How early-career family physicians integrate social accountability into practice

Abstract

Objective

To explore how early-career family physicians integrated social accountability into their practices, how it shaped their practice choices, and the challenges they encountered.

Design

A secondary analysis of qualitative interview data.

Setting

British Columbia, Ontario, and Nova Scotia.

Participants

Early-career family physicians.

Methods

Initially a deductive analysis was conducted using a framework for categorizing 3 different levels of social accountability (individual patient [micro], community [meso], and system [macro]). An inductive analysis was then undertaken to explore how social accountability informs practice choice and to understand challenges encountered. A reflexive thematic analysis guided the inductive process.

Main findings

Social accountability was most commonly discussed at individual and community levels, with more limited system-level examples. Many early-career family physicians valued providing holistic care and derived professional satisfaction from meeting patient and community needs. These values, which are consistent with social accountability, informed their choice to pursue medicine and family medicine specifically. Available practice and payment models were described as barriers to socially accountable practice. Participants believed they lacked the knowledge, skills, and power to influence policy.

Conclusion

There is a need to support practice environments that are conducive to socially accountable practice and for curricula that can provide physicians with tools to engage with community- and system-level policy issues.

In 1995 the World Health Organization defined social accountability in the context of medical education as “the obligation [of medical schools] to direct their education, research, and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve.”¹ Social accountability is a focal point in medical education and informs evolving roles and expectations of family physicians. It is a goal of undergraduate medical education^2-4 and is being increasingly emphasized in postgraduate training and practice as well.^5,6 In 2001 Health Canada published a report defining principles of social accountability including maintaining the physician-patient relationship, working with and responding to community needs, and collaborating with health care organizations, government, and other stakeholders to develop a shared vision for the health care system.⁷ The importance of social accountability in medicine was affirmed in the 2011 report⁶ from the Association of Faculties of Medicine of Canada and is now reflected across Canadian medical schools’ curricula. Most recently, the Residency Training Profile released by the College of Family Physicians of Canada was developed “to reflect our aspirations for a socially accountable family medicine workforce in Canada”⁸ and includes advocacy for “access to culturally safe, affordable, high-quality, and comprehensive health care, along with the social conditions that promote health. This requires outreach and engagement, such as working with community partners and including patients experiencing hardship and/or barriers to care,” as described in the Family Medicine Professional Profile.⁹ The importance and value of socially accountable care was reaffirmed and emphasized in the context of pandemic recovery.⁵

Social accountability in family medicine has been categorized across 3 levels of patient proximity.¹⁰ The individual (micro) level is the closest proximity to patients, and places emphasis on the importance of recognizing and taking appropriate action in response to social determinants of health affecting individual patients. The community (meso) level outlines a role for family physicians to recognize and be adaptive to the needs of their broader community. The system (macro) level acknowledges the opportunity for family physicians to contribute more broadly to discussions on public policies that have implications on health.^11-13 This concept and framework have contributed to the evolving role of a family physician as they call upon practitioners to address not only medical concerns, but also the social context of their patients and broader communities across different levels of patient proximity.

To date, most research on social accountability has focused on undergraduate medical education,^11-15 with limited research at the postgraduate level or in continuing medical education.^2,16 How social accountability translates into practice is less clear. This study aims to explore how early-career family physicians (ECFPs) integrate social accountability into practice and to understand challenges related to having a socially accountable practice.

METHODS

Study design and population

This study used data collected through a larger mixed-methods study investigating factors shaping practice intentions and choices of ECFPs and residents. Semistructured interviews were conducted virtually in British Columbia, Ontario, and Nova Scotia.^17,18 Recruitment of participants for the qualitative arm of the larger project was conducted through the use of family medicine residency program email lists, posts on relevant Twitter and Facebook accounts, and the provincial medical association in Nova Scotia (Doctors Nova Scotia). Purposive sampling was conducted to maximize variation of participants. This was facilitated through use of a questionnaire that gathered initial information from interested participants regarding demographic and practice characteristics. Sixty-minute interviews were conducted in 2019, with 63 of 69 ECFPs invited to participate. This sample size is considered large for a qualitative study of this type. Scheduling conflicts (n=2), nonresponse (n=3), and withdrawal with no explanation (n=1) were reasons for not participating in the study. Interviews were audiorecorded, professionally transcribed, and quality checked. Participant demographic characteristics are outlined in Table 1. The original study was approved by research ethics boards from Simon Fraser University in Burnaby, BC (#H18-03291); the University of Ottawa in Ontario (#S-05–18-776); and the Nova Scotia Health Authority (#1023561).

Table 1.

Demographic characteristics of participants: N=63.

CHARACTERISTIC	PARTICIPANTS, n (%)
Province
• British Columbia	23 (36.5)
• Ontario	18 (28.6)
• Nova Scotia	22 (34.9)
Gender*
• Woman	36 (57.1)
• Man	26 (41.3)
• Prefer not to answer	1 (1.6)
Relationship status
• Single, divorced, separated, or widowed	22 (34.9)
• Married, common-law, or life partner	39 (61.9)
• Other	1 (1.6)
• Prefer not to answer	1 (1.6)
Dependents
• Children	34 (54.0)
• Adults	2 (3.2)
• Both	1 (1.6)
• None	26 (41.3)
Location of medical school
• Canada	48 (76.2)
• Outside of Canada	15 (23.8)
Years since graduation from residency
• 1-3	31 (49.2)
• 4-6	20 (31.7)
• 7-9	12 (19.0)

^*Participants were given the options of “nonbinary or third gender” and “prefer to self-describe”; however, these were not selected.

Data analysis

An initial codebook was created using the individual- (micro), community- (meso), and system-level (macro) framework for categorizing socially accountable activities (Appendix 1, available from CFPlus^*). Using this framework, interview data that aligned and related to how ECFPs made choices about the services they provided or how they addressed community needs were explored. Following this initial familiarization and deductive coding, a second phase of analysis was subsequently completed using an inductive approach informed by Braun and Clarke’s method of reflexive thematic analysis.^19,20 The inductive analysis was conducted to examine the transcripts closely without reference to the framework, using an organic process to identify impact on practice choices and barriers to socially accountable practice. Braun and Clarke’s reflexive thematic analysis was selected as it resonated well with our ontological and epistemological approach to this work. Themes and subthemes were discussed and agreed upon in research team meetings. An audit trail was maintained throughout the analytic process for reference and to enhance trustworthiness. The first author (L.M.) is a medical student who participated in a research experience program between her first and second year of training. Her interpretation of the transcripts was informed by her perspective as a trainee and by her life experiences. The second (A.G.) and third (A.S.) authors were also medical students in the early years of their training. Other authors have expertise in qualitative research (C.M.), family medicine and health education scholarship (I.S.), and health services and policy research (M.R.L.).

FINDINGS

Three main themes were formulated through the qualitative analysis. Each will be discussed individually. After applying the framework, we observed social accountability was commonly discussed at individual and community levels, and less commonly at the system level. Participants described values of providing holistic care and meeting community needs as shaping the choice to go to medical school and subsequently choosing family medicine. As such, values consistent with social accountability shaped decision making at multiple stages, up to and including practice choice. When entering practice, different models of practice and payment have the ability to help or hinder socially accountable practice. Aligning with the observations of more limited system-level engagement with social accountability, participants described lacking knowledge and power to shape policy and systems.

Social accountability is evident across different levels of patient proximity

Examples of social accountability were evident at the individual (micro) and community (meso) levels. Participants commonly described activities within their practices that were consistent with social accountability at the individual level. Many participants described supporting patient health holistically and individualizing care based on background and context. There was near ubiquitous recognition of the impacts of structural and social determinants of health such as poverty, criminalization, and social isolation. Being mindful of and adaptive to the broader community needs was also a priority for many physicians, as participants expressed feeling personal responsibility to address resource shortages at the community level. Examples of social accountability at the community level included compromising factors such as location, niche of practice, or preferred patient population to respond to known health issues in specific communities. Notably, some participants described taking on areas of focused practice to address unmet community needs.

Activities that aligned with the system-level (macro) categorization were less commonly described, with only 1 participant providing an example of involvement in system change. Many ECFPs described policy change as being outside of their control, including both policies that would support more socially accountable practice and broader policies that support better health outcomes for all. Some mentioned lack of knowledge about policy processes and uncertainty about who possessed this information. Many perceived that people in decision-making roles did not understand the realities of day-to-day practice, but individuals with this knowledge were not at the table. The ECFPs also mentioned lack of time and compensation were factors that prevented them from participating in work that would shape policy. Illustrative quotations of social accountability at micro, meso, and macro levels are included in Table 2.

Table 2.

Quotations illustrating social accountability across different levels of patient proximity

LEVEL OF PATIENT PROXIMITY	QUOTATION
Individual (micro) level	“I don’t want to just be prescribing medications or getting people in and out through the door. I do want to be working with them on a bit more of a deeper level. That’s where some of my interest in getting a bit of a niche and focusing in and spending a bit more time with patients has come from” (Female FP, British Columbia) “Like I think it’s a lot more sort of the whole person, right. Like not just okay, you have a cough. It’s like okay, well, what are things like for you at work? Like where are you living right now? Like do you have enough money to buy a jacket so you’re not outside.… You know what I mean? Like it’s looking at the whole person and the whole picture” (Female FP, British Columbia) “So I think the relationships are like everything. It’s kind of like how I also practice even on an individual level with my patients. I see a lot of people who have been subjected to state violence. And sometimes that happened through the medical system in their home country. And a lot of distrust of the system. And the health system are representatives of the state. And one of the ways that like my therapeutic goals is actually to develop a trusting relationship with this person over time so they can begin to trust the health care system. So those things are super important” (Female FP, British Columbia)
Community (meso) level	“I’m acutely aware of the fact that, you know, we have resource shortages and physician shortages everywhere, but especially in rural and remote areas. And therefore I feel it is incumbent upon me to continue to provide those services, especially because there aren’t a lot of graduates who are comfortable working in these kinds of environments with the uncertainty and the chaos and the unpredictability and the broad scope that it entails. And so for me it’s about trying to consider what kind of a balance is going to be needed to keep my foot in those doors and helping out as needed for those populations but also for my own personal and professional development” (Female FP, Ontario) “Like I like to fill like needs in the community. Like I do like that. Like you’re a resource to a community. So that’s why I still go down.… Well, one of the reasons I still go down to [rural community in Nova Scotia] as opposed to doing more work locally. Because they have a great need like in rural NS. And I also do a methadone clinic.… So I did a locum for somebody for 9 months who did a methadone clinic, which is how I started it. Just because there was a need there. It wasn’t overly an interest of mine initially. But there’s a huge need for it in rural NS so I kind of just filled that gap” (Female FP, Nova Scotia) “So I really like obstetrics, and I think that I was good at it. That was the feedback. But MAID was something that was underserviced. And the woman that was only doing it at the time was quite stressed out. And when she approached me, it just made sense to do it. So I think it’s what my community needs definitely influences what I would change my practice to” (Female FP, British Columbia)
System (macro) level	“And the community that I work in has afforded the ability to participate in the primary care system improvement initiative as well. So that’s given my office a chance to participate in sort of piloting some new ways of working in our community, which has been really rewarding” (Male FP, British Columbia) “I don’t feel that doctors are playing a big enough role or being asked enough what’s working for them and what isn’t working for them. It’s kind of … I feel like it’s a bit of an aggressive health authority. I probably shouldn’t be saying all this. And it’s kind of … I don’t know, I don’t feel it’s collaborative; I don’t feel that we’re in a really open environment where we can start to brainstorm as to how to make things better for everyone” (Female FP, Nova Scotia) Interviewer: “So let me follow up about the fee code question. Do you feel that there are communication conduits in place where it’s possible to have the conversations to get some of these needed fee codes added or existing codes revised?” FP: “I don’t feel like I know who they are or how I would go about doing it. I’ve heard other people have tried and had little luck. So I guess I feel I have a bit of a defeatist attitude towards that in that I wouldn’t know where to start and I feel like it would never be listened to. But maybe it’s there. I don’t know about it” (Female FP, British Columbia) “And then over the last couple of years I’ve also kind of really tried to protect a little bit of time in my week to do academic activities. Because for me, I really like to think a lot about how I look at the same questions that I see … the same problems that come up for me in an individual level in my clinical work, how to also address them from like a larger structural and policy perspective. And so over the past few years I’ve done a little bit of research training” (Female FP, British Columbia)

MAID—medical assistance in dying.

Values consistent with social accountability shape practice choices

Participants in this study described values influencing their practice choices that are consistent with social accountability. These include valuing provision of holistic care, making a difference, and responding to patient and community needs. Providing holistic care included supporting patients’ medical and social needs through understanding the context of individual patients’ life circumstances and addressing community needs. Participants described experiences and circumstances before medical school that shaped these values such as upbringing, previous education, or occupational experiences. Residency experiences provided exposure to practice settings that made it possible to practice in ways consistent with these values. Participants less commonly spoke about their experiences in medical training as being important for shaping values. Participants derived professional satisfaction from being able to practise in a way they believed was consistent with their values. Quotations reflecting values consistent with social accountability shaping practice choices, including the association with professional satisfaction, can be found in Box 1.

Box 1. Quotations illustrating values consistent with social accountability shaping practice choices.

“For me it is related to social justice. So yeah, in short, I think for me it’s about sort of supporting communities’ rights to access or to live healthy fulfilled lives with like a very holistic view of health. And the way that plays out for me personally is that when I’m working in settings where I feel that I’m able to move the dial in that direction” (Female FP, British Columbia)

“Like I really want to be doing something that feels meaningful to me, and feels that it’s in line with my values and … I don’t know, like I want to be able to.… 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” (Female FP, Nova Scotia)

“Probably I’d say flexibility and, yeah, just kind of like continuing to get better at what I do. Like a good learning atmosphere, I think that’s something that’s very important to me, too.… That it’s a place with good colleagues who are kind of interested and engaged in getting better and teaching. And like where there’s opportunities where I can work with a specialist to kind of learn more and get better at certain things” (Male FP, Nova Scotia)

“The medical school there [in Newfoundland] like the dean who was there at the time were very much interested in kind of a social accountability like paradigm or model. And I don’t know that that’s necessarily something that … I mean I think we all want to be socially accountable. But I don’t know that that’s something that was a huge driver for me. But 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. Because I think that that was something that was really instilled where I went to school” (Male FP, Nova Scotia)

“I do want to, you know, be doing something that I feel is making a difference and has meaning. So you know, that has actually been one of my challenges with family medicine, is sometimes I feel like I am just plugging away in a system” (Female FP, British Columbia)

Practice and payment models help or hinder social accountability

Many participants highlighted difficulties associated with setting up or finding opportunities that aligned with their values of providing holistic care. There was also a clear intersection between practice model and remuneration. Tension about fee-for-service funding models was common, coupled with lack of access to collaborative team-based care, making the provision of holistic care and meeting individual and community needs challenging. Participants frequently found this funding model made it difficult to spend an appropriate amount of time with patients, particularly those with complex needs such as comorbidities or advanced age.

In contrast, participants who discussed working in multiphysician collaborative or interprofessional clinics described various ways in which their practice was able to overcome barriers and meet individual and community needs. On a micro (individual) level, collaborative practice models allowed for interprofessional collaboration to strengthen responses to individual contexts and needs of patients. Availability of interprofessional teams made it possible to meet patient and community needs more comprehensively. The opportunity to work with others meant the responsibility for social accountability was shared and supported. Quotations reflecting the implications of practice models as a hindrance or facilitator of social accountability are presented in Box 2.

Box 2. Quotations illustrating the influence of practice models on social accountability.

“So in the Downtown Eastside, 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. So, 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” (Female FP, British Columbia)

“It’s so interesting in BC [British Columbia], people have this understanding and expectation that they’re only allowed to talk about one thing at an appointment. And that the government only really pays us for 9 minutes of time or something like that—ridiculous. And so yeah, people will truncate their problems. And are often really surprised when I ask them a second question or when I ask them about something else that’s related but not directly related. So I think for me I’m wrestling with that. I feel like there’s a bit of cognitive dissonance for me because the way I’m forced to practice to have the personal life and the sanity I need does not let me be the kind of doctor I thought I was going to be” (Female FP, Ontario)

“And the thought of having to like bill and like worry about like oh, when I saw this patient, did I have to bill this code or this code? It makes me like anxious and it takes away for me the medicine. Like I would rather spend … you know, instead of having to spend 20 minutes at the end of my day trying to figure out my billing, I’d rather see an extra patient a day than worry about that” (Female FP, British Columbia)

“I just think we have a lot going on in the province, and we have to figure out how to do things differently to help our aging population and our rural populations because it’s a tough go. And you know, physicians are getting burnt out, the ones who are there. We’re not nailing it at all. And it’s hard when everyone’s working so hard to even get the time to figure out to do things differently” (Female FP, Nova Scotia)

“And the actual addictions interest didn’t really come until I started doing psychiatry. And there I just noticed that a lot of people who were in the psych ward were using some sort of substance. And the psychiatry treatment wasn’t doing very much about it. And that’s where that interest came from” (Male FP, British Columbia)

DISCUSSION

Our findings show that socially accountable practice is a priority for many ECFPs. There was recognition and frustration about system-level issues from various participants, and participants more commonly discussed individual- and community-level examples of socially accountable practice. As system-level problems are the furthest away from clinical practice and among the most complex to address, it is understandable that discussion was less common at this level. However, it was clear from the interview data that ECFPs in this study had a clear understanding of system-level challenges, and experienced frustration as a result.

The findings suggest that values shaping social accountability in practice appear to stem from experiences physicians have before their medical education. Although there has been a strong focus on instilling social accountability in medical education, more attention may be needed to provide physicians with the tools and resources required to engage with community- and system-level policy issues. Further research is needed to identify frameworks and evidence to support social accountability in practice.²¹ Opportunities to enhance social accountability through collaborative practice models was also highlighted in this study. Collaborative and interdisciplinary practices have various benefits, including strengthening patient care and accessibility of care to the community, and more comprehensively meeting patient needs and addressing nonmedical determinants of health. The shortcomings of the fee-for-service model have been well researched and documented.^22-24 Findings from this study further expand on how some practice and payment models act as system-level barriers. Given recent changes in payment models in British Columbia and Nova Scotia, further research will be needed to assess the impact of payment reform on social accountability activities in family medicine.

This study also illuminated an association between the value of providing holistic care and professional satisfaction. This association is relevant because professional satisfaction is an important aspect of both physician wellness and high-quality patient care. Previous studies have highlighted a link between decreased job satisfaction and burnout and turnover, and an association between level of job satisfaction and quality of patient care.^25,26 Physicians in this study described finding value and fulfillment in providing holistic care that was consistent with all levels of social accountability. Creating health care systems that promote and foster opportunities for social accountability in practice is an important and synergistic aspect of increasing professional satisfaction in family medicine. This consideration is particularly relevant within the context of family physician shortages, challenges with retention, and ongoing reform of practice models.

Strengths and limitations

A large sample size with representation from 3 Canadian provinces, complemented by a diverse team of qualitative analysts, are strengths of this study. Trustworthiness and rigour were demonstrated by use of an audit trail and collaboration with senior research team members. Secondary use of data is a limitation of this study. Although subsets of the data are reflective of social accountability in practice, there were no specific questions concerning this topic in the original interviews. Lack of discussion about social accountability at the system (macro) level may be attributed to this limitation of secondary use of data. Direct questions about social accountability may have brought about more information and examples of socially accountable activities at the system level.

Conclusion

Participants spoke about aspects of social accountability in their work across all 3 levels, with more examples provided at the micro and meso levels. Values consistent with social accountability appeared to shape practice choices. Practice and payment models were noted to either help or hinder socially accountable activities. Findings highlight the importance of adequately preparing physicians to engage with policy and system-level issues pertaining to health. Values consistent with social accountability predate medical education and suggest an opportunity to shift education toward curricula that can provide physicians with the tools required to engage with community- and system-level policy issues.