Characteristics of walk-in clinic physicians and patients in Ontario: Cross-sectional study.

OBJECTIVE: To describe family physicians who primarily practise in a walk-in clinic setting and compare them with family physicians who provide longitudinal care. DESIGN: A cross-sectional study that linked results from a 2019 physician survey to provincial administrative health care data in Ontario. The characteristics, practice patterns, and patients of physicians primarily working in a walk-in clinic setting were compared with those of family physicians providing longitudinal care. SETTING: Ontario. PARTICIPANTS: Physicians who primarily worked in a walk-in clinic setting in 2019, as indicated by an annual physician survey. MAIN OUTCOME MEASURES: Physician demographic and practice characteristics, as well as their patients' demographic and health care utilization characteristics, were reported according to whether the physician was a walk-in clinic physician or a family physician who provided longitudinal care. RESULTS: Compared with the 9137 family physicians providing longitudinal care, the 597 physicians who self-identified as practising primarily in walk-in clinics were more frequently male (67% vs 49%) and more likely to speak a language other than English or French (43% vs 32%). Walk-in clinic physicians tended to have more encounters with patients who were younger (mean 37 vs 47 years), who had lower levels of prior health care utilization (15% vs 19% in highest band), who resided in large urban areas (87% vs 77%), and who lived in highly ethnically diverse neighbourhoods (45% vs 35%). Walk-in clinic physicians tended to have more encounters with unattached patients (33% vs 17%) and with patients attached to another physician outside their group (54% vs 18%). CONCLUSION: Physicians who primarily work in walk-in clinics saw many patients from historically underserved groups and many patients who were attached to another family physician.

Chronic pain management in primary care: Using population-based data to examine family physician practice patterns.

OBJECTIVE: To examine trends in chronic pain (CP) practice patterns among community-based family physicians (FPs). DESIGN: Population-based descriptive study using health administrative data. SETTING: British Columbia from fiscal years 2008-2009 to 2017-2018. PARTICIPANTS: Patients with an algorithm-defined CP condition and community-based FPs, both registered with the British Columbia Medical Services Plan. MAIN OUTCOME MEASURES: Using British Columbia health administrative data and a CP algorithm adapted from a previous study, the following were compared between fiscal years 2008-2009 and 2017-2018: CP patient volumes, pain-related medication prescriptions, referrals to pain specialists, musculoskeletal imaging requests, and interventional procedures. RESULTS: In the fiscal year 2017-2018, among community-based family physicians (N=4796), an average of 32.5% of their patients had CP. Between 2008-2009 and 2017-2018, the proportion of CP patients per FP who were prescribed long-term opioids increased by an average absolute change of 0.56%; the proportion prescribed long-term neuropathic pain medications increased by 1.1%; and the proportion prescribed long-term nonsteroidal anti-inflammatory drugs decreased by 0.49%. The proportion of musculoskeletal imaging out of all imaging requests made by FPs increased by 2.0%; pain-related referrals increased by 1.73%; there was a 4.6% increase in the proportion of community-based FPs who performed 1 or more pain injections; and 10% more FPs performed 1 or more trigger point injections within a fiscal year. CONCLUSION: Findings show that the work of providing care to patients with CP increased while CP patient volumes per FP decreased. Workforce planning for community-based FPs should consider these increased demands and ensure FPs are adequately supported to provide CP care.

"Family doctors are also people": a qualitative analysis of how family physicians managed competing personal and professional responsibilities during the COVID-19 pandemic.

BACKGROUND: Family physicians (FPs) fill an essential role in public health emergencies yet have frequently been neglected in pandemic response plans. This exclusion harms FPs in their clinical roles and has unintended consequences in the management of concurrent personal responsibilities, many of which were amplified by the pandemic. The objective of our study was to explore the experiences of FPs during the first year of the COVID-19 pandemic to better understand how they managed their competing professional and personal priorities. METHODS: We conducted semi-structured interviews with FPs from four Canadian regions between October 2020 and June 2021. Employing a maximum variation sampling approach, we recruited participants until we achieved saturation. Interviews explored FPs' personal and professional roles and responsibilities during the pandemic, the facilitators and barriers that they encountered, and any gender-related experiences. Transcribed interviews were thematically analysed. RESULTS: We interviewed 68 FPs during the pandemic and identified four overarching themes in participants' discussion of their personal experiences: personal caregiving responsibilities, COVID-19 risk navigation to protect family members, personal health concerns, and available and desired personal supports for FPs to manage their competing responsibilities. While FPs expressed a variety of ways in which their personal experiences made their professional responsibilities more complicated, rarely did that affect the extent to which they participated in the pandemic response. CONCLUSIONS: For FPs to contribute fully to a pandemic response, they must be factored into pandemic plans. Failure to appreciate their unique role and circumstances often leaves FPs feeling unsupported in both their professional and personal lives. Comprehensive planning in anticipation of future pandemics must consider FPs' varied responsibilities, health concerns, and necessary precautions. Having adequate personal and practice supports in place will facilitate the essential role of FPs in responding to a pandemic crisis while continuing to support their patients' primary care needs.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond.

INTRODUCTION: Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice. METHODS: We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach. RESULTS: We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward. CONCLUSIONS: The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

Evaluating the cost of NP-led vs. GP-led primary care in British Columbia.

In 2020, British Columbia (BC) opened four pilot Nurse Practitioner Primary Care Clinics (NP-PCCs) to improve primary care access. The aim of this economic evaluation is to compare the average cost of care provided by Nurse Practitioners (NPs) working in BC's NP-PCCs to what it would have cost the government to have physicians provide equivalent care. Comparisons were made to both the Fee-For-Service (FFS) model and BC's new Longitudinal Family Physician (LFP) model. The analyses relied on administrative data, mostly from the Medical Services Plan (MSP) and Chronic Disease Registry (CDR) via BC's Health Data Platform. Results show the cost of NPs providing care in the NP-PCCs is slightly lower than what it would cost to provide similar care in medical clinics staffed by physicians paid through the LFP model. This suggests that the NP-PCC model is an efficient approach to increase accessibility to primary care services in BC and should be considered for expansion across the province.

Access to episodic primary care: a cross-sectional comparison of walk-in clinics and urgent primary care centers in British Columbia.

AIM: This study aimed to identify publicly reported access characteristics for episodic primary care in BC and provided a clinic-level comparison between walk-in clinics and UPCCs. BACKGROUND: Walk-in clinics are non-hospital-based primary care facilities that are designed to operate without appointments and provide increased healthcare access with extended hours. Urgent and Primary Care Centres (UPCCs) were introduced to British Columbia (BC) in 2018 as an additional primary care resource that provided urgent, but not emergent care during extended hours. METHODS: This cross-sectional study used publicly available data from all walk-in clinics and UPCCs in BC. A structured data collection form was used to record access characteristics from clinic websites, including business hours, weekend availability, attachment to a longitudinal family practice, and provision of virtual services. FINDINGS: In total, 268 clinics were included in the analysis (243 walk-in clinics, 25 UPCCs). Of those, 225 walk-in clinics (92.6%) and two UPCCs (8.0%) were attached to a longitudinal family practice. Only 153 (63%) walk-in clinics offered weekend services, compared to 24 (96%) of UPCCs. Walk-in clinics offered the majority (8,968.6/ 78.4%) of their service hours between 08:00 and 17:00, Monday to Friday. UPCCs offered the majority (889.3/ 53.7%) of their service hours after 17:00. CONCLUSION: Most walk-in clinics were associated with a longitudinal family practice and provided the majority of clinic services during typical business hours. More research that includes patient characteristics and care outcomes, analyzed at the clinic level, may be useful to support the optimization of episodic primary healthcare delivery.

Evaluation of audit and feedback to family physicians on prescribing of opioid analgesics to opioid-naïve patients: A pragmatic randomized delay trial.

BACKGROUND: Exposure to opioid analgesics have historically raised concern for a risk of developing opioid use disorder. Prescriber audit-and-feedback interventions may reduce opioid prescribing, but some studies have shown detrimental effects for current users. We examined the effectiveness of an audit and feedback intervention, named Portrait, to reduce initiation of opioid analgesics among opioid-naïve patients experiencing pain. METHODS: REDONNA was a single-blinded, two-arm (Early vs Delayed mailing) randomized trial of a portrait for eligible family physicians (FPs) in British Columbia (BC), Canada. The primary outcome was the change in the number of initiations of opioid analgesic prescriptions written by FPs for acute/chronic pain management. We compared outcomes for a 6-month window before vs. after each mailed intervention, using differences in percent differences (DPD) with 95% confidence intervals (CI) and odds ratios (OR) from logistic regressions adjusted for clustering of patients by FP. RESULTS: In the Early (n = 2260) and Delayed (n = 2156) groups, opioid initiations per month were the same in the Before (2.10 Early; 2.06 Delayed) and After (1.94 Early; 1.95 Delayed) windows. The DPD was -2.1% (CI: -4.4% to 0.3%), and ORs were: 0.98 (CI: 0.96 to 1.01) for any opioid, 0.97 (CI: 0.94 to 1.01) for codeine (62% of initiations), and 1.0 (CI: 0.97 to 1.07) for tramadol (25% of initiations). There were no differences in mean quantity of tablets, mean milligrams of morphine equivalents (MME), or mean number of days. CONCLUSION: Portrait had no impact on FPs' rates of prescribing opioid analgesics to opioid-naïve patients experiencing pain. TRIAL REGISTRATION: The study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).

Productivity Decline or Administrative Avalanche? Examining Factors That Shape Changing Workloads in Primary Care.

Background: In Canada, family physicians (FPs) per capita have increased but so have access challenges. We explored changes in population characteristics, service delivery and FP practice that may help understand these trends. Methods: We used linked administrative data in British Columbia to describe changes in patient ages and comorbidities, hospitalizations and receipt of services that may require FP coordination, review and/or follow-up: prescriptions dispensed, laboratory tests, diagnostic imaging (radiology and ultrasound), specialist visits and emergency department visits. We estimate the number of FPs delivering community-based comprehensive care and report changes in service volume per community-based FP visit. Results: Between 1999/2000 and 2017/2018, people experienced fewer days in hospital, but the number of treated comorbidities, day surgeries and other services requiring FP coordination increased over and above the expected levels attributed to population aging. While the total number of FPs per capita have increased, numbers in community-based care have not and visits per physician have fallen. Increases in services that may involve FP coordination per community-based FP visit ranged from 32.2% for diagnostic radiology to 122.1% for lab tests. Conclusion: Findings suggest substantially increased coordination workload per FP visit. Ongoing impacts of population aging and changing service delivery on primary care workload require further examination.

Changes in comprehensiveness of services delivered by Canadian family physicians: Analysis of population-based linked data in 4 provinces.

OBJECTIVE: To describe changes in the comprehensiveness of services delivered by family physicians across service settings and service areas in 4 Canadian provinces, to identify which settings and areas have changed the most, and to compare the magnitude of changes by physician characteristics. DESIGN: Descriptive analysis of province-wide, population-based billing data linked to population and physician registries. SETTING: British Columbia, Manitoba, Ontario, and Nova Scotia. PARTICIPANTS: Family physicians registered to practise in the 1999-2000 and 2017-2018 fiscal years. MAIN OUTCOME MEASURES: Comprehensiveness was measured across 7 service settings (home care, long-term care, emergency departments, hospitals, obstetric care, surgical assistance, anesthesiology) and in 7 service areas consistent with office-based practice (prenatal and postnatal care, Papanicolaou testing, mental health, substance use, cancer care, minor surgery, palliative home visits). The proportion of physicians with activity in each setting and area are reported and the average number of service settings and areas by physician characteristics is described (years in practice, sex, urban or rural practice setting, and location of medical degree training). RESULTS: Declines in comprehensiveness were observed across all provinces studied. Declines were greater for comprehensiveness of settings than for areas consistent with office-based practice. Changes were observed across all physician characteristics. On average across provinces, declines in the number of service settings and service areas were highest among physicians in practice 20 years or longer, male physicians, and physicians practising in urban areas. CONCLUSION: Declining comprehensiveness was observed across all physician characteristics, pointing to changes in the practice and policy contexts in which all family physicians work.

For health or for profit? Understanding how private financing and for-profit delivery operate within Canadian healthcare (4H|4P): protocol for a multimethod knowledge mobilisation research project.

INTRODUCTION: Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery. METHODS AND ANALYSIS: This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada's healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation ('cases'). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery. ETHICS AND DISSEMINATION: We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.

What can publicly funded schools teach us about how to fix the family doctor shortage?

Recent estimates suggest that up to 22% of Canadians over 18 do not have regular access to a family doctor or nurse practitioner. This lack of access is often characterized as a "family doctor shortage" and has been making headlines for decades. However, we have more family doctors than ever before, and in fact, the lack of primary care access is less about a shortage of physicians and more a need to develop a modern infrastructure and new way of funding and organizing care. Real change will require a paradigm shift from doctor- to clinic-organized care. The example of how schools are organized for public education may hold answers about how to make that paradigm shift and with investment in infrastructure see improvements in access to care across the country.

"I'm almost opioid-a-phobic": family medicine residents' perceptions of enhancing opioid analgesic and agonist treatment training in a Canadian setting.

PURPOSE: As deaths from the illicit drug poisoning crisis continue to rise in Canada, increasing the number of healthcare professionals qualified to effectively prescribe opioids could be beneficial. The willingness of family medicine residents to undertake structured training in prescribing opioids for Opioid Agonist Treatment (OAT) and pain management have not been well described. MATERIALS AND METHODS: Family medicine residents (n = 20) in British Columbia, Canada, were asked about their experience with and willingness to enrol in OAT training. Informed by the Consolidated Framework for Implementation Research, data were analysed thematically using NVivo software. RESULTS: Four themes were identified: (1) challenges to training implementation, (2) feelings and attitudes on prescribing practices, (3) helpful learning spaces and places of substance use training, and (4) recommendations for implementing training. Preparedness, exposure, and supportive learning environments for substance use education increased willingness to pursue OAT accreditation, while ineffective learning experiences, mixed feelings about opioid prescribing, and lack of protected time were the most common reasons for unwillingness. CONCLUSIONS: Protected time and a range of clinical experiences appear to facilitate residents' willingness to complete OAT and opioid training. Implementation strategies to enhance the uptake of OAT accreditation in family medicine residency must be prioritised.

Up-to-date on cancer screening among Ontario patients seen by walk-in clinic physicians: A retrospective cohort study.

Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care.

Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study.

BACKGROUND: Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. METHODS: We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. RESULTS: Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21). INTERPRETATION: Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.

"There's nothing like a good crisis for innovation": a qualitative study of family physicians' experiences with virtual care during the COVID-19 pandemic.

BACKGROUND: Prior to the pandemic, Canada lagged behind other Organisation for Economic Cooperation and Development countries in the uptake of virtual care. The onset of COVID-19, however, resulted in a near-universal shift to virtual primary care to minimise exposure risks. As jurisdictions enter a pandemic recovery phase, the balance between virtual and in-person visits is reverting, though it is unlikely to return to pre-pandemic levels. Our objective was to explore Canadian family physicians' perspectives on the rapid move to virtual care during the COVID-19 pandemic, to inform both future pandemic planning for primary care and the optimal integration of virtual care into the broader primary care context beyond the pandemic. METHODS: We conducted semi-structured interviews with 68 family physicians from four regions in Canada between October 2020 and June 2021. We used a purposeful, maximum variation sampling approach, continuing recruitment in each region until we reached saturation. Interviews with family physicians explored their roles and experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support their patients through the pandemic. Interviews were audio-recorded, transcribed, and thematically analysed for recurrent themes. RESULTS: We identified three prominent themes throughout participants' reflections on implementing virtual care: implementation and evolution of virtual modalities during the pandemic; facilitators and barriers to implementing virtual care; and virtual care in the future. While some family physicians had prior experience conducting remote assessments, most had to implement and adapt to virtual care abruptly as provinces limited in-person visits to essential and urgent care. As the pandemic progressed, initial forays into video-based consultations were frequently replaced by phone-based visits, while physicians also rebalanced the ratio of virtual to in-person visits. Medical record systems with integrated capacity for virtual visits, billing codes, supportive clinic teams, and longitudinal relationships with patients were facilitators in this rapid transition for family physicians, while the absence of these factors often posed barriers. CONCLUSION: Despite varied experiences and preferences related to virtual primary care, physicians felt that virtual visits should continue to be available beyond the pandemic but require clearer regulation and guidelines for its appropriate future use.

Declining Comprehensiveness of Services Delivered by Canadian Family Physicians Is Not Driven by Early-Career Physicians.

We describe changes in the comprehensiveness of services delivered by family physicians in 4 Canadian provinces (British Columbia, Manitoba, Ontario, Nova Scotia) during the periods 1999-2000 and 2017-2018 and explore if changes differ by years in practice. We measured comprehensiveness using province-wide billing data across 7 settings (home, long-term care, emergency department, hospital, obstetrics, surgical assistance, anesthesiology) and 7 service areas (pre/postnatal care, Papanicolaou [Pap] testing, mental health, substance use, cancer care, minor surgery, palliative home visits). Comprehensiveness declined in all provinces, with greater changes in number of service settings than service areas. Decreases were no greater among new-to-practice physicians.

The roles of family physicians during a pandemic.

Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by family physicians in five distinct stages of pandemic response: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting public health guidance to ensure continued access to primary care services, family physicians were often expected to operationalize public health roles (eg, staffing assessment centres), modulate access to secondary/tertiary services, help provide surge capacity in acute care facilities, and enhance supports and outreach to vulnerable populations. Future pandemic plans should include family physicians in planning, explicitly incorporate family physician roles, and ensure needed resources are available to allow for an effective primary care response.

Changes over time in patient visits and continuity of care among graduating cohorts of family physicians in 4 Canadian provinces.

BACKGROUND: Lack of patient access to family physicians in Canada is a concern. The role of recent physician graduates in this problem of supply of primary care services has not been established. We sought to establish whether career stage or graduation cohort were related to family physician practice volume and continuity of care over time. METHODS: We conducted a retrospective cohort study of family physician practice from 1997/98 to 2017/18. We collected administrative health and physician claims data in British Columbia, Manitoba, Ontario and Nova Scotia. We included all physicians who registered with their respective provincial regulatory colleges as having a medical specialty of family practice or who had billed the provincial health insurance system for patient care as family physicians, or both. We used regression models to isolate the effects of 3-year categories of years in practice (at all career stages), time period and cohort on patient contacts and physician-level continuity of care. RESULTS: Between 1997/98 and 2017/18, the median number of patient contacts per provider per year fell by between 515 and 1736 contacts in the 4 provinces examined. Median contacts peaked at 27-29 years in practice in all provinces, and median physician-level continuity of care increased until 30 or more years in practice. We found no association between graduation cohort and patient contacts or physician-level continuity of care. INTERPRETATION: Recent cohorts of family physicians practise similarly to their predecessors in terms of practice volumes and continuity of care. Because family physicians of all career stages showed declining patient contacts, we suggest that system-wide solutions to recent challenges in the accessibility of primary care in Canada are needed.