Recent reforms in healthcare delivery have greatly modified primary care medical practice, by fostering the grouping of physicians into more complex and large organizations [
Echoing this trend, solo medical practice has been considered obsolete [
Solo practice has generally been studied from the angle of its size, as measured by the number of physicians it comprises. Studies have examined the relationship between size of practice and various measures of utilization, experience or quality of care. Overall, these studies report a favorable experience of care, high degree of satisfaction, and appropriate use of services among patients treated by solo physicians [
Such isolation is not generalized. Solo physicians do not necessarily constitute a homogeneous group, precisely because of the different networking strategies they adopt [
This paper aims to identify the different forms of solo practice in two regions of Quebec, Montréal and Montérégie, in 2010 and to determine the extent to which they are associated with variations in patient experience of care.
In the early 2000s, Québec initiated important reforms of its healthcare system. Family Medicine Groups (FMGs) and Network Clinics (NCs) were created with the aim of improving continuity, integration of care, and accessibility of services. As of October 2013, there were 254 FMGs out of the 300 targeted. A complementary PHC organizational model, the Network Clinic, is being currently implemented. This PHC model aims at fostering accessibility through walk-in visits and providing access to specialists and to technical support services, such as X-rays and lab tests. Their creation was initiated by the Montréal Regional Health Agency as a complement to FMGs, in response to requests by the regional medical association. The healthcare reform also included the creation of health and social services centers (HSSCs), merging acute care hospitals, long-term care hospitals, and local community health centers (CLSC) on a geographical basis. In addition to their responsibility for providing health services to the population of their territory, HSSCs were mandated to lead the implementation of local services networks, notably by fostering collaboration involving PHC organizations, and to support the implementation of FMGs.
Our study consisted of two surveys conducted in 2010 in the two most populous regions of Quebec, Montréal and Montérégie which represent more than 40% of the province’s total population [ only one doctor on site; unique civic address or, if in a building with other doctors, a unique suite or office number; unique and distinct telephone number; no sharing of resources with other doctors on the premises (office space, personnel, medical charts, etc.).
The study was carried out according to the principles of the Helsinki Declaration. The research Ethics Committee of the Agence de la Santé et des Services Sociaux de Montréal approved the study. Participants had to sign informed consent forms and were told that they could withdraw any time during the study.
The population questionnaire assessed respondents’ current affiliation with PHC organizations, their health services utilization profiles, attributes of their care experience, and their reported unmet needs [
We selected 21 indicators of experience of care and grouped them under the four following dimensions: accessibility (6), continuity (5), comprehensiveness (5), and care outcomes (5) [
Aside from information on experience of care, the population questionnaire contained information on use of services, reporting of unmet needs, presence of morbidities, and preventive care received, as well as sociodemographic characteristics of respondents [
The structure of the organization questionnaire was based on four core elements of organizations. Vision refers to goals, values, and orientations shared by members of an organization; resources concern availability, quantity, and types of resources that can be mobilized by the organization’s members; structure formalizes rules of governance, conventions, and procedures that regulate the behavior of organizational actors, and practices relate to coordination, administrative, and professional mechanisms that underpin service delivery [
The questions stem from various sources [
Because of the type of indicators generated from the questions, notably their objective and descriptive (reporting) rather than evaluative (rating) character, they were considered to form composite formative indices rather than metric reflective scales [
The following indicators characterizing solo practices were used as active variables for constructing a taxonomy: presence of a nurse; presence of specialist doctors and other professionals in the building; availability of information technology; access to X-ray services or blood sample collection in the building; collaboration agreement with other PHC clinics; collaboration agreement with a hospital; and doctor’s affiliation with other PHC clinics, emergency rooms, or hospitals. These active variables served to construct a taxonomy of solo practices, using a multiple correspondence analysis associated with a hierarchical ascending classification [
In addition to the active independent variables, the following illustrative variables were used to further characterize the classes of the taxonomy: age and sex of physicians, presence of other GPs in the building, time spent in the clinic (26 hours/week or more), scope of services provided, and acceptance of new patients.
Dependent variables are related to experience of care and utilization of services reported by population survey respondents. Experience of care variables are accessibility, continuity, comprehensiveness, care outcomes, reporting of unmet needs, and having a family doctor. Details concerning operationalization of these variables are presented in Table
Questions used for constructing experience of care indices.
Accessibility | Comprehensiveness | ||
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At this place, if the doctor who is responsible for your care is not available, you can see another doctor | (0) Never | At this place, all your health problems are taken care of, whether they are physical or psychological | (0) Not at all agree |
(1) Sometimes | (1) A little | ||
(2) Often | (2) Somewhat | ||
(3) Always | (3) Strongly agree | ||
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At this place, how long does it take to see the doctor by appointment? | (0) 4 months or more | At this place, during your visits, the doctor takes the time to talk to you about prevention and asks you about your lifestyle habits | (0) Not at all agree |
(1) From 1 to 3 months | (1) A little | ||
(2) From 2 to 4 weeks | (2) Somewhat | ||
(3) Less than 2 weeks | (3) Strongly agree | ||
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How long does it usually take to get there? | (0) More than 30 minutes | At this place, they help you get all the health care services you need | (0) Not at all agree |
(1) From 15 to 30 minutes | (1) A little | ||
(2) Less than 15 minutes | (2) Somewhat | ||
(3) Strongly agree | |||
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At this place, the office hours are convenient | (0) Not at all agree | At this place, your opinion and what you want are taken into account in the care that you receive | (0) Not at all agree |
(1) A little | (1) A little | ||
(2) Somewhat | (2) Somewhat | ||
(3) Strongly agree | (3) Strongly agree | ||
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It is easy to reach someone at this place by telephone to make an appointment | (0) Not at all agree | At this place, you are given help to weigh the pros and cons when you have to make decisions about your health | (0) Not at all agree |
(1) A little | (1) A little | ||
(2) Somewhat | (2) Somewhat | ||
(3) Strongly agree | (3) Strongly agree | ||
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It is easy to talk to a doctor or nurse by telephone when this place is open | (0) Not at all agree | ||
(1) A little | |||
(2) Somewhat | |||
(3) Strongly agree | |||
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Continuity | Outcomes of care | ||
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When you go to this place, you see the same doctor | (0) Never | The services you get there help you to better understand your health problems | (0) Not at all agree |
(1) Sometimes | (1) A little | ||
(2) Often | (2) Somewhat | ||
(3) Always | (3) Strongly agree | ||
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How long have you been going to this place? | (0) Less than 2 years | The services you get there help you to prevent certain health problems before they appear | (0) Not at all agree |
(1) From 2 to 5 years | (1) A little | ||
(2) More than 5 years | (2) Somewhat | ||
(3) Strongly agree | |||
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At this place, your medical history is known | (0) Not at all agree | The services you get there help you to control your health problems | (0) Not at all agree |
(1) A little | (1) A little | ||
(2) Somewhat | (2) Somewhat | ||
(3) Strongly agree | (3) Strongly agree | ||
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At this place, they are aware of all the prescribed medications you take | (0) Not at all agree | The professionals you see there encourage you to follow the treatments prescribed | (0) Not at all agree |
(1) A little | (1) A little | ||
(2) Somewhat | (2) Somewhat | ||
(3) Strongly agree | (3) Strongly agree | ||
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At this place, you can receive routine ongoing care for a chronic problem | (0) Not at all agree | The professionals you see there help motivate you to adopt good lifestyle habits | (0) Not at all agree |
(1) A little | (1) A little | ||
(2) Somewhat | (2) Somewhat | ||
(3) Strongly agree | (3) Strongly agree |
In analyzing the relationships between taxonomy and experience/utilization of care, we controlled for the following variables, all derived from the population survey: age and sex of respondents, economic status, perceived health status, and presence of morbidities. Operationalization of these variables is itemized in Table
Patients’ characteristics categories.
Variables | Categories |
---|---|
Age | 18 to 29 |
30 à 44 | |
45 à 64 | |
65 or more | |
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|
Sex | Woman |
Man | |
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Level of education | No diploma (elementary school) |
High school diploma | |
College diploma (CEGEP) | |
University degree | |
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|
Economic situation | Very unfavorable |
Unfavorable | |
Favorable | |
Very favorable | |
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|
Perceived |
Poor |
Average | |
Good | |
Very good | |
Excellent | |
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|
Morbidities | No risk factor* nor chronic disease** |
One risk factor or more but no chronic disease | |
One chronic disease (with or without risk factor) | |
Two chronic diseases or more (with or without risk factor) |
We used two statistics to describe the taxonomy: value test and Cramer V coefficient. The value-test indicates the importance of a variable in constructing that taxonomy. It measures the distance between the mean of all observations and the mean of the class, expressed by the number of standard deviations of a normal distribution [
Four models emerged from the taxonomy of solo practices (Table
Organizational characteristics associated with the four solo practice models of the taxonomy.
Active independent variables |
Resourceless |
Resourceless |
Resourceful |
Resourceful |
All |
Cramer V | ||||
---|---|---|---|---|---|---|---|---|---|---|
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% | Value test | % | Value test | % | Value test | % | Value test | % | ||
At least one nurse in the practice | 2.5 | −5.5 | 5.7 | −3.2 | 43.9 | 4.5 | 62.5 | 4.5 | 21.1 | 0.558 |
Specialists or other health professionals in the building in which practice is located | 26.6 | −4.3 | 18.9 | −4.6 | 82.5 | 6.4 | 83.3 | 3.8 | 46.0 | 0.580 |
At least one information technology available | 34.2 | −2.5 | 37.7 | −1.2 | 63.2 | 2.9 | 62.5 | 1.5 | 46.0 | 0.268 |
Radiology or blood sample collection available in the building where practice is located | 3.8 | −6.7 | 5.7 | −4.6 | 70.2 | 7.6 | 66.7 | 3.9 | 29.1 | 0.691 |
Collaboration with other PHC practices | 1.3 | −6.8 | 66.0 | 7.3 | 0.0 | −5.9 | 75.0 | 5.3 | 25.4 | 0.754 |
Collaboration with hospitals | 2.5 | −7.0 | 64.2 | 6.2 | 7.0 | −4.4 | 87.5 | 6.2 | 28.6 | 0.728 |
Doctor’s affiliation with another PHC practice | 19.0 | −0.3 | 3.8 | −3.7 | 36.8 | 3.6 | 25.0 | 0.2 | 20.7 | 0.297 |
Doctor's affiliation with another health facility | 12.7 | −2.0 | 20.8 | −0.5 | 24.6 | 1.2 | 33.3 | 1.9 | 22.5 | 0.106 |
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Illustrative variables |
Resourceless |
Resourceless |
Resourceful |
Resourceful |
All |
Cramer V | ||||
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% | % | % | % | % | ||||||
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Age of doctor (≥65 years) | 32.9 | 37.7 | 19.3 | 12.5 | 28.2 | 0.199 | ||||
Sex of doctor (women) | 34.2 | 26.4 | 24.6 | 29.2 | 29.1 | 0.094 | ||||
Other general practitioners in the same building | 15.0 | 16.7 | 45.0 | 33.3 | 27.6 | 0.306 | ||||
Doctor works 26 hours/week or more in the clinic | 82.5 | 83.3 | 77.5 | 91.7 | 81.9 | 0.107 | ||||
Scope of services provided (broad or medium) | 58.2 | 67.9 | 86.0 | 83.3 | 70.9 | 0.260 | ||||
Doctor accepts new patients | 62.5 | 58.3 | 70.0 | 83.3 | 66.4 | 0.128 |
The model called “resourceless isolated” includes 79 practices (37.1%). It is characterized as having few resources in terms of availability of a nurse, other health professionals, information technologies, and X-ray and blood sample collection available on the premises. Moreover, level of collaboration of these practices is weak, both with other PHC practices and particularly with other healthcare organizations.
The 53 (24.9%) practices in the “resourceless collaborative” model also have few resources, but they have established collaborative relationships with other PHC practices and with hospitals. Doctors concentrate their activities in their main solo practice setting. In sum, these practices have probably compensated for their limited resources by establishing outside collaborations, to widen the range of services offered to their patients.
The 57 (26.8%) practices in the “resourceful not exclusive” model are characterized by their many resources, with their doctors likely to be affiliated with other PHC practices. These practices have not established collaborative relationships with other PHC practices and hospitals.
The fourth model is called “resourceful networked” and includes only 24 practices (11.3%). They show a high level of collaboration with other PHC practices and hospitals and have more resources. In addition, doctors tend to be affiliated with hospitals and emergency departments. These multisite activities, coupled with collaborative relationships with other practice settings, contribute to their high degree of networking.
Illustrative variables further characterize these four models. A high percentage of doctors in all four models spend 26 hours or more a week in their main practice, with the highest being in the “resourceful networked” (91.7%) and the lowest in the “resourceful not exclusive” model (77.5%). Practices in these two models are more likely to be located in buildings where there are other GPs and their doctors tend to be younger. Finally, these practices tend to offer a wide range of services (85%).
The degree of association between the four models and individual variables that served to construct the taxonomy is measured using Cramer’s V coefficient (Table
The four models of the taxonomy are not different regarding their patients’ characteristics. Patients of the “resourceless isolated” model differ in two characteristics: percentage of women and economic situation (Table
Characteristics of patients by solo practice model.
Resourceless isolated | Resourceless collaborative | Resourceful not exclusive | Resourceful networked | ||||
---|---|---|---|---|---|---|---|
( |
( |
( |
( | ||||
% | % |
|
% |
|
% | ||
Age (≥65 years) | 24.2 | 19.3 | 0.197 | 24.3 | 0.991 | 28.9 | 0.414 |
Sex (women) | 50.3 | 52.8 | 0.599 | 60.7# | 0.028# | 50.0 | 0.954 |
Level of education (high school degree or less) | 43.6 | 41.5 | 0.677 | 45.9 | 0.592 | 51.0 | 0.192 |
Economic situation (unfavorable) | 43.8 | 39.8 | 0.376 | 34.1# | 0.033# | 41.3 | 0.642 |
Perceived health (average or poor) | 15.2 | 17.0 | 0.590 | 15.5 | 0.915 | 21.6 | 0.164 |
Morbidities (at least one chronic disease) | 35.7 | 36.6 | 0.847 | 40.8 | 0.271 | 39.2 | 0.540 |
Reference:
Patients whose usual source of care is a “resourceful networked” practice report a better experience of care than those of the “resourceless isolated” practices. In addition, patients in the “resourceless isolated” practices report less continuity than those in the three other models (Table
Mean scores (0–10 scale) of patients’ experience of care by solo practice model.
Resourceless isolated | Resourceless collaborative | Resourceful not exclusive | Resourceful networked | ||||
---|---|---|---|---|---|---|---|
( |
( |
( |
( | ||||
Mean | Mean |
|
Mean |
|
Mean | ||
Accessibility | 6.16 | 6.15 | 0.924 | 6.38 | 0.137 | 6.66# | 0.006# |
Continuity | 8.74 | 9.12# | 0.004# | 9.23# | 0.000# | 9.29# | 0.000# |
Comprehensiveness | 8.43 | 8.54 | 0.553 | 8.64 | 0.631 | 8.93# | 0.029# |
Outcomes of care | 8.73 | 8.88 | 0.344 | 9.00 | 0.104 | 9.32# | 0.003# |
Reference:
Relationships between patients’ experience of care and solo practice models*.
(Score on 0–10 scale) |
Resourceless
isolated
( |
Resourceless
collaborative
( |
Resourceful
not exclusive
( |
Resourceful
networked
( | |||
---|---|---|---|---|---|---|---|
Coeff. |
|
Coeff. |
|
Coeff. |
| ||
Accessibility | Reference | 0.033 | 0.901 | 0.152 | 0.431 | 0.531# | 0.039# |
Continuity | Reference | 0.116 | 0.560 | 0.244 | 0.236 | 0.320 | 0.101 |
Comprehensiveness | Reference | −0.038 | 0.879 | 0.038 | 0.893 | 0.359 | 0.189 |
Outcomes of care | Reference | 0.028 | 0.899 | 0.084 | 0.734 | 0.580# | 0.004# |
Reference:
The main result of this study is that solo practices do not form a homogeneous group. The four models presented differ on many characteristics, particularly the “resourceless isolated” and the “resourceful networked” models. To our knowledge, very few studies have addressed this question, solo practices being generally viewed as the lowest category on a scale of practice size. More specifically, three types of characteristics distinguish the models of the taxonomy: collaborative relationships of the practice with other PHC practices and hospitals, affiliation of doctors with other practice settings, and level of resources available. Two models are relatively resourceful and two are rather resourceless. Likewise, two models have established collaboration agreements with other PHC practices and hospitals, whereas the two other models have little or no collaboration. Physicians tend to have hospital affiliations in two models. Practices in the “resourceful networked” model have successfully established collaboration with other practices and doctor affiliation with hospitals; they also benefit from an appropriate level of resources. This model includes only 24 practices, whereas they are most prevalent (79) in the “resourceless isolated” model. This model representing 37.1% of the solo practices probably contributes to the poor reputation sometimes associated with solo practices. Since nearly a third of physicians in this group are aged 65 and over, these practices will likely incur severe losses in the near future. Practices in the “resourceless collaborative” model will be facing similar problems as 38% of their doctors are 65 and over (Table
The practices in the “resourceful networked” model yield better results regarding their patients’ experience of care, compared with the practices in the “resourceless isolated” model.
The results concerning solo practices must be regarded in the light of current reforms that have taken place in PHC organizations in Canada. They raise the question of whether the new PHC models, based on group of increasing numbers of physicians on single sites within large multidisciplinary teams of health professionals, are the solution to problems faced in the delivery of PHC services [
To meet population needs, alternatives to the strategy of concentrating efforts and resources on a few “organizational champions” must be envisaged. This point was well expressed by Wensing et al. in conclusion to a study of eight European countries [
A similar conclusion was reached by Smith et al. in a recent report of the King’s Fund [
In light of the taxonomy just presented, solo practices in two models seem to be better prepared to face the challenges posed by such changes: these are practices in the “resourceful networked” and, to a lesser degree, of the “resourceful not exclusive” model. The former present conditions required for integration into larger networks and partnerships; the latter have established collaborative links with other PHC practices and hospitals through formal agreements and their doctors’ affiliation.
The main limitation of the study is the relatively small number of PHC units (
In spite of this limitation, interesting conclusions can be reached about the relationship of the models of the taxonomy with patient experience of care. These conclusions would need to be tested on larger populations. The nominal link between respondent in the population survey and usual of source of care in the organizational survey provides the opportunity to establish the relationship of patient experience of care with characteristics of their usual source of care. This is an original feature of the study.
Far from being homogeneous, solo practice takes on different heterogeneous forms and configurations. The taxonomy of solo practices has identified four models: “resourceless isolated,” “resourceless collaborative,” “resourceful not exclusive,” and “resourceful networked.” The practices in these four models present characteristics that distinguish them with regard to type and level of resources available and their relationships with other PHC practices and hospitals. Resourceful and networked practices through collaborative agreements and affiliation of their doctors with other practices seem to offer greater organizational potential to address challenges posed by currently ongoing PHC reforms.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This study was funded by the Canadian Institutes of Health Research (CIHR), Fonds de Recherche du Québec-Santé (FRQS), Agence de la Santé et des Services Sociaux de Montréal, Agence de la Santé et des Services Sociaux de la Montérégie, Institut National de Santé Publique du Québec (INSPQ), and Ministère de la Santé et des Services Sociaux du Québec (MSSS). The authors underline the important contribution of the Santé des Populations et Services de Santé research team attached to Direction de Santé Publique de l’Agence de la Santé et des Services Sociaux de Montréal and INSPQ, which supported the realization of this study. Finally, while the contributions of the research team, partner representatives, and scientific advisors are recognized, the views expressed in this paper remain the sole responsibility of its authors.