Setting

The data for this study covers the province of Ontario, Canada. Ontario is approximately 909,000 km² in size with a population of 14.2 million people [17]. Although northern Ontario constitutes 87% of the total provincial land area, it only contains 6% of the provincial population. For health care management purposes, the province was geographically divided into 14 Local Health Integration Networks (LHIN). Although the regional delivery of health care services is now managed by Ontario Health Teams, we retain the LHIN terminology and geographic structure because it reflects the system in place at the time our data was collected.

Data sources

We retrieved Ontario’s 2017 administrative healthcare data from the Data and Analytics Service at ICES via an encrypted server. The data were anonymized, and individual physicians were not identifiable. The two primary data sources from which we retrieved data were the ICES Physician Database (IPDB) and the Ontario Health Insurance Plan (OHIP) billing database. The IPDB contains each physician’s demographic information, such as sex and age, as well as their location of practice (i.e., LHIN, sub-LHIN, and rurality), years in practice, billing specialty, full-time equivalent status, and certifications. The OHIP billing database contains billing codes submitted to the provincial government by physicians to receive remuneration for the services provided to each patient. For example, when a physician assesses a patient within their clinic, they may bill the government using the A007 code while a physician in the emergency department may use the H133 code. Although specific billing codes can vary among physicians and patient interactions based on factors such as the setting in which care was provided, the billing code database nevertheless indicates the general health services provided to a patient by the physician.

Defining the physician cohort

The complete IPDB covers the approximately 30,000 Ontario physicians who provide any type of medical service. To subset this database to only include family physicians, we first used the OHIP billing specialty code variable and selected physicians who were classified as “family practice and general practice”. Although some of these physicians are listed as family medicine or general practitioner in the OHIP specialty codes, their primary billings were that of a specialist. This likely occurred for physicians that hold dual certification where family medicine or general practice was their first specialty, therefore these physicians were removed from the analysis cohort. To ensure that a comprehensive physician population was used in the analysis, we analyzed the billing codes for all physicians in the IPDB with missing data for their specialty or certification.

Defining sentinel billing codes

Based on the existing literature, our analysis of physician billing codes, and an examination of the Ontario Schedule of Benefits for physicians [18], we classified the OHIP billing codes into 18 broad services that family physicians could be providing. These services were clinic, anaesthesia, emergency medicine, hospital medicine, home visits, mental health, long-term care, obstetrics, palliative care and medical assistance in dying, surgical assisting, chemotherapy administration, sports medicine, chronic pain, care of the elderly, addictions medicine, endoscopy, allergy, and sleep medicine. For each service, we created a list of billing codes that were unique to that service and could therefore be used to define whether a physician provided that service. For example, if a physician billed code H103, H133, or H153 in addition to several other codes for an emergency department assessment, that patient visit was categorized as an ‘emergency medicine’ service. The full list of these “sentinel” billing codes can be found in Table 1 below:

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Table 1. Sentinel billing codes from Ontario and thresholds for each service that are used to determine if a physician provided a service.

https://doi.org/10.1371/journal.pone.0316554.t001

Determining the services provided by physicians

To determine the range of services provided by each physician, we grouped all sentinel billing codes from each physician into their associated services and calculated each physician’s total number of patient interactions for each service. We then converted these sums to a binary variable indicating whether a physician provided a service. To represent only the services that each physician provided consistently, rather than for occasional or one-off patient visits, we set a minimum threshold of patient interactions for each service. For example, a physician who billed fewer than 50 patient encounters in the emergency department would not be considered as providing emergency medicine services given the low number of encounters. Thresholds for each service were defined using the billing data, following an approach similar to previous studies [8, 19, 20]. These thresholds are provided in Table 1. The final dataset had one row per physician, with columns containing physician demographic data, certification, geographical location, and a series of binary variables for each of the 18 service categories.

Analysis

For our analysis, we grouped the physician and services data into four regions defined by the matrix of geographic area (north vs. south) and rurality (rural vs. urban). Northern Ontario was defined based on the former boundaries of the Northwest and Northeast LHINs, as in previous studies [4]. The rural/urban classification for each physician was determined based on the rurality index of Ontario (RIO) [21]. This score provides a measure of rurality based on population size as well as the required travel time to both local and larger referral centers. Physicians were assigned the RIO score by ICES based on their primary practice, and any physician with a RIO score ≥40 was classified as working in a rural community [22]. This cutoff score is commonly used in ICES studies [23].

Using our data on physician demographics and provided services, we examined the differences in physician practice between rural and urban areas in northern and southern Ontario. We visualized the patient services landscape by producing an UpSet plot for each of the four study regions (north-urban, north-rural, south-urban, south-rural). Each plot showed the combination of services provided in a particular region, the proportion of physicians providing that combination of services, and the proportion of physicians with different ranges of years of practice experience [24, 25]. For clarity, each plot only shows the six most provided services in our data. All plots were created using R version 3.3.0 [26].

Ethics approval

The Research Ethics Board at Lakehead University approved this study (#1466634).

Summary of findings

Our results represent one of the most comprehensive descriptions of the services provided by Ontario family physicians in relation to geography, rurality, and number of years in practice. In addition, our data demonstrates the broad scope of practice for family physicians in Ontario. These observations are similar to previous studies that demonstrated that rural generalist physicians practice to a fuller extent of their scope of practice [4, 5]. However, our work extends these previous observations by identifying the frequency of different combinations of the most common services provided by family physicians. Overall, the six most common services provided by family physicians in Ontario were clinic services, palliative care, hospital medicine, emergency medicine, mental health, and home visits, though we found that physicians provided these services in different combinations and frequencies among our four study regions. We also identified the number of years in practice for the physicians practicing each of the provided service combinations.

Previous research

Previous studies have taken different approaches to identifying the services provided by family physicians: where some focused on the range of different services [4, 5], others focused on the comprehensiveness of the provided care [19]. Here, we used the OHIP Schedule of Benefits to identify a total of 18 different categories of physician services [18]. Unlike the Ontario-based studies by Schultz and Glazier [19] and Chan [27], which only considered comprehensive family physicians providing primary care, we examined the physician workforce from an HHRP perspective by including all family physicians (i.e., even those with a focused practice). The variability that we observed with respect to the services provided across our four study regions agrees with previous results from Wong and Stewart (2010) [5].

The value of physician-specific scope of practice data

By evaluating the more granular details of the specific number and types of services provided by family physicians, our results will support future reality-based forecasting and more robust HHRP in Ontario and elsewhere. For example, Ontario performed HHRP in the mid-2000s and concluded that the province would have a sufficient number of family physicians by 2018 [28]. However, this evaluation made incorrect assumptions about family physician services, including the assumption that family physician services are all clinic-based. As a result, Ontario has been facing a shortage of physicians able to provide services such as emergency medicine and hospital medicine. More recent studies have shown that many family physicians have diverse practices that include more than just clinic medicine [4, 5, 8, 19, 20].

Our results also provide valuable information that could be used to shape medical education. Although all family medicine residents in Canada are required to meet the same set of competencies, our results provide valuable information on the knowledge and skills that family physicians will need based on the region of Ontario in which they practice. Residents can use this information to pursue learning opportunities that will help them meet the needs of the population in which they intend to serve. Furthermore, medical schools can use this information to customize their curriculum: for example, one medical school in Ontario has already developed a rural generalist pathway to deal with the severe shortage of physicians in many rural communities [29].

Finally, our data will help policymakers plan for ensuring future decades of clinical services across the province. Our results also underscore the diversity of physician practices and the extent to which practices can vary between northern and southern Ontario and between urban and rural communities. Like Simkin et al. (2019), our results also demonstrate how physicians’ practices can change as they approach retirement [20]. In addition, the results show that a higher proportion of early career physicians practice in rural communities. Although the administrative data provides little insight into why this is occurring, Jolicoeur et al. (2022) found that physician retention in rural communities can be influenced by spousal employment opportunities, difficulty integrating into the community, physician burnout, and lack of resources [30]. Quantifying and understanding these differences is crucial for clinical service planning, especially for northern and rural communities where family physicians practice to greater extent of their scope of practice. The data from this study outlines the services already being delivered within different communities. Indeed, understanding the healthcare needs of a community requires an understanding of the number of physicians available, the type of care they can provide, and the number of patients they can service. Because many communities are already under-serviced, our findings should not be used to estimate demand, but they can nevertheless indicate whether a service should be offered within a community. Addressing these needs, however, will require developing new strategies to increase family physician recruitment and retention in rural Canada, where much of the historical emphasis has been on education, training, and financial incentives [6].

Family medicine practice internationally

Western countries such as Canada and the United States have the most comprehensive scope of family medicine training, covering primary, emergency, hospital, long-term, maternal, and intrapartum care [31]. Australia’s rural practice stream matches this breadth, but its general practice stream is more limited, excluding emergency and intrapartum care. New Zealand, the United Kingdom, and Ireland offer narrower clinical training, with less focus on hospital and emergency care, though they still emphasize primary care and long-term care [31]. In terms of physician training time, Scandinavian countries have longer training programs, while Canada and Lebanon, have shorter two-year residencies [32]. The analysis from this study provides a comprehensive approach for policy and decision makers to quantify family physician scope internationally.

Limitations and future direction

Although our study provides a comprehensive analysis of the services provided by family physicians, our approach does not account for private services or those not billable by the OHIP (e.g., aesthetic medicine, coroner work, or occupational medicine). Furthermore, family physicians who provide services outside the typical fee-for-service model will often submit shadow billings to the government for a small proportion of their billings. If these physicians do not submit their shadow billings on a regular basis or in a particular setting that is represented by one or several of our sentinel billing codes, our assessment of the services they provide may be incomplete. Given these limitations, our analysis likely represents a lower bound estimate for the number and types of services provided across Ontario. We additionally note that the data used in this analysis comes from 2017, three years before the COVID pandemic. Although the number of physicians practicing in Ontario has changed in the intervening years due to retirement and migration, we believe our analysis provides a thorough description of the family physician scope of practice in Ontario. This study also provides a methodology for future studies either in Ontario or other healthcare jurisdictions where health human resource planning is a challenge. Furthermore, longitudinal studies in Ontario could reveal changes in physician practices over time, which could inform HHRP for the future.