Table 6 Participant perspectives on influences on scope of practice

Training influences on scope of practice

 Residency

“And so I probably got the best person I could have. She was a young female physician, had done emergency medicine as well as family practice. And she also did the minor procedures clinics … Honestly, my practice is set up to mirror hers almost identically because that’s how much I liked it.” P41 NS

“I did it [residency] at the [clinic name] family health team. It was an academic unit. We saw a lot of complicated patients. I felt very prepared by the end of it to start working in full spectrum family practice.” P49 ON

“I don’t feel comfortable doing obstetrics, for example, because my exposure wasn’t quite the level that it would have needed to be for me to be able to walk out of residency and feel ready to take on delivering babies all the time. So that certainly shaped how I practice.” P52 ON

“I felt more comfortable even moving back to more of an urban setting and doing emergency medicine and obstetrics. The fact that I did have the rural practice skills really gave me the confidence to still continue to pursue it, even though it’s uncommon for urban family physicians to continue to do obstetrics and emerg.” P58 ON

 Additional training

“And then I did a third year fellowship. And so at that third year, I did more focused training in women’s health. So I did some work with women living with HIV. I did work around menopause, and sort of different life cycle issues in women’s health. I became trained to provide abortions and do focused sort of sexual and reproductive health work in [current practice].” P1 BC

“I ended up doing some extra training in obstetrics which like opened up some doors for locums in my community for when I finished. … A lot of it I think is to support rural physicians to do extra training so they can go back to their community and be more comfortable. I was able to do it … to become more comfortable practicing OB.” P7 BC

“That’s [sports medicine] a fellowship trained role. There’s different ways in. They try to close the door on you so you can’t get in. So I’m not even allowed to do it and write an exam for two years after I get out.” P50 ON

“It seems like right now in order to do full-time palliative care in many areas, you need to have a PGY3 in palliative … I’m told my skills are not adequate to run a palliative care unit or to see palliative care patients. I find that frustrating. The idea of doing a PGY3 feels a bit daunting.” P54 BC

“I was actually planning on doing my third year fellowship in obstetrics. And I ended up not doing it because I had my daughter and I didn’t want to be away from home. But instead of that I chose to do a locum with family medicine obstetrics support. So then I kind of, you know, used that as to further develop my skills in obstetrics during my locum time.” P58 ON

Professional influences on scope of practice

 Early career experiences

“I had a couple of careers before I came in. But primarily working in community health for 20 years… And a master’s degree in social work before I came to medicine like kind of by fluke. Like all of that influenced where I’m at. … And I knew that I wanted to work with marginalized communities and complex patients. And that’s effectively what I’m doing. So I’m very interested in helping folks who are experiencing a lot of barriers to healthcare, and understanding how, for example, the social determinants of health impact patients’ ability to be healthy and have contented lives.” P11 BC

“When I was in high school and I guess in undergrad as well, I did a lot of work at a nursing home. I did volunteer work at a nursing home. And I felt that that really actually had probably influenced my decisions to work as a hospitalist in family medicine, because I was always so exposed to the age group which I’m working with now.” P60 ON

 Meaningful and valued work

“Like I really want to be doing something that feels meaningful to me, and feels that it’s in line with my values and … Like it sounds super cliché or whatever but I want to be able to feel like I’m making some kind of difference, and that what I’m doing is important.” P29 NS

“I think I like to kind of build some close relationships with my patients. And I think that’s part of the reason why I like palliative care—because you kind of get to spend more time, kind of longer appointments with people, and you really kind of get to know them and what they’re about and what their life is like.” P51 ON

“Our obligation is to be responsive to our communities … So I have my favourite things in medicine, and then things that really I end up having to hone just by the population in the community that I’m serving.” P56 ON

“And working I think more with a marginalized population. A population where you felt that you left and you said, okay, if I wasn’t here, these people might … I don’t want to say not gotten care because there’s definitely lots of staffing there. But that they might face barriers in different ways. So that’s kind of the population I kind of like to work with.” P61 ON

 Confidence with service provision

“I don’t do IUD insertions. I know that’s really specific. I don’t have enough of a patient population that wants them routinely enough to maintain my competency.” P41 NS

“… I feel very, very comfortable with palliation. We see that a lot at the hospital. And that’s not really an interest but I find a lot of physicians are not adequately trained. I know I’m not but I think I’m more trained than some of my colleagues that I work with unfortunately.” P47 ON

Personal influences on scope of practice

 Family and relationships

“We’re fortunate in that my husband’s a medical specialist. And so I feel very little burden now in my career … I feel less burden from a family perspective to bring in income … in my marriage, obviously I’ve chosen to work less—we made that as a partnership decision—than had I been a single person or primary breadwinner.” P19 BC

“It’s [obstetrics] certainly like my all-time favourite thing to do in family medicine. But my husband is an obstetrician. And realistically balancing two call schedules with family is just … it would be a bit of a nightmare. Now once the kids are lot older, perhaps I would get retrained and consider doing that again, considering how much I love it. But realistically I don't know that it's ever going to happen again.” P36 NS

“I myself have a 3½-year-old. So before, like when I was first in practice for that first year, I probably did more stuff outside of my office. Like doing obstetric call. But whereas overnight, I’ve done less of that since my son has been around. And I would say likely when he is older, I would probably pick up doing more of that. “ P47 NS

 Gender

“So my preceptor, we used to get procedure clinic every month. And I loved it and I was good at it. … Then I went on mat leave … Then I was away for over a year and a half with my second child. And then doing locums, I wasn’t doing a lot of procedures because you’re sort of bouncing around a lot. … Like by the time I got to [current practice], I think I’d been 2 years or even 3 years since I’d done a procedure on someone. So I lost like my own confidence.” P22 NS

“So with gynaecology, for instance, I always give patients the option of, for instance, seeing me for that issue or seeing another physician—a female or whichever gender they choose. That would have affected me in terms of doing gynaecology versus anything else. And I think it does have bearing for me as well. Even though again I do the prenatal assessment, I usually don’t follow people prenatally. I do believe it has some bearing there … just for me it’s more I have this belief that a woman would be more comfortable around another woman for that situation rather than a man or any other gender.” P33 NS

 Personality and personal interests

“Like this very traumatic, terrible case happened. And as awful as it was, like I think it showed me that I … had the skills and the bedside manner to sort of help people in those times of need. … I practice with my emotions. Which is good and bad. But I really connect with people that way. And I think before it kind of scared me about doing things like palliative care and emergency medicine. But I think it showed me that I could do those and that it was something I wanted to do.” P17 BC

“I’m extremely patient. And in a lot of family medicine, you do get a lot of geriatrics. But I do feel like I have a little bit of a leaning towards geriatrics. And the reason I do feel you need more patience than any other is because just in terms of how information is communicated now or how the geriatric population does need more time. That’s kind of why I do sort of do long-term care as well.” P33 NS