can act as eyes and ears to monitor for nuanced change in health
- Build close relationships with allied health colleagues
- Allied health help with forms and other non-medical issues (e.g., Finances/social work)
- It allows time for care, opportunities for utilizing excellent communication skills with staff, patients and family (who often need guidance during a stressful time in the lives of their family)
- It is fairly flexible timewise, allowing for some freedom within one’s schedule
- This is a vulnerable group of patients
Cons:
Hospitalist/Addictions Medicine Consults
- It is hard working for Alberta Health Services (AHS) which often makes poor decisions for leadership
- You are bound by protocols and hospital admin restrictions
- Hours can be long and being on call isn’t fun
Long Term Care
- The responsibility doesn’t stop during work hours – unless you can organize cross coverage; you are on call 24/7. This can be hit or miss depending on whether patients are ill/complex. You have to build confidence/trust with staff as they are often on site when you are not, so you rely on their clinical skills as well as your own
- The billing codes can look small BUT it adds up and there is no overhead. Don’t ignore it
- More call requirements than clinic
Our participants also offered some general tips and advice for those who are new in practice:
- Think about the kind of patients you want to care for and what kind of model would be best to support their needs and the work you want to do
- Starting off, I would recommend trying different practice models, work settings, and clinics before committing to one
- I would encourage new physicians to keep an open mind and try a variety of experiences, sometimes you may develop a new interest! I personally disliked women’s health during residency but now I am a family physician with a women’s health interest and I see referrals from other primary care providers for women’s health concerns
- Earning potential in each practice model can vary based on your practice style – the most lucrative model for one physician may end up being less lucrative for another
- Don’t commit to too much clinic medicine too quickly – it is a common mistake to build and then have too big a panel which leads to struggles
- Be efficient, document well, set up templates, use an AI Scribe
- Try to get information about how the clinic runs and its governance structure before signing up so you know how to get information and who to give feedback if you have issues or questions that arise
- Some jobs aren’t publicly posted (e.g., Long Term Care or LTC) so reach out directly to sites or physicians already working in the area you’d like to work
- Join Communities of Practice such as the Blended Capitation Model (BCM) group through Alberta Medical Association’s Accelerating Change Transformation Team (AMA ACTT) if you are interested in a certain practice model. There are lots of support and pearls there
- If you are considering a certain practice style, reach out to currently practicing doctors/clinics for advice
Thank you to our wonderful colleagues who have provided some great advice! Trying to choose a practice can be daunting, so be sure to reach out to mentors and friends for support.
If you would like to add your experience or any other tips for starting or changing practice, please do so in the comments!
