Table 5 Participant perspectives on influences on practice type and model

Training influences on choice of practice type or model

 Medical school

“And I got to see how all these different GPs could find their own niche. Some of them liked to do more mental health, and some of them did endoscopy or GP anesthesia. And you could really just cater your practice to what you wanted. You could do everything. You could do a small specialty.” P6 BC

“I felt that that push and that obligation from the medical school that it’s an important thing to work rurally, it’s an important thing to be a comprehensive generalist, like it was a really huge mandate in the medical school. And like I still definitely feel that now. Like if I did give up my family practice to do something more focused, I would definitely have guilt about kind of like letting down like my mentors, you know.” P39 NS

“In my experiences with family medicine, in particular, however, I’m not sure if I loved it because it was so fee-for-service volume-based. It felt most of the doctors that I followed, you know, would see 30–40 patients a day … And it was exhausting. And I don’t think I saw myself in a model like that. And so even though I chose family, I think in my mind I knew I wasn’t going to practice in that manner.” P61 ON

 Residency

“Definitely [my preceptor] had like a full scope practice. You know, all ages and everything. And so I liked that aspect of it. But at the same time, didn’t want to be on call 24 h a day and that sort of stuff. So I think that it definitely influenced how I wanted to divide up my time. I mean I’m sure it influences it.” P22 NS

“When going through residency in [major city], you’re kind of a lower totem pole learner… There’s a lot of learners. So again, in my residency, my best times were times I was outside the city. So my [small town] rotation for 3 months again just kind of reaffirmed for me that comprehensive family medicine was what I liked. The kind of full care, hospital, office, different setting family medicine was what I really was passionate about.” P26 NS

“I mostly decided on doing hospitalist work just based on the different rotations I did during my residency.” P60 ON

Professional influences on choice of practice type or model

 Early career experiences

“And I took a locum, a 2½ day locum position at the site where I had done my primary family medicine site during residency. So I just continued on there … And so to me it was an opportunity … Knowing that there was going to be … the transition was going to be stressful and that as a sort of next step, I wanted to do it in a familiar environment with familiar people with whom I could feel comfortable asking questions.” P11 BC

“I did like a few clinics as well as the hospitalist work. And then I decided I liked just doing hospitalist work.” P60 ON

 Acquisition and maintenance of skills

“And so I started doing the rural locums. So yeah, part is financial, part is just kind of variety, and another part is also just making sure that I’m still competent, that I’m able to like keep up my family practice licence.” P18 BC

“And so it’s like every skill set, you know that if you don’t keep using these things, they’re going to be gone. You’re going to not have those skills in a while. You know, like it’s like that expression—use it or lose it … I very much thought I’ve got to keep this stuff alive. So I’ve tried with my locums to keep that stuff alive.” P35 NS

 Policies and regulations

“I think the fee-for-service system in this province is broken. And the only way that you could keep up with other professional options is to do kind of crappy medicine. And it’s disheartening to try to choose between making a more reasonable income versus doing a good job. So I didn’t make that choice. I picked something else [focused practice].” P5 BC

“I was going to take a job at a community health centre … doing a blend of addiction medicine and primary care. Which I would have been very happy doing. And then the provincial government took away the funding. So that’s not happening anymore.” P45 ON

“And the ambiguity as to how contract negotiations are going and that relationship has dissuaded me from considering signing onto a practice until I really know what the lay of the land is going to be like.” P48 ON

 Practice management responsibilities

“… family medicine clinic is more exhausting than it sounds like it should be. There’s a huge burden of paperwork. And there's a huge burden of demand with care … And so just for me, I can’t do family medicine clinic 5 days a week.” P26 NS

“I actually don’t see the financial benefit in opening up my own practice unless I’m able to employ plenty of doctors. And given all of the job postings online for family doctors to work at practices, and the really low overheads that people are offering because it’s so hard to find a family doctor to work with them … It is not a risk I’m willing to take right now.” P59 ON

“You know, if you start your own practice, and then you want to go on holidays, and you can’t find a locum because no one wants to work for less money than they would get somewhere else, then you’re kind of in a bit of a bind because you can’t leave.” P62 BC

 Desire for control

“I guess right now just that sense of not wanting too much commitment and wanting autonomy over my schedule after seeing many colleagues that feel chained to work … I think the past 5 years influenced my inability to commit to a job and stay mostly as a locum, and try to keep lots of freedom in my schedule.” P6 BC

“And so from that perspective, you have more control in a situation like mine [solo practice] where you’re able to fine-tune things exactly the way you want them to be. And something like that might not seem very big. But if it’s something that bugs you every day that you work, you know, for the next 25 years, it could rob you of the joy and satisfaction that you derive from work.” P46 ON

 Meaningful and valued work

“So in the [low-income neighbourhood], for example, I like that I’m not doing fee-for-service there because it gives me the ability to spend more time with my patients. I think that they need it. For example, it’s not uncommon to have somebody coming in in crisis and suicidal, or something like that, or having some sort of a family crisis. And in a fee-for-service clinic, it’s impossible to take an appropriate amount of time with a patient like that.” P2 BC

“… there are aspects of office-based family medicine that are rewarding but it’s not always very interesting. So the relationships you build with your patients are rewarding. But the actual day-to-day work of office-based family medicine I find becomes not that interesting or engaging over time. So I’m happy to do it as a part of my practice mix but realize that doing it as a 40 h a week, I become bored with it.” P37 NS

“I love the opportunity that academic medicine and education provides … I get to do all kinds of things. I do clinical medicine, I do didactic teaching, I do some leadership, administrative stuff. I can do research. So I think career-wise and for my own mental health, being able to have your hand in a bunch of different pies is really interesting.” P63 ON

Personal influences on choice of practice type or model

 Financial considerations

“Like really we have to do what pays well because otherwise the debt seems insurmountable. So I was seeking out things that paid well. Like my northern locums and the hospitalist pays better than family med clinic. To be honest, everything pays better than clinic. So I am not surprised people don’t choose it initially often. And so that’s a big consideration for me.” P26 NS

“Medicine is ridiculously expensive. I’m not someone from a particularly rich background. And so it certainly has been a significant debt for medical school. And I’m trying to claw my way out of it as fast as possible. Which is challenging. I think it might be part of the motivation to continue to do like the rural locum work.” P52 ON

 Family and relationships

“I don’t do any emergency medicine but it’s something that a lot of family doctors do here, and would have been an option. Or doing some extra walk-in clinics in the evenings, I’ve definitely forgone those to be at home and help support my wife and just to be home with my little one in the evening and get her tucked into bed.” P23 NS

“Because I don't have a partner, it’s given me the flexibility to explore doing locum work and then signing on in the community.” P55 ON

 Gender

“I think patients have different expectations of male physicians and female physicians. And that plays out in different ways, I think. But in terms of we were talking about compensation and so on, I think in a fee-for-service type of environment, that’s not beneficial to female physicians …” P2 BC

“The prospect of having to find a maternity leave locum with the difficulties that that entails … is a little bit frightening, I’ll put it that way. And it discourages me thinking about joining a model like that [community-based practice] when I’m worried about being able to find coverage or interrupt the continuity that I would want to provide to my patients.” P48 ON

 Personality and personal interests

“I like variety and I like diversity and I’m a bit of a … I’m a traveller and like to be on the go. So I think that’s a big part of why I’m working different places and coming and going from these various clinics and work settings." P12 BC

“I’m indecisive and I’m curious. And so that’s one of the reasons why I continue to locum and I’ve enjoyed locuming. Well, the indecision part is that I don’t really feel ready to settle into a practice of my own just yet because I really want to get a sense of who I am …” P48 ON

 Work-life balance

“I think that family medicine, it can be a pretty thankless job these days. And the main thing that is attractive to me about locuming is the ability to work when I want to and take time off when I want to. And my colleagues I see taking on practices, particularly early in their careers, are burning out pretty quickly.” P2 BC

“Why would I go and work as a family doctor, see patients for 6 or 7 h, have 3 h of unpaid paperwork on either end of it, and make, you know, $600, $700 a day when I could go work as a hospitalist and make $1500 a day? I can go work as an Emerg doctor and make $1500 a day. I could go do my work, go home, be with my family, and not have to worry about any of that. … I’ve made my career to fit my life, and not the other way around.” P14 BC