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Primary health care experiences and preferences : research highlights Watson, Diane; Krueger, Hans May 31, 2005

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Primary Health Care Experiences and Preferences: Research highlightsDiane Watson PhD MBAHans Krueger MSc PhD (Cand.)May 2005 “Primary Health Care Experiences and Preferences: Research highlights” was prepared by:Diane Watson PhD MBACentre for Health Services and Policy ResearchHans Krueger MSc PhD (Cand.)H. Krueger and Associates, Inc.Centre for Health Services and Policy ResearchThe University of British Columbia429-2194 Health Sciences Mall Vancouver, BC  Canada  V6T 1Z3Tel: (604) 822-1949Fax: (604) 822-5690Email: enquire@chspr.ubc.caYou can download this publication from our website at www.chspr.ubc.ca.This publication is protected by copyright. It may be distributed for educational and non-commercial use, provided the Centre for Health Services and Policy Research is credited.This project was funded by a grant from the Canadian Health Services Research Foundation. The results and conclusions herein are those of the authors and no offi cial endorsement by the funders is intended or should be inferred.Primary Health Care Research Highlights - May 2005   | iAbout CHSPR ............................................................................................................................................iiExecutive Summary ..........................................................................................1Citizen Experiences and Societal Expectations .................................................2Family Physician Experiences and Preferences .................................................5Health Human Resources ................................................................................................................... 5Policy Decisions and Preferences ....................................................................................................... 7Management Decisions, Activities and Preferences ........................................................................... 8Clinical Decisions, Activities and Preferences ..................................................................................... 9Service Qualities .............................................................................................................................. 10Work / Life Satisfaction .................................................................................................................... 11References ............................................................................................................................................. 12Table of Contentsii |  Centre for Health Services and Policy ResearchThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to stimulate scientifi c enquiry into issues of health in population groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda.CHSPR aims to contribute to the improvement of population health by ensuring our research is relevant to contemporary health policy concerns and by working closely with decision makers to actively translate research fi ndings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-government organizations in British Columbia (BC), Canada and abroad. CHSPR receives core funding from the BC Ministry of Health Services to support research with a direct role in informing policy decision-making and evaluating health care reform, and to enable the ongoing development of the BC Linked Health Database. Our researchers are also funded by competitive external grants from provincial, national and international funding agencies. Much of CHSPR’s research is made possible through the BC Linked Health Database, a valuable resource of data relating to the encounters of BC residents with various health care and other systems in the province. These data are used in an anonymized form for applied health services and population health research deemed to be in the public interest.CHSPR has developed strict policies and procedures to protect the confi dentiality and security of these data holdings and fully complies with all legislative acts governing the protection and use of sensitive information. CHSPR has over 30 years of experience in handling data from the BC Ministry of Health and other professional bodies, and acts as the access point for researchers wishing to use these data for research in the public interest.For more information about CHSPR, please visit www.chspr.ubc.ca.About CHSPRPrimary Health Care Research Highlights - May 2005   | 1Executive SummaryAcross the nation, there have been substantive investments and activities to renew primary health care in response to factors such as growing concerns among Canadians and health care providers. One key ingredient to renewal efforts is information about the expectations and preferences of key stakeholders, particularly citizens and family physicians. This document is intended to highlight evidence from across Canada to help primary health care decision makers identify priorities for local research on the expectations and preferences of citizens for the organization of primary health care; the expectations and preferences of family physicians on models of delivery; and ongoing temporal shifts in patterns of use and delivery of primary health care.Citizen experiences and societal expectations:  • Canadians are increasingly concerned about access to primary health care.  • Canadians are concerned about quality of primary health care.  • Canadians expect specifi c changes to primary health care.Family physician experiences and preferences:  • The population to physician ratio has stabilized.  • About half of Canada’s doctors are in family practice, but the physician workforce is becoming increasingly specialized.  • There are fewer and fewer medical students interested in family practice.  • The physician pool is aging and there are few younger family physicians.  • The number of female family physicians is increasing.  • The majority of family doctors are paid on a fee-for-service basis, but this reality is shifting.  • Experiences and preferences for different methods of remuneration are tied to age and, to a lesser extent, gender.  • Family physicians now prefer blended models of remuneration.  • Interdisciplinary collaboration is increasingly being considered as a way to address perceived primary health care provider supply gaps.  • Family physicians mainly work in an offi ce setting and are increasingly practicing in groups.  • Family practices are increasingly unavailable to new patients.  • Younger family physicians are providing fewer services per annum and older family physicians are providing more.  • Family physicians work long hours, but there has been a modest decline in their work week.  • Family physicians are reducing the comprehensive scope of services they once delivered.  • Many family physicians are satisfi ed with their professional life, but fewer are satisfi ed with their relationships with other providers or the balance between personal and professional committments.  • Middle-aged physicians are more dissatisfi ed with their professional life and the balance between work and personal life.  • Family physicians have been dissatisfi ed for some time.2 |  Centre for Health Services and Policy ResearchCitizen Experiences and Societal ExpectationsCanadians want to be included in important public policy decisions  • Based on various “citizen dialogues” regarding health policy there is strong evidence that Canadians’ “views on accountability (are) linked to their faltering trust in governments and others in positions of power.  They call for greater transparency in decision making and greater inclusion of the public in helping make those decisions… they do want a space where their voices can be heard, along with stakeholders and experts” (1, p. iv).Canadians are increasingly concerned about access to primary health care  • In 2001, 15% of Canadians who had used health care services in the previous year reported that they were sometimes unable to obtain such services when they needed them. In 1989, 2% of citizens reported these concerns (9).   • In 2001, 88% of Canadians reported having a family physician.  Among those who did not have a family physician, 63% indicated they had not tried to contact one and 29% cited reasons related to physician availability (18).  In 2003, 86% of Canadians reported having a family physician (14).   • In 2001, 11% of Canadians reported diffi culty accessing routine care and 19% had diffi culty accessing immediate care for a minor health problem.  In 2003, 16% reported diffi culty accessing routine care and 24% had diffi culty accessing immediate care for a minor health problem (14, 18).   • In 2001 and 2003, the top four barriers to accessing immediate care for a minor health problem during regular hours were getting an appointment, lengthy waits in offi ces, waiting too long for an appointment and contacting a physician.  Performance in all these areas declined between 2001 and 2003 (14, 18).  • In 2003, only 48% of Canadians reported being satisfi ed with access to care in the community and 43% were satisfi ed with the timeliness of that access (13).   • In 2004, 86% of Canadians felt there was a shortage of doctors (13).Canadians are concerned about quality of primary health care  • In 2001, 53% of Canadians who had a regular family physician reported that the quality of care they received was excellent.  An additional 39% rated their care as good Primary Health Care Research Highlights - May 2005   | 3and 7% reported that it was fair or poor (18).    • In 2004, 68% of Canadians in an international survey rated the quality of care received from their primary care doctor as excellent or very good.  This compares to 74% in New Zealand, 71% in Australia, 64% in the UK and 61% in the US (15).   • In 2004, satisfaction with access and quality was moderate to low (15). (Table 1)Canadians expect specifi c changes to primary health care   • In 2002, when asked to deliberate about various options to sustain their health care system, Canadians recommended interdisciplinary teams to provide more coordinated primary health care, and that they be supported by a central information system (8).  These deliberations also suggested that:  • Canadians are attracted to the idea that primary health care teams would not only provide more coordinated, cost-effective care, but also that such teams would have a greater incentive to focus on wellness, prevention and patient education.  They understand this will require changes in the behaviour of citizens, providers and governments (8).   • Canadians see the team approach, led by doctors, as the “centrepiece of the health care system” because it would be “responsive to individual needs, structured to emphasize wellness and prevention, and would offer integrated and coordinated care through a team of various professionals” (8, p. 32,37).  • Canadians identify interdisciplinary teams as the solution to the current challenge of fi nding a family doctor and “some hoped that a supportive and collegial team would reduce the burden on doctors, prevent burnout, and encourage health professionals to locate and stay in rural and remote areas.”  Through teams, Canadians expect professionals to share, criticize and use data and information, and thereby attain effi ciency gains in the health system (8, p . 37).Table 1: Citizens’ experience in fi ve countries with access and quality of primary care  (% and Canada’s rank in brackets).Q u a l i t y  o f  C a r e C a n A u s N Z U K U SGood access outside of weekdays 29 (3) 25 46 30 23Physician listens carefully 66 (4) 71 74 68 58Physician takes enough time 55 (4) 63 66 58 44Physician clear about diagnosis, etc. 70 (3) 73 73 69 58Physician clear about treatment 55 (3) 61 59 52 45Physician invites input 36 (3) 43 41 27 294 |  Centre for Health Services and Policy Research  • A majority of Canadians (74%) would prefer that their family doctor work as part of a team rather than practice on his/her own (9).   • Canadians report that they would be satisfi ed seeing a general or specialized nurse, who works with a doctor, for routine health care services (e.g. ear or throat infections, immunizations), to manage diabetes or monitor high blood pressure, and to check progress on a surgical wound (9).  • In 2003, Canadians strongly supported (70%) the idea of collaborative care, defi ned as “a team including a doctor, nurse, pharmacist, or other health care provider who would collectively provide care” (13, p. 25).  They also expressed the belief that collaborative care would improve quality of patient care (73%) and expedite access to care (69%), but they are not clear on how collaborative care will change the costs of service delivery (13).  • In 2004, fully 86% of Canadians supported requiring health professionals to work in teams; as well, 69% favoured requiring people to register with one doctor (13).   Primary Health Care Research Highlights - May 2005   | 5Health Human ResourcesThe population to physician ratio has stabilized  • In the course of the 1990s, perceptions about physician supply shifted almost overnight from surplus to shortage (5). This is striking in light of the fact that the ratio of supply in 2003 (477 population per physician) was virtually the same as in 1993 (467 population per physician), and that the ratio has actually declined dramatically over the longer term (4).  Clearly, there are reasons for concern that these ratios do not illuminate (21).About half of Canada’s doctors are in family practice, but the physician workforce is becoming increasingly specialized  • In 2001, there were approximately 29,000 family physicians in Canada. This represents 51% of physicians, down from 53% in 1993. This level of supply is similar to that of France and Australia, but well above the US and Germany (20-30%) (3).  • Medical students are increasingly selecting careers as specialists. The proportion of family physicians among those entering practice in the early 1990s was about 80%; in 2000, it was about 45% (5, p. 20).   • The decreasing pool of family physicians may have unintended consequences. Recent research has shown that population health is better in communities that have a higher proportion of primary care physicians relative to specialists (17). There are fewer and fewer medical students interested in family practice  • In 2002, there were 428 fi rst-year training positions in family medicine.  While most were fi lled, fewer than 30% of graduates indicated that this area of medicine was their fi rst choice (3).  • In 2002, 20% of medical students in Alberta and British Columbia identifi ed family We will use the Results-Based Logic Model for Primary Health Care to structure the descriptive analyses of the experiences and preferences of family physicians in Canada.This model is available at www.primary-care.chspr.ubc.ca.Family Physician Experiences and Preferences6 |  Centre for Health Services and Policy Researchmedicine as their fi rst career option, and about half ranked family medicine in their top three choices.  “Students who identifi ed family medicine as their fi rst choice tended to be older, to be concerned about medical lifestyle and to have lived in smaller communities at the time of completing high school; they were also less likely to be hospital oriented.  Moreover, students who chose family medicine were much more likely to demonstrate a societal orientation and to desire a varied scope of practice” (26, p. 1920).   • In 2004, the proportion of medical students opting for family medicine as a fi rst choice had dropped from 32% in 1994 (n=423) to 26% in 2004 (n=339) (7).The physician pool is aging and there are few younger family physicians  • In 2001, the number of family physicians under age 35 who worked in six provinces in Canada was signifi cantly less than the number of family physicians in this age bracket 10 years prior (Figure 1) (19, 22).Figure 1: Count of Family Physicians under 35 years of age • There is a decline in the proportion of physicians under age 35. The peak proportion in 1988 was 22%; in 2000 it was 13%. In contrast, the over 65 cohort has grown from 7% in 1981 to 11% in 2000 (5).  • An aging workforce has resulted in a gradual annual increase in the average age of family physicians (3).   • The aging physician pool has a number of implications.  For example, younger physicians are more likely to offer emergency department and obstetrical services (5).  Younger family physicians also provide many fewer visits and offi ce assessments per annum than older family physicians (19, 21).The number of female family physicians is increasing  • The total number of female family physicians has increased since 1992, whereas the number of male family physicians decreased.  Accordingly, females now represent a larger proportion of the family physician workforce (19).Table 2: Number of Family Physicians (1992 and 2001)Familyphysicians 1992 2001Males 20,254 18,969Females 7,193 (26%) 9,524 (33%)T o t a l 2 7 , 4 4 7 2 8 , 4 9 3  • The changing balance between male and female family physicians is largely due to a sharp decline in younger male physicians.  Since 1999, female family physicians have outnumbered males in the under 35 category (19).source: (19)1,00019922,0003,0004,0005,0006,0007,0001993 1994 1995 1996 1997 1998 1999 2000 2001MaleFemalePrimary Health Care Research Highlights - May 2005   | 7The majority of family doctors are paid on a fee-for-service basis, but this reality is shifting.  • Fee-for-service (FFS) still dominates as the remuneration method for family physicians, though the trend suggests a shift to alternative payment methods (12). (Table 3)Table 3: Percentage of family physicians earning 90+% from fee-for-service (FFS)1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 365 63 64 61 59 58  • In 2004, 57% of family physicians received 90% or more of their income from fee-for-service (11).Experiences and preferences for different methods of remuneration are tied to age and, to a lesser extent, gender   • In 2004, there was a substantive age differential in remuneration experiences among all physicians.  Forty-fi ve percent of younger physicians received fee-for-service, compared to 64% of older physicians (Figure 2) (11). Figure 2: Physician Remuneration Experience, by age  • In 2004, 49% of all female physicians received 90% or more of their income by fee-for- service compared to 54% of males (11).  • In 2004, there were substantive age differences in remuneration preferences among all physicians.  Nineteen percent of younger physicians preferred fee-for-service, compared to 48% of older physicians (Figure 3) (11).Figure 3: Physician Remuneration Preference, by agePolicy Decisions and Preferences  • In 2004, 22% of all female physicians preferred fee-for-service remuneration, compared to 32% of males (11).Family physicians now prefer blended models of remuneration  • In 2004, 25% of family physicians preferred fee-for-service as a method of remuneration, 51% preferred blended payment, and 11% preferred salary only (11). SessionalBlendedSalaryFFS100 %80 %60 %40 %20 %0 %< 35 35-44 45-54 55-64 65 +OtherPhysician Age% of Physicians7.3 % 7.7 % 7.5 % 9.0 %6.8 %30.9 % 30.6 %25.8 % 18.6 %37.0 %8.3 % 7.9 %8.0 %4.2 %6.3 %49.5 % 50.6 %56.8 %64.0 %44.8 %4.0 % 3.2 % 1.9 % 4.2 %5.1 %source: (11)source: (11)% of PhysiciansOtherPhysician AgeBlendedSalaryFFS100 %80 %60 %40 %20 %0 %< 35 35-44 45-54 55-64 65 +9.9 % 9.9 % 9.1 % 9.6 %10.5 %52.9 % 52.1 %45.1 %32.5 %58.6 %12.7 % 12.1 %13.7 %9.4 %11.5 %24.5 % 25.9 %32.1 %48.5 %19.4 %8 |  Centre for Health Services and Policy ResearchInterdisciplinary collaboration is increasingly being considered as a way to address perceived primary health care provider supply gaps  • The Primary Health Care Transition Fund (2001-2006), the Health Accord (2003) and the Ten-Year Plan to Strengthen Health Care (2004) establish a unifying national policy framework for investments in interdisciplinary collaboration in primary health care (20).  • In 2004, physicians identifi ed the following approaches to address current issues related to physician shortages (13) (Table 4): Table 4:  Approaches to address physician shortages and physicians recommending (%)Increase medical school enrolment   89%Better models of health care delivery 76%Train & delegate to professionals 69%More international medical graduates      64%Family physicians mainly work in an offi ce setting and are increasingly practicing in groups  • In 2001, 73% of family physicians worked mainly in a private offi ce or clinic, and almost 80% spent at least some time in that practice setting (10) (Table 5, above).  • In 2004, 60% of family physicians worked in group practice settings, 25% worked in solo practice, and 4% worked in a practice network (11).Table 5: Proportion of family physicians by practice setting (%)Main Setting % of family physicians Private offi ce / clinic 73Community clinic 7Emergency department 7Hospital in-patient 3Walk-in clinic 3Teaching unit 3Nursing home 1Other 4Family practices are increasingly unavailable to new patients   • In 2004, 60% of family physicians partially or completely closed their practices to new patients (10, 11) (Table 6).Table 6: Proportion of family physicians taking on new patients (%)2 0 0 1 2 0 0 4Practice is completely closed 5% 18%Partially closed with some restrictions to accepting new patients*68% 42%Practice is completely open 24% 20%*Typical restrictions are friends/family of current patients, referrals from other physiciansManagement Decisions, Activities and PreferencesPrimary Health Care Research Highlights - May 2005   | 9Younger family physicians are providing fewer services per annum and older family physicians are providing more   • In 2003, family physicians under age 45 provided, on average, 8.8 fewer hours of direct patient care each week than physicians of the same age group in 1982. This represents a 21% decrease (2).  In 1997, younger and older family physicians worked roughly the same hours each week (16).  • In 2001, younger family physicians provided many fewer offi ce visits/assessments than their same-age predecessors did ten years previously, and older family physicians provided many more (Figure 4) (19, 21). These temporal shifts in workload are gender neutral (21) and also exist when workloads are measured on the basis of work time (22).  • In 1992, every soon-to-retire family physician carried a workload slightly less than each new physician, but in 2001, each soon-to-retire family physician carried a workload 1.6 times higher than each new physician (Figure 4) (22).    • This scenario is accentuated if one considers family physicians that might retire between the ages of 55 and 64 years (early retirees).  In 1992, early retirees delivered 4,050 offi ce assessments per annum, a workload 1.5 times higher than each new physician. By 2001, early retirees carried workloads 2.1 times higher than each new physician (Figure 4) (22).Family physicians work long hours, but there has been a modest decline in their work week  • In 2004, the average family physician had a 49-hour work week.  In 1998, the average family physician had a 52-hour work week (11, 12) (Table 7).Table 7: Family physician weekly work hours Year Family physicianweekly work hours*1998 52.11999 52.52000 51.02001 51.12002 51.62003 50.92004 49.2  • In 2004, 17% of family physicians reported that they reduced weekly work hours over the past two years, and 8% increased them. A further 25% planned to reduce work hours over the next two years, whereas only 4% planned to increase them (11).*Not counting on-call hoursClinical Decisions, Activities and PreferencesFigure 4: Physician offi ce visits by age (1992, 2001)source: (19,22)5,0004,0003,0002,0001,0000< 35 35-44 45-54 55-64 65+20011992Office Visits Per Annum 3,9504,6504,0502,3502,6003,0004,1004,5503,4002,150Physician Age10 |  Centre for Health Services and Policy ResearchFamily physicians are reducing the comprehensive scope of services they once delivered.Between 1992 and 2001:   • The proportion of family physicians that participated in certain activities declined, but the average number of such services provided among those who continued to deliver the service increased (19).   • The proportion of family physicians that delivered babies went down from 28% to 16%.  There was an increase in the number of obstetrical services offered by individual family physicians still providing these services (19).  • The proportion of family physicians that provided hospital inpatient care declined from 71% to 62% (19).   • The proportion of family physicians that provided mental health care increased substantively (19, 23).   • In 2001, one quarter of family physicians saw people with mental health conditions as frequently as the most common conditions seen in primary care (23). Service Qualities Primary Health Care Research Highlights - May 2005   | 11Many family physicians are satisfi ed with their professional life, but fewer are satisfi ed with their relationships with other providers or the balance between personal and professional commitments   • In 2004, 66% of family physicians reported that they were very or somewhat satisfi ed with their overall professional life, and 52% reported this level of satisfaction with the balance between personal and professional commitments (Figure 5) (11).   • In 2004, 71% of family physicians were very or somewhat satisfi ed with their relationships with specialists, and 51% were satisfi ed with their relationships with hospitals (Figure 5) (11). Middle-aged physicians are more dissatisfi ed with their professional life and the balance between work and personal life.  • In 2004, there was a U-shaped association between physician age and satisfaction with professional life and the balance between work and personal life, with the lowest satisfaction consistently reported by middle-aged physicians (Figure 5) (11).Family physicians have been dissatisfi ed for some time.   • In 2001, 63% of family physicians felt their workload was heavier than they would like, and 56% felt that family or personal life was suffering because of their career choice (12).  • Between 1993 and 1999, the difference between preferred and actual hours of work among family physicians increased (24).Work/Life SatisfactionFigure 5: Percent of Physicians who are ‘very satisfi ed’ or ‘somewhat satisfi ed’ with selected work-related issuesOverall professional lifeRelationship with specialistsRelationship with hospitalsBalance between work and personal life100 %80 %60 %40 %20 %0 %< 35 35-44 45-54Physician Age% of Physicians55-64 65 +77 7964 62707854 52677750 487380515882 825677source: (11)12 |  Centre for Health Services and Policy Research1. Abelson J, Gauvin F. Transparency, Trust and Citizen Engagement. Ottawa: Canadian Policy Research Networks Inc.; 2004.2. Buske L. Younger physicians providing less direct patient care. Canadian Medical Association Journal. 2004; 170(8).3. Canadian Institute for Health Information. Health Care in Canada. Ottawa: Canadian Institute for Health Information; 2003.4. Canadian Institute for Health Information. Supply, Distribution and Migration of Canadian Physicians, 2003. Ottawa: Canadian Institute for Health Information; 2004. 5. Chan BTB. From Perceived Surplus to Perceived Shortage: What Happened to Canada’s Physician Workforce in the 1990s? Ottawa: Canadian Institute for Health Information; 2002.6. Chan BTB. The declining comprehensiveness of primary care. Canadian Medical Association Journal.  2002; 166(4): 429-34.7. Harvey A, DesCoteaux J, Banner S. Trends in disciplines selected by applicants in the Canadian resident matches, 1994-2004. Canadian Medical Association Journal. 2005; 172(6): 737.8. Maxwell J, Jackson K, Legowski B et al. Report on Citizens’ Dialogue on the Future of Health Care in Canada. Saskatoon: Commission on the Future of Health Care in Canada, 2002.9. Mendelsohn M. Canadians’ Thoughts on Their Health Care System: Preserving the Canadian Model Through Innovation. Saskatoon: Commission on the Future of Health Care in Canada, 2002.10. National Family Physician Workforce Survey (NFPWS). Results from 1997/98 and 2001 available at http://www.cfpc.ca/English/cfpc/research/janus%20project/default.asp?s=1. Accessed April 2005.11. National Physician Survey (NPS). Results from 2004 available at http://www.cfpc.ca/nps/ English/Physician_Stats.asp. Accessed April 2005.12. Physician Resource Questionnaire (PRQ). Results from 1998-2003 available at http://www.cmaj.ca/misc/prqindex.shtml. Accessed April 2005.13. Pollara Research. Health Care in Canada Survey: Retrospective 1998–2003. Toronto: Pollara Research, 2003. Available at http://www.mediresource.com/e/pages/hcc_survey/pdf/HCiC_ 1998-2003_retro.pdf. Accessed April 2005. Also see 2004 results at http://www.pollara.ca/new /LIBRARY/SURVEYS/HCICNov29FINAL1.ppt#44. Accessed April 2005.14. San Martin C, Gendron F, Berthelot J, Murphy K. Access to Health Care Services in Canada, 2003. Ottawa: Statistics Canada, 2004. Available at http://www.statcan.ca/english/ freepub/82-575-XIE/2003001/pdf/report.pdf. Accessed April 2005. Data tables available at http://www.statcan.ca/english/freepub/82-575-XIE/2003001/tables.htm. Accessed April 2005.15. Schoen C, Osborn R, Huynh PH et al. Primary care and health system performance: adults’ experiences in fi ve countries. Health Affairs Web Exclusive. 2004 October 28. Available at http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.487/DC1. Accessed April 2005.16. Slade S, Busing N. Weekly work hours and clinical activities of Canadian family physicians: results of the 1997/98 National Family Physician Survey of the College of Family Physicians of Canada. Canadian Medical Association Journal. 2002; 166(11): 1407-11.17. Starfi eld B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations’ health: assessing the evidence. Health Affairs Web Exclusive. 2005 March 15. Available at http://content.healthaffairs.org/webexclusives/index.dtl?year=2005. Accessed April 2005.18. Statistics Canada. Health Services Access Survey, 2001. Data tables at http://cansim2.statcan. ca/cgi-win/cnsmcgi.exe?LANG=e&ResultTemplate=CII&CORCMD=GETEXT&CORTYP=1& CORRELTYP=4&CORID=5002. Accessed April 2005.19. Tepper J. The Evolving Role of Canada’s Family Physicians. Ottawa: Canadian Institute for Health Information; 2004.20. Watson D, Wong S. Canadian Policy Context: Interdisciplinary Collaboration in Primary Health Care. Conference Board of Canada; 2005.21. Watson DE, Katz A, Reid RJ et al. Family physician workloads and access to care in Winnipeg: 1991 to 2001. Canadian Medical Association Journal. 2004; 171(4): 339-42. Note: this is a précis of Watson D et al. Supply, Availability and Use of Family Physicians in Winnipeg. Winnipeg: Manitoba Centre for Health Policy; 2003.22. Watson DE, Tepper J, Buske L, Slade S. et al. The impact of shifts in workloads among younger and older family physicians: a 10-year, population-based ReferencesPrimary Health Care Research Highlights - May 2005   | 13perspective. In press. 23. Watson DE, Heppner P, Roos NP, Reid RJ, Katz A. Population-based use of mental health services and patterns of delivery among family physicians: 1993-2001. Canadian Journal of Psychiatry. 2005; 50.   24. Woodward CA, Cohen M, Ferrier B, Brown J. Physicians certifi ed in family medicine.  What are they doing 8 to 10 years later? Canadian Family Physician. 2001; 47: 1404-10.25. Woodward CA, Cohen M, Ferrier B, Brown J. Professional activity. How is family physicians’ work time changing? Canadian Family Physician. 2001; 47: 1414-21.26. Wright B, Scott I, Woolchuk W, Brenneis F. Career choice of new medical students at three Canadian universities: family medicine versus specialty medicine. Canadian Medical Association Journal. 2004; 170(13): 1920-4.14 |  Centre for Health Services and Policy ResearchPrimary Health Care Research Highlights - May 2005   | 15Centre for Health Services and Policy ResearchThe University of British Columbia429 – 2194 Health Sciences MallVancouver, B.C. Canada  V6T 1Z3Tel:  604.822.1949Fax:  604.822.5690Email: enquire@chspr.ubc.ca                                                     Download this publication at: www.chspr.ubc.ca

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