The way family physicians think about their work may surprise you. When people ask me what kind of medicine I practise, the answer “I’m a family doctor” is usually met with one of two responses: either “Are you taking patients?” or “Are you planning to specialize in something?” Of course, I do specialize in something, but it isn’t a body part. Family doctors specialize in relationships.
Before family medicine became a recognized specialty in Canada in the early 1990s, doctors could do a one-year rotating internship after medical school and hang a shingle as a “general practitioner,” or GP. Today, family medicine in Canada requires a two-year residency program after the completion of a medical degree. At the end of that training, graduates are specialists in generalism.
Family physicians are trained in recognizing undifferentiated disease and managing uncertainty. As you probably noticed the last time you had an appointment with your doctor or nurse practitioner, primary care is a low-tech environment. Part of the reason why it’s so much less expensive than hospital-based care is that the care is usually one on one, and there are very few of those “machines that go ping” that we see in hospitals. Yet despite the fact that the tools we use are mostly our eyes, ears, and brains, family doctors are usually responsible for making the initial diagnosis upon which subsequent care is based. The importance of the accuracy of that initial diagnosis cannot be overstated. Dr. Iona Heath, the U.K. primary care leader mentioned earlier, has said that it requires us to combine “a robust appreciation of the range of the normal with a high index of suspicion for the dangerous.”
One of the most important things we do in primary care is what Dr. Heath has called “patrolling the border” between illness and disease.
Disease is what we learn about in medical-school textbooks: a somewhat arbitrary set of definitions that have developed over time based on pattern recognition. “Angina” and “schizophrenia” are just shorthand ways to refer to a set of symptoms and signs that tend to occur together.
Illness, on the other hand, is an individual human being’s experience of being unwell. It is “a perception of something being wrong, a sense of unease in the functioning of the body or mind.” Since no two people are the same, no two people have the same experience of illness, even if they share the same disease label.
Primary care providers like family doctors see more illness than disease—we spend much of our time accompanying patients along the journey of their experience of feeling unwell, whether they have acquired a disease label or not.
Therefore, one of the important functions of primary care is to allow our patients to experience illness without over-interpreting, over-labelling, or overtreating them. Much illness resolves on its own, so that one of the great skills of family medicine is the appropriate use of time—giving the body a chance to heal itself without missing the moments when more intervention is needed.
As a result of our work patrolling this boundary, family physicians are medical experts in the management of uncertainty. And we address uncertainty in myriad ways, including providing patients with objectivity, knowledge, and companionship.
How do we hold the border between illness and disease, or help our patients cope with uncertainty about the future? The most important principle that we teach our residents in family medicine training is that the patient–physician relationship is central to the role of the family physician. The secret sauce of primary care is the relationship.
Abida and I have learned together about the power of the relationship in patrolling the border between illness and disease. Because we know each other well, when she reports discomfort in her foot, for example, I listen and then I examine her. If I don’t see anything of concern, I can then say, “I’m not sure what might be causing that, but it doesn’t sound sinister to me. Let’s wait and see whether it goes away on its own rather than sending you for X-rays or blood tests today. We can reassess it in two weeks. In the meantime, try ice and heat to see if that will help with the pain.” I don’t doubt that her foot hurts, but I don’t jump to label her with a disease. It’s because of the trust she has in me, earned over these many years, that she feels comfortable waiting as I suggest—and it’s because I’ve come to know her as well as I do that I feel reasonably certain it’s safe to do so. For Abida, this is critical, because so often her symptoms are vague and could lead to enormous over-investigation if we did not hold that boundary.
Specialists also develop relationships with their patients, sometimes over many years. But family practice as a discipline explicitly defines itself by that relationship. Dr. Ian McWhinney, one of the founders of modern family medicine, articulated this beautifully when he said that in family medicine, “the relationship is usually prior to content. We know people before we know what their illnesses will be.”
In family medicine we teach our residents that every interaction with a patient, whether it’s to discuss a disintegrating marriage or a wart on the sole of the foot, must be seen as an opportunity to strengthen the relationship. I think of these as little deposits in a “relationship bank,” an account that accrues interest over time.
If we’re successful, people will feel heard and seen, and will have an enhanced ability to take care of their own health. They will need less time in our office, or anyone else’s for that matter, and they will forgive us our bad days, insensitive moments, and (true story) that time we forgot to cancel their clinic appointment before taking a long birthday weekend away.
It is this relationship that almost certainly underpins the repeated observation that health care systems centred on primary care are less expensive than those that are not. People who trust in and get good care from their family physician will need specialty care and hospital care less often. This is not just because of the “gatekeeper” function of primary care, in which a referral is needed to see a specialist; it’s because in going to see their family doctors, patients’ concerns may be addressed and no further interaction with the health care system may be needed.
I have experienced this with Abida. Over the years that we’ve worked together on her health, she’s stopped going to the emergency department so frequently. She has fewer specialists involved in her care, and when she does see specialists, she usually comes back to me to ask my views about the investigations or treatments they’ve recommended. This isn’t because she doesn’t trust the experts; it’s because she knows that I know the whole of her story and can put their recommendations into her life’s context for her.
The effectiveness of our interaction depends on mutual respect as much as it does on content expertise. Without trust and a relationship, family doctors are at risk of becoming referral and prescription machines. And without ready access to one’s trusted family doctor, a patient is at risk of becoming unmoored in the health care system.
Now I’m going to say something controversial: some kinds of health care don’t require a deep relationship. In fact, for many kinds of specialty services—including surgery—experience has shown that we can reduce wait times and improve experience by having less, not more, “face time” with specialists, or with one particular specialist. Team-based care, where much of the pre- and post-procedure work is done by non-physician providers, and models where people are seen by the next available team member rather than waiting for a particular doctor have shown great promise in many parts of the health care system.
This doesn’t hold true across the board, of course. In some kinds of specialty services, relationships are critical. (Examples like psychiatry and palliative care leap to mind.) But sometimes relationships can be built with a team or even an organization rather than with an individual specialist. Trust that the service is high quality and reliable may not depend on a deep and ongoing relationship with a single health care provider.
In primary care, however, the ongoing relationship is the core of our ability to be effective.
This is why I struggle with walk-in clinics. I understand why they exist. It’s convenient to just pop down during your lunch hour to the clinic in the basement of your office building. Or maybe you tried to make an appointment with your family doctor and she couldn’t get you in for two weeks. But even most doctors who work in them, if they’re really being honest, will tell you that a walk-in clinic isn’t ideal primary care. There’s no continuity, no comprehensive chart that can be used for your ongoing care, and usually no communication back to anyone who will ever see you again. The concept of relationship-based care generally goes out the window.
You might think that all you need is a quick prescription renewal or blood test requisition. That’s a legitimate agenda. But if you’d seen your family doctor, he could have used that opportunity to compare your blood pressure to last time, causing him to notice that it’s creeping up. He could have reminded you that you’re due for a Pap smear in three months and asked you to book it on your way out. You might have backed into a conversation about your weight, causing you to consider bringing your lunch to work instead of eating that horrible stuff with gravy on it in the cafeteria. You could have connected, investing in the “relationship bank” that you may well need to withdraw from in the future.
In a perfect world we wouldn’t need walk-in clinics, because all Canadians would be able to see their own personal primary care provider (or at least a team member who has access to their chart with their medical history) within a day or two if that’s what they need. When Abida’s lung disease flares and she starts to feel more short of breath, she needs to be seen now—not three days from now. I can’t be personally available to her 24 hours a day, 365 days a year, and I don’t think anyone expects that of me. But I can ensure that someone who has access to Abida’s chart and can connect back with me will see her when she needs to be seen, by sharing responsibility with my colleagues. That means same-day appointments; evening, weekend, and holiday appointments; and someone on call who can answer Abida’s questions about her breathing in the middle of the night.
It may be that in some communities the best answer will be to integrate walk-in clinics with the rest of the system, so that at least I get some notification when my patients have been seen elsewhere and can follow up with them. In other places, teams will establish walk-in options of their own so that patients who need to be seen urgently can drop in without an appointment and see a team member, if not their own doctor. To me, those options are preferable to a totally unconnected clinic that doesn’t provide any continuity of care.
It’s important to recognize the real value and importance of the primary care relationship, but we shouldn’t romanticize it. Like every relationship, this one has its ups and downs. I’m bound to have an off day and say the wrong thing sometimes, especially when the waiting room is full and I had an argument with my spouse last night, or when the previous patient had to be sent to the hospital because she was suicidal. You’d be right to feel annoyed when you sense that I’m distracted or when I made you sit too long in the waiting room. And you’re bound to push my own buttons sometimes, maybe by asking for a dermatologist referral to treat your mild acne or by refusing a tetanus vaccination for your child. We may not have chosen each other and maybe the perfect family doctor for you would be a different kind of person. But if you’re in my practice, I’m committed to making it work—and my colleagues feel the same way.
It’s a rare case that a family doctor “fires” a patient—I haven’t done it, and most doctors feel it should only be done in really exceptional circumstances. I do have patients who’ve left my practice. In most cases I called them to ask why, or the nurse I work with did, so as to not put them on the spot. From their answers I learned things about myself and my practice, and usually I agreed that we weren’t a good fit. I have many more patients who’ve stayed in my practice and we’ve made it work, even though we might not have chosen each other for compatibility if online matching existed for this sort of thing. There’s something that happens when the door clicks shut in that exam room that makes us both want to try.
Like many relationships, neither of us may give it much of a second thought until one day when it suddenly matters a lot. I think about one patient whom I used to see only once every year or so. We had accumulated a fair number of moments together over the years, though many of them were focused on her daughter’s health care needs rather than hers. Yet the cumulative effect of those small interactions was that we had invested in the relationship bank together. This meant that when her breast cancer was diagnosed—the same disease that killed her mother, so you can imagine her reaction—we had an established connection we could draw on. I believe it made a difference in my ability to give her what she needed, and for her to approach her treatment plan with dignity and optimism.
The relationship between a primary health care provider and her patient allows us to provide care that is personalized. But sometimes the flexibility of approaches that comes along with that can be a bad thing. Among the tensions family doctors have to grapple with is the one between our desire to provide personalized care and our duty to stick with guidelines for the care of people with particular conditions.
In general, health care is moving toward more standardized approaches to the treatment of many illnesses, and that’s mostly good. It’s helped us make enormous improvements in some areas over the last two decades, such as screening for and treating high blood pressure. Whether it’s making sure that everyone over fifty is offered colon cancer screening, giving diabetics a regular eye exam, or vaccinating people with chronic lung disease against pneumonia, there are some things that we know every person with a given disease needs. But we aren’t yet doing a good enough job of making sure they get them. In managing chronic disease, then, it’s critically important that primary care teams step up and start practising consistently.
Yet family doctors have sometimes pushed back against cookie-cutter approaches to disease management. This pushback comes in part from a good place. We have to manage the reality that giving people the care they “should get” for a particular disease and paying attention to the priority for that person at a given moment in time may not always be compatible. You might “need” to get your blood pressure down eight more points. But you might rather spend the time we have together talking about how to manage the stress in your job—and I might agree with you on that priority. Or we might decide to set aside the diabetes guidelines for now because you also have asthma and would prefer to focus on dealing with that.
One of the reasons why disease-based guidelines are often less useful in primary care is that they aren’t developed by family doctors. Specialists are three times more likely to contribute to drafting guidelines than are family physicians, with the result that those guidelines often fail to reflect the realities of primary care.
Furthermore, as we age, we all accumulate diagnoses, so that the list of guidelines and checklists that applies to each of us just grows. When you add up the amount of time required for a primary care physician to provide the recommended preventive services to patients as well as the recommended manoeuvres for the ten most common chronic conditions, the average family doctor could spend between eleven and eighteen hours per day just delivering preventive and chronic illness care. This is before we see anyone with an acute problem, fill out a form, answer a phone call, or have breakfast.
When I think about the number of guidelines that could potentially apply to a patient like Abida, my mind goes numb. She has a diagnosis for nearly every body part. She has heart disease, lung disease, thyroid disease, high cholesterol, arthritis, and osteoporosis. There are, of course, full sets of practice guidelines for each of these problems. Abida is also older and becoming frailer, so she’s at risk of falls, depression, social isolation, and a whole range of other problems—each of which I would love to address in a proactive way, and none of which may jell with her priorities, which often come back to needing a safe place to talk about what’s happening at home. So there has to be a balance.
To me, guidelines are useful in pushing us to build more reliable and standardized systems for taking care of people. It matters that I follow the same routine, every time, for every prenatal visit for every pregnant woman, so that none of the important steps are missed—even if we decide together not to do some things that the guideline says we should. Just the process of having that conversation increases reliability, and if done right, deepens the relationship.
The doctor–patient relationship is the foundation of high-functioning primary care, but there are two other relationships that are also critical to achieving the Big Idea of relationship-based primary care for every Canadian.
One is the relationship of your doctor’s office to the rest of the health care system. As a family doctor, I’m the go-to health resource for the group of people with whose care I’m tasked. My job isn’t only to develop relationships with those patients and take care of them, but to be their point of entry to and exit from many other services.
To practise good primary care I need to understand how the local health care system works, and how to make it work for you. How does one get to see a specialist in the neighbourhood? Which hospital offers general neurology, and which just headache consultation? Which ear surgeon has the shortest wait time? Which one is efficient, but lacks bedside manner? Which physiotherapist offers discounted rates for low-income people? How do I know when my patient has been admitted or discharged from a local hospital? By keeping up to date on the answers to these types of questions, I can effectively coordinate care for my patients.
This relationship with the system is updated and improved by my returning patients. They feel they can tell me where the waits are long or the service terrific. The team of health care providers I work with does the same. We constantly send each other quick messages to ask who knows a great chiropodist in the north end of the city, or how to get a psycho-educational assessment for a kid who’s struggling in school.
These informal networks do the job, but a more organized system for referrals would be so welcome in my universe. I’d love to feel confident that I was sending each patient to a competent, caring provider (or team) who’ll see them quickly, and I’d happily trade some of my informal connections for that reliability. But even when that day comes, the role of connector will still be a big part of my job.
In this role, primary care providers are medical experts in managing information. And there’s a lot of it: specialist consultation advice, lab and medical imaging results, email messages, diagrams of different body parts, hospital discharge summaries, illegible pink sheets of paper that once made up the back page of an emergency department record in triplicate—all must be integrated into a single chart that tells your medical story over time. We also manage a constantly shifting database of information about the system around us so that we can help you get the services you need.
The important relationship between primary care and the rest of the system doesn’t always work well. And when I run up against the brick wall of some other silo in the health care system that prevents me from getting what I feel a patient needs, I get mad. Luckily, the twenty-first century offers a productive outlet for professional frustration: the complaint email. Here are two (paraphrased, and admittedly rather testy) emails I’ve sent to one hospital’s CEO and another hospital’s VP in downtown Toronto over the last couple of years. I share them because I think they illustrate what happens when the relationship between primary care and the rest of the system breaks down—which fortunately isn’t all the time.
September 2010
Dear [Hospital CEO],
Are you aware that when a patient dies in your hospital, no one informs their family doctor?
I learned about this unbelievable oversight this week, when our clinic staff called a 54-year-old woman in my practice to inform her she is due for a pap smear. Her son, who answered the phone, informed the secretary that she had a sudden cardiac arrest three months ago. She was rushed to your organization by ambulance, spent two weeks in your ICU, and subsequently passed away.
I’m sure you can appreciate how upsetting it was for the son to have to explain this to his own family physician’s office. How is it possible that you have no process for informing the primary care providers of patients in your organization that our patients are deceased?
September 2015
Hi [Hospital VP],
I’m writing to give you feedback about an experience I had with your hospital this week as a primary care provider in the neighbourhood.
I saw a patient Wednesday evening in my clinic who had features suggestive of a possible neurosurgical emergency. The case was a tricky one with grey areas, and I was uncertain how best to help her get assessed rapidly, whether she needed to be assessed immediately, and whether there was more that needed to be done for her in the short term.
I paged neurosurgery on call at your hospital to ask their advice about how to manage the case. I was on the phone for 45 minutes, running progressively more late with the other patients sitting in the waiting room. At one point Dr. [XX], the surgeon on call, was patched in to the call but when the nurse who was holding the phone for me asked him to hold while she ran to get me, he hung up. When I called back he refused to take my phone call. The hospital operator told me to call 911, which was exactly what I had been trying to avoid.
We did call 911. My 74-year-old patient, who was in excruciating pain, sat in your emergency department until 1:30 in the morning and was eventually seen by the ED doc, had some imaging, and was sent home and told to come back to me to be referred as an outpatient to the various specialists she should see.
I’m sure you can imagine that this outcome was upsetting for my patient, and also for me. I’m not sure why I should stay in clinic until 8 pm seeing patients to give them rapid and convenient access to primary care if the purpose is not to keep them out of the ED. I can’t do that effectively without specialist backup when I run up against the limits of my scope of practice or my expertise….
Much as I was frustrated with Dr. [XX] that night, I suspect the response may have been similar if I had called any number of doctors. The family doc is dependent on the mercy of the individual at the other end of the line to help us figure out how to navigate the system, instead of feeling backed up by a community of health care workers who want to help us do our best for people.
I understand these are big issues to grapple with and that in general, hospital culture has been one of dealing with those people who are already present in the building, and not worrying much about the primary care community. But when I practised in rural northern Ontario, the specialists in [YY] hospital understood very clearly that their role was to be a resource to anyone in the catchment area who needed them. Through the use of telephone specialist backup, we managed dozens of cases both in clinic and in the ED that otherwise would have had to be transferred to the big hospital 300 km away.
In each of these cases, the hospital administrator responded quickly and appropriately. But as you can no doubt tell from the tone of my emails, the disconnect between the primary care universe and the hospital universe is an ongoing source of difficulty for patients and irritation for providers. Indeed, the fact that we regard each as living in a separate universe is part of the problem.
That disconnect isn’t just on the hospital side. My specialist friends tell me about the patients who come to their offices with virtually no information about the referral request from the family doctor, forcing these specialists to start from scratch and repeat investigations they know have already been done, wasting time and money in the process. Emergency department doctors and nurses experience extreme frustration when patients show up because their family doctor went on vacation and simply turned on the answering machine for two weeks, leaving people with no choice but to go to the ED or a walk-in clinic. And friends have shared stories of family physicians who refer their patients to specialists so freely that they feel it would be easier just to go see a specialist directly for any concern. This isn’t relationship-based primary care. We can do better.
That said, when the relationship between primary care and the rest of the system works well, the results can be extraordinary. I was in clinic recently when the secretary pulled me out of an exam room to take a phone call from a pediatrician at a local hospital. She was calling to tell me that one of my patients had been admitted with a potentially dangerous problem. She wanted me to know so that when he was discharged I could see him quickly and follow him closely—and she wanted to share some recommendations for monitoring him over time. It took about three minutes, and it wasn’t a fancy or high-tech integration solution. It was just a human interaction by telephone. But it saved me—and the patient and his parents—a lot of work trying to piece together exactly what had been done in hospital and what my role needed to be.
More systematic efforts are being made to ensure consistently good communication between primary care and hospitals. If you live in British Columbia, for example, your family doctor now has access to a program called RACE—Rapid Access to Consultative Expertise. This is a telephone advice line that family doctors can call to speak with a specialist for advice about patient care. Phone calls are directly routed to a specialist’s cell phone or pager. An evaluation of the program revealed that 80 percent of calls were answered within ten minutes and that nearly one-third of calls prevented an emergency department visit. This and other initiatives across the country give me hope for the future of the primary care—health system relationship.
And these kinds of initiatives are exactly what I need to be able to take good care of someone like Abida. Because of her medical and social complexity, when a specialist meets Abida for the first time she often ends up with more investigations that she may or may not follow through on. When I’m able to get a specialist on the phone instead, he or she can often talk me through Abida’s options so that she and I can then work together on a plan tailored to her needs. This also saves Abida the time and irritation of having to tell her story to someone new all over again.
The other relationship that’s critical for high-functioning primary care is the one where we have the most work to do: the one between primary care providers and the population we serve.
We’re only just beginning to consider the concept of “managing the health of a population” in Canadian primary care. That population would usually be a geographic one, though not always: some practices may specifically serve people living with HIV or adults with developmental disabilities who travel significant distances to see primary care providers with special expertise. But most of the time a primary care practice should serve the people who live or work in a given neighbourhood or community, no matter what their diagnoses. This has long been a stated principle in Canadian primary care, and is the approach taken in high-performing health systems: rather than waiting for patients to show up on the doorstep, doctors and teams who practise primary care see it as their job to improve the health of the people in their neighbourhood.
Since the advent of electronic medical records, our ability to do that job has been transformed. When I started out I had no way of knowing, say, who the diabetics in my practice were unless they came in the door. Now, with just a few keystrokes, my electronic record provides me with a list of everyone with that diagnosis, when they were last seen, and whether they’re due for routine diabetes testing and care. This allows me to reach out to people proactively and ask them to get their eyes checked or have their blood sugar tested.
Developing a relationship with my practice population means that, rather than waiting for people to call for an appointment, I need to establish routine ways of reminding families when it’s time for children’s immunizations or women’s Pap smears. It also means that I should track how many frail elderly patients are in my practice and organize home visits and non-medical support services for them. One day soon it will mean that, when one of my patients is discharged from a local hospital, I’ll be automatically notified by email and my office will reach out to that person to book a follow-up appointment so that we can debrief together.
Every primary care practice needs to use an electronic medical record, and we’re getting there: today about three-quarters of primary care doctors in Canada use them—a proportion that has nearly doubled since 2009. That’s a big improvement over a decade ago. But our connectivity to other IT systems is still poor, meaning that electronic files stay inside one clinic or institution rather than following patients into whatever part of the health care system they roam.
And so far, few Canadian primary care practices use their electronic records in a proactive way. Whether you’re due for a tetanus shot or a blood pressure check, chances are we’re leaving it up to you to figure that out. The occasional reminders people do receive tend to come from centralized programs, like cancer agencies, rather than from their primary care doctor’s office. We need to up our game.
I know one practice that brought in an electronic medical record (EMR) system in 2007 and used it to more reliably monitor patients with chronic disease. They developed a profile of each patient, with codes for seventeen major chronic diseases. Using those codes, the doctors were able to develop reminder prompts for patients who had diabetes or osteoporosis, for those with serious mental illness, or for those who were due for smoking cessation talks or cancer screening. They were even able to build patient education tools into the EMR and use them to guide conversation in the office, later emailing them to the patients at home.
Examples like these don’t just happen because you plug a computer into the wall. Technology makes population-based primary care much easier to deliver, but it isn’t always the critical element.
Hospitals and clinics that had good workflow in the old paper systems tend to continue to do well on EMRs, and the reverse is also true. As my colleague Dr. Darren Larsen likes to say, “When you add a computer to a mess, you just end up with a computerized mess.” Electronic records should offer a much more efficient way of helping organizations provide population-based primary care. But some providers may just be dumping information into the computer the way they used to dump it into the paper chart—in ways that aren’t useful for pulling reports, sharing information across the system, or improving care.
Eventually, the hope is that I’ll be a resource for those in my community who don’t even have a chart in my practice. The population I serve becomes more than just the people on my patient list, but in the broader community as well. In this universe, anyone who’s moved into my neighbourhood and needs a family doctor could be connected with me automatically. Other countries have figured out how to do this. An acquaintance of mine moved to Denmark a few years ago. As she tells the story, when she arrived she was given a number to call to set up her family’s health care access. She called the number, gave them her address, and they gave her the information about her new family doctor. That was it. In population-based primary care, looking for a family doctor shouldn’t feel like playing the lottery.
As a community-based service, primary care needs to incorporate elements of design that resemble those of our public schools. For example, your local practice shouldn’t have a choice about whether or not its doors are open to you—which means that our Ministries of Health and regional health authorities have to work with groups of physicians in each neighbourhood to ensure that this goal can be met without causing physician burnout.
Looking beyond the people in my practice to serve my community also means developing more of a focus on disease prevention and health promotion. I might partner with the public health unit to improve the health of kids in my neighbourhood through a running program or a nutrition program, or provide outreach services to a local high-rise building where many home-bound seniors live. Population-based primary care looks at the totality of the population a doctor or team is responsible for, identifies the risks to the health of that population, and then delivers services at the group and individual level to reduce those risks. It’s a daily challenge to shift our gaze outside the office to the community in which our office is located.
A relationship is a two-way street. What do I have a right to expect as Abida’s family doctor? When I need specialist advice to take care of her, I should be able to get it—in a timely way and without having to call on informal networks. And I should be able to expect some things from Abida, too. For the system to do what she needs when she needs it, Abida needs to help me be her air traffic controller. This means that she needs to see me, or someone in my practice, on a consistent and predictable basis. It also means insisting that information be communicated back to me when she’s been seen elsewhere.
That doesn’t just apply to Abida. It applies to all of us. You may need to trade in some of your “choice” in some circumstances—much of which is choice you probably didn’t want anyway, like the “choice” to be seen by someone who doesn’t know you or can’t access your chart—in order to participate in building a relationship with your personal provider and team so that they can support you when you need it.
When I began seeing Abida regularly, we had a conversation about her responsibilities and obligations as well as mine. I asked her not to use walk-in clinics, and to stop going to the emergency department unless she truly believed she had an emergency. I asked her to book appointments with me as much as possible, but I encouraged her to see a colleague on my team if I wasn’t around, and I put a note on her electronic chart asking team members to send me a message if they’d seen her so that I could follow up. Abida has never expressed concern about these requests. In some ways I think she was relieved to know what she could expect from me and what I expect of her.
But there are expectations I have—of myself and of the system—that aren’t yet consistently met. When Abida is admitted to hospital, I still hear about it more quickly from her than from the hospital. And I don’t know how many more Abidas are out there in my neighbourhood, in need of care I should be giving them.
Imagine a system in which all family doctors consistently know when their patients are admitted and discharged from hospital and what happened while they were there, so that we could better care for them when they go home. A system where patients with multiple chronic conditions receive more intensive support from home care and check-in phone calls or visits from their primary care provider. A system where family doctors can help connect people with social services, not just medical ones, to get to the bottom of what’s really making them sick—like a lack of decent housing or healthy food. A system where family doctors think about their communities, not just their practices, when they think about their work. That’s what I mean when I talk about relationship-based care. It’s a goal worth reaching for.