To revitalize primary care policy, focus on relationships

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  • Dan Eickmeier says:

    There is little doubt that some form of continuity is desired and perhaps even required for truly high quality healthcare. But the devil is in the details as it always is. Traditional continuity meant you saw a single provider (your physician) for essentially everything, even if that provider was not well suited to dealing with you issue, that is who you saw. That individual would struggle to be all things to all people at all times. Women’s health and delivering babies, ok that’s on 24/7 availability. High acuity emergency acute care like a Heart Attack. Another 24/7 availability as well as a second highly specialized of knowledge and skills. Palliative care in the home. Again 24/7 availability. Little pay and lots of knowledge required. Patients in the hospital or in the nursing home. Yet another 24/7 demand on your life.

    It’s simply not sustainable and it hasn’t been for decades. If we want a goal of continuity of care (which is laudable), it is team continuity that we need to strive for no individual responsibility. When I am forced out of work for fourteen days on C19 quarantine sometime this fall, do I remain responsible for this continuity even though I’m not funded in anyway to provide such a complex continuity. Even in a more “regular” time, is it really reasonable for me to be on-call and available 24/7/365 for all fifteen hundred patients in my roster? The patients need to be rostered to a team. They get to know how the team works, the team understands the patients, the team learns to communicate well in person and using technologies. Then it doesn’t matter so much which of the four docs, three NPs, two PAs or six RN/RPNs help your out because we all know who you are. And there are enough of us to cover most eventualities in terms of time.

    I worked as a full service family doc/GP for fifteen years. My practice did little shared care so your only real continuity was trying to get back into your family doc. As we developed an NP/PA program they definitely helped put more communication and continuity in place with the family doc acting as a quarterback mostly in coordinating care.

    For the past eighteen months, I’ve don’t focused practice in the ER. We have no continuity beyond what little is in our charts and the surprisingly high number of patients that use the ER as a “medical home”. The lack of continuity is a huge burden to us as practitioners but I also don’t grudge primary care needing balance. I work 60-80 weeks, at least two if not three overnight shifts most weeks and haven’t had a weekend off since April (it’s the end of October now) so please skip the arguments that I’m lazy and if I was committed to patients, continuity would be easy. I know a decent number of family docs who’s work hours would be almost as bad as mine.

    So let’s talk continuity but let’s figure out how to do it without killing our providers.

  • Jordan Peel says:

    I think continuity of care is overrated. Canadians want access to care, when they need it – they don’t always care if their family doctor is available. Family doctors are often not available 24/7. I think this argument of continuity of care is a figment of policy wonks and healthcare providers and so called “system thinkers” who are so far away from reality and the patient. It really doesn’t matter if my family doctor didn’t help me with my strep throat that flamed up on a sunday afternoon, nor do I care if he gets a copy of the visit i had with my virtual doctor for this matter. These policy wonks need to think more of healthcare as a service that we pay for. Heck we pay for these family doctor salaries through our tax dollars! Real-talk!!

    • Ed Weiss says:


      You’re absolutely right that in the end, it probably doesn’t matter if your family doctor isn’t involved in treating your Sunday-night strep throat. But you know what? If the worst medical issue you’re facing is a strep throat, then that’s a sign of privilege in and of itself. Continuity _does_ matter if you’re the Ukrainian-speaking vulnerable senior you referenced in a previous comment, the one who is on 8 prescription medications for various age-related ailments, just got discharged from hospital after her hip replacement, and now is feeling faint and light-headed because a hospital mistakenly prescribed a medication that exacerbated her heart condition and interacts with one of the other prescriptions she’s on. That’s where continuity matters. A doctor working at a walk-in clinic, real or virtual, who doesn’t have access to the patient’s records, who doesn’t know the previous history, will be completely hampered when trying to care for such a vulnerable patient. The patient’s own family doctor (or nurse practitioner), who knows her previous medical history, knows what medications she’s been prescribed (and whether or not she tends to take them as prescribed), and knows when something’s off, is the one who’s most likely to actually help someone in this situation.

      We may not be perfect in family medicine, but I think your comments are really misguided and don’t reflect the work that we actually do to get people healthy and keep them healthy, especially the ones who are mots vulnerable because of demographics or socioeconomic status.

      • Ravi Chakraburthi says:

        Mr. Weiss,
        I’m not sure I agree entirely with you. I am foreign-trained medical graduate from India. In my home country, we do not have such luxuries as continuity of care, neither in mega-tier 1 metros like Mumbai or rural villages. A physician’s ability to be an expert diagnostician should be good enough to provide high quality care, of course this concept of continuity is important but its not the end-all. We have Even our globally recognized All India Institute of Medicine (AIIMS) operates like this without systems that enable continuity of care. I think in North America, the practice of family medicine can be stifled with such demands on continuity of care, it may be the “holy grail” but I’m not so sure its realistic expectation, especially to serve the vulnerable members of the population.

    • James Dickinson says:

      You are quite right, that healthy young to middle-aged adults with no children, and earning well, seldom need continuity of care, since even walk-in clinics can assist with single, specific acute issues. Though we need to be careful that “quick-fix” medicine does not cause more trouble, for example by giving antibiotics on demand for every viral infection. Your family doctor will need to know what you were given when the drug reaction occurs! But once you leave that privileged state, and get chronic illness, depression, or an injury that takes rehabilitation, then continuity of care suddenly becomes critically important. So health care policy should not try to ensure that everyone has a family physician, rather that one is available for everyone who needs them. Then the tax dollars provide real value, and payment systems need to be structured to encourage that, including the availability of quality care at nights and weekends.

  • Sandy Tecimer says:

    Great article! The more we invest in primary care and a medical home, the more we can offer continuity and access. Having worked in a walk-in clinic and having my own practice, I can’t tell you how important the long term relationship & context are for helping care for and support patients.

  • Darren Larsen says:

    Dominik.. I think that the biggest benefit of continuity is a sense of responsibility and trust. I need my family doctor to care about me as an individual, be engaged in my journey and I trust him/her to help me make the best decisions for my life. Even though I am a doctor myself, I still need an objective stable and educated voice to do the right thing or weight the best options for my health and treatments. I need to be able to trust. This trust can be built in an instant when we show compassion, empathy and honesty with our patients. It’s built with careful listening, framing and conversation. It’s easier after 10 years of knowledge of each other’s worlds, but possible even in my urgent care clinic in a large family health team. We do not think about this as much when we are healthy as when we are sick. But we will all wish for it eventually .

    My challenge to you… how as an educator do you think we should build relationship into the way we teach? How do we convince our colleagues that family medicine is more than a transactional 9 – 5 job? How do we allow ourselves to be vulnerable enough to build strong lasting relationships with our patients? I see this being eroded in the current medical model, and like you, I am worried.

    Thanks for writing this, Dominik.

    • Jordan Peel says:

      ummm… interesting perspective, but its one that i bet comes from white privilege my friend. Where do you live? in a quaint 3 bedroom in Leaside? engaged in my journey? seriously – the primary care system that we need has to serve the vulnerable senior who just waited 18 months for hip surgery, speaks ukranian only and relies on shitty meals on wheels because her kids don’t come around to help her. its for the single black mother, overweight with diabetes, working 2 jobs and her kids are eating mcdonalds all day, about to be on the same diabetes train that she is. These are only a few examples of the 20% that are driving 80% of the primary care utilization….far from the privileged few who are looking for some sort of sage guru that will be my spritual healer along my health journey. that crap is for rich white folk can afford to think about how they can lose that extra 10lbs to move their BMI from 16 to 15.5.

  • Naushaba Degani says:

    Thanks for this article – I think it makes a critical and often overlooked point about the importance of relationships. There is certainly value in having same day/next day access to health care for urgent needs and this should be balanced with seeing the same provider for overall management of health.

  • Darren Cargill says:

    Great article Dominik.

    My parents have had the same FP since the mid-1980s. It has been a blessing.

    The only reason my brother and I aren’t still in the practice is because we moved away to other cities but both of us and our families now have long standing FPs of our own now.


Dominik Alex Nowak


Dominik Alex Nowak, MD MHSc CCFP, is a family physician, health systems strategist, and faculty member at the University of Toronto.

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