Influences on Scope of Practice: Not Only Population Size

To the Editor:

We read with great interest the article “Rural Curricular Guidelines Based on Practice Scope of Recent Residency Graduates Practicing in Small Communities” by Dr Skariah and colleagues.¹ Considering the lack of information about medical graduates’ scope of practice, we highly appreciate the authors’ endeavor to establish evidence for its impact on the quality of graduate medical education. However, we would like to point out two issues with the paper.

First, scope of practice in rural areas is different from that in urban areas in family medicine.² Since scope of practice should reflect community needs, factors affecting local health care must be taken into consideration. A recent study highlighted, in part, such factors. In this study, 67 items were identified as risk factors for disease and injury.³ This demonstrates that factors other than population influenced the incidence of diseases and injuries. The items include dietary factors, physical inactivity, and alcohol, tobacco, and drug use. Moreover, approximately 30% of scope of practice variation was attributable to geographic variables including distance to large hospitals, community size, and region. Among these three variables, distance to a large hospital had the greatest impact on physicians’ scope of practice.⁴ Thus, rural areas as defined by the authors solely based on population size could be heterogeneous in terms of disease structures and medical needs. We think it is reasonable to consider factors such as distance to large hospitals and other geographic variables and community needs in further studies.

Second, soon after graduation from residency, family medicine specialists are said to have a wider scope of practice compared to experienced family physicians, particularly in prenatal care, inpatient care, nursing home care, home visits, and women’s health procedures.⁵ Interestingly, work environments including job location influenced scope of practice less. One suggested hypothesis was that residents were too aspirational and tended to overestimate their scope of practice, because “residents may be unlikely to report that they do not intend to provide a service they have spent 3 years learning.” We would suggest for future research a similar study on the scope of practice of experienced specialists.