Impact of primary care physicians working part-time on patient care: A scoping review

Abstract

Background

Increasing numbers of primary care physicians (PCPs) are reducing their working hours. This decline may affect the workforce and the care provided to patients.

Objectives

This scoping review aims to determine the impact of PCPs working part-time on quality of patient care.

Methods

A systematic search was conducted using the databases PubMed, CINAHL, Embase, and the Cochrane Library. Peer-reviewed, original articles with either quantitative, qualitative or mixed methods designs, published after 2000 and written in any language were considered. The search strings combined the two concepts: part-time work and primary care. Studies were included if they examined any effect of PCPs working part-time on quality of patient care.

Results

The initial search resulted in 2,323 unique studies. Abstracts were screened, and information from full texts on the study design, part-time and quality of patient care was extracted. The final dataset included 14 studies utilising data from 1996 onward. The studies suggest that PCPs working part-time may negatively affect patient care, particularly the access and continuity of care domains. Clinical outcomes and patient satisfaction seem mostly unaffected or even improved.

Conclusion

There is evidence of both negative and positive effects of PCPs working part-time on quality of patient care. Approaches that mitigate negative effects of part-time work while maintaining positive effects should be implemented.

Keywords:

• General practice
• primary care physician
• quality of care
• part-time employment

KEY MESSAGES

• Studies suggest primary care physicians working part-time may negatively affect access and continuity, whereas the quality of medical care and patient satisfaction seem mostly unaffected or improved.

• Approaches exist to alleviate the negative effects.

• Future research should use a standardised definition of part-time work for comparisons.

Introduction

Increasing numbers of primary care physicians (PCPs) are reducing their work hours. Proposed factors contributing to this development are demographical changes in the workforce such as the increased proportion of female PCPs, and the rise of part-time (PT) work connected to shifting generational interests among younger PCPs from career-oriented perspectives to improved work-life balance [1–3]. Lastly, changes in how primary care is organised may enable this development, as primary care is moving away from PCPs working in full-time (FT) single-handed practices towards more extensive group practices with two or more PT PCPs [4].

'Full-time’ refers to the traditional work schedule of PCPs, typically involving a standard number of hours per week. On the other hand, 'part-time’ encompasses any form of reduced work hours compared to the standard full-time schedule. Considering the changing healthcare landscape, Hodes et al. highlight the complexities of defining full-time work in general practice. The definition of full-time work in the field of general practice has been a subject of debate, as the role of a PCP has become more demanding over time and many PCPs working part-time easily work longer hours than the official definition of FT hours [5].

Not only the workforce itself but also their patients face changes. Timely access to a PCP and continuity of care are both important indicators of quality of care [6,7]. Both indicators are affected if a PCP is only available a reduced number of days per week or a different PCP sees a patient due to reduced availability of their usual PCP. Other domains of the quality of patient care that may be affected by PT work are clinical outcomes, overall patient satisfaction and communication with the patient. The quality of care provided to patients must not suffer because of these developments. Therefore, knowledge of the consequences of PCPs reducing their work hours is vital so approaches mitigating harmful effects can be developed. This scoping review aims to determine the impact of PCPs working PT on quality of patient care.

Methods

To answer our research question, we conducted a scoping review following the guidelines of the PRISMA-ScR checklist (cf. supplementary material). A scoping review was the appropriate study design to support our aim as the heterogenous concept of PT does not allow us to pool quantitative results [8]. This study is a literature review without patient data and, therefore, requires no ethical approval.

Literature search

A systematic search was conducted using the following four databases: PubMed, EMBASE, Cinahl, and the Cochrane Library. The search string used a combination of MeSH terms (for PubMed), Emtree terms (for EMBASE), and free-text terms with Boolean operators. The search strings combined the two concepts PT work and primary care (cf. supplementary material). Finally, a hand search was performed based on the reference lists of selected articles.

Inclusion criteria

Peer-reviewed, original articles with either quantitative, qualitative, or mixed methods designs, published after 2000 written in any language were considered for inclusion. Studies were included if they examined any effect of PCPs working PT on quality of patient care, referring to the range of effects and outcomes that can arise when PCPs work part-time. We regarded any reduced (weekly/monthly/yearly) work hours as PT work, regardless of the terminology used by the articles in question. A PCP was understood to be a physician providing primary care, first-contact, accessible, continuous, comprehensive, and coordinated person-focused care as defined by the WHO [9].

Articles were excluded if (1) PT work was not studied as part of the research questions (2) patient impact was not examined (3) primary care was not the setting (4) the full text was unobtainable (5) the article was not a peer-reviewed original article, i.e. comments, opinions, editorials, or 6) there was insufficient information reported in the article to answer our research question.

Selection

We performed a selection in two steps. First, the abstracts and titles of the retrieved publications were screened by the first author (SK). A random sample of 659 abstracts (around 28%) was screened by a second researcher (RT) and an agreement rate of 89% was reached. Discrepancies in the selection choices were discussed among the two researchers and a third researcher was consulted in case of disagreements (SE). Both RT and SE have previous experience undertaking evidence reviews [10,11]. The 75 abstracts the authors disagreed upon consisted of 52 abstracts the second researcher ruled out and 23 papers the second researcher ruled in. The papers were screened manually without utilising any software tools. Second, full texts were reviewed for inclusion by both researchers. None of the 23 abstracts ruled in by the second researcher were included in the final selection.

Data charting

Data from the included articles were abstracted and structured in a table. The table contained the title, first author, year of publication, country of origin, study design, population, and outcomes. This process was performed by the first author and discussed with the other researchers. Finally, we critically appraised the individual articles using the MMAT tool [12]. SK appraised the quality and the results were discussed among the research team to finalise the reporting (cf. supplementary material).

Results

Study selection

The literature search was performed on 23 March 2023. As shown in Figure 1, the search identified 2,323 potentially eligible publications after removing duplicates, and 14 additional publications were identified by hand search. After screening titles and abstracts, 203 full texts were assessed and 14 quantitative studies were included for further analysis.

Figure 1. PRISMA flowchart.

Description of included studies

The included studies were published between 2000 and 2020 and utilised data from 1996 onward (Table 1). Eight were conducted in the USA [13–20], one in Canada [21], one in Australia [22], one in Denmark [23], and one in the Netherlands [24]. Two studies were conducted in multiple countries: the first was conducted in 9 European countries [25] and the more recent in 31 European Countries, Canada and New Zealand [26]. Eight studies used questionnaires [15,19,21–23,25,26] or telephone surveys [20] for data collection, one used administrative data [18], and four used a combination of questionnaires and administrative data [13,14,16,17] or practice visits [24]. Three questionnaire-based studies [23–25] used EUROPEP, an internationally standardised measure of patients’ evaluation of care [27] and two [21,26] used data from the QUALICOPC study, a large international cross-sectional study on primary health care performance conducted in 35 countries [28]. All studies addressed community-based PCPs and three additionally considered hospital-based PCPs [13,16,20]. Most studies exclusively investigated general practitioners or family physicians, whereas three studies also included PCPs of other specialities such as paediatrics, internal medicine, and geriatrics [14,15,18].

Table 1. Characteristics of included studies.

Title	Authors and year	Location	Design	Population	Impact of PT work on quality of patient care	PT Definition
The association between the workload of general practitioners and patient experiences with care: results of a cross-sectional study in 33 countries	Schäfer WLA et al. 2020	31 European Countries and 2 non-European (Canada and New Zealand)	Questionnaire-based cross-sectional survey, using data from QUALICO-PC study	7031 GPs, 67873 Patients	Higher GP work hours per week were associated with better patient-reported quality of care, specifically in the domains of: Communication (regression coefficient 0.01, 95% CI: 0.00–0.02)* Continuity (regression coefficient 0.05, 95% CI: 0.03–0.08)** Comprehensiveness of care (regression coefficient 0.04, 95% CI: 0.01–0.07)** No significant association with accessibility was found (regression coefficient 0.02, 95% CI: − 0.00 to 0.04) A longer consultation time was only related to better comprehensiveness. A positive association between GP job satisfaction and patient-reported experiences of care (all 4 domains mentioned above) was also reported. The relation between patient perceived continuity and work hours was stronger when the GPs were more satisfied. *p < 0.05 **p < 0.01	Weekly working hours
Primary health care organisational characteristics associated with better accessibility: data from the QUALICO-PC survey in Quebec	Paré-Plante AA, 2018	Canada, Quebec	Questionnaire-based cross-sectional survey, using data from QUALICO-PC study	218 GPs, 1,798 patients	Practices with GPs working longer hours were associated with better patient-reported accessibility (adjusted OR: 1.03, CI 95%: 1.00– 1.06, p-value: 0.03). Same-day access, higher family physician working hours, and an increased number of physicians from other disciplines in the clinic were associated with improved patient-reported accessibility. The presence of nurses offering primary care services in the clinic was not associated with first-contact accessibility.	Weekly working hours
Patient satisfaction with availability of general practice: an international comparison	Wensing M, 2002	Denmark, Germany, Netherlands, Spain, Belgium, Norway, UK, Switzerland, Slovenia	Questionnaire-based cross-sectional survey, (using the Europep instrument for patient evaluation)	481 GPs, 15,996 patients	Higher GP work hours and fewer GPs and health care providers per practice were associated with better patient-reported accessibility (OR > 1). None of the associations was found consistently across all countries.	Weekly working hours
Hours worked by general practitioners and waiting times for primary care	Swami M, 2018	Australia	Statistical analysis of MABEL Survey data 2008-2014 (a questionnaire)	14,544 observations of 3,561 GPs	A 10% reduction in work hours results in a 12% increase in waiting time.	Weekly working hours
Measuring Patient-Centred Medical Home Access and Continuity in Clinics With Part-Time Clinicians	Rosland AM, 2015	United States, 2 sites	Retrospective analysis of 110,454 primary care visits and patient-experience survey (N = 2,881)	68 PCPs, 110,454 primary care visits, survey of 2,881 patients	Patients of part-time PCPs had less same day access to their usual PCP than patients of full-time PCPs (predicted probability 17% for PCPs with 2 sessions/week, 20% for 5 sessions/week, and 26% for 10 sessions/week). However clinic-level same-day access, same-week access to the usual PCP, and the overall rate of continuity (> 92%) were similar for patients of part-time and full-time PCPs.	‘At the examined sites, PCPs are assigned 120 patients for each half-day session they cover in PC clinic each week’. […] A cut-off of 480 or fewer patients (corresponding to 4 half-day sessions/week) distinguished ‘part-time’ from ‘full-time’ PCPs in dichotomous analyses’.
Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access	Panattoni L, 2015	1 site, California, United States	12 month observational study of PCPs and patient survey	104 Family physicians, 101 internal medicine physicians, 12688 patient survey responses	Higher Physician FTE was associated with: Better continuity of care received (0.172 % per FTE, p < 0.001) Better continuity of care provided (0.108 % per FTE, p < 0.001) better access to care (−0.033 days to third next available appointment per FTE, p < 0.01) Worse patient satisfaction (−0.080 % per FTE, p = 0.03) ‘Physicians who worked fewer clinical FTEs and who cared for more of their own patients received higher patient satisfaction scores, regardless of their patient’s continuity of care received or access to care’.	% FTE (100%= 34 clinical hours/week)
Part-time physicians. Physician workload and patient-based assessments of primary care performance	Murray A, 2000	Massachusetts, United States	Cross-sectional study, questionnaire-based patient and physician survey.	992 physicians (whereof 78 PT), 6,810 patients	7 domains of performance were assessed through 11 summary scales: accessibility (organisational and financial), continuity of care (longitudinal and visit-based), comprehensiveness (contextual knowledge of patient and preventive counselling), integration, clinical interaction (clinician-patient communication and thoroughness of physical examinations), interpersonal treatment, and trust. Physicians working more than 65 h per week provide higher visit-based continuity of care (p < 0.05) however all other physicians (including part-time physicians) performed the same in every other category examined. The authors note that the organisational structure within which a physician works may have a greater influence on visit-based continuity of care than physician work hours alone. There was no difference between the groups with the physicians’ satisfaction with the quality of care provided. Physicians working more than 65 h were significantly less satisfied with the amount of time they had for family and personal life as well as the amount of time they spent with each patient (p < 0.05).	full time = 40-65 h/wk, part time < 40 h/wk
Productivity, quality, and patient satisfaction: comparison of part-time and full-time primary care physicians	Fairchild DG, 2001	2 Hospital and affiliated Community based PCP, Massachusetts, United States	Retrospective Cohort study utilising administrative hospital data	69 PT PCPs and 63 FT PCPs	Comparison of FT and PT PCPs in the following categories: Productivity (measured as relative work units) Quality of preventative care (measured by PCP compliance with screening goals for Pap smear, mammography and cholesterol measurement) Patient satisfaction (questionnaire) Risk adjusted resource utilisation (based on claims data) PT PCP achieved a higher score in productivity (2.1 vs. 1.3 relative work units, 62% higher than FT PCPs) and achieved similar results as FT PCPs in all other categories. Most PT PCPs practiced clinical medicine part-time but were employed full-time, performing responsibilities such as teaching, research, or administrative duties.	PT < 20 bookable hours per week in ambulatory clinical practice
Effect of part-time practice on patient outcomes	Parkerton PH, 2001	25 outpatient-clinics of a single medical group in western Washington, United States	Retrospective Cross-sectional study utilising administrative data	156 PT PCPs and 38 FT PCPs	Comparison of FT and PT PCPs in the following categories: Preventative services (cancer screening, specifically rates of Pap smears and mammographies) Treatment services (diabetes management, calculated by the mean rates of micro-albuminuria testing, haemoglobin A1c testing, annual retinal examinations, and annual foot examinations) Patient-reported outcomes (patient satisfaction, measured with a survey) Economic outcomes (ambulatory costs) After controlling for confounders PT PCPs had higher rates of preventative services / cancer screening (4% higher, p = 0.001) and treatment services / diabetes management (3% higher, p = 0.033), but no significant association was found in the categories of patient satisfaction (p = 0.212) and ambulatory costs (p = 0.323). PT PCPs were more likely to be female and less senior than FT PCPs.	% FTE (100%= 35 clinical hours/week)
Panel Size, Clinician Time in Clinic, and Access to Appointments	Margolius D, 2018	Ohio, United States, 20 locations	Retrospective analysis utilising administrative data	44 family medicine, 42 internal medicine, 13 medicine-paediatrics, 13 paediatrics, and 2 geriatrics	Lower FTE was associated with worse access to care (measured as number of days until third next available appointment) independently of panel size and number of clinicians per site (r = −0.51, SE 0.11, p < 0.001). Panel size was not independently correlated with access to care, but larger panel size adjusted for clinician time in clinic was associated with worse access.	% FTE as determined by the number of weekly half-day sessions
Doctor and practice characteristics associated with differences in patient evaluations of general practice	Heje HN, 2007	Denmark	Questionnaire-based patient survey (DanPEP survey data)	365 GPs, 28 260 patient evaluations	The patient questionnaire covered five dimensions: doctor-patient relationship, medical care, information and support, organisation of care, and accessibility GPs in single-handed practices received the best evaluation with regard to accessibility. Long weekly working hours were associated with more positive evaluations in all assessed dimensions (including continuity) except accessibility, however, a larger number of patients per GP resulted in worse evaluations of accessibility. GPs working part-time in partnership practices were assessed least favourably with regard to accessibility, however, they were assessed slightly more favourably with regard to the GPs’ technical care. Evaluation of accessibility was mostly influenced by practice characteristics while GP characteristics were mainly associated with patients’ experience of interpersonal aspects of care.	Weekly working hours
Part-time physicians…prevalent, connected, and satisfied	Mechaber HF, 2008	Upper Midwest and New York City, United States	Questionnaire-based survey of physicians and patients	77 PT physicians, 343 FT physicians, 1,794 patients	‘Patient satisfaction (1.45 for part- time vs 1.52 for full-time, p =.206) and trust in the physician (4.57 vs 4.50, p =.200) did not differ between part-time and full- time physicians’.	< 35 h = Part-time cut-off point
High workload and job stress are associated with lower practice performance in general practice: an observational study in 239 general practices in the Netherlands	van den Hombergh P, 2009	Netherlands	Practice visit and questionnaire-based cross-sectional correlational analysis (using the instruments EUROPEP and VIP)	239 Practises with 546 GPs (whereof 179 FT GPs), questionnaires answered by 30 patients per GP and 30 patients per practice	Working more hours per week resulted in better patient experiences of accessibility and availability (b = 0.16 ± .07, p < 0.05). Patient opinion of quality of care was higher when doctors spent more time per patient (b = 0.45, ± 0.12, p < 0.0001) but time spent on direct patient care as a proportion to the GPs total workload had no significant effect. Less job stress was associated with better organisation of the practice (b = 0.25 ± 0.1, p < 0.05) and better patient experiences of accessibility and availability (b = 0 .21 ± .09, p < 0.05). ‘For a practice of 2000 patients an average GP would have to work on average more than 40 h to score over 80%’. The measure ‘prevention and disease management’ was not associated with weekly work hours.	Weekly working hours
Is the professional satisfaction of general internists associated with patient satisfaction?	Haas JF, 2000	11 general internal medicine practices (whereof 6 hospital-based practices) in the greater-Boston area, United States	Cross-sectional survey of patients and physicians	166 physicians (whereof 77% worked full time) and 2,620 patients	Patients of doctors working part-time reported higher overall satisfaction with their healthcare (-2.49, 95% CI: −3.91, −1.06) and their most recent physician visit (-1.17, 95% CI: −2.21, −0.13).	Differentiates between FT and PT but does not explain on what basis

The studies’ definitions of PT work varied. Four studies defined PT work as several sessions or weekly work hours below a predefined cut-off [13,15,16,19]. Three studies measured the percentage of a PCP’s full-time equivalent (FTE)[14,17,18] and six studies did not dichotomise between FT and PT status but instead measured weekly work hours as a continuous variable [21–26]. One study differentiated between FT and PT status but did not explain the definition used [20].

Narrative synthesis

Analysis of the studies revealed various outcomes of PT work impacting patient care. These outcomes, i.e. accessibility, continuity of care, clinical outcomes, overall patient satisfaction, and communication, are summarised hereafter.

Accessibility

We found 10 studies determining patients’ ease of access to their PCPs. The studies mostly agreed that a higher FTE was associated with better accessibility. Seven studies supported this finding [13,14,18,21,22,24,25], e.g. by showing that a 10% reduction in weekly work hours resulted in a 12% increase in waiting time [22]. Two studies measured accessibility as a PCP's mean number of days until the third-next available appointment [14,18]. In the study by Panattoni et al. that mean was 3.8 days among PCPs working FT, and 6.2 days among PCPs working 50--60% FTEs [14]. Rosland et al. reported that patients of PT PCPs had less same-day access to their usual PCP than patients of FT PCPs [13]. However, clinic-level same-day access and same-week access to the usual PCP were similar for both patient groups. At the sites studied, patient panels were assigned to teams of one FT PCP, one registered nurse, and one medical assistant. One FT PCP role could be shared among several PT PCPs.

Three questionnaire-based studies found no association between working hours and accessibility [15,23,26]. A Danish study reported that practice characteristics mostly influenced accessibility: PCPs in single-handed practices with short patient lists received more positive evaluations from patients, whereas working hours had no significant effect on perceived accessibility [23].

Continuity of care

We found five studies that measured the continuity of care experienced by patients. Three of these studies found a positive association between weekly work hours and continuity of care [14,23,26]. One study [14] further differentiated between continuity of care provided (which measured the percentage of time PCPs spent seeing their patients) and continuity of care received (which measured patients’ experience). Both measures were positively associated with higher PCP FTE.

Two studies addressing continuity of care found no statistically significant difference between FT and PT PCPs [13,15]. However, PCPs working overtime (more than 65 h per week) were associated with improved continuity. The effect size was relatively small and the authors noted that the organisational structure in which PCPs operated had a five-fold more significant effect on continuity than work hours alone. Further, no group difference was found in the category ‘knowledge of the patient’ [15].

Patient satisfaction

Six studies measured patients’ satisfaction with their PCPs. Four studies found no difference between FT and PT [15–17,19]. In one of the four studies, patients were asked if they would recommend their PCP to a friend [15]. When comparing FT with PT PCPs, no difference was found. However, the proportion of patients who would recommend their PCP was statistically significantly greater among PCPs working overtime (i.e. more than 65 h per week). This was the only study reporting a positive correlation between higher FTE and patient satisfaction.

Two studies found improved patient satisfaction for PT PCPs [14,20]. Haas et al. found that patients of PCPs working PT reported higher overall satisfaction with their health care and their most recent PCP visit. Additionally, patients were more satisfied with these two outcome measures if their PCPs reported a higher professional satisfaction [20].

Three studies used questionnaires answered by patients regarding their opinions on the care they received from their PCPs [23,24,26]. Two of these suggested that patient-reported quality of care increased with work hours [23,26]. An international study found that patients of PCPs working more hours per week reported better comprehensiveness of care, defined as PCPs addressing multiple problems, including personal problems [26]. While Van den Homberg et al. found no statistically significant association between work hours and patient-reported quality of medical care, they identified a powerful association between total PCP time per patient and increased patient-reported quality of medical care [24].

Clinical outcomes

Various measures assessed the clinical outcomes: Two studies used clinical indicators, specifically rates of Pap smear and mammography [16,17], diabetes management [17], and cholesterol measurement [16] to quantify this dimension. One study used 11 indicators (including diabetes mellitus, cardiovascular disease, asthma/COPD, Pap smear, and lifestyle advice) to measure prevention and disease management [24]. One study surveyed PCPs’ satisfaction with the quality of medical care they provided [15].

Most studies found no difference in clinical outcomes associated with work hours [15,16,24]. One report showed a slight increase in quality: After controlling for confounders, PT PCPs had higher rates of Pap smear and mammography (4% higher) and diabetes management (3% higher) [17]. Murray et al. found no statistically significant difference between FT and PT PCPs regarding their satisfaction with the quality of medical care they provided. PCPs working more than 65 h were significantly less satisfied with the time they had for each patient [15].

Communication and the PCP--patient relationship

Only three questionnaire-based studies examined interpersonal aspects of care, such as communication and the relationship between PCPs and their patients. Two studies found positive effects of longer work hours for this domain, reporting better communication, [26] and an improved PCP-patient relationship [23]. One study found no difference between PT and FT PCPs in any interpersonal aspect of care [15].

Discussion

Main findings

We found evidence of undesirable effects of PCPs working PT on quality of patient care: Accessibility was generally shown to be positively associated with longer work hours, and there is also evidence of a similar association for continuity of care. Both accessibility and continuity may not be influenced by PCPs’ working hours alone but also by the organisational characteristics of the practice. Also, communication and the PCP--patient relationship were negatively impacted by PT work.

However, neither clinical outcomes nor patient satisfaction were negatively affected by shorter PCP work hours; several studies showed that PT PCPs performed better in these domains.

Implications on how to maintain the quality of patient care

The framework put forth by the Institute of Medicine (IOM) includes six domains of healthcare quality: Safety, patient-centeredness, timeliness, efficiency, and equity [29]. The domains of safety and effectiveness were most accurately captured by the clinical outcomes examined by the studies included in this review. The clinical outcomes were unaffected [16,24] or improved [17] by all studies using measuring them. This implies that the safety domain is not jeopardised by PCPs reducing their hours. However, no study measured rates of medical errors or clinical outcomes using any form of more objective outcome such as avoidable hospitalisations or hospitalisations for primary care sensitive conditions and it is therefore difficult to draw any more detailed conclusions regarding safety and effectiveness.

The outcome most closely related to timeliness in the review is accessibility. Our results seem to indicate that accessibility as well as continuity of care may suffer when doctors reduce their weekly hours. However, studies also suggested that organisational factors of the practice influence these two dimensions [13,15,23], which implies that practice organisation may hold the key to mitigating the negative effects of reduced working hours. Heje et al. found GPs in single-handed practices received the most positive evaluations regarding accessibility. In contrast a higher number of employees and number of listed patients per GP, and working in a training practice were associated with more negative evaluations [23]. Wensing et al. also supports this finding, with fewer PCPs per practice associated with better patient-reported accessibility [25]. This finding is alarming, as the trend in primary care is moving towards larger practices with several PCPs in many countries. Future research should explore why these particular factors impact accessibility in greater depth. No paper examined the impact of different PCPs, such as practice owners, acting PCPs and PCPs working salary-based. This is unfortunate, as the rise of salary-based PCPs working in group practices may be a significant driving force behind the increasing prevalence of PT work.

Bodenheimer et al. proposed several organisational approaches to improve access and continuity of care [6]. One approach suggests that PT PCPs work more half-days per week instead of fewer but longer days. This change enables PCPs to be available to patients on as many weekdays as possible. Further, continuity and access may be improved through increased usage of alternative communication with patients other than face-to-face visits, such as answering emails every day. Another approach suggested was to create job-sharing arrangements between two PT PCPs. Two PCPs would jointly be responsible for a full panel of patients, so that the same two PCPs would always see a patient. The last approach, i.e. team-based care, was examined by Rosland et al. [13], who showed that same-day access to a patient’s usual PCP was worse if the PCP worked PT but that clinic same-day access to a PCP remained unaffected. For some patients, continuity of care is more critical than for others. In single, acute problems continuity is less important than in longer episodes of care involving chronic illness and multimorbidity. The latter type of health problem often involves plannable care. As it is policy in some practices, if you want to see a GP today or tomorrow, we will decide who you’ll see and if the consultation can be planned, you can see the PCP of your choice. It should be noted that the physicians in a practice and the composition and size of the whole team determine accessibility. Interestingly, Paré-Plante et al. found that the presence of nurses offering primary care services in the practice did not improve accessibility [21].

Despite reduced access and continuity, PT PCPs seem to achieve an equal or even better patient experience [14,15]. This relates strongly to the domain of patient-centeredness. Murray et al. hypothesised that one explanation may be that PT PCPs take on smaller patient panels, thereby increasing the time and energy available for each patient. The study reported that PCPs working more than 65 h weekly were significantly less satisfied with the time they spent with each patient, which supports this theory. However, studies need to directly investigate whether this is the case. This theory could be relevant, as Homberg et al. found a robust correlation between the time PCPs had for each patient and the patient’s perceived quality of care [24]. Further, patient-reported quality of care is influenced by PCPs’ professional satisfaction, as demonstrated by Schäfer and colleagues [26]. PCPs’ job satisfaction was found to be higher for PT PCPs [19] and was shown to be directly associated with patient satisfaction [20]. As this review found several positive effects of PT work, approaches should be developed which mitigate adverse effects while preserving or increasing the positive effects.

Notably, eight out of the fourteen included studies, were published between 2000 and 2009. In contemporary societies, including the field of medicine, working PT is becoming increasingly normalised, which may affect how patients perceive and evaluate PT work in primary care settings.

A 2018 scoping review of the Norwegian Institute of Public Health focusing on effects and experiences of PT work in the health- and community-care services found that studies in the review were very heterogeneous hampered any attempt to pool or compare results. The authors conclude that future research would benefit from a standardised definition of PT work [30]. The comparability issue was also found in our review. Eight of the included studies were performed in the USA with primary care systems that are not comparable to European ones. For example, the study by Rosland et al. was set in two large sites with 68 PCPs that cater exclusively to veterans, to which there is no equivalent in Europe [13]. Further, the average size of practices not only differs between Europe and the USA but also between individual European countries. Finally, the lack of a standardised definition of FT and PT hours means that several weekly work hours, which passes as FT work in certain countries is considered PT work in others [26]. There is, therefore, a need to define PT and FT status more clearly and there is a need for more quantitative studies, which are comparable between countries [5]. These issues may also explain why none of the associations examined in the study by Wensing et al. were found consistently across all countries the study was conducted in [25].

Our review did not yield any specific findings related to efficiency and equity. The approaches proposed earlier should be considered to enhance efficiency of practices and the healthcare system.

Strengths and limitations

To our knowledge, this is the first review to examine the impact of PCPs working PT on quality of patient care. This scoping review followed the guidelines of the PRISMA-ScR checklist [31]. A thorough search strategy was designed, and four databases were searched. The MMAT documents the high quality of the included studies, except relatively high nonresponse rates in studies using data from extensive multinational surveys and one study employing the validated Press Ganey instrument, which still maintained a response rate comparable to the national average.

One limitation of this study is the wide-ranging understanding of what comprises a PCP. Most European studies shared a similar concept of the ‘general practitioner’ whereas north American studies used terms such as ‘family physician’ or ‘general internist’ and, in some cases, included other specialists. The role PCPs hold in healthcare systems, as well as what procedures and diagnostics are performed by PCSs varies considerably between countries. Further, some studies included community-based PCPs and hospital-based PCPs and a wide range of practice sizes. We did not want to exclude any of these professions as we hypothesise that the underlying mechanisms of PT-induced changes in patient care are similar in all primary care settings. We recognise that the heterogeneity of definitions of PT work did not allow us to pool the quantitative results. Still, we are confident that the scoping review provides a valuable overview and baseline for future research and systematic reviews.

Conclusion

There is evidence of both negative and positive effects of PCPs working part-time on quality of patient care. PCPs working PT does influence quality of patient care, particularly access and continuity of care, which may be negatively affected. The clinical outcomes and patient satisfaction seem mostly unaffected or even improved. Approaches that mitigate negative effects of PT work while maintaining positive effects should be implemented.

Disclosure statement

No potential conflict of interest was reported by the author(s).