ADDRESSING UNCERTAINTY: CONTRIBUTIONS OF KNOWING PATIENTS
AND TEAM MEMBERS TO NEGOTIATING TEAM-BASED PRIMARY CARE
by
Erin Cathleen Wilson
B.N., University of Manitoba, 2000
M.S.N., University of British Columbia, 2006

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
IN
HEALTH SCIENCES

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
February 2017
Erin Wilson, 2017

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ABSTRACT
The interprofessional team-based primary care model currently being
implemented in northern British Columbia represents a significant shift in primary care
delivery. The purpose of this study is to examine how patients feel known in the context
of an interprofessional primary care team that is not co-located, and to illuminate how
practices of connection between patients, providers, and team members can influence
how care is negotiated within the team. Through methods of observation and interviews,
data were collected then analyzed interpretively.
The findings of this study highlight practices within patient-provider encounters
that contribute to patients feeling known and maintain therapeutic relationship. The way
in which primary care providers know patients influences decision-making about which
patients need team-based care, and when. The relationship between primary care
providers and team members is also influential in deciding who needs team-based care,
yet existing relationships can be disrupted by the degree of uncertainty that occurs
alongside major shifts in primary care delivery. Team-based primary care is negotiated
through practices of connection and genuine conversation. These practices and
conversations influence the timing of team involvement, the information that is shared,
and the type of care that is provided.
Implications of these findings can support efforts to increase relationship-based
care for patients and improve understanding about what patients value in receiving teambased care. Engaging in practices of connection and genuine conversation helps relieve
uncertainty, whether at a team or patient level, and re-aligns the core attributes of primary
care as central to delivering high quality team-based care.

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TABLE OF CONTENTS
ABSTRACT ....................................................................................................................... ii
TABLE OF CONTENTS ................................................................................................ iii
LIST OF FIGURES ......................................................................................................... vi
ACKNOWLEDGMENT ................................................................................................ vii
Introduction ....................................................................................................................... 1
Chapter One: Situating Team-Based Primary Care ..................................................... 4

Moving Towards Transformation ............................................................................................4
Modeling Primary Care.............................................................................................................6

Chapter Two: Uncovering Gaps in Understanding ..................................................... 12

Working in Teams....................................................................................................................12
Examining Core Attributes .....................................................................................................15
Patient-centredness ................................................................................................................17
Accessibility ..........................................................................................................................18
Comprehensiveness ...............................................................................................................19
Coordination ..........................................................................................................................20
Continuity ..............................................................................................................................21
Assessing Gaps in Methods .....................................................................................................26
Assessing Gaps in Content ......................................................................................................32
Summary ...................................................................................................................................38

Chapter Three: Methodology and Methods ................................................................. 40

Identifying Practices ................................................................................................................40
Methodology: Engaging with Gadamerian Hermeneutics ...................................................42
Identifying a horizon..............................................................................................................43
Methods .....................................................................................................................................45
Research questions.................................................................................................................45
Research site selection: PCH in Northern Health ..................................................................46
Attributes of participants .......................................................................................................49
Interprofessional team members and primary care providers ................................................49
Patients interviewed: Pseudonym and gender........................................................................50
Unit of analysis ......................................................................................................................51
Field work ..............................................................................................................................51
Observations of primary care providers ..........................................................................................52
Observations of interprofessional team members ...........................................................................54
Documentation ................................................................................................................................56
Interviewing ....................................................................................................................................57

Data management ..................................................................................................................59
Analysis .................................................................................................................................59

Rigour..............................................................................................................................................61

Ethics .........................................................................................................................................62
Role of the researcher ............................................................................................................62
Ethical procedures .................................................................................................................65

Chapter Four: Explicating Implementation of Interprofessional Teams .................. 66

Locating Team ..........................................................................................................................66

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TABLE OF CONTENTS, CONTINUED
Contending with Technology ..................................................................................................71
Questioning Function...............................................................................................................73
Taking Sides .............................................................................................................................75
Dis-location ...............................................................................................................................80
Summary ...................................................................................................................................84

Chapter Five: Exploring the Patient-Provider Dyad .................................................. 87

Patient Perspectives of Team and Health ..............................................................................87
Defining team ........................................................................................................................88
Feeling known .......................................................................................................................91
Providing Primary Care ..........................................................................................................98
Connecting environment ........................................................................................................98
Attending patients ................................................................................................................102
Knowing patients .................................................................................................................105
Getting to know ...................................................................................................................107
Articulating intentions .........................................................................................................111
Knowing the specifics..........................................................................................................113
Summary .................................................................................................................................115

Chapter Six: Involving Team ....................................................................................... 121

Requesting Service .................................................................................................................121
“Straightforward” service requests ......................................................................................125
“Foot in the Door” service requests .....................................................................................132
“All Hands on Deck” service requests .................................................................................136
Expanding Team ....................................................................................................................138
Considering place ................................................................................................................141
Summary .................................................................................................................................144

Chapter Seven: Negotiating Primary Health Care .................................................... 149

Staying Connected..................................................................................................................150
Connecting with Patients .......................................................................................................156
Valuing discontinuity...........................................................................................................156
Explaining the system ..........................................................................................................160
Making suggestions .............................................................................................................160
Checking in ..........................................................................................................................163
Summary .................................................................................................................................165

Chapter Eight: Contributions of Knowing in Team-Based Primary Care ............. 170

Knowing the Team .................................................................................................................171
Knowing in the Patient-Provider Dyad ................................................................................173
Access ..................................................................................................................................177
Comprehensiveness, continuity, and patient-centredness ....................................................178
Coordination ........................................................................................................................182
Information in transition................................................................................................................184

Equity...................................................................................................................................188
Not Knowing the Patient .......................................................................................................191
Team-Based Care ...................................................................................................................196
Lessons for Moving Forward and Summary of Implications ............................................208
Key messages ................................................................................ Error! Bookmark not defined.
Implications for health care professionals ...........................................................................210

v
TABLE OF CONTENTS, CONTINUED
Implications for educators ...................................................................................................211
Implications for health care planners ...................................................................................212
Implications for researchers .................................................................................................215
Conclusion ..............................................................................................................................217

Bibliography .................................................................................................................. 218
Appendix A: Interview Guide ...................................................................................... 240
Appendix B: Ethical Approval .................................................................................... 242

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LIST OF FIGURES
Figure 1: Patient medical home in BC ………….…...……………………..…………… 9
Figure 2: How practices of connection can improve primary care attributes ………… 189
Figure 3: Resources for health and health care …………………………………….…. 198

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ACKNOWLEDGMENT
Many people have supported me in this endeavour. First, I wish to sincerely thank
the health care professionals and staff who participated in this study. I have profound
appreciation for your professionalism, grace, and expertise in a demanding environment.
Thank you for welcoming me into your space and allowing me to observe your practice.
I am indebted to the patient participants for your willingness to allow me to
observe part of your care. Thank you for taking the time to talk with me and helping me
to learn about patient experience from a researcher perspective.
I’d like to express thanks to my committee, Dr. Neil Hanlon, Dr. David Snadden,
and Dr. Brenda Cameron. Thank you for remaining engaged, responsive, and helpful
throughout this process. Our discussions and your feedback enhanced my dissertation and
challenged me to develop as a researcher and scholar.
Thank you to my supervisor, Dr. Martha MacLeod, who stands out as a true
mentor as well as an excellent supervisor. Your intelligence, focus, and integrity added
depth to my dissertation and greatly enriched my professional development. Thank you
for all your guidance and encouragement.
I wish to acknowledge my employers, UNBC and Northern Health, for supporting
me to undertake this degree. I am grateful to have received financial support from UNBC
and CIHR towards completion of this dissertation.
I owe a great deal of thanks to my colleagues and friends for kind words and
acceptance of my erratic schedule. I am indebted to those of you who understand what it
is like to juggle many roles and feel confident about none of them.
Thank you to my parents, who supported me tirelessly from two provinces away
by sending me “normal” books to read and helping me secure protected writing time.
Thank you for teaching me the importance of noticing things, and the value of a good
story.
Completion of this dissertation would not have been possible without the patience
and commitment of my husband and sons. Thank you for helping me to discover the
reward of being persistently curious and for such interesting conversations. Thank you for
always being on my side and making sure I never quite lost my sense of humour about it
all.

1
Introduction
Interprofessional team-based primary care models are increasingly being
implemented in Canada, as well as in many other countries in the world. Team-based care
represents transformation in primary care delivery, and a significant shift away from
traditional solo provider primary care practice. These primary care reforms are an
opportunity to sustain primary care systems and improve health outcomes for patients.
However, as attention turns to the ways in which new models of primary care are
performing, the processes by which teams develop and offer primary care services remain
insufficiently understood. Within these models, patient experiences of team-based
primary care are also under-represented in terms of how or whether patient experience or
outcomes are improved.
This interpretive study is about how patients and providers negotiate team-based
primary care. The purpose of this study is to examine how patients feel known in the
context of an interprofessional primary care team, and to illuminate how patient-provider
relationships can influence how care is negotiated within the team. The research
questions of this study are:
1. How do patients feel known or not known by a team?
2. How are therapeutic relationships between patients and providers established,
maintained, and nurtured over time?
3. How is primary care negotiated from an interprofessional team?
The participants in this study include patients, primary care providers, and
interprofessional team members in an urban setting of northern British Columbia. The
methodological approach to this research is through engagement with Gadamerian

2
hermeneutics. The power of hermeneutics is that it allows us to see what is questionable
(Gadamer, 1976/1996). It is this task (Gadamer, 1960/2011) that is taken up within this
research using methods of observation and semi-structured interviews.
Articulation of the processes and practices through which interprofessional teams
function and provide care can offer insight and direction to those interested in delivery of
high quality primary care. Attention to how patients feel known and engage in careseeking practices can improve understanding of how to best offer team-based primary
care services. Implementation of interprofessional teams brings change and uncertainty to
the practices and relationships of patients and providers. This calls for an approach that
seeks to uncover possibilities for new understandings of practice and ways of practicing
in the context of team-based primary care.
As an approach, hermeneutics calls for understanding “…the whole in terms of
the detail and the detail in terms of the whole” (Gadamer, 1960/2011, p. 291), and that
“the movement of understanding is constantly from the whole to the part and back to the
whole” (Gadamer, 1960/2011, p. 291). The “details” in play throughout this study are the
practices of individuals, while the “whole” is team-based primary care. Examining
practices of connection between patients, providers, and interprofessional team members
can inform how team-based care is negotiated. The word “negotiate” is selected
intentionally to reflect the movement of understanding between the detail and the whole
as described by Gadamer.
Practices are defined in this study as “activities repeatedly performed over time”
(Kesselring, Chesla, & Leonard, 2010, p. 4). Practices are influenced by the sociocultural
and historical situation of individuals. A study of practices, then, requires attunement, or

3
careful attention to and persistent awareness of, personal, structural, and paradigmatic
influences on the way in which practices are embodied and enacted.
The structure of this dissertation unfolds over eight chapters. The first chapter
provides an overview of team-based care and background to the development of the
Patient Medical Home model in Canada. Chapter Two reviews current literature to
identify gaps in method and content in the area of team-based primary care. Chapter
Three provides detailed methodology and methods for the study. The description of the
analysis, a section on the role of the researcher, and ethical procedures are also in Chapter
Three. Chapters Four through Seven are the findings of this study. Chapter Eight provides
conclusions and implications based on the findings. The implications of this study serve
to inform health care professionals, educators, and health care planners, and advance the
research agenda for primary care in Canada.

4
Chapter One: Situating Team-Based Primary Care
Moving Towards Transformation
Team-based care is a relatively recent development in the Canadian primary care
system (Shortt, 2004), with a vision that emphasizes the need for health care
professionals from various disciplines to work to their full scope of practice, share
expertise, and work together to improve service delivery and patient care outcomes
(Kirby & LeBreton, 2002; Romanow, 2002). While most provincial governments have
identified team-based care as a cornerstone of sustainable, high quality primary care
(Government of Manitoba, 2012; Government of Ontario, 2010; Government of
Saskatchewan, 2016), implementation of team-based care across the country has been
variable, and evaluation of team outcomes and models in primary care remain mixed with
positive and negative findings (Flieger, 2016; Glazier, Zagorski, &Rayner, 2012;
Rodriguez, Rogers, Marshall, & Safran, 2007).
Re-forming primary care services and delivery requires major transformation in
organization and structure of services and human resources. Efforts in this direction are
primarily to improve health outcomes for patients (The Conference Board of Canada,
2014). However, the impetus for this shift was propelled in part from growing recognition
that the traditional solo physician family practice model is no longer adequate to provide
all manner of care for all patients (Sargeant, Loney, & Murphy, 2008), that family
physicians require further support in caring for populations with growing needs and
complexities (General Practice Services Committee [GPSC], 2015c), and that new
models may help to ease physician burden (Pelak, Pettit, Terwiesch, Gutierrez, &
Marcus, 2015).

5
While the call for transformation of primary care may initially appear somewhat
physician-centric, it is important to identify that family physicians have long been
considered to be the backbone of primary care (Martin et al., 2004). However, as
concerns about the sustainability and quality of the primary care system persist (Health
Council of Canada, 2012), other changes to facilitate realigning of services are required.
One example is the legislative and regulatory changes made in Canada to facilitate
optimization of role and scope of practice for different health care professionals.
In some provinces, such as British Columbia, activities that were previously
restricted to physicians have been opened to other professionals through re-structuring of
legislation to a competency-based framework. Prior to 2005, only physicians had
prescribing authority, which was granted to them based on professional title. Today,
nurse practitioners and pharmacists are able to prescribe medication autonomously, and
registered nurses can diagnose some conditions and dispense medication with a “certified
practice” designation from the regulatory college (College of Registered Nurses of British
Columbia, 2016). These legislative changes have introduced nurse practitioners as
primary care providers alongside family physicians, and also have increased the function,
role overlap, and interdependence of health care professionals who are increasingly
expected to collaborate (Macnaughton, Chreim, & Bourgeault, 2013) in order to provide
effective team-based care.
With commitment to primary care reforms at the forefront of policy and practice
discussions, decisions are required about implementation of new primary care models.
Organizational and structural changes require significant financial and professional
investment on many levels. Further understanding of how primary care transformation

6
might achieve the Triple Aim (Berwick, Nolan, & Whittington, 2008) while preserving
the core values of primary care (McWhinney, 1998; Starfield, 1998) is necessary in
moving forward to transform delivery of high quality primary care in Canada.
Modeling Primary Care
Acknowledgment that new models of team-based primary care are essential to
sustainable primary care service delivery is now pervasive in countries such as the United
Kingdom (The King’s Fund, 2015), Australia (Australian Commission on Safety and
Quality in Health Care, 2010), and the United States (Agency for Healthcare Research
and Quality [AHRQ], n.d). In order to better understand the origins and influences on the
model of team-based care currently unfolding in northern British Columbia (BC), which
is the location for this research, a brief overview of the development of primary care
models in the Canadian context is given here.
In the United States, a model that has been widely adopted, implemented, and
evaluated is the Patient Centered Medical Home (PCMH). The PCMH is a blending of
the patient medical home, a term coined in 1967 in response to a call to house a child’s
medical records in a central location (American Academy of Pediatrics, 2016), and
Wegner’s Chronic Care Model (Flieger, 2016). The PCMH renews the focus on primary
care (Sweeney, Bazemore, Phillips, Etz, & Stange, 2012). The PCMH is seen as a model
to implement the core tenets of primary care (Westfall et al., 2014), and a vehicle to
achieve the Triple Aim of improving health and patient experience while reducing per
capita cost (Fontaine, Flottemesch, Solberg, & Asche, 2011).
In Canada, the College of Family Physicians of Canada (CFPC) released its vision
for the Patient Medical Home (PMH) in 2011. Although the CFPC (2011) acknowledges

7
many shared elements with other models, such as the PCMH, the PMH is distinctly
Canadian due to incorporating values of fairness, equity, and access for all to health care
(p. 5). The PMH is defined as the place where patients feel most at home to discuss
“personal and family health and medical concerns” (p. 8), and is built on ten pillars. The
pillars include patient-centred, personal family physician, team-based care, timely access,
comprehensive care, continuity, electronic records and health information, education and
training, system and supports, and evaluation (CFPC).
The CFPC alternately describes the PMH as a vision, a concept, and a frame of
reference, in addition to referring to it as a model. This language may be an attempt to
reinforce the CFPC message that the PMH is not an attempt to “re-engineer” (p. 19)
primary care. Rather, there is encouragement towards contextualization of initiatives so
that the objectives of the PMH may be achieved without suggesting a heavy-handed
course correction that might detract from innovation and success in creating a patientcentred health care system.
In all provinces and territories, primary care reform initiatives were underway
years before the CFPC (2011) published their vision for PMH. The Primary Health Care
Transition Fund (PHCTF) provided $800-million to provinces and territories, and also for
regional and national initiatives, to invest in primary care renewal beginning in
September, 2000 (Health Canada, 2007). Thus, by 2011 when the CFPC published the
PMH model, many objectives outlined for the PMH model were already being met
through initiatives such as Family Health Teams in Ontario, Family Medicine Groups in
Quebec, and Primary Care Networks in Alberta (CFPC). The PMH concept can serve to
strengthen such initiatives (CFPC).

8
British Columbia did not use the province-specific PHCTF monies of $74-million
to invest significantly in projects committed to implementing team-based care. Rather,
projects in BC focused on Quality Improvement Days to engage physicians, patient
mapping, creation of chronic disease management guidelines, and financial incentives to
physicians to improve chronic disease management (Health Canada, 2007). Initiatives to
support patient self-management were also supported through the PHCTF (Health
Canada). One critique of the BC government’s use of the PHCTF from pharmacists and
nurses was that the focus was too much on physicians (Health Canada).
Critique of the government of BC for failing to embrace interprofessional teambased primary care continues, a decade after the PHCTF concluded. Lavergne and
McGrail (2016) calculated the costs of the financial incentives provided to physicians for
providing extra services such as complex care and mental health counselling. The costs
for this program overall were more than $150 million, with no associated changes in
number of primary care visits or hospitalization rates (Lavergne & McGrail), indicating
poor cost effectiveness.
Shifts towards team-based care in BC are now being implemented. In 2014, the
provincial government identified interprofessional teams as a priority for primary and
community care (Ministry of Health, 2014), and by 2015 gave explicit support to
establish “team-based family practices” (Ministry of Health, 2015, p. 10). The General
Practice Services Committee (GPSC), which is a partnership between the provincial
government and Doctors of BC (legally the BC Medical Association) adopted the CFPC
(2011) pillars of the PMH to support goals of patient-centred comprehensive care (GPSC,

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10
In Northern Health, where this research took place, commitment to
interprofessional primary care teams is ahead of provincial initiatives, as outlined by the
objectives of the study Partnering for Change: Understanding the Contribution of Social
Entrepreneurship to Primary Health Care Transformation (MacLeod et al., 2011). As
interprofessional team development and implementation progresses within Northern
Health, language and definitions used to describe team-based primary care have changed
to reflect current and common understandings of this phenomenon. As such, Northern
Health also uses the term PCH to describe interprofessional team-based primary care. The
definition is:
A person-centred medical care setting, such as a family doctor’s office, where
people establish a long-term relationship with a personal physician or nurse
practitioner who provides and directs their medical care. Interprofessional teams
are available to the person and family if the person and their primary care
provider, including the primary care nurse decide together that the person might
benefit from team involvement (Northern Health, n.d.b).
This definition of PCH is different from the one offered by the GPSC, and there
are some other inconsistences and phrasing that are of interest to note in light of the
research questions for this study. First, Northern Health places the PCH description under
the heading of Primary Health Care on their webpage. Yet, the PCH is described as a
medical care setting, with the social aspects of health care not explicitly included.
Second, it is clear that not every patient is expected to interact with the interprofessional
team, and there may be a temporal element as well as a gate-keeping element to
determine who receives team-based care as well as when they might receive it. Both these
elements highlight the importance of improved understanding of how team-based care is
negotiated within a PCH, and how a feeling of being known may influence provider and
team member understandings of who needs team-based care, and when.

11
This overview to the development of team-based primary care models serves to
highlight some of the influences and drivers of current thinking and investment in
primary care reforms in BC. The complexity and high stakes for success of
implementation of interprofessional primary care teams emphasizes the importance of
understanding who needs team-based primary care, and when, in order to receive high
quality primary care. The next chapter will turn to examine some of the gaps in current
understandings of team-based primary care, to further illustrate how the focus and
approach to this research can contribute to knowledge of interprofessional primary care
teams in Canada.

12
Chapter Two: Uncovering Gaps in Understanding
Transforming primary care requires major changes to the organization and
delivery of primary care services. Some of these changes have been closely examined in
terms of the structure, process, and outcomes of PCMH/PMH models in Canada, the
United States, and other countries. This Chapter will consider current understandings of
team-based primary care, highlighting areas of attunement in this research, while at the
same time drawing attention to aspects of team-based primary care that may require
further differentiation and articulation.
Working in Teams
With team-based care trending towards the norm in Canada (Martin, 2012), the
concept of interprofessional collaboration has received much attention. Services have
been realigned with hopes of bridging disciplinary silos1 (Sahota, 2009) and flattening
hierarchies (Nutting, Crabtree, & McDaniel, 2012). Yet structures can be shifted more
quickly than relationships (Flieger, 2016), and health care professionals can be
significantly affected with implementation of new models of care delivery (Armstrong,
2013).
Changes that a shift to team-based care brings to a primary care environment can
be overwhelming and challenging (Allan et al., 2014; Rodriguez et al., 2014). The
cohesion and effectiveness of a team may be negatively affected when there are
competing priorities (Allan et al., 2014), when teams are not co-located (Allan et al.),
when implementation of change is prescriptive (Doctors of BC 2015; Van Roy,
Vanheule, & Deveugele, 2013) and when professionals are uncertain or uninterested in

1 A “silo” is a term used to describe isolation in health care, usually indicating groups or departments who do not frequently share
information or resources.

13
one another’s roles (Edwards et al., 2015). In the BC context, where team-based primary
care is in early stages of implementation, attunement to challenges such as the ones listed
above may contribute to understanding how such issues develop or resolve. The influence
of co-location is of particular interest in this research, as most teams in urban areas of
Northern Health are not co-located.
Information technology is also an important factor when considering the
negotiation of team-based primary care in terms of understanding how information is
shared and transferred over time. The teams that are not co-located in Northern Health do
not fully share an electronic medical record (EMR). Rather, physicians in fee-for-service
practices use one version of an EMR, and the interprofessional team members use a
different version. The way in which team members use the EMR, particularly in how it
influences factors such as communication and coordination, has been articulated in this
research. Issues with information technology can be exacerbated when there are
limitations of interoperability or inconsistency of use between team members (Banfield et
al., 2013; Denomme, Terry, Brown, Thind, & Stewart, 2011; Krist et al., 2014;
McMurray et al., 2013).
Current understandings of team-based primary care also reflect what facilitates
effectiveness and collaboration within teams. Some authors report facilitators that are
simply the polar opposites of attributes that detract from team-based care. Thus when
team members know one another’s roles and scope of practice (Brown et al., 2015;
Gaboury, 2009; Rodriguez et al., 2014), are co-located or have physical proximity to one
another (Brown et al., 2009; Chang et al., 2014; Cromp et al., 2015), it has been found
that collaboration can be strengthened.

14
Other factors, such as opportunity for team-building activities (Brown et al.
2010), a shared vision (Brown et al., 2015; Smith-Carrier & Neysmith, 2014), and
leadership (Allan et al., 2014; Cromp et al., 2015, Flieger, 2016; Rodriguez et al., 2014;
Smith-Carrier et al., 2016), are indicators of high-functioning teams. Examining the
process of how and whether these facilitators are present in this research will contribute
to knowledge about team-based primary care implementation in northern BC.
Communication between team members is another attribute of interprofessional
collaboration that resonates throughout the primary care literature as central to effective
team-based care (Banfield et al., 2013; Brown et al., 2009; Chang et al., 2014; Cromp et
al., 2015; Gaboury, 2009; Morgan, Pullon, & McKinlay, 2015). Notably absent from
current literature, however, and particularly with regard to interprofessional teams who
are not co-located, is any guidance about how interprofessional team members become or
stay involved in patient care. The timing, process, and factors influencing decisionmaking about which patients need a team is unknown. Further, the length of time or
composition of interprofessional team members required for a patient’s optimal care is
variable, and how this is negotiated within the team is also unknown. These gaps in
understanding are indicative of a knowledge base not yet caught up with the shift in
evolving systems of primary care delivery that involve teams.
Questions about how and when patients receive team-based care uncovers further
questions about how patients feel known within a team. Almost no literature exists that
includes discussion of patients as team members, while studies that have been published
are within the acute care context (for example Lavoie-Tremblay et al., 2014). Aside from
these scant findings, patients seem to be included mainly through efforts to involve

15
patients in management-level decision-making that is sometimes termed as “userinvolvement processes” (Martin & Finn, 2011, p. 1053) in health care.
Understanding how patients are engaged with different health care professionals
over time and who patients consider part of their team is not found in current literature.
While it is recognized that it is possible to have multiple healing relationships (Scott et
al., 2008) between patients and health care professionals, and that patients want to feel
known (Cheraghi-Sohi et al., 2008; Schers, Van den Hoogen, Bor, Grol, & van den
Bosch, 2005; Turner et al., 2007), how this unfolds within a primary care team, and how
feeling known contributes to negotiating care towards improved outcomes in primary
care, is missing from the ongoing discourse of team-based primary care.
The PCMH/PMH models of primary care hinge on team-based care (Cromp et al.,
2015), yet team-based care is only one pillar of the PMH vision for high quality primary
care (CFPC, 2011). It is necessary to consider some of the other pillars, with particular
attention to how team-based primary care might influence some of the other attributes
that are recognized as core values of primary care.
Examining Core Attributes
With the twinned motivations of evidence and policy guiding BC towards
implementing the PMH, it is timely to inquire and examine how the widely recognized
core attributes of primary care (Ferrante, Balasubramanian, Hudson, & Crabtree, 2010;
Haggerty et al., 2007; Leatherman & Sutherland, 2010; Picker Institute Europe, 2016;
Romanow, 2002; Starfield, 1998) are conceptualized. There is some variation in
terminology when talking about aspects of primary care, which can threaten to obscure
common understanding of key concepts.

16
Words like “values” (McWhinney, 1998; Starfield, 1998), “principles” (Picker
Institute Europe, 2016), “attributes” (Haggerty et al., 2007) or “factors” (Christakis et al.,
2004), are variously used to describe essential elements of high quality primary care. For
clarity of purpose, the word attribute is selected for this study. The core values of primary
care include key attributes but also intangibles for which evidence of effectiveness is not
always possible or desirable; McWhinney (1998) gives the example of compassion. Thus,
a focus on attributes extracts, to some degree, the highly debatable aspects of what might
be inherently “good” about primary care.
Attributes of primary care have key characteristics through which they can be
defined, and this process was carefully completed by primary care researchers in Canada
(Haggerty et al., 2007). These attributes were then rated by recognized primary healthcare
experts as to the importance of the attributes within different models of primary care
(Levesque et al., 2011). Thus, there is a point of reference to understanding how primary
care attributes are prioritized or emphasized in the Canadian context. Noticing which
attributes are prioritized by health care planners and clinicians can also indicate what is
valued about primary care in contemporary settings.
In this chapter, the attributes of patient-centredness, accessibility,
comprehensiveness, coordination, and continuity are given priority for two reasons. First,
these are attributes for which key characteristics can be enacted through practices of
patients, primary care providers, and interprofessional team members. Second, these are
attributes represented by pillars within the CFPC (2011) PMH model and adapted by the
GPSC (2016) model.

17
While consideration of the role of personal family physician (or primary care
provider) will be offered in the context of team-based primary care, the primary care
provider role is not considered in isolation. Similarly, the CFPC (2011) pillars relating to
information, system supports and evaluation are embedded within this research but are
not a dedicated focus. Instead, attention is turned more fulsomely to the attributes that can
be interpreted through practices to better understand how team-based primary care is
negotiated in the context of therapeutic relationship and knowing or not knowing patients.
The GPSC PMH model (2016) provides descriptions for each attribute
represented in the model, and the attributes are organized into three domains with titles of
service, relational, and structural attributes or enablers2. The descriptions are based on the
CFPC (2011) framework (GPSC, 2015b), thus not necessarily on definitions of attributes
found within the academic literature. This section will provide an overview of these
attributes, which informed the approach and data collected for this study.
Patient-centredness
At first glance, the attribute description of patient-centred, whole-person care is
directed towards outcomes, and not process or method. The description states that care is
easily navigated, centred on the needs of the patient, delivered in a culturally appropriate
manner, with recognition of social determinants of health (GPSC, 2016). This idealized
descriptor embeds a number of factors that require coordination between multiple levels
of the health care system while assuming cultural competence and a broad understanding
of health by providers. There is no indication of who determines the needs of the patient,
or how providers might achieve patient-centred care. To improve understanding of how

2 The list of descriptions is accessible only by clicking on the hyperlink “12 attributes of a patient medical home in BC” via the GPSC
(2015) webpage at the following link: http://www.gpscbc.ca/what-we-do/primary-care-bc/patient-medical-home

18
to provide patient-centred care in order to achieve the outcomes described for this
attribute, the descriptor could be modified to include the four interactive components of
the patient-centred clinical method (Stewart et al., 2014). These components, widely
recognized in research and education fields, are exploring health, disease, and the illness
experience; understanding the whole person; finding common ground; and enhancing the
patient-clinician relationship (Stewart et al.).
Accessibility
The description of access by the GPSC (2016) appears to be a blend of the
definitions offered by Haggerty et al. (2007) for first contact access and accessibility –
accommodation. Yet the language is changed somewhat, from “[t]he ease with which a
person can obtain needed care …” (Haggerty et al., p. 340), to “[p]atients are able to
access …” and “patients know how to appropriately access …” (GPSC, 2016). The
difference in this phrasing invites analysis and questioning.
The GPSC (2016) description seems to shift the onus of responsibility to the
patient being the one requiring the knowledge and capacity to seek the care needed, rather
than the PMH or health care system taking the responsibility to ensure patients do not
encounter barriers when attempting to seek primary care. The GPSC description of access
is further limited by focusing narrowly on availability of services (Aday & Andersen,
1974), while failing to recognize there are predisposing factors that contribute to patient
decisions about accessing health services (Andersen, 1995), and that the structure of the
PMH will influence care-seeking practices (Andersen, Vedsted, Olesen, Bro, &
SØndergaard, 2011) and thus access (Hogg, Rowan, Russell, Geneau, & Muldoon, 2008).
The concept of “appropriate access” as described by the GPSC for this attribute is

19
unexamined within the model, and may inadvertently widen the significant and unequal
gap in care, particularly for marginalized populations (Adelson, 2005; Conradson &
Moon, 2009).
Comprehensiveness
The GPSC (2016) description for the attribute of comprehensiveness, following
the CFPC (2011) vision and objectives for this pillar, outlines how comprehensive care is
delivered across care settings, throughout the lifespan, and regardless of geographical
location. Comprehensive care is provided within the PMH, or via linkages to
“comprehensive services”. In this description, it appears that this model of PMH focuses
on the individual patient as the unit of analysis or interest. While the patient-centred
attribute description for the PMH does state that care is centred on the “needs of the
patient, family, and community” (GPSC), it is the patient as an individual that is the focus
in the remaining descriptions of the attributes. This raises questions about comprehensive
care, from a population health perspective. While the comprehensive care description
includes health promotion and prevention (GPSC), there is no explicit linkage between
the PMH and public health. Unless public health is conceptualized as a “specialized
service” (GPSC), which would be inconsistent with the way in which it is usually
discussed and operationalized within the Canadian context (Martin-Misener & Valaitis,
2009), the tenets of population health and linkages with public health appear to have been
overlooked in this model of the PMH. This lack of a population orientation (Haggerty et
al., 2007) may be cause for concern as the PMH is implemented.

20
Coordination
Coordination within and outside the PMH is linked with relational and
informational continuity in the GPSC (2016) description of this attribute. In this way, it
appears that agreement about defining coordination in contrast to continuity aligns with
the findings of Saultz (2003). Saultz reviewed the Reid, Haggerty, & McKendry (2002)
definitions of relational, informational, and management continuity with the conclusion
that the definition of management continuity is a better fit within the concept of care
coordination, as opposed to being a third type of continuity.
Coordination is dependent on continuity in the PMH (GPSC, 2016), and clear
pathways are required particularly as patients transition “to and from specialized
services” (GPSC). Attention is drawn again to the choice of language in this description,
as coordination is focused only between the PMH and specialized services. Patients
receive care and support from many community-based services that also influence health
and primary care outcomes. Neglecting to consider how these services might be
coordinated for patients and understood by team members within the PMH may be
problematic in providing comprehensive, accessible, patient-centred, and team-based
care.
A second important issue regarding the description of coordination within the
PMH model (GPSC, 2016), is understanding how team members will establish and
maintain personal relationships and informational continuity with one another,
particularly for the PMH (or PCH) where team members are not co-located. The PMH is
referred to as the “hub” for coordinating care, but this may be difficult if team members
included as part of the PMH are not geographically proximal to one another. How

21
primary care providers and interprofessional team members know one another and share
or transfer information related to knowing and caring for patients is of interest to this
study.
Successful coordination of care relies on more than simply having information
available (Banfield et al., 2013). Coordination is not at all observed by patients, but they
will assume it is happening (Haggerty, Roberge, Freeman, & Beaulieu, 2013). Thus,
within the PMH, it is worthwhile to pay attention to what information is disclosed by
patients and what information is shared with patients.
Coordination is notoriously difficult to measure, and inconsistently defined within
the literature (Banfield et al., 2013). Noticing and articulating what factors influence how
information is incorporated into planning care for patients, as well as how information is
shared or transferred between team members may be helpful to advance understanding of
this attribute. In this study, attention to salient features and the process of how care is
coordinated (or not) within and outside the PMH may offer new insights to improve
coordination in primary care.
Continuity
The description of continuity for the conceptualization of the PMH in BC is:
Longitudinal relationships support patient care across the continuum of patient
care, spanning all settings. The enduring relationship between the patient, family
physician (or NP where appropriate) and PMH team is key, and needs to be
supported by informational continuity (two way communication that informs
appropriate and timely care) (GPSC, 2016).
The full description is included as this attribute is central to the framing of the
research questions of this study, and is deserving of careful attention. Continuity of care
is viewed as a principal attribute of primary care (Hill, Twiddy, Hewison, & House,

22
2014) and is usually understood as intrinsically desirable (Tousignant et al., 2014). Thus,
some of the language within the GPSC (2016) description seems somewhat limiting.
The first sentence in the description is that longitudinal relationships will support
patients across all settings. The scope of this statement is unclear. It seems uncertain
whether it is expected that the strength of the longitudinal relationship between patient
and provider will be supportive regardless of setting, whether longitudinal relationships
can be expected to develop in various settings, or whether an entirely different meaning is
intended. Further, the focus on longitudinal continuity is representative of the temporal
aspect of the relationship, while wording to highlight the healing aspects or expectation
of quality in a longitudinal relationship is missing.
In choosing a word to describe the longitudinal relationship between patients and
providers, the GPSC (2016) description includes “enduring”. The word endure can have
both positive and negative connotations, but seems a unique choice given the array of
research that focuses on describing the patient-provider relationship as healing
(McWhinney, 1998; Scott et al., 2008; Tarrant, Windridge, Boulton, Baker, & Freeman,
2003), and further research that suggests that continuity is dependent on the strength of
connection (Heaton, Corden, & Parker, 2012; Phillips-Salimi, Haase, & Kooken, 2011;
Ridd, Shaw, Lewis, & Salisbury, 2009) in order to be sustained (Reid & Wagner, 2008).
If words such as healing, sustained, or connected seem inadequate to describe the
relationship between patients and providers, it is equally puzzling to consider why the
GPSC (2016) description does not incorporate widely accepted definitions of types of
continuity as developed by Haggerty et al. (2003). Relational continuity is
straightforwardly reported as “an ongoing therapeutic relationship between a patient and

23
one or more providers” (Haggerty et al., p. 1220). This definition captures a degree of the
temporal and quality dimensions, and it also keeps the patient central to the definition.
The definition of informational continuity may have been just as helpful; “the use
of information on past events and personal circumstances to make current care
appropriate for each individual” (Haggerty et al., p. 1220). This definition is broad yet
indicates the type of information that may be considered. It refers to using information,
rather than the much narrower term of “two way communication” (GPSC, 2016).
Specifying informational continuity within the GPSC (2016) description as twoway communication is a restricted interpretation. If it is meant that information is
communicated between two providers, leaving the patient out completely, it lacks patientcentredness. It also lacks application for team-based care, particularly for written
communication. When information is not recorded or transferred, it is a barrier to
continuity and high quality care (Agarwal & Crooks, 2008; Schers, van den Hoogen,
Grol, & van den Bosch, 2006). Team-based care may be less effective, and poor
informational continuity can also impact relational continuity, comprehensiveness, and
coordination.
Continuity is an attribute that is experienced by patients (Haggerty et al., 2013),
and dissatisfaction will result if patients receive conflicting advice (MacPhail, Neuwirth,
& Bellows, 2009), repeat their story multiple times (Jones et al., 2009), or have to “start
all over” with someone new (Wong, Watson, Young, & Regan, 2008, p. 95). Patients are
ever in a process of managing asymmetrical relationships with providers (Andersen et al.,
2011), and are already required to navigate numerous obstacles as they attempt to
penetrate the clinic system and communicate information (Newcomb, McGrath,

24
Covington, Lazarus, & Janson, 2010). Thus, efforts to decrease and avoid instances of
poor continuity can help prevent some of the consequences of missed opportunities for
coherent care such as mistrust, miscommunication, relational disengagement (PhillipsSalimi et al., 2011), and social distance (Tarlier, Browne, & Johnson, 2007).
Understanding how practices of knowing and connection within patient-provider
relationships contribute to all types of continuity, and how these practices influence the
negotiation of team-based primary care, is a primary focus of this research.
The purpose of drawing attention to some of the key attributes and descriptions of
the PMH model in BC is related to the novelty of the model, as it became available only
recently (GPSC, 2016). Given that the PMH in BC has not yet been implemented
extensively, there is opportunity to examine the language, tenets, and domains of the
model. The intent is not to critique but rather to examine and see what might require
further articulation through an in depth consideration of how the PMH model may
influence patient and provider relationships as well as the delivery of primary care.
The GPSC (2016) PMH model does not incorporate patient perspectives, or the
perspectives of any interprofessional team members. It focuses mainly on primary care
providers. While this is not ideal, it is sensible considering the nature and purpose of the
GPSC. This model also represents the only conceptualization and visualization available
that is specific to the BC context. While Northern Health created a model for
implementation of interprofessional teams, it did not include definitions to the detail as in
the PMH (GPSC, 2016) model. Because the GPSC model stems from thinking on behalf
of the provincial government and physicians, it can be expected to be influential in
decision-making about the structure and function of the PMH across the province.

25
Some idealized language is used within the descriptions for primary care
attributes within the GPSC (2016) model, and there is also some ambiguity. One key
concern is how access is defined, as well as a lack of a population orientation. Also, there
is no attribute of equity included in the GPSC PMH model. Although equity is identified
as a value in the CFPC (2011) vision, which is the foundation for the GPSC model, it is
left undefined as an assumed good in the CFPC document.
A lack of explicitness about equity in a PMH model is troublesome. Recently in
Quebec, it was found within the new models of primary care delivery, continuity
worsened for patients with chronic disease (Pineault et al., 2016). The findings of this
study report that over time, continuity and perceived outcomes of care improved more in
the traditional practices, while in the new models, accessibility and responsiveness
increased only for patients who did not have chronic disease (Pineault et al.). Thus,
patients with greater burdens of illness did not benefit from new models of care (Pineault
et al.). Without close attention to how access, continuity (particularly relational
continuity), patient-centredness, and team-based care are described and operationalized,
and without orientation to the health of the population or attending to inequities, BC risks
implementing a model that will not improve health outcomes or patient experience.
As the model of the PMH is operationalized in BC, further attention will also be
required towards understanding practice structures that contribute to high quality primary
care delivery. The structural domain as it is currently outlined within the GPSC (2016)
model is quite high level and does not dwell on important features of practice structures
within the primary care office. Ideas about how team members might be offered to
patients, the referral or consultation system between team members, feedback and

26
communication loops, or planning and coordinating care are all of interest in
understanding how team-based care can be negotiated, yet there is little guidance both
within the model or in the current literature about what works well, especially for teams
that are not co-located. With transformation of primary care, the design can be critical in
fostering and maintaining relationships that can improve primary care (Andersen et al.,
2011; Haggerty et al., 2011; Haggerty, Roberge, Freeman, Beaulieu, & Breton, 2012;
Ridd et al., 2009). The structural domain of primary care is as important as the
performance domain (Hogg et al., 2008).
A last point to note here is that many of the GPSC (2016) descriptions of
attributes are quite narrow, and exclude widely accepted definitions of attributes for
primary care. Creating a unique set of descriptions for primary care attributes may
contribute to problems in evaluation of outcomes of the PMH model. When definitions
that are used to give meaning and provide understanding for diverse groups of people
working within the same system vary widely across regions or countries, it is difficult to
credibly compare and learn whether what is working in one context might be applicable
to another context.
Assessing Gaps in Methods
Current methods of research in primary care overemphasize some approaches
while overlooking others. This section highlights gaps in methods through examining
studies that focus on continuity of care. The attribute of continuity is selected for
examination in part because it is foundational to primary care, making evaluation of this
attribute critical to understanding how high quality primary care is conceptualized and
delivered. Second, the attribute of continuity is selected for examination of methods

27
because it may be the attribute most affected with implementation of the PMH and the
accompanying shift towards team-based delivery of primary care.
To examine gaps in method, a straightforward approach was taken. First, with the
understanding that continuity is experienced, the search for relevant literature centred on
studies that endeavoured to understand how patients experience continuity as well as how
providers might offer or foster continuity. Second, consideration of the methods used by
authors in this topic area were reviewed to note what the common and uncommon
approaches tend to be, including selection of participants, in order to identify gaps in the
current knowledge base of how continuity is experienced. The following is a summary of
the research reviewed organized by method.
The most common method to evaluate continuity is the patient survey or
questionnaire (Baker et al., 2007; Campbell et al., 2010; Christakis et al., 2004; Dolovich
et al., 2004; Gulliford, Cowie, & Morgan, 2011; Gulliford, Naithani, & Morgan, 2006;
Hjortdahl & Laerum, 1992; Liss et al., 2011; Nutting, Goodwin, Flocke, Zyzanski, &
Stange, 2003; Pineault et al., 2016; Rodriguez et al., 2007; Safran et al., 2006; Schers,
van den Hoogen, Bor, Grol, & van den Bosch, 2004; Schers et al., 2002; Stokes et al.,
2005; Tourigny et al., 2010). Numerous authors conducted semi-structured interviews
with patients (Andersen et al., 2011; Broom, 2003; Cowie, Morgan, White, & Gulliford,
2009; Frederiksen, Kragstrup, & Dehlholm-Lambertsen, 2009; Jones et al., 2009; Miller
et al., 2009; Naithani, Gulliford, & Morgan, 2006; Newcomb et al., 2010; Tarrant, DixonWoods, Colman, & Stokes, 2010; Tarrant et al., 2003; Thorne et al., 2005) or
unstructured interviews (Rhodes, Sanders, & Campbell, 2014) to evaluate experience of
continuity. Studies that used a mixed methods approach were somewhat common, and

28
most combined patient surveys with interviews or record audits, and are longitudinal or
cross-sectional studies (Boulton, Tarrant, Windridge, Baker, & Freeman, 2006; Green et
al., 2008; Katz, McCoy, & Sarrazin, 2013; Lee et al., 2006; Kristjansson et al., 2013;
Mainous, Goodwin, & Stange, 2004; Menec, Sirski, Attawar, & Katz, 2006; Panattoni,
Stone, Chung, & Tai-Seale, 2014; Tousignant et al., 2014; Williams, Dunning, & Manias,
2007). Focus groups with patients is also a method used by several authors (Alazri, Neal,
Heywood, & Leese, 2006; Locatelli, Hill, Talbot, Schectman, & LaVela, 2014; Matthias
et al., 2010; Noël, Frueh, Larme, & Pugh, 2005; Preston, Cheater, Baker, & Hearnshaw,
1999; Wong et al., 2008). Locatelli et al. and Preston et al. also conducted interviews.
Methods that are employed less frequently to study continuity include secondary
analyses such as systematic reviews (Agarwal & Crooks, 2008; Crooks & Agarwal, 2008;
Uijen et al., 2012), other literature reviews (Uijen, Schers, Schellevis, & van den Bosch,
2012; van Servellen, Fongwa, & Mockus D-Errico, 2006), and one qualitative
metasummary (Haggerty et al., 2013).
Three studies were found that employed discrete-choice experiments as method
(Cheraghi-Sohi et al., 2008; Gerard, Salisbury, Street, Pope, & Baxter, 2008; Turner et
al., 2007), while two studies included provider focus groups (Delva, Kerr, & Schultz,
2011; Sharman, McLaren, Cohen, & Ostry, 2010) (Sharman et al. also did provider
interviews). Less commonly used methods were interviews with providers and/or
decision-makers (Banfield et al., 2013), surveys of providers (Hjortdahl & Borchgrevnik,
1991; Schers et al., 2006), analysis of medical records or use of administrative data
(Parkerton, Smith, & Straley, 2004; van Walraven et al., 2008), and case study (MacPhail
et al., 2009).

29
Examining the methods of inquiry and measurement of a concept such as
continuity uncovers current thinking about evidence-informed primary care. The methods
that are commonly chosen highlight that the types of knowledge that have legitimacy and
currency in health care commonly focus on a single aspect or perspective, which may be
misleading regarding the simplicity with which a problem may be addressed or
understood. There are three main issues when relying to a large extent on quantitative
data, and in particular with survey data. First, it is known that surveys tend to oversample
those with higher levels of education and literacy (Haggerty et al., 2011), thus obscuring
the experiences of many patients who may not be encountering continuity in primary
care.
The second issue with over-reliance on survey data is that results tend to be
positively skewed (Haggerty et al., 2011; Willis, Evandrou, Pathak, & Khambhaita,
2016), even when negative experiences are described (Willis et al.). In particular, Willis
et al. found that when negative experiences could be attributed to structural issues, such
as workload, perceived shortcomings in care were excused by patients. This finding
indicates that with patient surveys as a single method for a study, there is risk of covering
up negative experiences. Choosing a patient survey as a single method for data collection
also risks creating a disconnect between the experience of the patient and other perceived
inter-related factors that may affect patient experience of care, such as structural issues,
of which staff workload is one example.
Finally, evaluating the experience of continuity solely through patient survey
answers obscures how patients weigh any number of factors that they may consider when
deciding about their experience of continuity. Some of the factors, such as those from the

30
structural domain of care, may not be included on a survey. Ordinal scales provide little
understanding of how or why participants select the answers they choose.
Patient surveys can be helpful in providing a large amount of aggregate data on
which quantitative analyses can be performed. However, there is a risk in how these
analyses may be used to inform practice or policy. Malone (2003) identifies how a
paradox may occur when anonymous units of aggregated data, such as patient responses
to surveys, are analyzed in order to suggest very particular interventions for patients who
exist in complex circumstances.
While the patient survey is identified here as a commonly employed method that
oversimplifies the complex experience of continuity, other methods reveal similar issues
through study design. A key concern with most of the studies reviewed in this section is
the dichotomizing of interrelated variables. Although continuity cannot be experienced
without providers and patients interacting with one another, only six of the studies
reviewed elicited perspectives or experiences of both patient and providers within a
single study (Becker & Roblin, 2008; Kristjansson et al., 2013; Panattoni et al., 2014;
Roberge, Beaulieu, Haddad, Lebeau, & Pineault, 2001; Scott et al., 2008; von
Bultzingslowen, Eliasson, Sarvimaki, Mattsson, & Hjortdahl, 2006).
The concern with dichotomous thinking, which tends to “dull the analyst’s eye”
(Rosaldo, 1983/1987, p. 295) is magnified in primary care research through the way in
which primary care attributes are frequently treated as independent entities, or sometimes
as a trade-off, for example to see if patients prefer accessibility or continuity (Locatelli et
al., 2014). Primary care attributes cannot stand alone; rather there is a significant amount
of overlap between continuity and other attributes (Banfield et al., 2013). For example,

31
the attributes of accessibility, continuity, and patient-centred care overlap (Brown, Ryan,
& Thorpe, 2016), comprehensiveness is associated with equity and continuity (O’Malley
& Rich, 2014), and continuity and coordination are often found to overlap (Uijen et al.,
2012).
With a combination of attribute overlap and variability of definitions for each
attribute, measurement quickly becomes unruly. For example, in a recent systematic
review, Schulz, Pineda, Lonhart, Davies, & McDonald (2013) identified 96 measurement
instruments for the attribute of coordination. While a lot of tools and measures are being
produced through research efforts, there is risk of “methodological sterility” (Gadamer,
1976/1996, p. 117) in that the findings of these studies are unable to address key
questions, such as how teams in primary care work (Bleakley, 2013).
The isolation of interrelated variables is an echo of the positivist paradigm.
Current understandings of continuity and primary care exist within contemporary
paradigms, where innovation will always land among existing paradigms, accompanied
by social, historical, and cultural context (Kuhn, 1970). As such, although many health
regions are attempting to transform primary care towards a team-based approach,
measurement and evaluation as evidenced by the studies reviewed in this section, has
been slower to shift away from measurement of traditional, solo-provider models of
primary care. For example, it was not until 2014 that a measure was validated to assess
continuity from more than one provider (Tousignant et al., 2014).
Researchers are now identifying significant issues with the proliferation of
measures and metrics in primary care. These issues stem from both a lack of consistency
and appropriateness, as well as the issue of allowing metrics (particularly performance

32
metrics) to “drive” care processes (Bower et al., 2011; Kansagara et al., 2014; Barrett,
Ricco, Wallace, Kiefer, & Rakel, 2016; Eidus, Pace, & Staton, 2012; Ryan, Brown,
Glazier, & Hutchison, 2016; Schulz et al., 2013). To redress some of these issues, there is
increasing acceptance of the interrelatedness of variables influencing primary care,
accompanied by calls to incorporate more patient-reported outcomes and patient-oriented
experiences as measures of interest (BC Support Unit, 2016).
The gaps identified in this section are a reminder that with too much classification
we distance ourselves from experience (McWhinney, 1996). None of the methods of the
studies reviewed in this section included observation of practices of patients or providers
in primary care, and authors did not examine experience as it was unfolding.
Understanding team-based primary care is not achieved through study of a single
attribute or variable. There is room for research drawing on a contextualized practicebased approach to potentially stimulate new knowledge about how patients and providers
engage in situated, practical decision-making (Benner, Tanner, & Chesla, 2009) to
negotiate team-based primary care.
Assessing Gaps in Content
The nature of the gaps in methods that have been identified uncover
accompanying voids in content in terms of how knowing or not knowing patients and
team members may contribute to understanding how team-based primary care can be
negotiated. How primary care is negotiated within the PMH (or PCH) is largely
unexamined in the BC context. Addressing this gap is necessary to fulfill calls that
primary care be responsive to patient needs, preferences, and values by “… discern[ing]

33
what contextual factors are most relevant and ascertain[ing] how these factors interact”
(Bayliss, Bonds, et al., 2014, p. 267).
Seeking to uncover how primary care is negotiated between patients and health
care professionals is to be reminded that relationship is a priori to content in primary care
(McWhinney, 1996). There is a need to examine more attentively the roles that
relationships play in order for the PMH to be implemented successfully (Flieger, 2016),
and sustained. While the relationship with the patient is considered central to primary
care (Sweeney et al., 2012), a neglected facet may be “the extension of relationships with
trusted colleagues to patients” (Stange, Burge, & Haggerty, 2014, p. 274). This aspect
may have been neglected in the past because evaluation was based on traditional models
of providing primary care.
With regards to tradition, Gadamer (1960/2011) urged reflection on the
significance of the role of history and tradition in understanding. Primary care as
practiced by family physicians comes with a long history of tradition understood by
patients and providers that is disrupted with a shift towards interprofessional teams.
Gadamer (1960/2011) explained how it is out of the past from which our present is
shaped that we project a past horizon into our future. Things matter to us when they are
accounted for in our projections, and so understanding how accepting patients are of team
members, and how patients feel known by providers and team members is shaped by
experience, and these experiences will inform present and future expectations of care.
We never become free of all tradition (Gadamer1960/2011). We have reasons to
preserve traditions, though frequently those reasons may be unexamined (Gadamer). One
example of an unexamined tradition may be hierarchy in health care settings. In this

34
study, attention was given to practices and structures that perpetuate or disrupt tradition
from the provider and the patient perspective, to the extent that they facilitate or impede
practices of connection or negotiation of care with a team. Thus, this research considered
issues such as when and why primary care providers involved team members,
communication between team members in terms of timing and content, and whether
practices reflect efforts that contribute to or detract from providing team-based care.
Within the PCH model (which, in BC, identifies interprofessional team members
as employees of the health authority or a community agency, and thus not exactly the
same model as a PMH), the relationships between team members with one another may
be just as important as the relationships between patients and team members (Flieger,
2016), particularly when a team is not co-located. Attunement to these relationships and
how patients and providers feel known helps to reveal how primary care is negotiated
within a team.
Acknowledgment of the primacy of longitudinal relationships in primary care
(McWhinney, 1996; Stange et al., 2014) leads to a focus in this research on practices of
connection in therapeutic relationships. Clinical practice itself is a negotiation of
“applying general knowledge for the concrete case” (Gadamer, 1996, p. 16), and the
sense of being known is central to human connection (Thorne, 2005). Thus, the
interpretation of practices of connection in order to better understand the negotiation of
primary care is a worthwhile approach that can help bring forth new possibilities for
understanding team-based primary care.
Attunement to connection in therapeutic relationships, (as opposed to longitudinal
or enduring relationships (GPSC, 2016)) brings forth opportunities to investigate what it

35
means to feel known. It is recognized that “when the chips are down … patients long to
be known as a person” (Stange et al., 2014, p. 275). What has not been widely studied,
however, are questions of how patients feel known, how interprofessional team members
might get to know patients outside the traditional patient-provider dyad, and how this
influences negotiation of primary care.
Dominant paradigms in health care may be one consideration as to why primary
care research overlooks issues related to how patients feel known. Paradigmatic thinking
can constrain practices and limit the pathways of change (Rabinow & Sullivan, 1988).
Two such paradigms are efficiency and evidence. Both of these concepts have validity
and clearly belong in health care discourse. However, for this study, the purpose of
calling attention to these paradigms is to examine whether there may be unintended
consequences when practices appear to prioritize evidence and efficiency.
Failure to achieve efficiencies within the system may result in recommendations
for more of a “top-down” approach to attempt to achieve the desired outcomes (Allin,
Grignon, & Wang, 2016, p. 52), and this may be a concern at a stage of early
implementation for the PMH model. In this study, practices were considered in terms of
how they might be influenced by efficiency and evidence, where there might be too much
focus on accommodating forms of organization (Gadamer, 1996) with intensifying
adherence to things like protocols, standardized procedures, or checklists (Chan,
Brykcyznski, Malone, & Benner, 2010; Day, 2009). A focus on efficiency and evidence
may overshadow other aspects of care that might otherwise both reveal and strengthen
how patients feel known.

36
Illuminating how patients feel known can provide a significant contribution to
apprehending how patient preferences, values, and goals are understood by and between
health care professionals within the PCH model. Whether, and to what degree members
of the PCH are able to incorporate this knowledge about patients may influence the care
that is provided, as well as the care that is offered. Decisions are made about whether to
involve team members in a patient’s care, as well as decisions about which patients need
team-based care (Eidus et al., 2012), and when. How these decisions are made have been
largely overlooked in the primary care literature.
In part, processes of knowing and negotiating care may remain hidden due to the
extent that providers draw on tacit knowledge to make these decisions. Peile (2014)
asserts that learning relevant information about patient values is in the realm of
professional judgment. Tacit knowledge is considered to be professionally relevant
knowledge, yet is often ignored in medical decision-making (Epstein, 1999). This study
seeks to address the research questions in part by attempting to articulate the tacit in
negotiating team-based primary care.
Three facets of influence regarding how tacit knowledge shows up in the
enactment and embodiment of practices of connection are accorded particular attention in
this study. The first facet is language. The role of language in a hermeneutical sense is
more than learning to convey empathy or checking that a patient understands how to take
his medication. In primary care settings, and particularly within patient-provider
encounters, there are constitutive rules regarding conversation and social practices. This
means that the action in context would not be appropriate for any other context, and along
with such actions are ranges of language that are inseparable from the action so that

37
particular practices are not without them (Taylor, 1971/1988). Examining how agendas
were tended to during a visit and then asking the provider or team member about it after
the visit was one approach that helped to draw out some of the interpretations of social
practices that occur within patient-provider encounters and how they facilitated or
impeded therapeutic dialogue, issues of connection, or therapeutic relationship.
Language is also helpful towards an understanding that practices may not always
seem rational in observation. A situation may be replete with contradiction, but dialogue
allows us to gather an adequate depiction so that while not necessarily rational, the
practices are coherent within the particular situation (Taylor, 1971/1988, p. 43-44).
However, caution must be employed in this exercise when relying on text created by one
person about another. What one team member or primary care provider records with the
intent to provide a coherent depiction of the important aspects of a patient encounter may
be inadequate information for a different team member. In this way, gaps can appear
between what is said and understood during an encounter and what is documented about
the visit. How providers and team members recount and prioritize the issues of a patient
encounter can result in certain practices of the encounter becoming invisible.
The second facet influencing practices that was considered in this research was
that of identity. A primary care encounter unfolds with a conversation at its centre, as
patient and provider seek common understanding to project towards particular goals. The
provider seeks to understand the patient’s identity, to hear the narrative of their selfidentity (Giddens, 1991) and interpret that narrative to not only diagnose an illness or
disease but also to understand what the illness means for the patient at that particular time

38
in the experience of their life. This process contributes to how care is planned for
patients, including making decisions about involving team members.
The third facet this research is attuned to in the study of practices of connection is
Schutz’s Systems of Relevance (Wagner, 1970). Schutz asserts that in any situation, there
are manifold degrees of understanding (Wagner). Thus, in varying situations, we have
knowledge that has differing layers of clarity, coherence, and relevance (Wagner). Our
knowledge at hand partially arises from the many roles we have, and it is because of such
roles that knowledge can become inconsistent, or knowledge may be inconsistently
applied in practice.
Summary
This chapter has attempted to highlight gaps in understanding about team-based
primary care and how it is negotiated within the Canadian and BC context. As BC moves
towards implementing the PMH and PCH models of team-based primary care, it is timely
to inquire and analyze how the hallmarks of primary care might be incorporated within
these new models. Team-based care, patient-centred care, accessibility,
comprehensiveness, coordination, and continuity are foundational to a strong primary
care system, and each of these attributes must be kept “in play” (Grondin, 2015) for
appropriate research in primary care.
Through examination of how the core attributes of primary care might be assessed
in the context of the PMH, there is recognition that paradigmatic influences may have
contributed to some methods gaining acceptance and repeated use over other methods. In
particular, efforts to integrate or recognize interdependence between key variables have
been overlooked in favour of methods that isolate or dichotomize these variables.

39
In an attempt to reconcile and integrate some of the key attributes known to
contribute to high quality team-based primary care, this research is a study of how teambased primary care is negotiated. The design and intent of this research is to prioritize
relationship and how patients and providers feel known, who they consider to be on their
team, and how that might change over time. Attention to these overlooked facets of
primary care can help address some of the outstanding questions and uncertainties that
accompany transformation of a primary care system towards team-based care, such as
who needs a team, when do patients need a team, and how this can be negotiated. The
research questions will be addressed interpretively, through a study of practices of
connection. The next chapter outlines in detail the methodology and methods of this
study.

40
Chapter Three: Methodology and Methods
This chapter reviews how a study of practices was undertaken through engaging
with Gadamerian hermeneutics. The first section explores what is meant by “practices”,
and frames the term within an interpretive stance. The section on methods describes how
this research was carried out. Detail is provided to lend transparency and credibility to the
approach, field work, and analysis. Last, a section on ethics is included to describe the
role of the researcher and outline ethical procedures followed for the duration of this
study.
Identifying Practices
A study of practices such as this research undertook is otherwise absent from
primary care discourse. In the health care literature, there are some studies of practices
that draw on organizational theory from the field of management and use an “intended
eclecticism” in methodological approach (Nicolini, 2010, p. 1395). Like interpretivists,
organizational theorists are interested in focusing on everyday activity (Feldman &
Orlikowski, 2011), and understanding how practitioners “… recognize, produce, and
formulate the scenes of everyday affairs” (Corradi et al., 2008, p. 3). However, from a
methodological standpoint, it is an interpretivist definition of practice that informed this
research. As such, practices are defined as “activities repeatedly performed over time”
(Kesselring et al., 2010, p. 4). An interpretive approach helps to explicate what gets
covered up when certain practices are emphasized, as well as the way in which
understanding and enacting practices changes over time.
Studying practices can be difficult, particularly to explicate a practitioner’s
decision-making, as practices are often taken for granted (Kesselring et al., 2010). The

41
purpose of research on practices is to help make them visible through articulation, and
“… bring recognition to embedded aspects of practice” (Kesselring et al., p. 114).
Uncovering practices can help to preserve them, while at the same time calling attention
to the personal and situational aspects that may influence how practices are enacted
(Kesselring et al.). In this study, practices of connection between primary care providers
and patients, primary care providers and team members, team members among
themselves, and between team members and patients were all observed in order to
address the research questions of this study.
As practices are interconnected with context, studying practices can illustrate
what happens when “…purposes trip over each other” (Geertz, 1973, p. 17). Purposes trip
over each other through practices because an individual’s practices are themselves an
interpretation of the broader social world (Dreyfus, 1991), and so the ideas and meanings
of a practice are not just in the minds or actions of individuals (Taylor, 1992). In this
research, practices that were perpetuated for reasons related to situational or structural
aspects of team-based primary care delivery were considered in order to better understand
how primary care is negotiated within a team that is not co-located.
Individuals inform their lives through their own interpretations. Errors in
interpretation of meaning can therefore be sustained by certain practices that are a result
of decisions made based on the initial errors of interpretation (Taylor, 1992).
The paradoxical nature of practices is that they can be invisible (Solomon & Flores,
2001), yet they include choice and making decisions among possibilities (Gadamer,
1996). The way in which some practices remained unquestioned, or were otherwise taken
for granted by participants was of interest in this research. Noticing practices that may

42
have been enacted related to errors in interpretation were also consequential to this
research, and contributed to understanding how primary care providers, patients, and
team members know one another, or feel known.
An interpretive study of practices has the ability to run alongside findings of
empirical studies. An interpretive examination of a topic can help to assess and diagnose
instead of measure and predict (Geertz, 1973). The purpose for a study of practices such
as this one is that problems can be “dissolved by a description of everyday social
practices” (Dreyfus, 1991, p. 7). Although interpretivists can only offer “an interpretation
of the interpretation already in the practices” (Dreyfus, 1991, p. 22), that can be enough
to see things differently, to question the way things are done and open the possibility of
“bringing about a social changing of the mind” (Geertz, 1973, p. 319). In this way, the
findings of this study draw attention to practices worthy of further attention and action in
order to improve team-based care organization and delivery so that experience and
outcomes can be improved for patients, primary care providers, and team members.
Methodology: Engaging with Gadamerian Hermeneutics
Historically, hermeneutics has application in theology, linguistics and
jurisprudence, in order to help clarify the standard approaches and methods of such
disciplines, and also as a process to assist disciplines to move beyond methodological
limitations (Mueller-Vollmer, 1994). The task of interpreting and understanding
something is in relation to the whole of which it is a part, and vice versa (MuellerVollmer, 1994). This is described as the hermeneutic circle, and movement between the
whole and the part guides understanding, which is constantly occurring and being revised
(Gadamer, 1960/2011). There is a temporal aspect to understanding as well, whereby

43
time is “… the supportive ground of the course of events in which the present is rooted”
(p. 297). This study draws primarily on Gadamer’s philosophy of hermeneutics to address
the research questions.
Gadamer (1960/2011) asserted that language is the medium of hermeneutic
experience, and that our understanding is dialogic, whether with text or conversation.
When the joint meaning of a common subject matter is disturbed, understanding becomes
a special task (Gadamer, p. 180). Yet, interpretation is not just the subjective intention of
an author or speaker; reconstructing what the author had in mind is a limited undertaking
(Gadamer, p. 366). Rather, it is a hermeneutical necessity to achieve a “fusion of
horizons” (p. 367) to ensure meaning is not reduced simply to what is stated (p. 464) or
the intention of the speaker. The situations where joint meaning of a common subject
matter may be disturbed within a primary care encounter, or between team members who
are not co-located, are frequent in practice. Thus, attention to language and dialogue
between primary care providers, patients, and team members was methodologically
valuable in this study.
Identifying a horizon
The way in which we encounter something and it says something to us is through
what Gadamer termed prejudices (Gadamer, 1976/1996). The word prejudice is used
deliberately in attempting to re-unite the word with positive meaning. In Gadamer’s
(1960/2011) writing, prejudices provide a framework for interpretation, are a necessary
condition of understanding, and give a hermeneutical problem its real thrust (p. 272). In
arriving to a situation, it already matters to us in some way (Magee, 1987).

44
Prejudices are pre-understandings that make up our viewpoint, which constitute
how we are directed towards our experience (Gadamer, 1960/2011). Importantly,
prejudices are not falsely set aside, or bracketed, in hermeneutic inquiry (Gadamer, p.
273). Rather, the purpose of acknowledging our prejudices is to create openness, as it is
the ability of recognizing our own prejudices that allows us to constitute a horizon and set
about the task of understanding (Gadamer).
The term horizon is an important word in hermeneutic study drawing on
Gadamer’s work. An individual’s horizon is an essential part of a situation and “… is the
range of vision that includes everything that can be seen from a particular vantage point.
“To have a horizon” means not being limited to what is nearby but being able to see
beyond it” (Gadamer, 1960/2011, p. 301). The choice of this word fits well with being
able to describe expanding a horizon or discovering new horizons as we are situated and
engaged in a temporal and constant process of understanding (Gadamer).
As our prejudices are based on our past experiences and historical consciousness,
we cannot form a horizon of the present without the past (Gadamer, 1960/2011). As we
project a historical horizon, it fuses with the present horizon, and is simultaneously
superseded (Gadamer, p. 306). Thus, there is a “constant process of new projection [that]
constitutes the movement of understanding and interpretation” (Gadamer, p. 269). It is
important to note that Gadamer viewed understanding as interpretation, that interpretation
is not occasional but instead is the explicit form of understanding (p. 306). It is this
approach to considering that practices are informed by the past while projecting to the
future that was helpful to be able to interpret and articulate the practices observed and
discussed in this research.

45
The focus of this study is to understand practices of connection within primary
care settings. When patients, team members, and primary care providers interact with one
another, they are engaging with others who have different cultural, historical, and social
influences and thus different prejudices and different horizons. In order to discover the
standpoint of another, conversation is necessary (Gadamer, 1960/2011). This is not to say
that agreement results from a conversation (Gadamer), nor is it failure to recognize there
can be meaning in silence (Heidegger, 1962/2008). Rather, the art is in the question of
“… how did he come to such an opinion” (Gadamer, p. 181). In a hermeneutical
interpretation, language is primary, because “everything that is reflects itself in the mirror
of language” (Gadamer, 1967/1994, p. 284). The ways in which participants in this study
practiced and engaged in conversation to attend to agendas and exercise clinical judgment
was important to this research. Attending to language and conversation between patients,
providers, and team members facilitated understanding how patients feel known, how
connections are maintained, and how patients and providers negotiate primary care.
Methods
This section describes the methods used to collect and analyze data in order to
address the questions of this research. Detail is included to provide transparency to the
research process. Data collection for this study took place between August, 2014 and
February, 2015.
Research questions
The research questions for this study are:
1. How do patients feel known or not known by a team?

46
2. How are therapeutic relationships between patients and providers established,
maintained, and nurtured over time?
3. How is primary care negotiated from an interprofessional team?
Research site selection: PCH in Northern Health
The Northern Health Authority is one of seven health authorities in British
Columbia, and has been providing health services to northern British Columbians since
2001. In 2009, Northern Health’s strategic plan introduced a priority to establish Primary
Care Homes (PCH), defined as a place where “…people establish a long-term
relationship with a multidisciplinary team, and through this team, receive health care and
are supported in managing their own health” (Northern Health, 2009). Although the
current definition of PCH has changed, it is noteworthy that this language was introduced
seven years before the GPSC (2016) published the PMH / PCH model based on the CFPC
(2011) vision.
The focus by Northern Health on interprofessional primary care teams and PCH
dovetailed with the formation of Divisions of Family Practice in BC, which are an
initiative of the GPSC composed of “… affiliations of family physicians working
together to achieve common health care goals … [providing] physicians with a stronger
collective voice in their community while supporting them to improve their clinical
practices, offer comprehensive patient services, and engage with their local health
authority to enhance their ability to deliver care” (GPSC, 2015a). One Division of Family
Practice is established in the urban centre where this study took place.
Prior to the vision for PCH in Northern Health, primary care services outside the
primary care provider office such as mental health, public health, physiotherapy, or social

47
work were available but generally siloed, each with their own structures, communication,
and documentation processes. If a patient required, for example, mental health
counseling, he would be referred by his primary care provider, attend for the duration of
the counseling, and then be discharged out of the service. If the patient required mental
health counseling at a later time, he would be referred again to the service by his primary
care provider.
Between 2009 and 2015, Northern Health managers and leaders actively engaged
physician members of the Division of Family Practice in implementing interprofessional
primary care teams in six prototype communities, including the community in which this
study occurred. In May, 2014, the first interprofessional team members began work in the
urban site of this study. By September 2014, two teams in this urban setting were
operational, but stretched in terms of human resources to accommodate 11 primary care
practices, some of which are group practices with large numbers of patients in their panel.
In the model conceptualized by Northern Health as a Primary Care Home within a
System of Services (Northern Health, 2015), patients have the opportunity for more
coherent and connected care whereby interprofessional team members are assigned to
physician offices, all interprofessional team members use the same electronic medical
record (EMR) (although it is important to note primary care providers use a different
version of this EMR), and patients are no longer discharged between times of receiving
service. Instead, the interprofessional team, similar to the primary care provider, is
responsible for the primary care of the patient for the duration of time the patient is
attached to that practice.

48
The data collected for this research took place when primary care teams were first
being implemented. So new were the teams that data collection was delayed slightly to
wait for a team to be operational. This influenced site selection.
From the researcher perspective, several criteria were considered important in site
selection for this research considering the focus of this study. First, a team in which some
of the team members had experience working together previously was helpful, as teams
that have been working alongside one another for some time can be expected to practice
differently from teams who have had less time to learn and practice together (Bunniss &
Kelly, 2008). Second, a team where members had various years of experience in their
role could help to elucidate differences in practices, as it is noted that providers who have
more years of experience in their role will practice differently than providers with a
shorter length of experience in a particular role (Benner et al., 2009). Third, a setting in
which visitors such as students are a familiar presence in the clinic is beneficial, as
patients are somewhat used to seeing unfamiliar people about, including in the exam
room during the encounter. Providers may be more likely to assume a teaching role by
explaining what they are thinking and doing as they proceed in their day, as found by
MacLeod (1996).
Given the newness of PCH implementation, I sought advice and permission from
a member of the Northern Health executive leadership team to approach particular sites.
Three sites were approached with approval from Northern Health leadership and midlevel management, and two fee-for-service offices that were participating in the PCH
implementation were approached. One urban fee-for-service office aligned with one
interprofessional primary care team consented to participate in the study.

49
Attributes of participants
Participants in this study were assured of confidentiality when they consented to
participate, and they were advised that their anonymity would be protected to the greatest
extent possible considering some details may identify them to those working or living in
geographical proximity to where this study took place. For the participants who are health
care professionals, they may be identifiable by others who work with them or know of
their work or practice. All participants have been assigned pseudonyms.
In the text, health care professionals are identified both by their pseudonym and,
when relevant, their professional designation. Throughout the findings and discussion of
this dissertation, the term primary care provider(s) is used to represent the four family
physician participants and one nurse practitioner participant in this study. Similarly, the
term interprofessional team or interprofessional team member is used to represent the
clinician(s) employed by Northern Health who are not family physicians or nurse
practitioners. For patient participants, any identifying details such as their specific
diagnosis or details of their care have been changed or omitted if such details are not
crucial to understanding the patient’s experience.
Interprofessional team members and primary care providers
Pseudonym

Practice Experience

Gender

Peggy, social worker (SW)

38 years

Female

Nora, registered nurse (RN)

14 years

Female

Ruby, registered nurse (Case
Manager)
Mel, occupational therapist
(OT)
Odette, mental health clinician
(MH)

23 years

Female

6 years

Female

23 years

Female

50
Quentin, mental health
clinician (MH)
Sonia (Lifeskills)

12 years

Male

8 years

Female

Ursula, primary care assistant

14 years

Tessa, acting team lead

7 years

Female

Leah, family nurse practitioner
(NP)

5 years in NP practice

Female

24 years in RN practice

Henry, family physician (FP)

35 years

Male

Isaac, family physician (FP)

14 years

Male

Jack, family physician (FP)

20 years

Male

Kate, family physician (FP)

1 year

Female

Patients interviewed: Pseudonym and gender
Adam, male
Brent, male
Charlotte, female
Diane, female
Eleanor, female
Frank, male
Gary, male
The term “patient” is used throughout the paper for these participants, because
they participate from their experience in this role, just as primary care provider and team
member participants represent their roles, and not the many other roles they take on as
individuals in society. Patient is also preferable to the transactional implication of the

51
term “client”, for the Latin root of patient is “pati” meaning “to suffer”. That patients
seek care for relief of suffering is a reminder of the “being-for” (Heidegger, 1962) and
“being-with” (Bauman, 2004) nature of team.
All the patient participants but one are empaneled with the fee-for-service practice
that is one of the settings for this study. Initially, I hoped to interview patients who had
been able to see members of the interprofessional team several times so that they would
be able to comment on their experiences with the team. However, the patients requiring
more time, visiting, and care by more than one member of the interprofessional team are
the most complex patients. They are patients with severe and persistent mental illness or
dementia, or have been recently discharged from an acute care setting and await
placement in a long-term care setting. These patients were inappropriate to interview for
ethical and medical reasons. This is somewhat telling about who needs a team, but it is
also a limitation of this study.
Unit of analysis
The unit of analysis for this research are the practices themselves, as this is what
is being interpreted for this study. The practices occur in the offices of primary care
providers and team members, as well as patient homes. While it is the level of the team,
as opposed to the singular office or organizational level that is the focus for this study, the
practices of connection within the team are the entities contemplated for analysis and
interpretation.
Field work
My presence in the field ranged from half to one and a half days each week of the
data collection period, during which I observed 37 patient encounters, attended meetings

52
and patient rounds, and passively observed clinic “flow”. Sixteen provider and
interprofessional team member interviews were conducted during the period of the study,
and seven patient interviews were conducted, for a total of 23 interviews. Field notes and
a personal journal were maintained throughout the period of data collection.
Observations of primary care providers
The months of August, September, and part of October 2014 were spent
collecting data from the fee-for-service physician office. The fee-for-service office was
visited first to allow a longer time for the interprofessional team members to be
operational in their new offices and roles. The purpose of the observations was to observe
practices in action (Kesselring et al., 2010).
To begin, I conducted exploratory observations of the medical office assistants
(MOA) and reception area, to gain an understanding of how appointments were booked,
how patient recalls were orchestrated, and how the clinic flow and office processes
unfolded over the course of a day. I also spent time observing one MOA conduct her
work, so that I could ask clarifying questions (Huby, Hart, McKevitt, & Sobo, 2007)
regarding what I was observing.
After approximately one and a half days of reception area observations, I began to
observe patient-provider encounters between primary care providers and patients. I aimed
to spend 1-2 half-day sessions with each provider. At the primary care providers’ request,
I composed a short typewritten note to say I was a student researcher studying primary
care teams, which the MOA gave to each patient the provider was seeing the day I was
shadowing them. This allowed the patient to say yes or no to my observation of their
encounter. If the patient said yes, I could enter the room ahead of the primary care

53
provider to complete the full informed consent with the patient and not extract face-toface provider time from the patient.
For each patient-provider encounter observed in the primary care provider office,
I attempted to remain a passive observer, although sometimes a patient would seek to
include me in a joke, or fill in a detail of their history for my benefit. Once, the provider
could not resist a teachable moment knowing I am also a nurse practitioner and
encouraged me to palpate a joint.
During each patient-provider encounter, I sat off to the side as much as possible,
and left the provider a choice of where to sit or stand. I maintained an expression of
neutral interest, and did not attempt to make eye contact with the patient or the provider. I
kept a field journal with me, but to varying degrees found it difficult to keep up with
notes, as I did not wish to detract from the visit by writing in the notebook in a fairly
confined space. I waited for natural transition times to make notes, for example as the
patient moved to the exam table or if the provider was completing a requisition for the
patient.
Throughout 28 patient-provider encounters observed in the fee-for-service office
with five different providers, I paid attention in each to the spatial aspects of proximity
and distance (Malone, 2003; Tarlier et al., 2007). I considered the dialogue, silences, and
interruptions. I paid attention to how services or suggestions were offered to patients,
how sensitive subjects were broached, and signals the provider gave to indicate the
conclusion of the visit. I attempted to understand practices that appeared representative of
issues of power or connection, how the context of patient circumstances was accounted

54
for or dis-counted during the visit. Finally, I considered how the encounter might have
influence on future practices of care-seeking and negotiating care.
Between patient encounters, there was sometimes opportunity to informally debrief about the visit. The provider might disclose patient background that informed his or
her decision-making for that visit, or discuss why s/he selected a particular service for a
referral over another. Other times, the provider exited the room to chart or dictate, or to
complete another task (for example to make a phone call) before seeing the next patient.
Observations of interprofessional team members
In late October 2014, the Acting Team Lead for the Northern Health
interprofessional team “assigned” to the physician practice that was participating in the
study introduced me to the interprofessional team. I spent October, November, part of
December, and January observing and interviewing the interprofessional team members.
To begin, I attended some meetings that included all or most members of the
team. Patient rounds were conducted first thing each morning, and so I observed this
meeting initially. Next, I conducted some exploratory observations in the office space of
the team.
The setting of the interprofessional team office was conducive to passive
observation. I spent a half-day with the primary care assistant observing and obtaining
clarification regarding scheduling of the interprofessional team, documentation processes,
how patients were contacted, and other duties of the primary care assistant.
Following these initial observations, I began to book half days with
interprofessional team members to observe patient-provider interactions. Some team
members were reticent to commit to a time for me to observe them. One mentioned that

55
because she was so new to the team, she wasn’t very heavily booked. Another struggled
to find a suitable day because so many of her days included more than one meeting, so
that her time to see patients was impacted. A third provider expressed discomfort with my
attendance because she was meeting so many of her patients for the first time; she did not
wish for the process of establishing rapport to be disrupted by the presence of a
researcher. By the end of the observation period, I was able to observe a total of 9 patientprovider interactions with two mental health clinicians, one registered nurse, and one
occupational therapist.
When arranging time to observe an interprofessional team member, I advised
them I wished only to observe them in their everyday practice, so whether it was
attending meetings or seeing patients or another activity, my objective was to passively
observe them in their role. Some team members, however, expressed worry that this type
of observation would not be an accurate depiction of their role. Particularly for providers
who were accustomed to providing direct care to patients as the mainstay of their role,
my observation of them sitting through meetings did not rest comfortably with them.
Of the patient-provider encounters I observed with IPT members, six occurred in
the patient’s home, two occurred in assisted living / residential care-type settings, and one
in a Northern Health office. For each visit, I followed the team member’s lead and
attempted to remain as unobtrusive as possible. Patient consent was obtained either ahead
of time by the team member telephoning the patient to ask if I might accompany the team
member to the home, or other times consent was given on arrival at the meeting place of

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patient and interprofessional team member. Through this process one person declined to
be observed.
During patient visits, I sat off to the side or stood leaning against a wall, unless
the patient asked me to come and be seated by the provider. In one home the patient
insisted on making tea. When the team member accepted a cup and the patient urged me
to do the same, I also accepted a cup of tea. I did not wish to appear rude or as though I
was making a point of having professional boundaries more rigid than the team member
by declining the tea.
As I spent time with different members of the interprofessional team, I did
observe a number of meetings. I sat in on rounds each morning I was present. I sat in on
process meetings, evaluation meetings, and caseload review meetings. I occasionally
asked clarifying questions of the interprofessional team, more so than I did of the primary
care providers, in order to understand what was going on. I recognized my horizon was
oriented to the primary care provider perspective of primary care.
Documentation
Throughout the period of data collection, a field journal and personal journal were
maintained. The field journal was utilized during observations and interviews to write
down impressions of what I was seeing and hearing in order to inform later analysis. The
personal journal was used to record end-of-day reflections, and to monitor my own
changing prejudices or horizon as the research proceeded. Grey literature also helped to
inform the primary data collection and analysis. News reports, knowledge of community
resources and demographics, and attendance at, or minutes from, meetings connected to

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primary care transformation and integration helped to contextualize the data in a sociohistorical and temporal manner.
Interviewing
The purpose of interviewing in interpretive studies is to provide a disclosive space
for narrative access to uncovering practices (Kesselring et al., 2010). The researcher
should strive to maintain openness and curiosity about the answers provided to the
interview questions, and interrupt as minimally as possible (Kesselring et al., 2010). The
interviewer should listen with a “sensibility for significance” (Kesselring et al., 2010, p.
18), in order to inquire further in a particular direction and revise previous conceptions of
understanding as the conversation progresses.
While I have experience as a diagnostic interviewer in my role as a nurse
practitioner, I discovered interviewing to uncover practices to be a new skill. In order to
practice the interview skills required to obtain the depth of information I was seeking to
answer the research questions, I conducted practice interviews with one provider and two
“patients”, as other researchers have done while in novice researcher roles (MacLeod,
1996; Simmons, 2007).
During the interviews for this study, I tried to keep in mind some guiding
questions that Kesselring et al. (2010) suggest in order to apprehend the practices
disclosed in the interview, as opposed to reflections about the practices or the causes or
results of the practices. The questions are: “What matters to the participant here; why is
the participant telling this story and why now; how does this narrative align with or
discriminate the concerns of this participant with other narratives in the whole text; how
does it fit with the whole of her expressions (both narrative and reflexive); how/who is

58
the participant in the story; how does the participant show up in the story; within what
kind of world does this story make the best sense” (Kesselring et al., p. 19)? One other
consideration I tried to keep in mind as individual interviews progressed was to notice
what I was not hearing about.
Throughout data collection, I held the research questions at the forefront of my
mind as a reminder to focus on uncovering and interpreting practices of connection and
negotiation of care with an interprofessional team. This helped me to maintain the
researcher stance throughout the interview process. To guide creation of the semistructured interview questions I relied on suggestions or descriptions offered by other
hermeneutic researchers (Crist & Tanner, 2003; MacLeod, 1996; Sorrel & Redmond,
1995), and the full interview guide for patients and providers is in Appendix A.
I interviewed each participant once. Primary care provider interviews were
conducted in the fee-for-service office, and interprofessional team member interviews
were conducted in Northern Health office space. These interviews were conducted at the
conclusion of the observation period for each location. Patient interviews were conducted
at two different times during the study, with two patients near the mid-point of the data
collection period, and five patients near the end of the data collection time period.
Patient interviews were conducted in different locations based on patient
preferences and availability. One interview took place at my office at the University of
Northern British Columbia, one was conducted over the telephone, four were conducted
in the lobby of a quiet public building, and one was conducted at an interviewee’s place
of work in a private office. All interviews for this study (patients, providers, and nonclinician team members) were between 30 and 60 minutes in length, were recorded with

59
permission, and transcribed by a health care transcriptionist who signed a confidentiality
agreement prior to completing the transcribing. The transcripts were then reviewed for
accuracy, anonymized, and analyzed after data collection was concluded.
Data management
During the phases of data collection and analysis, field journals and the digital
recorder were stored in a locked box in a private location when not in use. Consent forms
and all other documentation that contains participant information are stored in a secured
office at the University of Northern British Columbia. All forms of electronic data are
stored on a computer that is password-protected. Hard copy data will be destroyed at the
time of the completion of the dissertation. Digital data will be destroyed five years after
completion of the dissertation.
Analysis
Analysis in a hermeneutic study is synonymous with interpretation (Moules,
2002). Interpreting originates in understanding and so the task begins with the research
questions and is never completed (Mueller-Vollmer, 1994) with final interpretations
being left to readers (Crist & Tanner, 2003).
Hermeneutic interpretation seeks to understand meaning in practices that may be
invisible or taken-for-granted (McLeod, Tapp, Moules, & Campbell, 2010). The process
of this seeking began with several reads through of the text (McLeod et al.; Thirsk &
Moules, 2013) while considering what it is that addresses me (Thirsk & Moules). Initial
readings were intended to invite general impressions, noticing of resonances, and
familiarities and differences in the content of the text (Moules, 2002).

60
Following multiple readings of field notes and interview transcripts, interpretive
memos are written of initial interpretations (McLeod et al., 2010; Thirsk & Moules,
2013), which is a process of attention to the particular (Moules, 2002). Each re-reading of
the data was an effort to identify “echoes” of something that “… might expand
possibilities of understanding” (Moules, p. 14).
Interpretive memos were expanded upon throughout the analysis. The analysis
attempts to preserve the meaning of the whole, and so there is no extracting of themes or
coding of data (McLeod et al., 2010). Rather, a hermeneutic interpretation allows the
everyday to stand out and be uncovered (Moules, 2002). Hermeneutics considers what is
said and also what is not said, and continuously questions things that are taken-forgranted (Moules).
Literature can be an aid in analysis when it is used to further grasp what
participants have to say about a particular topic (Thirsk & Moules, 2013). In this regard, I
restricted my review of the literature to updates about PCH implementation or other
Northern Health reports. I avoided the research literature at this stage on my supervisor’s
advice, in order to remain open to the possibilities of the data rather than to conform or be
swayed by other authors.
Another aid in analysis is to subject initial interpretation to further dialogue. This
was accomplished through meetings with my supervisor, who prompted me to articulate
“what this research is about”. Discussion of interpretations can create further openness
for understanding. To reach an adequate interpretation, it was important to put my own

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interpretations at risk by admitting the limits of my understanding (Moules, 2002) and my
ability to succinctly describe my findings.
Geertz (1973) discusses a paradoxical problem that I considered while planning
and conducting the final interpretations of this study. Understanding can be obscured
through both the inclination to attach transcendental properties to the understanding, or
through the opposite difficulty, which is to confuse understanding with reductionism
(Geertz). The paradox is that the more detail that is included, the more attached one
becomes to the particularities, but the more detail is omitted the potential is to lose touch
with the foundation the research questions are based upon (Geertz, p. 313). To help avoid
this, I wrote and prominently displayed a piece of advice from my supervisor to remind
me that I am seeking a reasonable interpretation that goes beyond my own (Martha
MacLeod, personal communication, 2012).
Rigour
Evaluative criteria for qualitative research are controversial (Cohen & Crabtree,
2008). There is a wide range of interpretive studies employing various criteria in efforts
to legitimize knowledge and interpretations. For the purpose of this research, I chose
criteria outlined by Moules (2002), in a landmark article that is frequently cited by
Canadian nurse researchers employing hermeneutics guided by the thinking of Gadamer.
Hermeneutic interpretations should have resonance. Readers should recognize that
something in the interpretation “rings true” (Moules, 2002, p. 3), and takes the reader “…
to a place that is recognizable” (p. 17). The validity and trustworthiness of interpretive
research is what makes it believable (Moules, p. 17). It is for this reason that hermeneutic
interpretations must be excellent descriptions.

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Clear, coherent description of hermeneutic analysis also adds to the credibility
and dependability of the interpretation. Koch (1994) suggests that credibility arises not
from a reader necessarily agreeing with the interpretation but rather that the reader can
understand how the author came to the final interpretation. It is careful documentation of
the entire research process that helps demonstrate the dependability of the findings
(Moules, 2002).
The “truthfulness” of hermeneutic interpretation is equated to “… a meaningful
account that corresponds to experience”, so that truth is understood to be ever changing
(Moules, 2002, p. 11). The truth of an interpretation is not whether or not the research can
be replicated but rather that the understanding of the interpretation lingers (Moules).
While hermeneutic interpretations are not generalizable, they can be transferable if
readers recognize that findings are meaningful and applicable to fit into contexts outside
the original circumstances of the study (Moules, p. 16). In this research, the adequacy of
the analysis will be determined through assessment of whether or not the interpretations
are revealing of “richly textured” understandings (Sandelowski, 1995, p. 182).
Ethics
Role of the researcher
An ethical approach begins with reflexivity regarding the role of the researcher.
Prior to entering the field, I dedicated some time to consider my role as a researcher.
Although my stance is not unique, there is little guidance in the literature for an
experienced health care provider to take on a novice researcher role in a politically
charged environment while continuing to work part-time in a primary care setting in the
same health region.

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Given my experiential knowledge of primary care, I recognized the area in which
I needed to exercise the most caution was in displaying or accepting a level of familiarity
with the environment. Ledger (2010) discussed how she found herself exchanging
knowing looks with other providers, or joining in on a joke that only someone familiar
with the setting would get. Simmons (2007) noted her participants assumed her
knowledge on particular topics because of her professional role. These sorts of things did
occasionally take place during data collection.
My strategy to address familiarity was to reflexively and persistently consider the
boundaries of my role, as is necessary working in smaller communities (Baca, 2011;
Moules, MacLeod, Thirsk, & Hanlon, 2010; Zibrik, MacLeod, & Zimmer, 2010).
Applying knowledge of boundaries in this way was helpful, as I grew up and worked for
several years in rural and remote communities. I could not entirely avoid situations of
familiarity, in part because most health care providers wear so many “hats”, and also
because I knew I had to maintain a working relationship as a NP with many of those I
came into contact with after this study was completed. Furthermore, I realized I needed to
protect many of these relationships if I hoped to be able to carry on a research programme
in this area in the future. Through these experiences, I recognized how my own horizon
and situation was changing as data collection progressed.
Throughout the course of this study I was regularly confronted by situations in
which I had to consider how I knew information, and whether I could comment on a topic
or not. This was one of the biggest challenges to me during the study and throughout the
period of analysis. Analysis was also affected by my role because once data collection
was completed, I did not truly exit the field. I continue to work as a nurse practitioner in

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Northern Health and have not infrequent involvement with interprofessional teams and
management-level discussion regarding future implementation of teams because of my
roles as nurse practitioner and educator. While this level of engagement is potentially
useful when considering knowledge mobilization and the application of my findings, it
does affect the temporality of the analysis in that I continued to see things develop and
unfold for interprofessional teams after data collection was completed.
Advice to clinician researchers from the literature includes an awareness that as
an “insider” to the culture of health care I might not question things in the same way as
someone with greater distance to the health care arena (Burnard, 2004). However, I think
my knowledge of primary care was an asset to this study. Where I did notice my
prejudices addressing me was with regard to the bureaucratic mechanisms of Northern
Health. Between all of the rules and forms and certifications, not to mention meetings and
spreadsheets and committees, I know that my expression was not always as neutral as it
should have been as I observed, for example, an interprofessional team member duplicate
charting or implement a process that was then reversed a few weeks later.
Researchers have also cautioned health care professionals taking on a research
role in a health care setting in terms of patients wishing to interact with the researcher as
a provider (Ledger, 2010). This was not a concern for me due to my experience as an
educator in clinical settings. In my role as an educator, I cannot act as a clinician and so
have been able to refer patients easily back to providers in their own setting, without
engaging with the patient as a clinician. The setting of this research also served to
alleviate this concern. The primary care provider participants frequently preceptor

65
students in their practice, and so patients were somewhat accustomed to having an
observer in the clinic room during their visit.
For the duration of data collection, I tried to view my time in the study setting as
work (Murphy, 2005). I regularly questioned my role and identity as a researcher. I made
efforts to be careful to think before I spoke, and consider my position before I responded
to questions or engaged in discussion. Maintaining a personal journal assisted me to be
reflexive. Meetings with my supervisor were also helpful to debrief and discuss my role
where it overlapped with other roles that I was attempting to maintain.
Ethical procedures
This research was undertaken towards partial fulfillment for requirements of a
doctoral dissertation. Ethical approval (Appendix B) was obtained jointly from the
Research Ethics Board of the University of Northern British Columbia
(E2014.0512.031.00) and the Northern Health Authority Research Review Committee
(RRC-2014-0011).

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Chapter Four: Explicating Implementation of Interprofessional Teams
Chapter Four marks the beginning of the findings of this study. In this chapter, the
focus is on understanding the changes associated with the process of implementation of a
newly formed interprofessional team. The implementation of this team changed the
everyday practices of team members, impacting confidence, morale, and relationships
within the team. Many of the changes associated with the process of implementation of
team-based care were unanticipated. This chapter examines key changes and experiences
of interprofessional team members and primary care providers that influence how teambased primary care is negotiated and understood.
Locating Team
Data were collected for this study between two main locations, as well as patient
homes. The first location is the fee-for-service office, where the primary care providers
Henry (MD), Isaac (MD), Jack (MD), Kate (MD), and Leah (NP) keep offices and
usually see patients. In this as in most fee-for-service primary care offices, co-location is
not currently economically or, usually, spatially feasible, so the primary care provider
“side” of the team is located in one office, and the interprofessional “side” of the team is
in another office across town. The interprofessional team members include Mel (OT),
Nora (RN), Odette (MH), Peggy (SW), Ruby (Case Manager), and Sonia (Lifeskills).
Although “side” is placed in quotations in the above paragraph, this physical gap
between team members means the two sides infrequently see one another face to face,
which contributes to a diminished ability to engage in conversation and informal
dialogue. This, in turn, can affect how team members understand one another. Most
clinician participants referred to the other part of the team as “on the other side” (Ruby),

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or “on their side” (Mel), or “on the Northern Health side” (Jack). That both primary care
providers and interprofessional team members thought of each other as being on different
sides, and not necessarily on the same team, is a divergence from the conceptualization of
the PCH and the expectations of Northern Health, and also from the ways many of these
same individuals had collaborated and shared responsibility for care of patients in the
past.
Four of the five primary care providers and four of the six interprofessional team
members had worked collaboratively between 2008 and 2014 as part of a separate
initiative. Mel, Nora, Peggy, and Ruby had all been part of a special services team to
provide care and support to a specialized population who were patients of Henry, Isaac,
Jack, and Leah.
Yet as part of a newly formed interprofessional primary care team, almost all aspects of
work for Mel, Nora, Peggy, and Ruby changed. Interprofessional team members were
adjusting to a new office location, a broader range of patient ages and conditions for
which to be responsible, a new referral and documentation process between team
members, increased administrative burden, and new team members.
One of the main changes in role for interprofessional team members is a shift
towards generalist practice instead of specialized practice. The intent from the
organizational standpoint is that a generalist role would facilitate team members to
employ a broad scope of practice. This in turn would allow the team to be more flexible
and responsive to patient care needs.
Increased role overlap could mean that multiple team members would be able to
perform different types of assessments or functions, such as assessing older adults for

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long-term care placement, or cognitive behavioural therapy for patients with mild
depression or anxiety. This does sound promising and practical; however, it does not
consider the years some health care professionals have dedicated to gain expertise in a
particular area. The expectation to shift from a career of working, for example, in the area
of mental health, to now becoming competent in administering immunizations or visiting
new mothers was intimidating to interprofessional team members. Nora (RN) summarizes
some of her concerns:
[T]hat’s something that I struggle with too is what’s my role, am I a generalist, or
am I a specialist that goes into a certain area, and I think you’re losing a lot of really
valuable, well not necessarily losing it, but chopping it up and maybe one person
from the MS [Multiple Sclerosis] Clinic is on this team but not on the other four
teams. I think people have a lot of really good information and some people have
been working in one spot for 20+ years and they have a lot of valuable information
and that’s a huge loss if it’s not accessible to everyone so I don’t know. And I do
struggle with just what my role is supposed to be in that regard too. I don’t know
that I can do a patient as good a service as they would get just going to that [MS]
clinic.
It makes me nervous just being in this role and not really knowing what the
expectations are for what I can offer to our patients. [T]hey were talking about
sending pregnant people over here and wanting Public Health support and why
would you do that? You’re doing that [patient] such a disservice, even
contemplating bringing her over here right now. Go to Public Health, there’s good
people there that know what they’re talking about and at least she’ll get proper care.
(Nora)
Nora’s concerns, which are similar to those of other interprofessional team
members, are not indicative of a resistance to change or safe-guarding of specialized
knowledge. Rather, she focuses on understanding how patients are going to receive good
care. Interprofessional team members see the direct impact of changes in processes of
care on patients and may hold off changing practices until they feel confident that
patients will be adequately supported and cared for within new structures of service
delivery.

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Changes to both structure and role interfered with and disrupted the previous
relationship that was enjoyed between primary care providers and former special services
team members, now interprofessional primary care team members. Time and attention
that was previously focused on relationships with patients, primary care providers, and
each other, was now re-directed out of necessity towards process changes at the
organizational level of the health authority. The interprofessional team members
lamented these changes both informally during conversation and observation periods, as
well as during their interviews.
The team members who were previously part of the special services initiative
described themselves as having been a cohesive group with a lot of autonomy. They
regularly met with the primary care providers with whom they shared patients, to discuss
plans of care or interventions, and they also saw patients with the primary care provider
in joint appointments. As part of the newly formed interprofessional primary care team,
these functions of team-based case management and joint visits with primary care
providers did not take place.
Ruby reflects on how regular formal and informal contact with the primary care
providers had been a benefit to the previously existing special services team:
It gave us an opportunity to get to know each other, know each other’s world,
problem-solve together and develop relationships with our practices. I mean it’s
taken a long time to develop the relationships we have with them and it’s been
wonderful to be able to call and know the MOAs and know the doctors and trust
each other and like each other. (Ruby)
Ruby’s reflection calls attention to aspects of team members knowing one another
beyond roles or functions. She highlights the value of longitudinal relationships between
team members. Trusting and liking a team member provides a degree of comfort as well

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as increased willingness to reach out to a team member who is not co-located, in order to
discuss a patient or ask a question.
Knowing “each other’s world” includes understanding what another team member
may wish to know about a change in a patient’s status or care, it may include knowing
whether a team member prefers being reached with a phone call or text message, or to
consider when the best time might be to reach another team member. For example, if
Ruby knows a primary care provider reserves one afternoon per week for home visits, she
will not waste time trying to reach him through his office during that afternoon.
Understanding the practice world of another team member increases knowledge about
how to effectively navigate team-based care for patients, providers, and team members.
Throughout the study, interprofessional team members were frequently observed
in the Northern Health office discussing whether or not to involve or update a primary
care provider about a patient’s condition, and whether to do it in writing or with a phone
call, or whether it would “bother” the primary care provider. Often these discussions
were informed by a team member who knew the primary care provider, and could tell the
undecided team member what the primary care provider would likely prefer in that
situation. This type of knowledge about provider and team member practices informed
judgment and thus decision-making about patient care.
A number of primary care providers had differing preferences and expectations
about how the interprofessional team members would be involved with “their” patients.
“Everybody seems to want different amounts of information” (Nora, RN). Requests from
primary care providers for information about patients ranged from wanting all
documentation, to one-line notes, to updates only when something significant occurs with

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the patient. The inconsistency of this feedback loop impacted both “sides” of the team. “It
would be really nice to know when our [patients] are going to see the doctor. That way if
there is something brewing, a lot of times we don’t know...” (Ruby, Case Manager).
When information is insufficient for a team member to be able to discern what the best
course of action is for a patient, care can be affected. Effective feedback loops so that
both “sides” of the team have enough information to provide timely, relevant care for the
patient are desirable, however in the current system, pathways to communicate and
document patient information are convoluted and time-consuming for the
interprofessional team.
Contending with Technology
Dismantling service delivery silos in primary care in terms of allocation of human
resources surpassed the pace of aligning technological solutions to streamline care.
Interprofessional team members became mired in the reality of this. There are nine
electronic systems the interprofessional team members variously have to use or monitor.
MOIS is the electronic medical record (EMR). It is the same EMR the primary care
providers use, but it is a different version and so data cannot be pushed into or pulled out
of the system easily, and this means an immense amount of duplication of data entry.
There is Synapse, which is the documentation system used by all mental health
professionals, including community psychiatrists. Procura is used by home care,
Powerchart and eHealth Viewer gives access to hospital and laboratory data, Pharmanet
tracks most prescription medication that is dispensed to patients, and Pixelaire is for
wound care. Panorama contains all immunization data, and Momentum is for RAI, which

72
is a comprehensive assessment tool for determining the long-term care needs of adult
patients.
In addition to duplicating data entry between the primary care provider office and
the interprofessional team office, data also frequently must be entered by
interprofessional team members in more than one system. “There’s a lot of double
documentation for the RAI and MOIS, like the medications. I have to care plan in RAI …
I’ve only done it on the RAI, but I need to, obviously, do it on MOIS so how do I do it?”
(Ruby, Case Manager). Due to different operating systems and formatting within the
systems, there is no easy way to port data without the interprofessional team members
spending long periods at their computers copying information first into one system, and
then into the next, to try to ensure information shows up for all members of a team that
are involved in a patient’s care. Yet even after documenting in MOIS, if interprofessional
team members wish the information to be passed back to the primary care provider office,
the information still needs to be collated, printed, and then faxed to the other office.
Adding to the difficulty of understanding and managing multiple electronic
information systems, new interprofessional team members waited a long time to gain
access the various systems. This hinders the ability of interprofessional team members to
be fully operational.
I didn’t have the software that I needed on my computer until last week. So some
of the stuff that I was supposed to be able to do, I was not able to do because I didn’t
have the required equipment. And then MOIS, there were problems [because] when
we started, some of the people were already well versed in MOIS so we would be
doing things like looking how to do recalls and I was trying to find out how to even
[look up a patient] on MOIS. (Odette)
Interprofessional team members received an orientation to use MOIS, and
participants mention this was very well done. However, when they were unable to

73
immediately put these new skills into practice and form habits to use MOIS in a
consistent way, their documentation practices were affected. Nora (RN) speaks about
attempting to document in the required format learned during the MOIS orientation. “It’s
hit and miss. It’s not part of my daily process” (Nora). Not being able to smoothly
complete documentation as a task that can be taken-for-granted in the course of a health
care professional’s role disrupts the workflow of the interprofessional team.
Throughout the period of data collection with the interprofessional team members,
some team members were unable to sign on to the EMR at all and had to take notes by
hand during patient rounds. Although Northern Health provides information technology
support, it is via a call centre. Interprofessional team members had little recourse except
to call, receive a ticket number, then wait for service. Some participants waited beyond
two weeks to receive assistance for a technological issue that was essential to performing
their role.
The administrative burden to locating, completing, and updating information
required by various systems is significant to the workload of interprofessional team
members. Ruby (Case Manager) remarked during one meeting that although the
administration time of interprofessional team members was not tracked or measured, it
was so substantial that some days she did not even feel as though she was caring for
patients.
Questioning Function
The burden of this change in processes and structure with its subsequent impact
on interprofessional team member availability and capacity to see patients was somewhat
invisible to primary care providers, because it took place elsewhere. Primary care

74
providers did not as regularly come face-to-face with these changes as did the
interprofessional team members. Consequently, some primary care providers were
somewhat confounded by the impact the change in structure had on team member
function, such as the initial limited volume of patients the team was able to see:
I know it’s just a start-up and they’re working through processes but five members
on a team, if they each got to spend two hours with a client, which is reasonable,
then you could say that’s a minimum of three clients each in a day. If you give them
an hour or two for driving around or whatever and they get to spend two hours, they
should be able to do paperwork inside the two hours. That’s three times five is a
minimum of 15 clients a day. So in the first month of operation, they managed 13
clients in a month. … right. So you know … there’s the culture that’s around, they
want to get all their processes right and all of that, that’s all well and fine but at the
end of the day, you know, what pressure is there to get the job done. To actually
get the job done. (Henry)
The lack of exchange of information and knowledge between primary care
providers and team members contributed to a disconnect between the “sides” of the team.
This lack of understanding about the changing practices of team members created some
hesitation in primary care providers, inhibiting referral of some patients to the
interprofessional team. Primary care providers could not assure patients of when they
would be seen, nor was there any certainty of what services would be provided:
They haven’t been very clear in what they’re actually going to offer. It’s almost like
a carte blanche, well, whatever you need we will offer, but really what does that
mean? So to have a team that says ‘oh, we’ll do whatever it takes’, it doesn’t fly,
because you don’t know what the restrictions are. I think it would be nice if they
told us what the team cannot do, rather than say we can do whatever because if you
can’t deliver then I’ve wasted my time trying to access you for something that I
could’ve taken care of by myself. (Jack)
Jack’s comments illustrate how, in order to determine who needs a team,
gatekeepers (in this case primary care providers), require meaningful information in order
to understand what services and types of care the patient will receive if referred to the
interprofessional team. While Northern Health may have intended a message of

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comprehensiveness in terms of care to be provided by interprofessional teams, primary
care providers interpreted this message as lacking in clarity and definition. The lack of
exchange in communication about role and function of team members at the outset of the
primary care team implementation resulted in a degree of disengagement by primary care
providers who were left wondering what the interprofessional teams could actually do.
Taking Sides
The primary care providers experienced ambiguity in understanding the services
offered by the new interprofessional team. Isaac talks about presenting a “united front” in
terms of providing patients with consistent advice and maintaining a plan of care
regardless of who sees the patient. He remarks, “That works well in our office because
we are constantly communicating. It doesn’t work well outside my office because I have
no communication” (Isaac). In the primary care provider office, a “united front” is
achieved not because of co-location, but rather because sharing physical space facilitates
constant opportunities for face-to-face dialogue and information exchange that increases
provider knowledge of colleagues and patients.
Jack explains a consequence of not being able to constantly and informally
communicate with all team members:
Who’s going to be doing what in the role because often what happens when the
roles are fuzzy and it’s not clear to the patients who they can contact about
investigations or follow-up, it creates confusion. And if a patient feels frustrated,
and feels that they are not being well cared for, even though it might be excellent
care, the problem is no one’s been clear enough to tell him that. (Jack)
Nora also notes the difference in how team members know one another between
belonging first to the special services team compared to the new primary care team:

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It felt a lot more “teamy” before and I know they talk a lot about breaking down the
silos and having a lot of exchange in our roles and overlap in our roles and I don’t
see that like I did when we were the [special services team]. (Nora)
While a change in job or job description always brings a degree of uncertainty and
there can be a sense of loss for the way things “used to be”, Nora’s statement alludes to a
disconnect between the strategy of implementing interprofessional primary care teams
and the reality for the clinicians who experienced “team” under the auspices of a narrow
and then much broader initiative. The “they” that Nora alludes to in her statement are the
team lead, care process coaches, and other middle managers, who were charged with
implementing the Northern Health “side” of the newly formed interprofessional primary
care teams. In structuring new teams, opportunities to include processes to allow for faceto-face dialogue and exchange of information between team members and primary care
providers is diminished compared to interactions between the previous special services
team and primary care providers.
Within the new structure of the primary care home, the interprofessional team
members who were previous members of the special services team moved from a small,
non-hierarchal membership with much informal dialogue and organic process to a large,
shared office where they experienced close oversight from supervisors, increased
administrative responsibilities such as learning a new charting system, attending daily
case management rounds, and weekly or more frequent process meetings where progress
and milestones were colour-coded onto a large spreadsheet with many tasks and
deadlines that focused on team process.
Related to difficulties in understanding one another that were exacerbated through
a lack of face-to-face dialogue, primary care providers perceived some of the newly

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structured practices of interprofessional team members as adhering unfavourably to
“protocol”. Isaac gives an example of patients being taken off the interprofessional
team’s waiting list if the patient is not contacted after three attempts:
The problem is they’re very protocol driven. I get a letter from them saying, thank
you for referring this patient, we’ve been unable to contact them, we are returning
the referral. … Which kind of makes me wonder, that’s a protocol, whereas doctors
are more guideline driven because I can speak to being a physician. We’re taught
that these are the guidelines but you have the knowledge and experience to step out
of it, to question and to do what’s best for the patient. (Isaac)
Isaac’s reflection of his experience from a physician’s perspective indicates
clinical judgment to provide high quality primary care is required beyond patientprovider clinical encounters. Even for something that may at first seem strictly
administrative, such as contacting a patient to book an appointment with an
interprofessional team member, requires knowledge of the patient, and a questioning
approach. Isaac points out that the issue of the patient being inaccessible may in fact be a
symptom, “… with the patient not being organized enough, and that could be a mark of
pathology in itself” (Isaac). In these instances, knowing whether patients cannot be
contacted because they are out of town for work, versus not answering their phone
because of mental illness and paranoia, is a salient detail that cannot be attended to via
protocols. This observation and questioning of what can be done through a standardized
process and what requires clinician judgment and knowledge raises questions as to how
structures and processes can be implemented and evaluated at an organizational level for
effective team-based care.
There are other worries fostered by lack of clinician-to-clinician dialogue and a
reliance on policies or protocols usurping clinical judgement:

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The biggest concern I have as a physician is that the ball doesn’t get
dropped. And when you don’t have clearly defined roles in a team and what that
team’s going to deliver, that sets up alarm bells in my mind because the moment I
know if I was going to refer to this team out there and the patients fall through the
cracks, whose fault is it? (Jack)
Isaac’s and Jack’s comments reflect concern for their patients that is a result of
not understanding the practices of interprofessional team members. Primary care
providers may feel uncertain whether interprofessional team members possess
comparable levels of discernment or an ability to recognize salience in a clinical
situation. This uncertainty about how interprofessional team members use clinical
judgment as opposed to adhering to organizational policies and protocols influences
referral and communication practices, and thus the access patients may have and care
they may receive from an interprofessional team.
In an attempt to partially remedy ambiguity of services provided by the
interprofessional team, Northern Health developed a flyer to be distributed to physician
offices. Some of the services to be offered by teams included “[chronic] disease
management strategies”, “short term counseling”, and “coordination of community
resources” (Northern Health, n.d.a). Also included in the flyer were strategies to deliver
these services, such as “supporting self-management”, “follow up, monitoring and
recalls”, “harm reduction strategies”, and “prevention and health teaching”, among others
(Northern Health, a).
At first glance of this brochure, the services offered by Northern Health via the
interprofessional team do not appear to extend beyond what already normally occurs
between patients and primary care providers in a family practice office. Primary care
providers were not convinced that asking the interprofessional team to perform some of

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these primary care functions that already overlapped with their own day-to-day functions
would be of benefit to patients. “As soon as patients leave what they identify as their
primary care home, immediately their relationship hasn’t been established. So nothing
can be leveraged from that, you still need to develop a relationship” (Isaac). Isaac
recognizes the influence that longitudinal care and knowing the patient has on effective
primary care delivery. The current process of referring a patient to a team member that
neither the patient nor the primary care provider knows may be less preferable to the
extent that a primary care provider forgoes a referral to the team for functions he can
perform, in order to maintain consistency of care and provider for the patient.
In the interprofessional collaboration literature, one frequently endorsed benefit of
teams is to ease some of the burden of complex patients from primary care providers
(Bodenheimer & Smith, 2013), particularly in areas that pertain to health yet are outside
the purview of traditional primary care and remain as gaps in the system, such as housing
or finances (Virani, 2012). Primary care providers are engaged with this idea, and with
the concept of team-based care; “team-based care is fantastic. If there is consensus about
what the plan is” (Isaac); “I’m very much a team member” (Jack); “I think it makes all
sorts of sense” (Henry). Yet the disconnect persists between the idea and the reality, and
uncertainties remain about endorsing team-based care for their patients. “It’s not about
just sending them off and saying you get fixed in whatever way, but it’s also about
maintaining that relationship because things aren’t always that smooth for many
[patients].” (Leah).
In other words, equivocal written communications are not enough to advance
primary care provider engagement levels to a point of guaranteed or functional use of an

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interprofessional team that is not co-located. Neither is a promise to shoulder some of the
burden of caring for complex patients a reason to involve the interprofessional team if it
risks damaging the therapeutic relationship with the patient, particularly for those patients
who may have experienced disconnected care or been marginalized within the health care
system previously. The concerns voiced above by primary care providers highlight that
saying what an interprofessional team can do is not the same as knowing individuals who
make up an interprofessional team and learning their strengths, knowledge base,
preferences, and communication style through interpersonal contact and dialogue. The
extent to which primary care providers and interprofessional team members are able to
know and understand each other’s practice “world” can influence understanding who
needs a team, who receives team-based primary care, and how it is enacted.
Dis-location
Although four of the primary care providers had experience working with four of
the interprofessional team members in their previous role, this pre-existing relationship
was almost undetectable at the time of data collection. Peggy reflects on the change in the
relationship comparing her time as part of the special services team and her present role
as an interprofessional team member:
I think we all took a lot of pride in the work that we did and the accomplishments
and the subjective comments that we would get from family members and all the
physicians, I mean they glowed, they just loved the work that we did, but if you ask
them that today, I don’t think you’d get that. (Peggy)
This perceived change in relationship between primary care providers and
interprofessional team members who had previously worked together was understood to
be detrimental not just to members of the team, but also in forming new relationships
with patients.

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Physicians need to become versed in what we do, what does my team do, who is on
the team, what are their names, what do I know about them, right. If [a patient went]
to [their] physician’s office and have that trusting relationship and [the doctor] says
it sounds like you need “this” and you know, “Mary” is going to come see you and
this is what she does … if [the doctor] is not well versed in that, then they won’t
know where to send that person. That information, if it’s not delivered properly,
then people might not follow up. (Mel)
Importantly, both primary care providers and interprofessional team members
acknowledge that relationships with patients have to be leveraged. Optimally, trust and
understanding exists between team members, but trust must also be obvious to patients to
maximize patient uptake and willingness to participate in team-based care. The disruption
to the relationship dynamic that resulted from the members of the special services team
assuming new roles as interprofessional team members also altered the mechanism by
which team members, primary care providers, and patients all knew one another.
Formal and informal mechanisms such as joint case management meetings, joint
patient visits, as well as informal consultations or face-to-face time between primary care
providers and special services team members were lost to stringent new directions, new
processes, and change. “You see us with our energy diminished and we’re pushed back,
and people clam up and we don’t say very much. … [O]ur expertise that we come with is
diminished and we don’t have the voice around that” (Peggy).
During a time of system-wide transformation at the health authority level, a topdown approach may be necessary to ensure deliverables are met and processes are
sustainable. The implementation of this approach can have unintended consequences,
such as the muting of input from front-line team members that Peggy describes. The long
reach of such consequences can also impact patient care. Diminished confidence and a
reduced sense of expertise while new processes and protocols are implemented can

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contribute to the problem recognized by Isaac; rather than relying to a great extent on
clinical expertise and judgment in day-to-day work, following protocols and policies
allows health authority employees to cope with sea change.
The interprofessional team members were overwhelmed with change at the outset
of implementation and had little time to maintain existing relationships, as they were
intended to be responsive to nine different family practice offices, of which the five
primary care provider participants in this study represent only one office. “[The] pace is a
little bit crazy. … And it doesn’t feel good. You don’t leave work going wow, I did great
today. No, no, no” (Ruby). The interprofessional team members describe a steep curve of
learning a new role that coincides with substantial and cumulative increases in patient
load, termed elsewhere as “change fatigue” (Allan et al., 2014). “I think the problem is
there’s so much change all the time, and people can only be saturated with so much,
especially when the workload is extreme” (Odette).
Odette’s perspective can be juxtaposed with that of Henry’s earlier comments,
when he wondered what pressure the interprofessional team members had to see an
adequate volume of patients. The two “sides” of the team were far apart at this point,
neither really understanding the other’s experience or world of practice. For
interprofessional team members, they felt disconnected from physicians who previously
thought highly of their work but were now uncertain about what a new team structure
might bring, and they felt equally disconnected from their employer and organization.
[M]orale right now is not really that great … we do spend a lot of time chatting
about what’s going on and that can be time-consuming and it brings you down,
you’re not as efficient …[N]ot having great communication, or just being told what
to do, that’s caused a lot of grief and morale issues [because] they [managers] want
our feedback but then at the same time, they just do what they want to do and

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sometimes it’s against what we would’ve wanted, so it’s hard to change your ways,
and especially if it’s not delivered in a great way. (Mel)
Interprofessional team members did not believe they had power to change very
much about their work flow. Feedback loops, despite the presence of an on-site team lead
and two care process coaches, were inadequate. The horizon for managers may have been
focused on how the team was aligned with the organizational vision for the PCH, which
may be different from the horizon of team members who focused on how patient care
aligned with the function of the team in its current state.
Some of the juncture in power and leadership also may have resulted from a gap
at the interface of managerial direction with clinicians who provide patient care. “I think
leadership would be nice, it would be nice to have a team lead here who’s accessible,
who you can come to with your clinical questions and feel like you can get an answer”
(Nora). “Clinical direction is something that’s lacking” (Ruby). Lack of clinical
leadership may have facilitated increased focus on change management versus patient
care that, for some, worsened morale.
I struggle with decisions being made from up above as opposed to how they
[Northern Health managers] talked about us doing PDSA’s [a continuous quality
improvement cycle of Plan-Do-Study-Act] and then making decisions or working
with that or revamping things. I don’t have a sense that we’re actually involved
with the PDSA. We’re simply told what to do… It’s being, again brought down
from above, and that doesn’t help with staff morale. (Peggy)
From Peggy’s comments, it appears that morale is impacted not just by the rate of
change or being involved in a major undertaking of transforming the primary care
system. Implementation of this interprofessional team felt top-down to team members,
with little control over their day-to-day work, and little ability to draw on their own

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judgment and knowledge to structure their days, the care they provided, or the
relationships they wished to forge and maintain.
The early stages of implementation of team-based care are burdened with
comparisons to the way things used to be, as well as sadness for changes in professional
relationships. Yet a central, common goal maintains a strong thread of purpose for both
interprofessional team members and primary care providers: high quality patient care. “I
think the hope is: what are some of the lessons we can take from this and it would help
patients ... I’m learning from it and we’re problem-solving together and the patient wins
out in the end” (Ruby). “It becomes about what’s best for the patient and that is
something that any doctor can always reconcile: what’s best for the patient” (Isaac). All
interprofessional team members and primary care provider participants were genuinely
committed to putting patients first, and it is this commitment that fostered much of the
resolve among the participants of this study had to keep up with the changes in
implementing team-based primary care.
Summary
The physical, political, and psychological milieu of interprofessional team
implementation is one of change and uncertainty. As interprofessional team members
time is taken up to change their role, physical location, documentation and
communication practices to form as a new team, a rift becomes apparent whereby
primary care providers and interprofessional team members recognize that a loss of
connection and understanding one another has inadvertently taken place.
Between interprofessional team members and primary care providers, gaps in
knowledge and information about one another accumulate as opportunities for face-to-

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face conversation are depleted. As primary care providers and interprofessional team
members stand on different “sides” of the same team, confusion is replaced with misunderstanding, and without physical proximity to one another, practices of othering can
be observed. The lack of understanding each other’s world, however, is not a result of the
infeasibility of co-location. Many of the individuals on the current team worked together
on a previous non-co-located team, and report knowing and understanding one another
well. The change is not in the composition of the team, or the role of the team, but rather
the context in which team-based care is taking place and the lack of opportunity for
connecting and conversing with one another.
New structures and processes, particularly for interprofessional team members,
hinder the ability of all team members to know one another. The influence of structure
and process in health care delivery cannot be overlooked, for as organizations shape
processes, the processes shape practices of individuals3. When health care organizations
make decisions about priorities or how clinicians will spend their time, it alters how their
everyday role is enacted. From the interprofessional team members’ perspective, this is
not fully recognized by managers. The unanticipated consequences of new structures and
processes seen in this study are how changing practices impacts relationships between
team members, which influences delivery and quality of patient care.
Interprofessional team members and primary care providers recognize how gaps
in information and knowledge about one another affect patient care. Knowing a team
member or their preferences in terms of communication alters understanding of a

3 This wording is based on a quote from Winston Churchill (1943) who said, “we shape

our buildings, and afterwards our buildings shape us” (para 1).

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patient’s situation, and this affects decision-making about patient care. Uncertainty as a
result of not knowing a team member can delay care or result in mis-steps that may
further strain relationships between team members. Finally, when interprofessional team
members and primary care providers do not know one another well, it is difficult to
genuinely offer team-based care to patients. Participants acknowledge that it is important
for patients to feel known in order to leverage relationship and provide effective care.
Some primary care providers who did not know interprofessional team members, or were
unclear about the role of the interprofessional team, initially felt concerned and somewhat
uncomfortable advising their patients to venture outside the family practice office for
primary care services.
Team-based care and initiatives in interprofessional collaboration have shown up
in numerous iterations over decades, arguably none of which have revolutionized primary
care delivery with resulting improvements in patient outcomes. Ultimately, the successes
and failures of these initiatives in fostering team-based care are borne by clinicians and
patients. For these reasons, it is timely to pay closer attention to the patient-provider and
provider-provider interface to better understand practices that lead to expanding the
patient-provider dyad to include the interprofessional team. To more fully understand
how team-based primary care unfolds in practice, the next chapter turns to examine the
perspective of patients, and the practices that take place within patient-provider
encounters that influence decisions to involve the interprofessional team.

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Chapter Five: Exploring the Patient-Provider Dyad
While the context of providing primary care was transforming during the period
of data collection for this study, the mechanism for patients to initially access primary
care remained unchanged. The patient-provider dyad remains the cornerstone of primary
care, and providers in this study continued to be gatekeepers for patients to initially
access members of the interprofessional team. Chapter Four illustrated that the ways in
which providers and interprofessional team members understand or know one another can
influence how or when patients might be referred to the interprofessional team. In this
chapter, attention is shifted to practices of connection and ways of knowing within the
patient-provider relationship.
The patient-provider dyad has long been viewed as a foundational longitudinal
relationship through which patients can feel known (McWhinney, 1998) and receive care
and treatment to help maintain or restore their health. In spite of this, little is understood
about who patients consider to be part of their “team” or how they feel known when
thinking about their own health and care. This chapter will explore patient perspectives
on how patients feel known and define “team”. These perspectives will help to inform
how practices of connection are enacted within patient-provider encounters in ways that
help patients to feel known. How providers know patients influences understanding of
who needs a team, and when.
Patient Perspectives of Team and Health
While the primary care provider “side” and interprofessional team “side”
represent one depiction of an interprofessional team, this is a somewhat health systemcentric definition of team. Incorporation of the patient perspective is necessary if patient-

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centred care is to be understood in the context of team-based care. Understanding how
patients conceptualize who makes up their team is central to understanding how teams
can provide patient-centred care.
Patients are people emplaced in their community, where they work, live, and play
in their everyday environment. If health is conceptualized as an equilibrium, then it is
“…experienced as weightlessness in which different forces balance each other out”
(Gadamer, 1996). A person’s situation that prompts seeking primary care is one where
health is no longer taken-for-granted, but instead moves to the foreground as they take on
the role of patient. Articulation of how patients define and draw on team members or
other resources to help restore health is lacking. This research attempts to partially
address this question by inquiring how patients define teams, and how they feel known by
team members over time.
Defining team
Patients include themselves as part of their health care team.
I look at this as I’m the middle of the wheel and that wheel will only move
efficiently and appropriately if all of us are on board together, so there can’t be one
spoke of the wheel that is a stronger influence than the other. (Charlotte)
Recognizing that patients may desire equal voice and power as a member of their
health care team is a shift away from a hierarchal model of care. Charlotte visualizes all
team members as equals. The image of a wheel is a familiar one, but reflects patient
wishes for coherent, connected care.
Primary care providers are not necessarily the first or only person patients identify
as helping to restore or maintain health. Other people and strategies are important as well.
Charlotte names her fitness instructor and her dentist. Gary reads and listens to tapes.

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Diane mentions her animals and her job, while Eleanor identifies individuals at a
community-based support group. These supports and resources are outside the boundaries
of the traditional health system, and help patients stay healthy without requiring contact
with the formal health care system. When primary care providers and interprofessional
team members understand the particular supports and strategies of their patients, there is
opportunity to mobilize, enhance, or increase these supports or resources when the patient
seeks primary care. This in turn may strengthen the patient’s ability to restore or maintain
health with minimal or less health system intervention.
Patients also include more mainstay supports, such as friends, as members of their
team. Diane says, “if I’m really in a bad way emotionally or really scared about
something, they can hear it. They’re stable enough to handle it.” For Diane, a friend who
can see her at her lowest and still listen is important. Charlotte further identifies this type
of support by saying, “gosh, I think everyone needs a confidante.”
Another way friends offer support to patients is by allowing them to retain
dignity and independence. Gary has a condition that affects his mobility:
I’ve got a friend that owns a farm next to me and I work with him off and on but
he fully understands what I’ve got and he’s already told me, come on over, give me
a hand, if you get tired, call it a day. They’re people I can go to without being doted
upon … [but] a[nother] friend of mine, I was seeing him, so he’s moving stuff out
of my way. It’s nice, but you know, it’s pride. (Gary)
Friends can help patients like Gary to retain parts of their identity that remains
unaffected by illness. Friendships for patients are an informal support of high value when
people have to take on the role of patient. The role a particular friend plays to support the
patient, however, is individualized to the patient’s preferences and needs, which may
change over time.

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Family is also a significant support for patients.
You can phone them and say here’s the latest on my condition … and you get
feedback from people who know you as a person and it’s not just as an objective
question. There’s another layer there of, well I don’t know if Mom can take that.
(Charlotte)
In Charlotte’s case, her family physician and surgeon recommended a second
surgery for her condition. Rather than immediately agreeing to have the surgery,
Charlotte consulted her closest family members to take their opinions into account in her
decision. This action reveals how patients may involve supports who can be considered
team members outside the health system and is a reminder that there may be
discrepancies as to whose opinion may be considered “expert” by patients.
Patients rely on and use a number of strategies, factors, and supports to maintain
health outside the formal primary care system. The extent to which patients can rely on
these supports and resources impacts the timing and decision-making about seeking
primary care. Even when patients can identify supports and resources that help to
maintain or restore health, some can remain taken-for-granted. For example, when Diane
identified members of her health care team, she omitted any type of health care
professional. When asked if this was intentional, her response was, “Oh, that’s terrible. I
guess maybe in some ways, they’re almost invisible, but not in a bad way … this is
probably a Canadian thing too, that we’re so lucky that we have this” (Diane). By “this”,
Diane is referring to Canada’s publicly funded health care system. Unless primary care
providers demonstrate intent in getting to know patients, which in some cases may
require asking direct questions about supports and resources, patients may not volunteer
information about resources that contribute to health being experienced as a state of
equilibrium.

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Knowledge of the social world of a patient does have a place in a primary care
patient-provider encounter. This information is usually collected under a heading of
“social history” of the patient. Most aspects of information collected in a health history
interview with patients have a biomedical or clinical focus, such as asking about
symptoms of an illness, or what medications a patient is taking. The social history covers
topics of upbringing and family circumstances, home life such as marital and income
status, as well as hobbies, beliefs, and habits (Seidel et al., 2011). The social history is a
window that offers a glimpse into the patient’s life as a person emplaced in community.
Social history is by definition historical as people are married, quit smoking,
retire, and otherwise change aspects of their identity, existence, and consequently, their
health status. Primary care providers and interprofessional team members who have an in
depth understanding of their patient’s social history can know the patient beyond the
limits of an illness-focused lens. This can lead to improved understanding about how the
balanced state of health has altered, and what supports and resources were employed until
capacity is surpassed and tips the patient into the realm of seeking formal primary care
services. If understanding a patient’s social circumstances can lead to better
understanding of why patients decide to seek care, it may also contribute to patients
feeling known, thus strengthening the therapeutic relationship. To uncover this possibility
further, patients identify which health care providers know them best, and what it is about
a connection with that provider that makes them feel known.
Feeling known
Of seven patient participants, six identified a physician (five family physicians
and one internist) as the health care professional who knows them best. This selection by

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patients likely reflects traditional models of health care delivery, namely solo family
practice. Family physicians in fee-for-service practice remain the backbone of primary
care delivery in Canada (CFPC, 2011). However, patients may perceive some changes in
health care delivery; of the six participants who identified a physician as knowing them
best, only three reported it was their current physician. The other three patient
participants believed a previous physician knew them better.
The patient who did not think any health care provider knew him well states, “I
only go for trauma. I think doctors are controlled by the pharmaceutical industry and a lot
of what doctors learned is wrong” (Adam). Adam experienced a misdiagnosis of early
dementia in his early 40s, which reinforced deep mistrust of the medical establishment.
He currently relies primarily on alternative practitioners for diagnosis and treatment of
ailments that are not physical injuries. He adds, “How well do you know the doctor other
than they know your specific complaints?”
Adam sees no benefit in his primary care provider knowing anything beyond his
biomedical status. Given that Adam plans to attend his primary care provider only for
acute episodic concerns, this seems reasonable. However, Adam is a participant with
whom I also observed a patient-provider interaction, on a day Adam attended for follow
up of his most recent episodic issue. During this visit, I observed that his primary care
provider did incorporate other knowledge about Adam into the visit. For example,
inquiring about Adam’s mobility, the primary care provider asked about stairs and
assistance from his wife, as well as returning to work. Adam and the primary care
provider also had an amicable conversation about the hobby that led to Adam’s injury.
The primary care provider was well aware of Adam’s views about Western medicine.

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There is a mismatch between Adam not feeling known and what the primary care
provider did actually know. This discrepancy is a reminder that high quality patient care
can take place even when patients do not feel known, and that social history can be
collected skillfully and informally by primary care providers. For patients like Adam,
whose mistrust influences his beliefs and care-seeking practices, primary care providers
can sustain a therapeutic relationship simply by keeping the door open and allowing
patients to choose what type of care to access.
The remaining six patients who reported a physician knew them well all gave
similar reasons as to why they felt known. Gary says, “I guess, actually he just seems
concerned about me, whether it’s [my progressive health condition] or physical and we
converse about the family and all this other stuff. So you know, he’s a personable
person”. Gary’s physician expresses interest and asks about Gary’s life and personhood
outside his role as patient.
Frank has had a few family physicians, as previous physicians have retired or
moved. He says, “I’ve been lucky in all of the doctors … they’ve all been personable,
knowledgeable, kind of straight shooters I think” (Frank). Like Gary, Frank chooses the
word “personable” as a descriptor. He also uses the word “lucky”, reflecting an
impression that not all patients are so fortunate to have primary care providers who are
easy to relate to or are able to sustain a therapeutic relationship.
Charlotte describes her relationship with her family physician to explain why he knows
her best:
Well, first of all, there’s nothing I can’t tell him. The second thing is the day he told
me you’re the expert on your body and I’m the medical expert and between us it’s
a partnership so I need you to tell me everything that you’re thinking and I trust that

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you and I can do this together. And I’ve had really good luck with my doctors, yes,
but he’s the first one that’s really said that. (Charlotte)
Charlotte, too, recognizes the role of “luck” in finding a primary care provider
who intentionally takes time and effort to understand her and include her as a partner in
her own care. It is important to Charlotte that her family physician explicitly invited her
into partnership and encouraged her to not limit her contribution during visits to
providing only her biomedical information.
The three remaining patient participants identified that a previous physician knew
them better than any other health care professional.
[H]e said ‘oh, my sister had rheumatic fever’ … it was almost a very personal
feeling that we had with him for that many years. It was a very comfortable feeling,
and he’d speak to us in public, not that we talked about anything. Rap on the [glass]
walls of the airport and he’s waving … so it was very nice. (Eleanor)
For Eleanor, who also had rheumatic fever, a physician who disclosed some
personal narrative helped her to feel understood. Further, he acknowledged her
outside the clinical realm, in the world where she lives as a person, not a patient.
Brent explained how he felt known by his previous physician:
I don’t believe in a lot of chatter with the doctor, but I, you know, there’s more than
just the physical side, there is an emotional part to it … I know [my previous
physician] is a hiker, I was a hiker… We never spent much time about these things
but we knew things about each other. (Brent)
For Brent, a shared interest helped him to feel known. Mutual understanding in a
therapeutic relationship does not have to result from an over-sharing of information on
behalf of the primary care provider or the patient, but patients may feel better understood
when the patient believes their provider understands things that are important to
maintaining their health. Conversely, knowing about a patient’s life and interests as a

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person also helps providers to understand how people’s lives can be impacted by ill
health.
Patients identified four components that prompted confirmation of feeling known
by their primary care provider. Primary care providers can help patients feel known by
being personable, treating patients as partners, disclosing personal narrative, and
acknowledging the personhood of patients, accomplished in part by understanding patient
interests and strategies that help maintain health. Feeling known by a health care
professional does not necessitate delivery of high quality care, however, and there is a
distinction to be made between patients feeling known and believing they are receiving
good care.
I consider [my current physician] to be more an engineer than a healer, but he’s a
very conscientious man. He watches the numbers. ... Once a year he gives me the
thing, do you drink liquor, how much a day and all these kinds of things and that’s
about it. (Brent)
Brent illuminates two important concepts in this excerpt. First, as patients age
they may be more likely to require ongoing management of prevalent co-morbid chronic
diseases, such as diabetes, arthritis, heart failure, and congestive obstructive pulmonary
disease, than they are to require cure of an acute episodic illness. This gradual shift in
focus and patient presentation has created parallel need for management guided by
evidence. Care of patients with complex co-morbidities is a complicated undertaking and
has prompted a burgeoning field of research. This is the second concept to which Brent
refers when he mentions being asked about drinking. Annual screening for risk of alcohol
dependence reflects adherence on behalf of Brent’s primary care provider to national
guideline recommendations. Brent is a patient diagnosed with several co-morbid
illnesses. He believes he is receiving good care, but by a provider who does not know

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him very well. Perhaps there is less time to talk about hiking when trying to keep up with
evidence-based practice.
It is possible that as guidelines are implemented with consistency in primary care,
the therapeutic relationship is altered to some degree. This may be for better or worse in
the field of family medicine, but it has important implications for interprofessional teambased primary care. Many interprofessional team members specifically address social
aspects of health, such as helping with finances, housing, or support for children with
special needs. If some components of a patient’s social history are not well understood or
neglected by primary care providers, this will affect how primary care providers are able
to assess which patients may require an interprofessional team. If some parts of the social
history are not known, this also reduces the amount of pertinent information that gets
passed on to interprofessional team members when they become involved in the patient’s
care.
A secondary interpretation of Brent’s comments that his current physician seems
more an engineer than a healer may be one that is indicative of nostalgia. Brent is in his
mid-60s, and he asked during his interview if I had ever seen Dr. Welby, a television
physician who has been stereotyped as the “myth” of family medicine (Guthrie & Wyke,
2000). Brent talks about Dr. Welby; “… he was one of those doctors that knew all the
kids … everybody loved him because he was such a nice man. He probably wasn’t the
most competent but …”. Brent goes on to compare this image with one of his current
physician, who keeps track of everything on the computer and makes sure Brent is
referred to appropriate specialists. It is for this reason, Brent says, that “I’m staying with
[my current physician] … he is very exact”. Yet between referrals and technology and

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keeping up with evidence, Brent believes there is a missing element. “Technology is
more advanced today … but it also leaves some gaps. … I would feel better in the system
and such that he and colleagues would sometimes talk. But I don’t think they do” (Brent).
Brent’s comments reflect a desire for connected, coherent care within the health
care system, particularly in the area of communication between providers. That patients
are cognizant of breakdowns or limitations of current provider-to-provider
communication practices has implications for newly formed interprofessional teams that
regard themselves to be on different “sides” of the team. Communication difficulties and
disruptions between providers will be noticed by patients.
Brent also recognizes that the Dr. Welby stereotype may not be considered
competent by today’s standards, and perhaps there is a perceived trade-off between
competence or professionalism with feeling known by one’s physician. However, helping
patients feel known is a competence in itself. Understanding what supports, resources,
and strategies patients use to help keep themselves healthy, and how alteration in these
supports and resources might influence care-seeking decisions, may be a necessary skill
or competency for primary care providers to provide patient-centred team-based care.
Insights gained here into how patients define their own health care team, and how
they feel known in the context of a therapeutic relationship can guide an examination of
understanding what actually happens in primary care, and how patients and providers
negotiate care with one another in the context of an interprofessional team. Remaining
attuned to the value of understanding a patient’s social history and recognizing the
person, not just the patient, can help to identify practices of knowing or connection in a
therapeutic relationship.

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Providing Primary Care
This section will explore key dimensions of knowing in patient-provider
relationships observed during encounters at the family practice office shared by the
primary care provider participants of this study. Due to the risk of confusion using the
word “practice” or “practices”, in this section, the term “office” will refer to the location
where family practice takes place, and “practice” or “practices” will be used when
referring to the recurrent actions or language of providers in a hermeneutic sense.
This exploration of practices through conversation and observation with participants
serves to call attention to aspects of the structures and processes that foster connection,
the deftness of skill required through application of clinical judgment, and the benefits
that practices of connection can contribute to sustaining effective therapeutic
relationships.
Connecting environment
Patients form impressions about primary care providers based on more than their
direct experience with the primary care provider. The office environment, interactions
with the medical office assistant (MOA), and office processes such as whether there is a
long wait in the waiting room can also influence whether a patient feels welcome, or a
“good fit” with the primary care provider. These components of patient experience merit
further description and examination, because they are frequently overlooked.
The office is a clean, calm environment with a bright waiting area, a table with
books and toys for children, and a central workstation for the MOAs. Satellite radio plays
quietly in the background; there is art on the walls, the flooring is unmarked and smooth.
Consultation rooms and offices are out of sight, extending down two well-lit hallways.

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Each of the physicians maintains his or her own panel or roster of patients, while
the nurse practitioner sees patients from the entire panel of the different physicians. Each
physician works with his or her own MOA, and the MOAs are the first to connect with
patients. When a patient approaches the desk or the phone rings, they step away from
their other significant work of managing data such as chart transfers or data entry or
generating recall lists. The MOA picks up the phone:
Hi, Roger! How’s your summer? Doing lots of bike riding? … That’s good, nice to
hear that. So Monday if you want to come in … Okay. You know what I’d do with
that? Take it to the Access Centre. (MOA)
During this phone call, which lasted less than a minute, the MOA is friendly and
knows exactly who the patient is. She takes the time to exchange pleasantries, and asks
him about a hobby she knows he enjoys. She books his appointment and when he has a
question about his driver’s medical papers, she identifies the agency he should contact.
Conversations such as this between the MOAs and patients occur dozens of times
each day, both in person and on the phone. Whether patients need an appointment, lose a
form, or have a question about a prescription or results, the MOAs are smiling, patient,
and resourceful. As the MOAs escort patients to consultation rooms for their
appointments they are welcoming and offer reassurances, “It shouldn’t be too long.” This
is not a false reassurance. Patients do not spend time languishing in the waiting room, but
are seen close to their scheduled appointment time.
Henry (MD) says the average wait time for patients between arriving and being
seen is about 12 minutes. This can be calculated using the electronic medical record
(EMR). He attributes this to how well the MOAs know the patients.
I really think part of it is (the MOA) knowing the patients so well. She’s the one
who’s booking them, and obviously it’s [also] me knowing the patients well. But I

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notice a difference if anybody else is booking. [For example,] that person who’s
only supposed to be coming in for 10 minutes because they’ve just got one thing,
she knows the last four times it took 30 minutes and I just can’t get them out the
door. So she won’t ask me ‘do you want me to make it 30 minutes,’ she’ll just
make sure they have more time. (Henry)
Through a long period of working with Henry and knowing the patients, the MOA
can quickly make decisions about booking patients. Rather than giving every patient the
same block of time, the MOA synthesizes the information she has about the patient and
determines the length of time they may need. This helps the office run on time, Henry can
see more patients, and patients get enough time. The MOA and physician know one
another so well that these practices can occur without discussion. Other providers in the
office also have established structures that facilitate appropriate booking of patients that
rely on knowledge of patients.
Isaac (MD) reserves six 30-minute appointments per week for complex patients
who may require, for example, chronic non-cancer pain management. His MOA also
knows Isaac’s expectations. For example, she will check to ensure all relevant
investigations are available for review before calling the patient to return for follow-up. If
a result is not available and the patient has an appointment, the MOA will call to re-book
the patient rather than allowing them to attend the appointment only to be told they will
have to re-book once the result is available. This also demonstrates respect for the
patient’s time and signals to the patient that the provider is paying attention to what is
happening with her care.
Jack (MD) has a relatively new MOA, who does not know the patients as Jack does.
To counter this, Jack has a brief meeting with her each morning. Through these
meetings, Jack orients her to the same expectations that the other MOAs take for
granted through knowing the physician they work with.
“I tend to spend time with my MOA discussing the daybook, why people are
coming in. How urgent is it? And sometimes, if patients will be coming in for lab

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values or imaging results and it’s not available I’ll say to her why waste their time
or my time, see if you can track it down. If you can’t, reschedule that
appointment. And if you do have it, I want to review it before I see the patient.
I’ll give you a classic example of today how that worked, I had a patient that I saw
last week with abdominal pain and some bleeding vaginally so I sent her for an
ultrasound and the ultrasound came back this morning. By the time I contacted the
patient with the results of the ultrasound, I’d already spoken with a consultant and
had an appointment set up for her to see them today.” (Jack)
These brief meetings between Jack and the MOA helps ensure the day unfolds
smoothly for providers and patients. A telephone call to a patient with abnormal
ultrasound results saves time, and with a plan already in place for follow up, the patient is
also saved the anxiety of wondering what will happen next. These actions that providers
perform recurrently “behind the scenes” culminate in patients experiencing care that is
timely and attends to their needs.
For most patients attending this office, there is no frustration of having to talk
with a harried MOA, no irritation of long waits before being seen, no anxiety about
showing up for results that have not yet been processed, and no annoyance at having to
repeat the entire process in another week once the results arrive. Such issues can be
common in some primary care offices. Avoidance of all of these factors is accomplished
through intentional, established structures of the office and, to a large degree, is taken for
granted in the day-to-day work.
This is not to say that the office is a utopia or without snags. Printer problems,
minor communication mix-ups, and other technology issues do surface. However, the
structures of this office, from the calm atmosphere to the pleasant reception, to the timely
visit that is conducted in an organized manner, all contribute to a facilitative environment
where practices of connection can take place. Primary care providers can help “set the
stage” for practices of connection through implementing structures and processes that

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affirm that patients have lives outside the health care system, that their time is valuable,
and that the patient experience should be smooth and coherent when attending the office.
Attending patients
In the office, each provider “runs” two consultation rooms at a time to conduct
patient-provider encounters. Most of the rooms are almost identical, with a sink, counter,
cupboards, chairs, and examination bed with a bar of assessment equipment hung on the
wall above. Patients are roomed by the MOAs, who check vital signs and ensure
necessary supplies or forms or equipment are present before the visit with the provider.
With each of the five providers in the office, I observed between four and six
patient encounters. Through the process of obtaining consent with the patient when the
MOA called the patient from the waiting room, I was able to observe the provider from
the moment they entered the room with the patient. As the provider came into the room,
patients might relax, or brighten, or sit up straighter when the handle of the door to the
room turned. Some patients took photos out to show a provider, or offered garden
produce to give away. The demeanor of patients as they waited for providers ranged from
comfortable and relaxed to anticipatory and alert.
In making a decision to seek primary care, patients have experienced a disruption
in their equilibrium so that they are no longer able to take health for granted (Gadamer,
1996). For some patients, such a disruption may be ongoing; they may seldom feel well.
When individuals experience an alteration in their health status, they will draw on
supports and resources as described in the previous section. In everyday life, routine and
ritual are coping mechanisms (Giddens, 1991). If these actions of drawing on usual
supports or strategies do not satisfactorily resolve health, primary care may be sought.

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Primary care encounters thus disrupt everyday routines in life, and to some
degree, are a source of anxiety. As such, the primary care provider is prompted to
recognize that illness embodied in a patient is “not just a biomedical state of affairs, and
not just a social state of affairs, [but] also a psychological-moral state of affairs”
(Gadamer, 1996, p. 20). The task of the primary care provider is to engage in therapeutic
dialogue, which is “a form of attentiveness, namely the ability to sense the demands of an
individual person at a particular moment and to respond to those demands in an
appropriate manner” (Gadamer, p. 138). In the following exemplar, Isaac engages in
therapeutic dialogue with one of his patients.
Issac is seeing a patient well known to him, and her concern today is “sleep”. He
begins the visit by asking about her family. The nature of the conversation indicates
she has a stressful relationship with one of her children, but she is feeling better
now that he is no longer living with her. The patient remarks she has “time for me
now”. Isaac picks up on this thread. He asks about her goals, and presses with gentle
questioning for specifics. “What do you want to accomplish?” he asks. She is a
patient with chronic non-cancer pain. She reflects, “I might live another year. I
don’t want a [joint] replacement for this old body though, it’s not worth the
government’s money!” Isaac responds genuinely, “I think you have lots of value”.
As they talk it becomes apparent the patient is actually afraid to have surgery, and
is likely a poor candidate for general anesthesia. Isaac offers and discusses many
options. His language is encouraging and inclusive, saying, “Let’s have a
conversation”, or “let’s keep that on the table”, or “let’s talk more about that.”
After a few minutes, Isaac raises the topic of sleep. The patient squares up in her
seat to say, “I’ll tell you how I’m getting to sleep but you’re not gonna like it”.
Isaac’s face remains open and he allows her time to tell him she’s been having a
few drinks in the evening to help her fall asleep. He proceeds to screen her for
problematic alcohol use by using the familiar CAGE tool. However, he asks the
questions naturally and conversationally, by changing the wording just a tiny bit to
match her context and circumstances. Isaac talks with the patient about addressing
her pain in order to improve her sleep. He asks her to return for a longer visit next
time and completes a requisition for an x-ray to investigate her joint pain. The visit
appears to be drawing to a close when the patient asks, “Are you going to help me
out with the Ativan or not?” Isaac says, “Ahhhh”, because she was not explicit in
asking for medication for sleep. He reiterates some of his message about adequately
treating pain to improve her sleep. The patient informs him, “Well it’s Ativan or
booze”.
Isaac and the patient negotiate the management plan. The patient will receive a

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short-term prescription for lorazepam (Ativan) but must return next week for follow
up. By then the x-ray result will be back so that an approach to pain management
can be decided upon, and the Ativan prescription will not be renewed. (Field Notes)
Isaac’s encounter with this patient reveal many practices of connection
established through therapeutic dialogue. He begins the visit with a conversational tone,
and is not problem-focused. He does not start out asking what sort of problems she is
having with her sleep. Instead, he allows her to direct the conversation, but he focuses the
discussion in a goal-directed manner by asking what she wants to accomplish now that
she has some time for herself. When the patient expresses low self-worth, Isaac explicitly
addresses it to disagree with her. He does not gloss over the statement or ignore it, and he
doesn’t dismiss her concerns about surgery, which reveal her fear as the root of the issue.
When Isaac does re-direct the patient to the reason for her visit, it is not abrupt,
nor is he dismissive of the other issues the patient has raised. When the patient tells Isaac
how she has been falling asleep, his verbal cues match his facial expression in staying
open and interested in the patient. His screening for alcohol use uses language that relates
to the patient’s specific circumstances. Finally, as the plan is made, there is clear
discussion about expectations and follow up.
After the visit, Isaac tells me some of the details of the patient’s significant
psychiatric and trauma history. He knows her very well and it is evident that she feels
safe with him. She provides him with all the information necessary to make decisions
about her care, she is invited to participate in her plan of care, and the conversation is
non-punitive, focusing on solutions and goals that meet the patient’s needs.
This exemplar illustrates many attributes of excellent primary care including a
longitudinal relationship, patient-centredness, and comprehensiveness. This 10 to 15

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minute visit covered topics of sleep, medication, alcohol use, pain, and family dynamics
for a medically and socially complex patient. Isaac allowed the patient to shift the visit
topics according to her priorities, and he describes this to me as choosing when to tweak
or push patients to help them “drive” their own care. Gadamer (1996) explained this as
knowing how to distinguish, and that this is the true art and meaning of diagnosis. The
practices in this encounter show how skill in practices of connection, and knowledge of
social history can foster therapeutic dialogue. This allows for effective care of complex
patients with significant co-morbidities to take place in a routine primary care visit.
Knowing patients
Henry (MD) has been in this office the longest, and he has known many of his
patients for more than ten years. When Henry enters the room to see a patient, it is
obvious there is a long-standing relationship. The patient sits relaxed in her chair, her
purse on the floor at her side. Henry smiles warmly and sits nearby while he asks what is
new in her life. As they exchange brief pleasantries, Henry is able to hear an update about
her home life, her family, and her activities.
It is this type of exchange that patient participants identify as a “personable”
quality in their provider. The conversation takes place in a manner that would be
expected of anyone who knows you well and is politely asking after your family and life.
For Henry, however, this information provides additional insight, because this patient has
a number of health issues: She has longstanding depression, insomnia, polymyalgia,
gastroesophageal reflux disease, and frequent fungal skin infections. She is here today to
discuss trying a special diet and also medication for sleep.

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Henry’s initial conversation helps him re-affirm a trusting relationship. It also
helps him to contextualize the patient’s health status into the wider lens of her life. He
can now discuss her eating habits, diet, and sleep knowing about recent stressors in her
family life, who is acting as a key informal support for her, and strategies she has been
trying to keep herself well and to get enough rest. Through this initial, seemingly
informal conversation, Henry has gained understanding of how the patient initially
involved members of her “team” outside the formal health system, what supports and
resources are currently available to her, and what the issue is that tipped the balance
towards her decision of seeking primary care.
Through discussion, Henry uses recognizable motivational interviewing strategies
to ask what the benefits might be if she were able to do more of the activities she enjoys
compared to any risks she might identify to taking medication for sleep. In this way,
Henry demonstrates understanding of the patient’s interests, another component that
patients in this study identified as contributing to feeling known. He helps the patient
further understand linkages between depression, sleep, and chronic pain. She changes her
mind about wanting medication for sleep and is agreeable to try some of Henry’s
suggestions about eating and activity, and also a trial increase in her antidepressant
medication. In this approach, Henry treats the patient as a partner in her care by helping
her to choose among possibilities for safe and effective treatment.
Henry knows this patient in a way that extends beyond her physical health issues,
so he can help her challenge the narrative she presented of “only medication will help me
get a good sleep” (Patient), and assist her to make different decisions about her plan of
care that incorporate her current habits, values, and lifestyle without adding to her

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medication burden. His recommendations “fit” into her life and do not disrupt her
identity. This is accomplished within a 10 to 15-minute appointment, and Henry makes
sure the patient knows when to return for follow up.
Following this encounter, Henry tells me some background information about the
patient, what medications the patient had tried previously, her relationship with her
spouse, what her previous employment was, and her state of health now compared to a
couple of years ago. Almost all of the providers discussed cases with me in this way after
visits concluded, and these updates serve to fill in gaps in the history not apprehended
during a visit because all of this information remains tacit during the encounter. The
primary care providers investigate symptoms and make recommendations based on
already knowing the patient, and this tacit knowledge is accumulated through maintaining
a longitudinal therapeutic relationship with the patient. What is unknown, however, is
how this information is conveyed to other team members when necessary, especially
those who are not co-located and so do not have the opportunity as I did for a quick postencounter update in the office.
Getting to know
The two encounters described above were interactions where patient and provider
knew one another well, over a period of years. Kate (MD), in contrast, is a novice
primary care provider who joined the office during the period of data collection. With
Kate I observed encounters to understand how or whether getting to know patients as a
new provider showed up as different practices, and how therapeutic dialogue might be
achieved when a patient is not known well by a primary care provider.

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To begin, I was able to observe Kate as she was taking new patients for her own
panel. This process involved a “meet and greet” visit so that she could collect health
information about patients and arrange for chart transfers from patient’s previous
providers. During each of these visits I observed, Kate offered information about what
types of service she planned to offer, such as seeing patients if they are admitted to
hospital, or delivering babies, and how she handles common requests such a telephoning
a prescription renewal to the pharmacy. This recurrent offering of information to new
patients by Kate during each “meet and greet” is a practice of connection because it
clarifies expectations for the foundation of the therapeutic relationship.
After taking some health history from patients, arranging for charts to be
transferred, and discussing services available by having Kate as a family physician, Kate
tells her new patients where she grew up and attended school, a bit about her family, and
her plan for staying in the community. The patient reaction to this disclosure of personal
narrative from Kate is chiefly interest and accommodation. It is also one of the
components identified earlier by patients as contributing to feeling known by providers.
Patients leave these appointments with some understanding of what roles Kate assumes
as their primary care provider, and there is reassurance that patients can get to know her
better, because she communicates that she is not planning to leave the community within
the next several years.
The practices of connection enacted through the “meet and greet” visits with Kate
help to begin to establish the foundation for a therapeutic relationship between patient
and provider. Patients also get to tell Kate about themselves; if they have any pressing or
chronic health conditions, what their home and work environments are like, and about

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their family. In this way, Kate is able to acknowledge the personhood of her patients, to
understand who they are when they are not patients. Kate then documents this
information, because this is new knowledge, and not a tacit accumulation of knowledge,
which the more experienced primary care providers are able to rely on with patients they
know well. Writing down the social history of patients, including their interests,
activities, supports and resources for health, she has prompts for future visits to continue
to develop therapeutic relationships with her patients. For example, when the man with
the hip pain returns, she can check to see that he works twelve hour shifts on his feet.
This helps her to contextualize and understand his meaning of the symptoms, as opposed
to giving bland reassurances about hip pain being common for people with osteoarthritis
in their late 50s.
There are other instances whereby providers who do not know patients well might
shape their language and practices to promote connection, and facilitate therapeutic
dialogue. As mentioned by patients, and illustrated by Henry in the earlier example,
experienced providers frequently use a conversational interview style. These providers
are not put off by patient forays into tangents about their personal lives, but rather probe
further, and ask questions to link patient experiences to how health or their presenting
concern for that visit is influenced by these experiences. These practices are indicative of
genuine understanding. Genuine understanding occurs when attention is focused not on
outward facts or actions indicating a lived experience, but rather what lies behind them
(Wagner, 1970).
Kate, as a novice provider, did not have the same level of conversational tone
with her patients compared to more experienced providers who knew their patients well.

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Kate spent much more time explaining her rationale and findings to her new patients, and
her interview style was slightly more rigid in that the textbook format of eliciting history
is still discernible. In one patient encounter I observed with Kate, the male patient had left
lower quadrant abdominal / groin pain. Kate spent time reviewing with the patient the
differential diagnoses she was considering, that she was planning to order an ultrasound,
and why the ultrasound could help to establish the diagnosis.
With these explanations, Kate is performing practices to treat the patient as a
partner in his care, which can help patients to feel known. Kate includes the patient by
articulating her decision-making and rationale, which allows the patient to understand
and agree or disagree with the plan of care. The patient is not expected to unquestioningly
follow Kate’s orders for him.
While a novice provider may have to explicate her intent and actions more
thoroughly to engage patients and establish a therapeutic relationship, a different provider
who knows their patient well can summarize the plan by saying, “Here’s the form for the
ultrasound, come back in a couple of weeks.” A provider who knows his patients well can
rely on an established therapeutic relationship and past practices of connection to convey
a plan that is understood by the patient. Mutual understanding between patient and
provider of this tacit information saves time in the encounter, which can also facilitate
providers who know their patients well to be able to address multiple issues in an
encounter.
Based on Kate’s practices, efforts to treat the patient as a partner in their own
care, combined with a personable approach, may be the first steps in establishing a
therapeutic relationship. If a provider can satisfactorily resolve the patient’s anxiety about

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the health care encounter, in part by discerning the salient aspects of the patients’
narrative, this affects what the patient is willing to disclose, which in turn influences
provider judgment and decision-making. When an attentive provider is seeking to
understand the meaning of the patient’s situation as well as articulate their own
intentions, the resulting therapeutic dialogue can foster plans of care that are fitting for
individual patients who feel known by their provider.
Articulating intentions
The practices of an attentive provider seeking to make meaning of a patient’s
situation through therapeutic dialogue are frequently tacit. This does not diminish the
value of such intentions, and when asked, providers who are experienced in these ways of
being with patients are able to clearly articulate their intentions. Leah (NP) describes an
encounter during a busy day where she is asked to see a 23-month old patient she has not
met before between other booked appointments. Leah enters the room without first
reviewing the chart because she is running behind. She immediately picks up on some
defensiveness from the mother, as well as a disconnect between the level of concern
exhibited by the parents and the health status of the child, who was “toddling around,
looking quite swell” (Leah). As Leah begins the history, she could not immediately
uncover the source of defensiveness and concern she sensed in the room. Eventually,
Leah asked the mother if the child had ever been hospitalized. Leah summarizes what the
mother said:
Atypical cystic fibrosis, hello. The bombshell drops, boom. And this well of
information came flowing out which made me then understand the anxiety level of
the parents. I said, Look I apologize, I don’t know everything about your child, I
never met you before. That’s why I’m asking all these questions. And I will check
your child over, no problem, but I do need this information first. Wow, she looks
really well today. I do apologize for all these questions.” And then they said, “It’s

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okay, we’d rather you ask more than less.” So … people have so many experiences
with the health care system that their guard is up. (Leah)
This re-telling of a patient encounter speaks to several facets of therapeutic
dialogue. First, the experience of the provider is revealed through her knowledge that
something was “off” regarding the parent’s concern as soon as she stepped into the room.
Leah recognized the anxiety evident in the parents and intentionally sought to uncover the
source of that anxiety and discover the parents’ motivation for seeking care for their
child. This is evident in her response to the distraught parents. She stopped the interview.
She apologized for all the questions. She explained why it was important to ask the
questions. She offered reassurance about the appearance of their child. With these
intentional practices, she created a space for the parents to feel safe, which allowed the
parents to feel more assured their concerns would be addressed in that visit.
As much as language is an important way to convey to patients that they can feel
safe and understood, silence is also necessary. Recognizing when silence is called for,
and being silent, is a practice that recognizes the personhood of the patient. Leah (NP)
describes an encounter with an older woman who made a decision to disclose abuse, and
begin to examine how it was affecting her health.
It was actually just sitting down, allowing her, going through the history … then
just giving her time to share some of the abuse she’s gone through and just hearing
that. And not that I know exactly what to do about that but I can hear it, I can
validate her experience and then for this particular person, it was regular meetings
for her to get that out. I mean she was looking for help in that she had symptoms,
but she needed a safe place to get rid of this burden … I would say for older people
or older women, if they look back on their life and there’s been trauma or abuse,
there’s continual self-blame and guilt and shame. They may be presenting with
anxiety, but if I have the time to work with them it can be very, very powerful.
(Leah)

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In this situation, Leah was cued that there was something more to the patient’s
clinical presentation of anxiety. She intentionally returned to “going through the history”
so that factors beyond clinical symptoms could be surfaced. Once Leah makes a
conscious decision to explore a sensitive topic with the patient, she gives the patient the
time to talk about her abuse. In this way, providers demonstrate an understanding of the
moral responsibility that accompanies an intention to create a safe place for patients to be
known. Leah understands that her role in maintaining therapeutic relationship includes
being prepared to hear and address sensitive topics with patients. In this situation, Leah
uses her judgment to seek genuine understanding by allowing the patient to present a
previously unheard narrative of her identity. The intention of the provider is not to treat,
but an intention to understand, so that healing and resolution of symptoms can begin to be
formed.
Knowing the specifics
The dialogue between patients and providers who know one another well may not
be as explanatory or detailed, as much of the understanding is tacit within the patientprovider dyad. However, practices of connection are still evident in provider language
and conversation with patients. For example, patients with multiple co-morbid conditions
may experience deteriorating health status when initial interventions no longer keep up
with disease progression. The best plan of care becomes increasingly challenging for
providers to manage and patients to implement, as medication burden and
symptomatology increases. To prevent a patient’s function and quality of life from
decreasing when medication is maximized, increased attention to other interventions
focusing on behaviour change may be emphasized. This may be an especially important

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time to have meaningful knowledge about a patient’s supports, resources, strategies, and
personal interests to apply to the patient’s situation in efforts to restore or maintain health.
For behaviour change to be effective, generic advice such as “eat less processed foods”
may not be useful to the patient.
Providers who are able to plan care incorporating patient values and preferences
do so using particular practices of conversation. Jack (MD) consistently employs these
practices with patients, one example being to avoid topical questions when it comes to
inquiring about a patient’s social history. With a diabetic patient, he does not ask what
her diet is like. Instead, he asks about what cooking methods she prefers, which can help
to determine if she fries a lot of foods or eats a lot of processed foods. He asks if she eats
only when she is hungry, which helps to identify if she has any habits related to unhealthy
snacking or overeating that might affect her blood sugars. He asks if she knows about
different portion sizes for food groups, and has her demonstrate what a desirable portion
size for protein or vegetable might look like. This helps Jack to quantify what she means
when she says something like “I eat a lot of vegetables”. Specific questions such as these
helps Jack go beyond the “outward facts” (Schutz, 1970) to distinguish what the patient
means. Jack can help the patient to identify problem areas, such as snacking after supper,
to help her improve her diet. He can also help her to identify ways she might make small
changes, that are practical recommendations based on the patient’s own rituals and
routines, and that the patient agrees to try. Jack’s plan includes a follow up appointment,
so that the patient can return to report on progress and the plan can be modified as
needed.

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Jack asks for a similar level of detail about exercise for an overweight patient.
Instead of asking the patient if he takes any exercise, he asks what types of activity the
patient engages in, for how long, at what intensity, and whether he enjoys it. Instead of
re-stating the evidence by telling the patient what he should be doing (get at least 150
minutes of moderate physical activity per week), Jack converses with the patient to figure
out how his patient can meet the recommendations. With a personable approach,
including the patient in decision-making, and knowing the patient’s interests, Jack
provides evidence-informed patient-centred care. Based on Jack’s intention to understand
the details of the patient’s situation beyond the biomedical detail that the patient is
overweight, Jack’s clinical judgment can be applied to determine the best course of
action. While in this case the decision is to support the patient to draw on his own
resources, in a different situation, or perhaps in the future, it may be determined by Jack
and the patient that the goals cannot be met by the patient using only his own resources
and strategies. In such cases, when patient needs or goals exceed their existing supports
and resources, this is a juncture of deciding whether or not to involve a member of the
interprofessional team.
Summary
This chapter began by exploring who patients include on a team that helps them to
maintain or restore health. The supports and resources patients identify such as friends,
family, employment, pets, and other groups and individuals, exist largely outside the
health care system. When patients become unwell, their resources and supports are drawn
upon both prior to and in conjunction with seeking primary care via the formal health

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system. How many available supports and resources a patient is able to access within
their community may influence when or whether the patient seeks care at all.
In order to understand how patients draw on existing supports and resources in the
community setting, as well as identify when resources and supports need to be bolstered
in order to maintain or restore health, it is necessary for primary care providers to know
their patients. Patients take for granted many aspects of how they maintain health in their
everyday life. Primary care providers must therefore be intentional to inquire and uncover
what sort of supports, resources, or strategies patients have at their disposal or not when
planning care to improve the health of a patient. Attention to these aspects of a person’s
life outside the biomedical and health system realm can help patients to feel known, and
may result in more appropriate plans of care with which patients feel engaged. Further,
understanding the supports and resources patients can draw on, or when they require
additional support or resources, has implications for involvement of the interprofessional
team.
Patients in this study distinguish four qualities enacted in practice by physicians
that contribute to patients feeling known. When primary care providers treat patients as
partners in their own care, have a personable demeanor during patient encounters, are
willing to share some aspects of their own life, such as a hobby, and take genuine interest
in the patient’s life beyond the patient’s health conditions, patients feel known. Patients
do not always experience practices that embody these qualities, and one reason for this
may be related to the prevalence of co-morbidity in patients.
Medical management of patients with multiple co-morbidities can be time
consuming. Treating patients with multiple co-morbidities requires diligence in tending to

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the many aspects of care for which evidence prompts primary care providers to adhere to
in order to facilitate optimal patient outcomes. It may be possible to provide high quality
medical care without knowing patients well, but some patients may not view this trade off
only as a benefit. Knowing patients in the context of their health and illness requires
clinical judgment in distinguishing which aspects require tending to within patient
encounters. This is a competency that facilitates care being experienced not just as high
quality, but also as coherent, from the perspective of patients.
The second half of this chapter turned to uncover the practices of primary care
providers that embody the qualities and ways of knowing that patients identify as helping
them to maintain or restore health, and feel known by a health care provider. These
practices of connection begin in the waiting room and with interactions with MOAs.
Attention to structural aspects of providing care, such as appointment bookings, are
intentional in this office, yet embedded in the everyday running of the office and help to
set the stage for a therapeutic encounter between patients and primary care providers.
Patients seeking primary care do so when their usual routine and rituals of
drawing on their personal resources, supports, and strategies no longer suffice to maintain
or restore health. Patient-provider encounters in primary care are a disruption to the
routine of the everyday lives of patients, and to some extent can be a source of anxiety. In
part, therapeutic dialogue between the patient and the primary care provider helps to
alleviate anxiety and facilitate practices of connection between the provider and the
patient. Practices of connection using therapeutic dialogue facilitate the ability of a
primary care provider to know patients well, and this can impact the coherence and
comprehensiveness of care. In this study, primary care providers were observed to deliver

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high quality patient-centred care to complex patients with significant co-morbidities
within a primary care encounter in a fee-for-service setting.
Experienced primary care providers in this study helped patients to prioritize their
health care needs and assist them to make linkages between their symptoms and health
issues. Patient concerns were addressed and not glossed over or ignored. Patients
participated in selecting safe and effective treatments, and plans of care incorporated
knowledge of patient preferences and habits. These practices reflect how primary care
providers draw on their clinical judgment to increase understanding of patients and their
health issues beyond the limits of their biomedical symptoms.
The novice primary care provider in this study demonstrated practices of
connection with patients she did not yet know well. This included offering patients some
information about herself, such as where she grew up and her plans for staying in the
community. Compared to providers who know their patients well, Kate spent more time
clarifying expectations and articulating her judgment or rationale about next steps for the
patient’s care. While being explicit about decision-making takes more time in an
encounter, it can facilitate mutual understanding and help patients to participate more
fully in their care. These practices may be key first steps in getting to know patients in a
meaningful way.
Other practices of connection observed during patient-provider encounters include
recognizing when an encounter is not going well. Stopping an interview and apologizing
for a misunderstanding can help to prevent any further disruption to the patient-provider
relationship and restore the possibility for patients to feel known. Allowing space, and
even silence, for patients to voice concerns, and then acknowledging rather than

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deflecting disclosure of sensitive issues is a practice of connection. Finally, providers
who ask particular, specific questions about patient practices, habits, and preferences will
better understand their patients in the context of their everyday lives outside the formal
health system.
Primary care providers in this study offer a personable, patient-centred approach
whereby the patient’s personhood is acknowledged, and the primary care provider
understands details of the social history of the patient, such as what the patient’s interests
and supports are. Through this approach, genuine understanding of the patient’s situation
can be apprehended. The primary care provider may assist the patient with treatment or
interventions to augment, mobilize, or increase the patient’s existing supports and
resources that the patient identifies as helping them to restore or maintain health. These
actions may assist the patient to return if not to equilibrium, at least to be better equipped
to return to the social world in which one lives and works (Gadamer, 1996). Rather than
focusing narrowly on the biomedical aspects and the paradigms of efficiency and
evidence-based practice that can dominate primary care delivery, primary care providers
in this study apply judgment to the particular case of the patient (Gadamer), resulting in
care that goes beyond the terms of high quality or continuous; it is also coherent. Patients
who are known by their primary care providers may be more likely to receive primary
care that is coherent to them, and thus it may be easier to follow individualized plans of
care to achieve improvements in health outcomes.
Within some patient-provider encounters, the primary care provider can
distinguish that interventions, education, or advice offered by the primary care provider
in combination with the patient’s resources, will be inadequate to restore health. This is

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when the patient-provider dyad may be expanded to foster the patient’s access to teambased care. The next chapter explores how the application of judgment by primary care
providers and interprofessional team members to the circumstances of patients can
prompt initial and extended involvement of an interprofessional primary care team.

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Chapter Six: Involving Team
Patients become formally connected to the interprofessional team beyond the
patient-provider dyad through a standardized process. Not all patients in a primary care
provider’s office will be involved at any given time with the interprofessional team.
There is a gap in understanding and articulation about how, when, and for whom the
interprofessional team becomes involved in providing longitudinal primary care for
particular patients.
This chapter examines the process of involving the interprofessional team to help
identify how primary care providers make decisions to expand the patient’s primary care
team. Attention is given to how interprofessional team members become involved in
patient care based on the information they receive from primary care providers about
patients they may not know well, or at all. In this way, distinguishing some of the
judgment required in deciding who needs a team can be uncovered.
Requesting Service
The current process to initially involve an interprofessional team member outside
the primary care provider office is via completion of a unidirectional form called a
Service Request. The Service Request is completed at the primary care provider office
and then faxed to the interprofessional team office. Patients cannot currently self-refer to
the interprofessional team. In the past patients could access Northern Health’s mental
health or public health services without first seeing their primary care provider. This may
change in the future but at present the primary care provider holds the decision-making
power about who needs a team.

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On the interprofessional team “side”, one person who sees every single Service
Request is Ursula, the primary care assistant. Mid-way through data collection, I asked
her if she was starting to see more consistency with the information provided on the
Service Request forms being faxed from primary care provider offices from around the
community. She raised her eyebrows as she showed me the Service Requests received
that morning. “It’s a dog’s breakfast,” she informed me.
Some Service Requests have a full care plan attached including information about
the patient’s health conditions, medications, goals related to health, and preferences for
care. Others have the primary care provider’s documentation from that day’s visit
attached, which might indicate, for example, that the patient has anxiety, and the request
for service is about counselling for anxiety. Other Service Requests are one-liners, with
“falls” (Mel, OT) as the only information provided.
All Service Requests are collected each weekday morning from the fax machine,
so they may be reviewed during rounds, which take place at 0830. Rounds are conducted
in a cramped meeting room and are attended by the interprofessional team, the primary
care assistant, and a care process coach. On a whiteboard is written the format to be
followed for rounds: Messages, Hospital Alerts, Review Last Day’s Appointments,
Coordinate Today’s Appointments, and Other/Updates. Each topic is supposed to be
reviewed in order every morning.
The primary care assistant hands out the messages, reviews the information
downloaded regarding patients in hospital or recently discharged, and introduces the new
Service Requests. These activities generate intense and disjointed conversation around
the table. The conversation revolves around “who is that patient”. As the primary care

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assistant shares information, team members examine the details and discuss who might
know the patient. This becomes necessary when the interprofessional team receives only
scant, often biomedically focused information on the Service Request. Based on the
information provided on the Service Request, interprofessional team members have to
triage Requests to make decisions about when to see patients, how long the appointment
should be, and who is the most appropriate team member to see the patient. Compared to
primary care providers, IPT members do not have the benefit of a MOA who knows the
patient, nor fulsome documentation on a patient chart, nor easy access to the provider
who knows the patient. Attempting to reconcile the lack of context with the information
on the Service Request, comments such as, “He’s the one I went to the urologist
appointment with”, “is that the lady whose daughters …”, or “I think he’s about to be
evicted”, fill the room as team members try to situate the patient into the social realm so
that the meaning and scope of the Service Request is better understood.
Odette (MH) gives an update of a patient’s status and sees blank looks from some
team members trying to place who the patient is. Odette adds some of the social
history from her own experience with the patient, saying that the patient’s daughter
lives with a man who is using cocaine and is frequently violent, and the patient is
very worried about the young child in the house. The daughter often calls the patient
asking for help. Ruby’s eyes light with recognition, saying she remembers now,
this was the patient who had just been to the emergency room for treatment of an
anxiety attack. There is small flurry of activity as someone enters the patient
information to retrieve the electronic report from the Emergency Room, so that
more information might be learned about the patient and her current circumstances.
(Field Notes)
The interprofessional team members use patient rounds to review Service
Requests and update others about patients recently seen. Rather than focusing on the
biomedical aspects of patients’ history, the discussion centers on social history. To cue
team members to recall who her patient is, Odette (MH) offers reminders about the

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patient’s relationships and stressors. This information is then pieced with the anxietyrelated emergency room visit that until then Ruby (Case Manager) had considered as
disparate information, and of which Odette was unaware. These pieces of information are
then put together to form a more complete picture of the patient, who is not just someone
with anxiety, but with particular issues impacting her anxiety that can be addressed with
assistance from the interprofessional team.
In a disconnected manner, interprofessional team members use their clinical
judgment to discern what might be salient details about the patient that foster improved
understanding of the patients supports and resources that are exceeded, as well as the
stressors that exacerbated the condition beyond what can be suitably or effectively
addressed between only the patient and primary care provider. The interprofessional team
members are seeking the same information that experienced primary care providers use to
deliver high quality primary care. Yet in this example, the social history of the patient
was not provided, and the interprofessional team had to piece together a more fulsome
history beyond the clinical manifestations of the diagnosis provided on the Service
Request. There appears to be a gap between the primary care provider deciding to involve
the interprofessional team, and providing relevant information on the Service Request
that might facilitate or increase meaningful understanding of the patient’s situation. To
better understand this gap, as well as other aspects of team-based care that are not
articulated clearly, it is worthwhile to examine from the interprofessional team members’
perspective the particular circumstances that prompt primary care providers to involve the
interprofessional team.

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At the time that data collection for this study ceased, interprofessional team
members had been accepting Service Requests for eight to ten months; a large volume of
Service Requests arrived to the interprofessional team office each day. The process of
reviewing and assigning interprofessional team members to address patient needs
identified in the Service Requests stretched the capacity of the interprofessional teams.
Based on the volume of Service Requests I observed the interprofessional team review
each morning, three distinct situations can be identified for which primary care providers
requested interprofessional team involvement in patient care.
“Straightforward” service requests
“Straightforward” Service Requests are characterized by the request for a single,
specific service. These requests are for services a primary care provider would not
routinely perform, such as installing a raised toilet seat, or arranging Lifeline (a medical
alert system triggered by patients in their home in case of falls or medical emergency).
Alternately, the “Straightforward” request may ask a specific team member for a service
the primary care provider could perform, but is anticipated to be time consuming, or an
interprofessional team member has more expertise about the issue than the primary care
provider. An example is a request addressed to the interprofessional team social worker
to assist a patient to complete forms for subsidized housing. The term “straightforward”
refers to the primary care provider’s perspective of the request.
When the interprofessional team receives and reviews a “Straightforward” Service
Request, the information on the form is usually short and fairly directive. It is anticipated
that an interprofessional team member will easily dispatch the service, and the patient is
unlikely to require very much follow up. However, this is not always the experience of

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the interprofessional team members. Sometimes, additional history would greatly assist
the interprofessional team member to provide meaningful care for the patient.
I attended a home visit with Mel (OT), to see her first patient of the day. The
Service Request was to “install Lifeline”. The first step of this process is to give the
patient information and a number to call to set up the service. Mel’s experience in visiting
this patient’s home helps to articulate why the seemingly “Straightforward” Service
Request can show up as complex and time-consuming in the world of practice, and how
missing information about the patient can significantly impact the therapeutic relationship
between a patient and interprofessional team member.
I wait for Mel (OT) to complete forms for Replay before leaving for a home visit.
She packs her bag for the morning, as we will see two patients before returning to
the office. Mel’s work phone is dead because she has to keep it locked up over the
weekend and there is no way to charge the phone and also store it in a locked drawer
as per Northern Health policy. She programs the patient address into her personal
phone, and we walk to the car. It is snowing sideways and the parking lot is a sea
of slushy puddles.
We drive and then park on the street and walk to a small rectangular apartment
block and press the buzzer to the patient’s apartment. The buzzer sticks and Mel
says this is a very common occurrence in winter in northern BC. On the seventh try
we hear it connect to an apartment above us.
The patient comes down three flights of stairs to let us in. As we arrive back to the
top floor, she is out of breath, struggles with her front door lock and curses in
frustration. At last we are in the small, cluttered apartment and remove our boots.
The patient thinks we are both nurses, and pays no attention as Mel corrects her.
Mel is visiting this patient to offer Lifeline. The Service Request from the primary
care provider included the information that the patient had fallen recently at home
and was stuck between her furniture for four hours. Mel pokes her head into the
bathroom and asks the patient how she manages getting in and out of the tub. The
patient is not interested in a non-slip mat or a bath seat; she tells us she loves a soak
in the tub, even though it can take more than 30 minutes to get out once she’s in.
We move to the living room, and the seating choices are limited. The patient
indicates that Mel and I should be seated together. The patient sits perpendicular to
us in a recliner. We now have our backs to the door, and the route out of the
apartment is around the recliner where the patient is seated, past an over-sized oak
hutch filled with china, and then past the bathroom to the entryway.
Mel begins to explain Lifeline. She offers a pamphlet to the patient and writes down
the name of the person who will help the patient install the service. The patient is

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curious about cost. As Mel explains there is a small cost that is often waived or
subsidized, the demeanor of the patient deteriorates. At the outset
of the visit, the patient came across as mildly eccentric, with an unkempt
appearance. However, her behaviour quickly escalates without apparent trigger
except for the mention of money, and she exhibits anger and paranoia. She raises
her voice in a tangential monologue and stands over us, angry and unresponsive to
Mel’s attempts at re-direction.
By this time, Mel had managed only to hand out a pamphlet and provide one other
number for the fire department to come for an emergency lift assist in case of fall.
One teaching point is conveyed: Mel asked that the patient carry her cordless phone
with her, so that if she falls she can call the fire department number that can be preprogrammed into the phone.
Mel has a Northern Health intake form with several different sections and numerous
tick-boxes. For some time, I watch Mel’s pen hover uncertainly over the form as
the patient rants above us. Finally, I see the pen droop and join the form in her lap.
This task for the visit won’t get completed today.
After some time, the patient pauses, and Mel takes the initiative. She calmly thanks
the patient and says we have to be going to see our next patient. There is now space
to stand without being directly in the patient’s physical space.
The patient’s voice is calmer now, and she appears nonplussed about our intent to
leave. Mel leaves the Lifeline pamphlet on a table but does not mention the service
again. As we put our boots on while trying to back-pedal out the door the patient
peers at Mel’s nametag. She mispronounces Mel’s name and asks if she got it right.
Mel smiles brightly, says, “You can call me whatever you want,” and we close the
door, walk quickly to the stairs and nearly run for the car.
In the car, we glance back to the door, half expecting to see the patient. Mel lets the
car run and warm up for a minute or two – it is still snowing heavily, and we collect
ourselves. Mel turns to me, dread on her face. “Oh no,” she says, “Where are my
glasses because they are not on my face.” We stare at each other. She hops out to
check her bag in the trunk and finds them. Relieved, we pull away from the curb,
off to the next visit. (Field Notes)
Mel’s visit to this patient’s house to complete a Service Request appeared
streamlined in intent, yet it took almost two hours to drop off a pamphlet and leave a
phone number. By taking a closer look at what transpired, some of the everyday
invisibility of the work of the interprofessional team can be made visible. The activities
the interprofessional team members must complete in addition to providing direct patient
care draws time, attention, and focus of interprofessional team members away from

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increasing opportunities to develop more fulsome relationships with patients and primary
care providers.
The first events that take up time are administrative and occur while Mel is still in
the office. First, she completes forms for Replay, a remote safety system logging the
interprofessional team member’s whereabouts that also prompts team members to contact
the patient to tell them they must lock away pets, that there is no smoking, and ask about
violence in the home. The arbitrariness of this system and risk to damaging rapport with
patients before meeting them means not all interprofessional team members use this
system in the same way. Primary care providers do not use it at all; its original use was
for home care nurses.
Next, Mel must consider the places she has to visit before she returns to the office.
She packs her bag with notes and resources, making a trip or two to the printer. She
enters the patient’s address into her personal phone so she can receive directions while
driving.
Mel exchanges her office footwear for winter boots and gets into the rest of her
winter gear. Coping with weather variations is another factor interprofessional team
members address regularly. Scraping windows, warming up the car, and maneuvering
down streets that have not been cleared of snow are common winter tasks. Once arriving
at the patient’s home, there is waiting for the patient to traverse three flights of stairs
down and then back up to her apartment and some shuffling about to remove footwear
and exchange greetings.
It is only at this point that the encounter between Mel (OT) and the patient
actually begins. Although the Service Request was to assist with Lifeline, Mel knows the

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patient fell and was trapped on the floor of her home. In her OT role, Mel begins to assess
the patient’s home for fall risks, such as her bathroom. This may be a function
unanticipated by the primary care provider making the Service Request. If the social
worker had attended the patient’s home for this task, a slightly different assessment may
have been completed, perhaps with a focus on finances or social isolation. This is
important to highlight: Although the primary care provider is the gatekeeper regarding
involvement of the interprofessional team, once the Service Request is received the
interprofessional team members decide who is best suited to visit the patient. This is in
part based on the information provided on the Service Request.
Mel did not have access to adequate information about the patient in order to
prepare for her visit. This patient suffered severe effects of abuse and childhood trauma,
appeared to have low literacy and financial insecurity. No mention of this history, or
anything regarding risk of angry outbursts or psychiatric diagnosis was made on the
Service Request.
Because of the unidirectional nature of the Service Request, the interprofessional
team members cannot know how much information gathered during a home visit is
known to the primary care provider, or whether the patient is well known to the primary
care provider. Given the impact mental illness, low literacy, and insecure finances can
have on a patient’s health, particularly for someone living alone, it is possible further
interprofessional team involvement would be helpful for this patient. Yet the
interprofessional team is not necessarily privy to the overall plan of care from the
perspective of the primary care provider, or whether the patient may be accessing other
supports or services.

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Uncertainty based on lack of information can leave interprofessional team
members in a quandary. Team members must decide whether to adhere to the
straightforward request, install Lifeline, and move on; write a note to the primary care
provider outlining their assessments resulting from the visit; or ask other interprofessional
team members to visit the patient. The amount of information shared between primary
care providers and the interprofessional team can impede team-based care even for
“straightforward” requests.
A few weeks following the home visit with Mel, I happened to encounter the
primary care provider who made the Service Request for the patient Mel and I visited.
The primary care provider raised the subject of the visit with me, telling me she had heard
about Mel’s experience was glad I’d attended the visit with Mel for safety reasons. I
asked the primary care provider if she was aware of the patient’s angry outbursts. The
primary care provider said, “Oh, yes. When she yells like that in here [a colleague] sort of
stands by…”. I ask if she has been to the apartment. “No, but I should go. On the Service
Request I said if Mel wanted me to go along I’d be happy to.”
The primary care provider was aware the patient could have an angry outburst at
the time of writing the Service Request, but instead of including sensitive information
about the patient on the Service Request, she offered to attend the visit. Over time, Mel
and other interprofessional team members later learned to recognize this as a type of
“code”; if a primary care provider offered to jointly visit a patient, interprofessional team
members recognized it was “… that hidden [message], you should give me a call before
you go see this person” (Mel).

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The incongruity between information known by the primary care provider
compared to information shared on the Service Request reveals there are degrees of
disclosure health care professionals may be comfortable sharing with team members in
writing. There are a number of factors to be considered in how primary care providers
make decisions when determining what information to provide on the Service Request for
the interprofessional team. The primary care provider may assume that for a
“straightforward” request, most patient history will not be necessary or appropriate to
fulfill the request. Primary care providers who are privy to sensitive family dynamics or
social history learned over the time in a therapeutic relationship may feel hesitant about
writing it on a form that is faxed to an office where it may be seen by several individuals
who may not be involved directly in the patient’s care.
Alternately, the primary care provider may know the patient so well that certain
aspects of the patient’s history are tacit, and not recorded in the chart. There may be a
misconception of the roles of interprofessional team members, for example that a
psychiatric diagnosis would not be useful knowledge to an occupational therapist.
Primary care providers will also have pre-conceived and evolving ideas about what
“team” means and whether interprofessional team members should be privy to all patient
information. It can be difficult to convey tone or intent in writing, and there is risk of
misinterpretation.
A lack of information on the Service Request might also simply reflect a busy day
for the primary care provider. Information may be omitted as a time-saving strategy.
Lastly, a technological issue may be the cause of missing information. Sometimes
attachments may be missed or not all pages are transmitted.

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These postulations of rationale for missing information illustrate how, without
face-to-face dialogue between primary care providers and interprofessional team
members the gap between the intent of the Service Request and the outcome can remain
wide. Over time, misunderstandings or mismatching of information may impair
relationships between primary care providers and interprofessional team members. Such
mismatches may contribute to perceptions about lack of role clarity and responsibility for
various aspects of patient care. This in turn reduces the effectiveness of team-based care,
which can impact therapeutic relationships and subsequently how it is determined who
needs a team.
“Foot in the Door” service requests
The second situation giving rise to Service Requests can be categorized by the
term “Foot in the Door”. These Service Requests seem to represent a large proportion of
the patients the interprofessional team sees. Nora (RN) describes this patient population
as “teetering”. Patients are not well enough to maintain or manage their health with only
the support of a primary care provider, but their health issues do not require acute care.
These patients often require a high degree of judgment and negotiation around
composition of team. The image is one of an upside-down funnel, where the primary care
provider writes one reason for the request on the form, but the interprofessional team
members on the other “side” see many interventions required in order to provide care for
the patient. The difference between a “foot in the door” request compared to a
“straightforward” request is that primary care providers involve the interprofessional
team knowing that team member involvement will likely be necessary beyond the reason
written on the Service Request.

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I filled in my first form for referral to this [interprofessional] team as of yesterday
for an 85-year-old woman who lives alone and is having some bilateral edema and
we’re going to try some compression stockings but she’s going to need some help
with that. I’ve been told that everything is going to get seen and there’s going to be
group rounds and things will be prioritized. What we’re looking for in our offices
is responsiveness. Can this get done? How quickly can it get done? What’s the time
frame type thing? For this particular person, I knew she would have to purchase the
stockings, be sized and fitted for them, so I made some phone calls to find out the
cost and was that even acceptable to her, ‘cause she’s possibly on a fixed income,
so I did that legwork, found the number, let her know the cost and said are you
agreeable to this? She said yes but I can’t go just yet, I have a visitor from out of
town. Where real life collides with our ideas and suggestions [laughs]. I also sent
her for blood work because she’s lost so much weight her dentures are flopping
around in her mouth … I wonder if there’s a degree of malnutrition. I am thinking
she may need way more support than just stockings. So stockings are just a tiny
way of getting somebody in there. It’s way more complex than just one thing (Leah,
NP).
Primary care providers anticipate team involvement, and there is a lot of tacit
knowledge that Leah is able to articulate in conversation but is not usually included in
writing on the Service Request. Thus, it is up to the interprofessional team members to
make decisions about who and when to involve other team members. Primary care
providers may call upon the interprofessional team as a generic entity via the Service
Request, but it falls to the interprofessional team to decide beyond that point who makes
up the team for individual patients.
This is one area where there is a risk of ineffective team-based care. Primary care
providers may know their patients well, including social history and usual supports and
resources of their patients, as well as patient preferences. Yet the interprofessional team
may receive little or none of this information and be required to make decisions about
patient care without further input from the primary care provider.
The patient may transition from feeling known by their primary care provider, to
being subjected to multiple visits by interprofessional team members who need to gather

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information, perform assessments, and make decisions about plans of care. While this
model provides somewhat continuous care for patients, it may not be perceived as
coherent.
Odette (MH) arranged to see a patient whose Service Request stated the patient
required “bath support”. The information received via the Service Request
indicated that the patient had diabetes and schizophrenia. Odette had met the patient
previously for a concern relating to the patient’s schizophrenia diagnosis. Because
Odette was the only one to have already met the patient, the interprofessional team
agreed during rounds that she should conduct the initial visit with the intent to help
the patient obtain bath support.
Upon arrival to the patient’s home, the first impression was one of disorganization.
The patient was unkempt, and directed much of the conversation to the fact that her
new shoes did not fit well. The patient also requested advice about a rash on her
chest. A support worker in the residence where the patient lived noticed our
presence and spoke with Odette about the patient’s poor nutrition status and
uncontrolled hyperglycemia. These matters took approximately 30 minutes. Odette
needed to decide who the patient could see in follow up for some of these issues
and conclude the visit in order to meet her next patient. We left without ever
discussing whether or not she needed help getting in and out of the bath. (Field
Notes)
Decisions about which interprofessional team members become involved in a
patient’s care may become more complicated than anticipated. These complications can
arise when the Service Request does not contain adequate patient history. Additionally,
patient priorities may change between the time the Service Request is made and the time
the interprofessional team member sees the patient.
During Odette’s (MH) visit, the patient required assessment of a skin condition,
decision-making about monitoring and follow up for a chronic disease, and assessment of
a chronic psychiatric condition. Odette also provided some solutions to the patient’s issue
of her ill-fitting footwear, in part because this was possibly the patient’s most pressing
concern during the visit. Although each of these assessments and decisions were made
quickly by Odette, they were not arbitrary.

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Involving interprofessional team members to address the health issues raised
during Odette’s visit may risk a misunderstanding with the primary care provider, who
only requested bath support for the patient. There is also risk of over-burdening
interprofessional team members in terms of patient load, and of dis-engaging the patient
from her care with too many people becoming involved at once. However, if all issues
unrelated to what is indicated on a Service Request are returned to the primary care
provider to address, the primary care provider may become disillusioned as to the
benefits of team-based care and what services can be provided. “Foot in the Door”
Service requests may in fact open the door to a number of unanticipated outcomes of
team-based primary care.
When patients shift between receiving care within a patient-provider dyad to
team-based care, attention to how information is communicated may be as important as
what is communicated. Decisions about how to best communicate patient information is
based on knowledge of the patient and of the other team members involved in the
patient’s care. Dialogue via face-to-face discussion between interprofessional team
members and primary care providers may be particularly useful to clarify and confirm
unfolding plans of care being implemented by multiple team members. Conversation can
facilitate shared knowledge and mutual understanding of patient needs, priorities, and
preferences. This may help to avoid instances of patients receiving conflicting advice or
duplication of services from multiple providers, which might disrupt therapeutic
relationships with one or more members of the patient’s team.

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“All Hands on Deck” service requests
The interprofessional team frequently uncovers multifactorial issues to be
addressed after meeting with patients for the first time. The “All Hands on Deck” Service
Request is one that differs from the “Straightforward” and “Foot in the Door” requests
because the information provided by the primary care provider is sufficient for the
interprofessional team members to recognize that multiple members of the
interprofessional team are explicitly required to assist in a patient’s care. These requests
may arise when a patient has had a health crisis and is just returning home or to the
community, or an attempt is being made to prevent a hospitalization. Many of the patients
named on these Service Requests belong to a “priority population” (Ministry of Health,
2014), such as frail elderly.
Throughout data collection, the interprofessional team regularly addresses issues
of: guardianship, power of attorney, housing, disability, uncontrolled disease, decreasing
competence, financial incapability, mental health, addiction, self-care, home support,
family disruption, medication issues, mobility and independence issues, differing levels
of service involvement, transportation issues, and safety issues. From the outset of the
implementation of the interprofessional team, the level of patient complexity threatens to
overwhelm the team capacity:
The supposed warm hand-off … I think could have been better. Some of the patients
… have been very complex. Never the simple patient that has maybe recovered
from their depression … and just needed a little bit of ongoing … instead it’s
dementia, delusional, unstable housing, can’t manage their finances … like a multicomplex patient as the first or second patient. It would have been nicer to have some
of the less complex people transferred over so you could get to know the team and
figure out how they work, when instead, all of a sudden, poof, you’ve got the big
one and then you’ve got to figure it out (Odette).

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A “warm hand-off” occurs in some health care settings prior to a transition in a
patient’s care, so that all members of the interprofessional team including the patient are
on the same page about the plan of care and can share knowledge about the patient. In
this way, interprofessional team members newly involved in the care of a patient can
have questions answered, avoid missteps, and obtain enough information to be able to
appropriately make decisions about the care of the patient. In these cases, patients are not
usually present. This is because the patient is so unwell that multiple people representing
a variety of services are already involved in providing care for the patient.
The type of information required to understand a patient’s situation, and how this
information is learned raises a question about the timing of sending Service Requests to
the interprofessional team. Meeting patients who have just experienced a health crisis, for
example a stroke, or are “multi-complex”, as Odette points out, may hinder the team in
getting to know the patient as a person. In such circumstances, the interprofessional team
members will be increasingly reliant on information from the primary care provider, as
the patient may be too ill or incapacitated to provide their own information about
supports or preferences for care. Thus, if Service Requests do not include information
reflecting the complexity of the patient, the interprofessional team may have incomplete
or inadequate knowledge with which to make decisions. It can be easy to mis-step when
expectations about patient needs are mismatched between primary care provider and
interprofessional team members. If interprofessional team members meet patients for the
first time when they are in crisis, the therapeutic relationship and thus effectiveness of
team-based care may be delayed or disrupted.

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Through the three different types of Service Requests reviewed, it is uncovered
that the sharing of information that helps patients feel known can be hampered based on
what information is shared, how it is shared, and the timing of the sharing, or in other
words when the services of the interprofessional team are requested.
Expanding Team
Although primary care providers may send a Service Request with anticipation
that more than one interprofessional team member will become involved with a patient,
these anticipations based on knowledge of the patient and patient’s needs are not usually
indicated on the Service Request. This information may be absent because primary care
providers are uncertain how care might unfold for the patient, or they may wish to avoid
being prescriptive about the priorities for patient care that can be better determined within
the team. However, this unspoken process for involving more than one interprofessional
team member means there is a gap in understanding about how the interprofessional team
expands to include other interprofessional team members after the Service Request is
received. This gap deserves further attention, to determine how interprofessional team
members make decisions to expand the team.
During the morning meeting when Service Requests are reviewed, the entire
interprofessional team is present. This offers an opportunity for each interprofessional
team member to hear about the roles, services, ideas, and interventions that others have
experience with or perform. The meeting room can be a synergistic environment and
provide opportunity for interprofessional team members to learn about the expertise of
others in a clinical context. Patient rounds as part of this morning meeting can be a way
to expand the knowledge of the entire team.

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Rounds every morning and discussing who we’ve seen … the fact that we get to
bounce that off different people … and now we have mental health to bounce things
off of. They come back with excellent suggestions and excellent resources and
having Lifeskills – she is a fountain of knowledge and the things she can suggest
[are] amazing. (Nora, RN)
Because rounds include all of the interprofessional team, everyone can have input
and also learn about resources for patients they were previously unaware of. For example,
the team discusses resources for children whose mother is receiving palliative care,
whether there is a support group for transplant recipients, and what Home Support will
and will not provide for patients. In this way, interprofessional team members increase
their breadth of knowledge, which is beneficial when there are overlapping roles and
functions of their work. Further, the interprofessional team is most likely to become
involved in a patient’s care at a point when the patient’s own resources and supports are
exceeded, and the primary care provider’s additional input has already been implemented.
By the time patients reach the services of the interprofessional team, more specialized
supports and resources may be required. There is no formal way to learn about resources
available for patients, and so this dialogue in rounds, which can sound informal and
scattered, is actually of substantial value to patients and team members.
This discussion in rounds also helps interprofessional team members to learn
about each other and areas of expertise; “She understands when people have to have their
power of attorney in effect and she knows how to present that in a way that is more
palatable to the patient” (Odette, MH). Odette has learned this through working with
Peggy (SW). Understanding what one another’s strengths are also helps to make
decisions about involving other team members. Odette knows she could call on Peggy to
help her explain power of attorney to a mutual patient.

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Through the discussion of patients during rounds each morning, interprofessional
team members can make decisions about whether or not a patient will require care from
more than one team member. Sometimes one interprofessional team member will
perform a function of another’s role, such as when Ruby (Case Manager) asked Mel (OT)
if she would feel comfortable asking about a patient’s medication changes when Mel was
on her way to visit the patient. Mel replied, “Sure,” and made notes to take back to Ruby
after she’d talked with the licensed practical nurse at the assisted living facility in which
the patient was receiving respite care.
Interprofessional team members decide who to involve based on their assessment
not just of the patient, but of the patient in their home environment.
I saw that he had several mason jars filled with medications … like a jelly bean jar
and [I say], “Oh, what’s this?”
“Well,” he says, “I go to [out of province city] and I’m away for long periods of
time, so I kind of stockpile, I kind of keep some medications and then I have a
bunch.” So [I] identified that nursing needed to go in. (Peggy, SW)
The image of jelly bean jars lined up filled with pills is something that may go
unnoticed if the interprofessional team member had not seen this in the patient’s home. In
an office setting, patients are rarely asked to bring their pills in, and instead a routine
question might be, “How are you managing your medications at home?” This patient
might have said he was managing quite well, as he obviously had a system. While
patients present a narrative about their health and identity to health care professionals,
this narrative may be challenged if there is a mismatch between the patient’s story and
their environment. With opportunity to observe the patient’s medication “system”, Peggy
can involve another team member to find out if this meant he was not taking his

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medication as prescribed, whether he was unaware he could ask to have a prescription
filled just before leaving town, or perhaps he was unable to afford all of his medications.
Interprofessional team members also made a point of inquiring into areas of
patient function that “belonged” to another profession’s scope of practice, as a way of
assessing need for the involvement of other team members.
We would always ask some questions about, “How are you getting up and down
the stairs? Is that hard for you? Or is it hard for you to get off and on the toilet and
if so, I’m going to get Mel to come in to see you.” (Peggy)
Observations made in the patient’s home by interprofessional team members who
understand one another’s roles can provide or plan for care that transcends beyond what
is salient only to their particular role or reason for that day’s visit. In team-based care,
knowing the patient is important, and it is equally beneficial for team members to also
know one another. Knowledge of patients and of each other influences judgment in
determining who needs a team.
Considering place
Team-based care can be enhanced by considering place. During an update to the
interprofessional team during patient rounds, Peggy discusses the plan of care for an
elderly female patient who had fallen beside her bed in her apartment at night. The
patient had Lifeline but knew if she pressed the button at the time of her fall, it would be
the firemen who showed up to assist her. Telling Peggy (SW) she was too embarrassed to
have the firemen see her in her underwear, she instead pulled her bedding over her on the
floor and waited until morning when home care arrived. Instead of trying to reason with
the patient to just call Lifeline, the interprofessional team members took the patient’s
wishes and dignity into account. Mel (OT) arranged to see the patient to teach her fall

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prevention and safe transfer techniques. Peggy (SW) arranged cleaning services for the
patient, because “her sheets were black.” This response for this patient would not occur if
not for an interprofessional team who could communicate easily with one another and see
the patient in her home. Seeing patients in place provides different cues about health
compared to seeing patients in a primary care provider’s office. Seeing a patient at home
adds a facet to knowing the patient that is often not observed by primary care providers.
The opportunity interprofessional team members have to see patients at home is
such that their knowledge of patients may develop differently than that of primary care
providers. The interprofessional team members’ understanding of the meaning of a
patient’s situation is augmented by the patient’s environment, and this may be lacking
from the perspective of the primary care provider. This may lead to differences in terms
of how interprofessional team members interpret what “counts” as health care.
The next day I went back to introduce Peggy [to the patient] because I was thinking
he’s getting taken advantage of by this guy and sure enough I took in Peggy and
[patient] said, “Oh yeah he’s buying it from me for $2000 but he’s selling it for
$3500.” It was way out of my league, so that’s when I said, “You know what I need
somebody to touch base with this guy and help him.” (Sonia, Lifeskills)
This patient’s landlord was taking advantage of him. When confronted with this
knowledge while sitting in the patient’s apartment and seeing what the landlord planned
to sell, the interprofessional team member felt compelled to act. Interprofessional team
members recognize what is called for in a patient’s particular situation. The moral facet
of health care addresses interprofessional team members differently compared to primary
care providers, perhaps because patients are visited in their home environment. Seeing
patients in place may contribute to different understandings between interprofessional

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team members and primary care providers in defining health, or deciding on appropriate
interventions.
It is one thing to see a patient in the office and think that the patient is shabbily
dressed, or their hygiene is a bit poor, or they are chronically late to appointments. A
primary care provider might unconsciously make allowances for these things, thinking
for example, “well, they’re sick today, they didn’t feel like dressing up,” or, “they’re just
a bit disorganized”. It is an entirely different experience to attend a patient’s home to see
they are wearing the best clothes they have, there is no hot water because they have not
paid their utility bills, and their basement keeps getting broken into because addicts are
crawling through a window so they can sleep inside.
Compared to the primary care provider office, the patient’s home presents a very
different social “front” (Goffman, 1959) to the team member. In essence, the patient’s
home can be understood as a patient’s “backstage” area (Goffman, p. 112). While control
of the setting for any type of encounter is considered an advantage (Goffman), the home
environment may offer unanticipated insights towards knowing the patient.
Impressions that can be maintained by patients when in an office setting may be
altered or discredited when the “backstage” of a patient’s life becomes visible to
interprofessional team members. The home environment affects how patients are known.
This knowledge gained by interprofessional team members may be shared with the team,
it can inform clinical judgment, and thus impacts what types of services patients may
receive and how patients feel known by a team. This in turn can reflect the degree to
which patient outcomes are impacted, and whether patients experience their care as
continuous, connected, and coherent.

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Knowing a patient in place also adds a facet of morality that may be muted in the
primary care provider office. When a patient tells a primary care provider “it’s hard to
get up the stairs,” it is primary care providers like Jack, who ask such specific questions
of his patients to help understand their meaning, who might ask how many stairs there
are, or how long it takes to recover from breathlessness at the top. Yet even if these
specifics are learned, it cannot replace the experience of following that patient up three
flights of stairs to her apartment while she huffs and wheezes and halts, stooped over for
breath while clutching the railing. Place influences health and understanding of health.
Seeing patients in place makes it difficult to negate moral impulses (Bauman, 2004) as
Sonia discovered in her distress when realizing a patient was being taken advantage of
financially. If interprofessional team members and primary care providers perceive the
overall concept of health differently, this may result in discrepancies of understanding
patient priorities, and thus differing judgment and actions regarding plans of care.
Through seeing patients in place, interprofessional team members assess the home
environment, relationships and supports, family dynamics, diet, literacy, financial
stability, and more. Patients who require an interprofessional team need and receive
something more than primary care; they receive primary health care. The question of who
needs a team can now be addressed by thinking about who needs primary care versus
who needs primary health care, and when.
Summary
In this chapter, it becomes clear that the primary care provider’s role in knowing
patients and understanding a patient’s social history, including the resources and supports
a patient is able to draw on to restore or maintain health, is important beyond the patient-

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provider dyad. What type of information, how, and when this information is shared with
members of the interprofessional team is central to understanding how the
interprofessional team is able to be effective and meet the needs of the patient as well as
other team members. At the time of data collection, the information passed between
primary care providers and interprofessional team members was highly variable and
impacted patient care.
Interprofessional team members draw on each other as information sources to
supplement information received about a patient. Dialogue between interprofessional
team members during a recurring morning meeting helps to contextualize the patient’s
situation and augment the information received from the primary care provider. In
particular, information that improves understanding of how or why the resources and
supports available to the patient and primary care provider have been exceeded is readily
taken up by the team. Understanding and incorporating this type of information improves
the ability of the interprofessional team member to be able to draw on clinical judgment
to make decisions about when the patient should be seen, and by whom.
There are three situations identified during this study that prompt primary care
providers to involve the interprofessional team; the “Straightforward” requests, the “Foot
in the Door” requests, and the “All Hands on Deck” requests refer to the initial reason the
unidirectional request is initiated. The order of requests as they are listed here can be
considered hierarchal in terms of how much interprofessional team involvement is
anticipated by the primary care provider. In other words, a “Straightforward” type of
request is anticipated to be just that, with perhaps one team member to perform one or
two specific functions with the patient. The “All Hands on Deck” request reflects a

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degree of social and medical complexity of the patient, and the primary care provider
expects multiple interprofessional team members will be involved over a lengthy or
intensive period of time with the patient.
With each type of service request, the amount of information provided by the
primary care provider may be influenced by a number of factors that impact the quality,
effectiveness, and coherence of team-based care experienced by the patient. With a
“Straightforward” request, the primary care provider may not include substantive social
history about the patient, because it may not seem relevant to the reason for the request of
interprofessional team involvement. With the “Foot in the Door” request, the primary
care provider may not be explicit about expectations for involvement of multiple
interprofessional team members, or what the priorities for the patient’s care are. The “All
Hands on Deck” request may arrive when the patient is in crisis or experiencing
significant ill health, so that interprofessional team members are even more reliant on
information the primary care provider sends, instead of having the opportunity to get to
know the patient prior to a health crisis.
In each situation giving rise to a service request, lack of information provided by
the primary care provider can lead to uncertainty, misunderstandings, duplication of
assessments, a mis-match between provider, team, and patient priorities, and delays or
disruptions in therapeutic relationships and effective team-based care. Interprofessional
team members who are not privy to a patient’s social history, or other information not
deemed pertinent to the reason for the service request, have less data to inform their own
clinical judgment and thus decision-making. Once the interprofessional team becomes
involved in a patient’s care, the risks of inadequate information sharing become bi-

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directional, and are exacerbated by the lack of opportunities for interprofessional team
members and primary care providers to have face-to-face conversations.
Although primary care providers retain their traditional gate-keeping function to
decide when to involve members of the interprofessional team, the details of which team
members will become involved initially and sequentially in patient care are determined
within the interprofessional team, predominantly without advice or recommendations
from the patient’s primary care provider. The second half of this chapter explored the
reasoning behind how and for what reasons the interprofessional team may be expanded
to include members not identified in the initial service request from the primary care
provider.
Interprofessional team members may ask one another to become involved in a
patient’s care based on the understanding of individual interprofessional team members’
strengths, interests, and areas of expertise. Interprofessional team members have formal
and informal opportunities to have face-to-face conversations through which they can get
to know each another. Through dialogue, interprofessional team members can learn and
understand the breadth of one another’s knowledge, where their roles overlap with other
team members, and skills of individual team members. They also learn what
interprofessional team members feel confident and competent in, which informs decisionmaking about asking different interprofessional team members to become involved with a
patient’s care.
The final consideration in terms of how interprofessional team members use their
judgment to decide whether and when to involve other interprofessional team members in
a patient’s care is about place. The majority of visits made by the interprofessional team

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to patients in this study took place in the patient’s home. Seeing patients as they live in
their everyday surroundings is a way of knowing patients not often afforded to primary
care providers who see patients only in an office setting. Interprofessional team members
may develop different ways of knowing and understanding patients that are useful and
important to share with primary care providers.
Understanding about a patient’s situation gained from being in a patient’s home
informs the clinical judgment and thus the practices of interprofessional team members.
Aspects of a patient’s health related to relationships, income, education level, hobbies or
interests, and values, is of considerable focus in an interprofessional team member’s visit
to a patient in their home. This may lead to interprofessional team members perceiving
the concept and definition of health of patients differently compared to primary care
providers. The role of place in this research is such that it shifts the focus beyond primary
care delivered within the patient-provider dyad, and into the realm of primary health care
delivered by an interprofessional team.

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Chapter Seven: Negotiating Primary Health Care
When a patient becomes involved with the interprofessional team, two things
have already taken place. First, the strategies the patient normally uses to draw on
existing supports and resources to restore equilibrium, and thus health, have not been
successful. This causes the balance to shift enough to prompt the patient to seek primary
care. How and when this balance shifts depends not only on the severity of the problem,
but also the type and availability of personal resources and supports an individual has
access to and is able to draw on.
Second, the primary care provider has seen the patient and determined that the
interventions, advice, and education that can be offered to the patient have been
implemented to as great an extent as possible, but the patient’s health has not been
restored. Further resources, supports, and knowledge are needed. The scale of health
system involvement shifts again, with health in the balance, and the primary care provider
requests service from the interprofessional team.
Although the longitudinal nature of the patient-provider dyad is intended to
remain consistent over time, the involvement of the interprofessional team can be
expected to vary in both frequency and composition of members. A fall for an older adult
may result in a series of visits from a nurse and physiotherapist, but when health is
restored these team members may not see the patient again for years, or perhaps never.
For a young adult with depression, the only interprofessional team member to be
involved will likely be the mental health clinician. These differences in the frequency and
composition of the interprofessional team compared to the ongoing involvement of the
primary care provider highlights how the relationship between the patient and the

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interprofessional team may be different from that of the patient and primary care
provider. This chapter will attend to the ways in which the interprofessional team
maintains a therapeutic relationship with patients over time, and how the nature of these
relationships can be expected to be different from those of patients and primary care
providers. Understanding these differences can also be helpful to distinguish how patients
and providers negotiate care over time within a team that extends beyond the patientprovider dyad.
Staying Connected
After interprofessional team members see a patient for the first time as per the
Service Request process, interprofessional team members make independent decisions
regarding the intensity and preferred method for planning and monitoring follow-up visits
and ongoing involvement with individual patients and families. There may be plans to
call or visit daily, to help prevent a patient’s deterioration or hospitalization. Some
interprofessional team members create a recall list or other electronic reminder. “Recalls
are key in that continuity” (Quentin); “… I usually just set a recall … because we need to
follow up” (Mel). Recalls remind interprofessional team members to re-connect with
patients to assess gradual changes in condition as with chronic disease or dementia, or
people who are likely to need increasing supports over the long term.
Quentin (MH) also uses a recall system to monitor patient transitions to other
parts of the health care system.
Even if I referred [the patient], I put them on recall for a time shortly after the first
visit [with a specialty mental health service] so I can connect with her and ask if
she did connect with the specialty and if not, I can ask her if there was a reason
where I can kind of pick that piece back up and send her maybe to another option.
(Quentin, MH)

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Patients are sometimes unsure about what they should do if they are sent to
another provider or service and for one reason or another it does not work out. This
practice of creating a recall list and following up with a phone call may be reassuring to
patients. It is a reminder that they are not forgotten, and can help patients feel known or
cared about during a time that their health care needs are requiring increasing numbers of
people and services.
Other interprofessional team members encourage patients and families to take
responsibility for follow up.
[We] rely a lot on patients and families to engage with us. I tell them right off the
bat when I meet them, “Now we have a lot of [patients] and we rely on you guys
really heavily to get in touch with us if something comes up or just if you have any
questions.” (Nora, RN)
This is a completely different practice, yet it can be equally helpful for patients.
Nora makes it clear that patients and their families are partners in care, and that there is
co-responsibility. This practice also conveys an “open door” approach, inviting patients
and families to be in touch with the interprofessional team if there are any concerns.
Understanding about where the onus may lie for patients or providers to take
responsibility for ongoing patient connections with the interprofessional team may differ,
however both approaches described here have the common intent of ensuring the patient
understands the interprofessional team is available to the patient and their family for
health care needs or concerns.
When patients no longer need interprofessional team involvement in their care,
they are not “discharged” from the team. However, during the early stages of
implementation of team-based care, it was uncertain how patients might access the team
after initially receiving service from team members. The process was not clear whether

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patients would contact the team again or first seek advice from their primary care
provider. To address this, interprofessional team members individually created systems of
recalls and check-ins based on judgment of a patient’s agency in conjunction with a
personal philosophy of what might work best for patients and their families. This helped
patients to be as connected as they needed to be within the primary care system. At any
given time, the patient’s team might have multiple interprofessional team members
involved, or none.
Team capacity also affects the ability of interprofessional team members to
participate in patient care. The volume of Service Requests to the interprofessional team
was such that the function of the team had to be altered by Northern Health to attempt to
retain capacity and thus engagement with primary care providers. The mental health
clinicians were advised to reduce sessions of cognitive behavioural therapy for patients to
three to five sessions only. After that, or if the mental health clinicians thought patients
would require more than that after meeting patients, they were to refer patients on to
specialized mental health services. The concern was that if patients required more than
five sessions that this service alone would consume all of the mental health resource
capacity within the interprofessional team:
I have to now farm them out and I have to apologize to people, when I start I say,
“I’m really sorry but I’m going to have to ask you 50,000 questions because I’m
probably going to have to refer you on to another program.” So instead of them
being open about what things are, they’re now filling in the blanks. (Odette, MH)
Interprofessional team members acting as a go-between for patients on their way
to a specialized service felt this was a disservice to patients. Rather than getting to know
the patient, they were only completing a task and moving the patient along in the system.
In this example, organizational requirements impaired the ability of the interprofessional

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team’s mental health clinicians to fully engage in therapeutic dialogue. This can impact
the patient experience of team-based care. If patients report dissatisfaction or antipathy
about their experience with the interprofessional team to their primary care provider, this
may inhibit the willingness of the primary care provider to engage with or refer to the
team. Restrictions on function due to over-capacity may lead to reduced utilization of the
interprofessional team. In this way, an organization can solve their own problem through
strict adherence to process, but in the end it may affect the success and effectiveness of
team-based care.
When patients are shifted from the interprofessional team to a specialty service, it
is unclear as to the future role of the team for the patient. “How do they know when to
come back?” Odette (MH) asked in a meeting, and no one at the table had an answer.
Presumably the patient would return to their primary care provider, with whom they
likely have an established relationship, and the primary care provider could then involve
the team again as necessary. Interestingly, no one at the table mentioned the primary care
provider, or considered the role of the primary care provider in the usual care of the
patient. The idea of repatriation to the primary care home, and whether this includes the
interprofessional team, is complex and not fully understood.
The demands on interprofessional team members reduced capacity so that some
members of the team had waitlists of more than a month before they could see a patient.
This impacted not just initial responses to Service Requests, but also how team members
were able to be involved in a timely manner in patient care. “People [are] saying they
don’t have enough time to do a follow up phone call. If we can’t manage that one person,
we shouldn’t be taking on a new person” (Nora, RN). “All the people we’ve been taking

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care of and I just don’t feel like we have a handle on them” (Ruby, Case Manager). The
question with high patient volume and need is no longer “who needs a team” but instead
“who gets a team,” because patients need to be prioritized and waitlisted.
Issues of high demand for services also influence the judgment of
interprofessional team members in terms of how they decide which functions they will
perform in their role and to what extent they can enact their full scope of practice.
Before we changed [from the special services team], and before we opened the
floodgates … my case management skills ... I was starting to get really good … my
skills were getting more broad and I was getting better with knowing medications
and that sort of thing and asking those probing questions… doing as much as I could
for that patient within my scope before having to branch out. Now with opening the
floodgates I do feel like we’ve all kind of gone back to I need to do my OT stuff,
you know. Then when I’m talking about [a patient], someone will say from the
team, will say, “what pharmacist do they go to?” Well, I didn’t ask them because
that was part of our old intake and I didn’t even think to ask them that because I
was too worried about this, this and this, right. I just need to get their home safety
[assessment] done now, so I can move on. (Mel, OT)
Mel goes on to explain how her competence is affected by decreasing capacity to
keep up with the demand for service:
When you just know it and things roll off your tongue, that’s where you show you
really know what you’re talking about, and you become efficient with your job …
there’s just so much going on right now that it’s hard to be efficient and do
everything that you were doing before. (Mel, OT)
Mel’s practice has shifted from a broad, generalist scope with ongoing
development of expertise to practices that are encompassed as narrowly as possible in
accordance with her role. This shift is described as a change in contextual competence
(Hodges & Lingard, 2012). A health care professional can be experienced and competent
in performing their role, but some of that competence dissipates when the context is
altered (Hodges & Lingard). At a time of early implementation of team-based care, this
has the opposite effect of what is hoped will be achieved through re-structuring primary

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care delivery. That is, Northern Health hopes to transform primary care to increase
generalist practice and reduce narrowly defined specialized areas of practice.
Mel’s portrayal of her changing practices also highlights the interplay between
providing access to care and scope of practice. If there is an attempt to increase access by
increasing volume, the outcome may be that scope of practice is restricted, because health
care professionals must adopt restricted, narrow functions of their role and do just the
necessities in order to manage patient load and demand. However, by increasing volume
or access and narrowing enactment of scope of practice, there will be a point where
increasing volume is self-defeating, because now more team members are required to
address all patient care needs. This effect may also inadvertently cause a persistent shift
away from generalism and reinforce specialization, because health care professionals may
perform the narrowest aspects of their role in which they feel most competent and
efficient.
These issues of the ability of team members to form a responsive, effective
primary care team around patients raises the question of what best practices might be in
terms of planning for delivery of team-based primary health care. For example,
determining optimum panel size for an interprofessional team might be worthy of further
inquiry. In health care, best practices frequently revolve around standardizing care, but
considering the variability of involvement of an interprofessional team that is required in
order to be responsive to patient health care needs, it may be difficult to optimize health
human resource planning in this area. The tension between standardization and patientcentred care deserves further attention and will likely require in depth understanding and

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attention to the specifics of the context in which team-based primary care is being
delivered in order to effectively resolve or address this tension.
Connecting with Patients
Interprofessional team members experience relationship with patients differently
than primary care providers based on setting, organizational structures and processes,
frequency of visits, and duration or intensity of involvement in a patient’s care. Despite
these factors influencing how practices of connection are carried out, both primary care
providers and interprofessional team members seek to establish and maintain therapeutic
relationship with patients by seeking understanding of a patient’s situation beyond
clinical symptoms. To improve understanding of the advantages interprofessional team
members bring to team-based care, a return to the patient perspective of experience with
interprofessional team members will aid to determine how, when, and why team-based
primary care is of value.
Valuing discontinuity
I arranged with Quentin (MH) to meet at a downtown office space where he had
an appointment to meet Diane for the first time, who was referred to the interprofessional
team for anxiety. The primary care provider had attached the most recent progress note
for the patient with the Service Request, and the name of a medication that had been
initiated for the patient. Quentin did not start the visit as though he was picking up the
information from the Service Request and carrying on with it in a continuous manner.
Instead he introduced himself, discussed his role, and the boundaries of his
confidentiality. Next, rather than assume the diagnosis of anxiety to be correct, he used a
form to take her history and screen for other psychiatric illnesses.

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This practice of “intake” with patients new to the interprofessional team was
contentious for primary care providers and Northern Health management. Primary care
providers believed that because they had already completed the assessment and made the
decision to involve the interprofessional team that the interprofessional team members
were duplicating work by re-assessing patients. From the Northern Health management
perspective, a “meet and greet” visit with patients did not enact the “team” model of the
primary care home that presupposed information, along with the patients, would be easily
transferred from the primary care provider “side” to the interprofessional team “side”.
For the interprofessional team members who completed their own assessments
with patients, two purposes were served. The first reason is to establish rapport. One team
member was overheard to say during a meeting that, “Rapport and relationship need to
come first,” and that the reason listed on the Service Request is “not my priority”
(Interprofessional Team Member). Given the many difficulties encountered with regards
to the content and process surrounding the embattled Service Request, it seems to have
little function in practice for primary care providers or interprofessional team members.
Regardless of what the Service Request says, interprofessional team members still need
to fill gaps in their knowledge of the patient and establish relationship with the patient to
the extent that patients wish to be engaged with the interprofessional team and decisions
about their care.
The second reason an interprofessional team member might complete an initial
assessment of the patient is to take responsibility for his own practice. Registered nurses
in hospital settings have long lamented the practice of physicians who will walk to a
patient’s side, ignore the nurse standing with the patient, disregard the written assessment

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the nurse has completed, and say to the patient, “so what brings you in today?” However,
there is a difference of time and location between this example and Quentin’s (MH)
practice of completing his own assessment.
For the hospital example, the physician completes her own assessment despite the
fact that a registered nurse has just completed the same assessment moments ago. In
primary care, the patient may have last been assessed weeks ago, and the condition or the
patient’s agenda may be different now. In the hospital setting, the nurse and the physician
are face-to-face, able to have a conversation about the assessment of the patient. In
primary care, the two professionals seeing the patient do not see each other, and Quentin
cannot see any other information from the patient’s chart when he meets with her.
As Quentin follows his own practice of taking Diane’s history, she discloses that
she has an eating disorder. When her anxiety worsens, the symptoms of her eating
disorder return. She asks Quentin if there is help available.
In this case, the process of not making assumptions about the patient’s problem
was not an onerous duplication of information. Instead, it led to identifying a problem
and helping Diane receive the help she needed. This encounter demonstrates that being
able to pick up where the last health care professional left off might be an assumed good,
or perhaps that partial information exchange is worse than no information at all.
A few weeks after observing Quentin’s encounter with Diane, I interview her. She
has now been referred to the Eating Disorders program and is very pleased to be
receiving help in this way. She talks about how she came to be able to discuss her eating
disorder with a health care provider.
I really wanted help. Having [Quentin] give me the information opened up the door
because they made the connection within [the system] for my treatment. I don’t

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know if I could’ve walked into that clinic [for eating disorders] and done it. The
fact that someone else did it for me … was what I needed. I was quite shocked
actually that when I asked for help that way that there was help available. (Diane,
Patient)
It was revealed to be a combination of events that led to Diane being able to
mention her eating disorder to a health care professional. She saw a locum physician
who also happened to be a woman:
This was just a random synchronicity that [locum physician] is a young female …
it was almost nicer for me that I didn’t know her because I could just tell her because
I wasn’t embarrassed. If I had [seen my regular, male GP] … I truly, I don’t know
if I would’ve had the guts really to go seek it out. I probably would have gone for
therapy [counseling covered by private insurance] but really, that’s not actually the
thing … I need help specially with that issue and the only way [was] someone
else made the call for me. I’m a professional person, I’m married, … I really focus
on being compassionate and effective and functional … it’s a really nice
opportunity to have just a chance where there’s somebody that
doesn’t know
you, and you can be brave in that minute and say, “Yeah, I’m all those things but
I’m also struggling with this.” Where they don’t know you, so this is your shot at
being really truthful. I really try not to lie but there’s part of you – because it’s
protective – and there’s shame – really you protect addictions quite highly because
you think that they’re helping you and you want to hang on to them even when you
know that they’re not useful for you so you can talk a good game, too. And people
do that … so when you do go to someone else they either don’t believe your game
or they don’t have to or you actually get a chance to be
brave and say, “Yeah,
I’m not going to game you.” (Diane)
Diane’s narrative about her experience and decision to disclose her eating disorder
reveals that there is value to discontinuity of care. Seeing an unknown interprofessional
team member offers patients a chance to divulge an aspect of their identity that they work
hard to cover up in other areas of their lives. The benefit of allowing patients a chance to
see a different team member shines light on a different aspect of thinking about who
needs a team. Diane’s explanation is also an important reminder of the gatekeeper role
primary care providers have within the interprofessional team. Patients who wish to
withhold information from their primary care provider may be deterred from accessing

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the interprofessional team if the patient is unable to convey a need to the primary care
provider that would instigate a Service Request.
Explaining the system
Another type of connection that patients value outside the patient-primary care
provider dyad is one where health system navigation is made clearer:
I have confidence in a person like [counsellor] because as far as I’m concerned, my
own point of view, she is my only window/doorway to the system for my daughter
because I’m not going around knocking on doors saying, “Will you treat my
daughter, will you see my daughter, will you take her on as a patient?” (Frank,
Patient)
Frank’s adult daughter is frequently unwell and often refuses help for her
psychiatric illness and alcohol dependence. Frank has consent from his daughter to speak
to her counsellor, who is able to suggest additional community resources and programs to
Frank to discuss with his daughter, or seek support himself. The availability of the
interprofessional team to a family member is a beneficial role. With knowledge of
specialized resources and services as well as an insider’s understanding of the health care
system, the counsellor increases capacity for Frank to understand his daughter’s situation
and care. The counsellor, as a “window” to the health care system, helps to make
navigation more clear rather than a foreboding and complicated series of barriers and
frustration for Frank.
Making suggestions
A third type of connection that patients report as a valuable benefit to team-based
care is the opportunity to meet and establish relationship with interprofessional team
members while they are relatively well. Gary has a progressive chronic illness that is

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currently stable. He met two interprofessional team members for a visit related to his
mobility.
They came out a couple weeks ago. They offered their suggestions; they’ve got a
couple grab bars. Again, great group of people. Their suggestions are suggestions,
I take them for what they are. I’ve got the grab bars sitting there, one of these days
I’ll get out a drill and put them on … It’s more of a suggestion … trying to be
proactive so I don’t end up cracking my head on the tub … “Maybe it would be an
idea for you to have a grab bar there.” And I think their method of suggestion works
a whole lot better than saying, “Well, we’re going to come in and we’re going to
do this and that.” (Gary, Patient)
Gary conveys the idea that the interprofessional team is intended to be a support, a
resource. By being proactive, the interprofessional team can offer Gary suggestions that
he can then weigh against his own priorities and preferences. The interprofessional team
members were personable, and they treated Gary as a partner in his care. These
components help establish therapeutic relationship by helping patients to feel known.
Access to the interprofessional team expanded Gary’s own resources and supports.
When I ask interprofessional team members about their approach to becoming
involved in a patient’s care, Peggy explains that she tells patients, “Everything we’re
giving to you is just a suggestion, so you know the options are there and if we can support
you in your home, we will do that.” It is an echo of Gary’s words. This approach was
something some of the team members learned working on the previous special services
team.
When we would first see people [with the special services team] we would ask them
to fill in a self-assessment, so questions like, “Are you concerned about your
memory, are you concerned about mobility? Are you concerned about falls or
nutrition?” And so based on those ... we made it clear that it was all about them and
that we were only interested in supporting them to remain in the home of their
choice as long as possible. And we would not be intrusive ... we would be there as
a resource. With our follow up visits, we would use those areas of their concern as
a jump-start. It was always about them. It allowed us to then look a little bit beyond

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because they would explain, “Oh, this is how I’m doing now with this area.”
(Peggy, SW).
Interprofessional team members cultivated this approach while working with a
specialized population, however the benefit may be applicable to all patient populations.
Mel talks about meeting people “… before things start to crumble.”
In establishing rapport with that person you also get a whole lot of ownership on
[the patient’s] part. They call me, “I remember when you said this, I’m starting to
see that now, I’m wondering if you could have a visit with me.” … [T]hen they
welcome you back. Instead of you saying, “You need this, because you have all
these problems.” (Mel, OT)
Interprofessional team-based primary care is improved if the approach is
proactive and not reactive. This has important implications for the timing of involvement
of the interprofessional team. Ruby (Case Manager) reinforces this by noting it is
important to meet patients “… when they’re not in a crisis”. Yet the current state of
interprofessional team involvement was perceived as reactive. “We’re going into crisis”
(Peggy, SW).
A proactive approach to interprofessional team-based care is patient-centred
because the patient is not in crisis and better able to participate in their own care. The
interprofessional team members and patient have a chance to get to know one another and
establish a therapeutic relationship. Interprofessional team members help patients to
understand the resources and supports they can provide for patients and convey the
message of having an “open door” should the patient require their assistance. The chance
for interprofessional team members to meet patients, perhaps particularly the “teetering”
(Nora, RN) population, before a significant deterioration in the patient’s health, might be
especially helpful to plan care.

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Checking in
Proactive or early intervention team-based care is similar to other upstream
solutions in health care in that it is difficult to measure a return on investment for
prevented events. There is also a risk that care provided by “checking in” with patients or
“making suggestions” can be viewed as an inefficient practice. Interprofessional team
members understand there is value in these practices.
So the guy I saw with you, I know him quite well and that’s just from a lot of visits.
He’s isolated and yeah, it’s just frequent visits, being able to have the time to chit
chat. I never went in especially for anything, Home Care sees him every three weeks
or so and … [changes] his catheter and that sort of thing, but [I] just look at his
pills, do a set of vitals, which is not totally necessary but it’s a good excuse to get
into people’s homes. “I just need to come and do a blood pressure.” It’s such an
easy in. People love it. That is usually my excuse and then people will open up to
you. Same as the gentleman I’ve been seeing this morning, I knew he didn’t look
well and had I been someone he didn’t know that well, I don’t think he would’ve
told me he has a raging scrotal infection … he never would have told anyone … the
doctor had no idea, nobody knew anything about it. Until he showed me. I don’t
think he would’ve shown me had he not known me so well. So that’s good payoff,
just from visits. (Nora, RN)
Nora established a therapeutic relationship with this patient in part by seeing him
regularly. She arranged to do this based on risk factors associated with his illness and
isolation. He is a patient who is “teetering”.
Nora’s knowledge of the patient and her application of clinical judgment allow
her to make pertinent assessments by seeing the patient in his home, talking briefly with
him, and giving him an opportunity to raise concerns without having to decide if it is
worth the effort to telephone someone or sort out transportation and assistance to see his
primary care provider. In Nora’s example, there are several patient and health system
benefits. First, there is a cost saving because the infection is identified in time to be
treated at home and not the hospital. The patient experience is improved because he was

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able to disclose a sensitive health issue to a professional he knew and trusted. That Nora
is able to do these home visits also increases the number of access points the patient has
to the health care system. Based on these criteria, Nora’s visits that first appear as casual
check-ins actually achieve the triple aim of health care.
In early stages of team-based care implementation, patients see value in access to
an interprofessional team. Sometimes, being able to see a health care professional who is
not the regular provider allows a patient to expand her narrative or change the “front”
(Goffman, 1959) she presents, and is able to access needed services. Patients value
interprofessional team members’ roles in helping them navigate the health care system
for themselves and loved ones. Interprofessional team members can help patients and
families understand referral systems and help them to access resources and supports they
were previously unaware of. Patients reported appreciating meeting team members at a
time when they understand their health may deteriorate, but that they still have control
over deciding among choices for care and what options they might select to access in the
future. Finally, patients reported valuing knowing and seeing someone they trust.
The interprofessional team offers opportunities for patients to improve, recover,
or maintain their health. In many instances, the resources or support they provide as
functions of their role serve to reinforce or sometimes temporarily replace the resources
and supports of the patient. For example, if family or friends are unable or unavailable to
help a patient with things like taking medication, driving to appointments, or performing
range of motion exercises, these activities are performed by interprofessional team
members. This is how team-based care is delivery of primary health care. Patients who
improve or recover their health regain their equilibrium, and resume their everyday

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activities. They can rely once again on their own resources and supports. Some patients
will require ongoing primary care, and some patients will require ongoing primary health
care. However, who needs what type of care and when can only be determined by
genuine understanding of the patient’s situation over time.
Summary
The ways in which interprofessional team members establish and maintain
relationships with patients over time is different compared to primary care providers.
These differences are in part a function of the role, duration, frequency, intensity, setting,
and purpose of the relationship between patient and team member compared to the
relationship between patient and primary care provider. This chapter focused on
examining some of these differences, as well as how these differences may be
experienced by patients.
Similar to primary care providers, the ability of interprofessional team members
to draw on their skills and knowledge in their role to perform the everyday functions of
their work depends in part on the volume and complexity of patients seen. Unlike primary
care providers, however, particularly those in fee-for-service offices, interprofessional
team members may have little control over the volume of patients requiring team-based
care, as well as little control over the administrative tasks assigned by their manager or
required by their employer. The overall capacity of the team to see patients influences
when and with whom patients can seek follow up care.
As volume increases, capacity may decrease because interprofessional team
members are also working in an environment where expectations as to the performance of
their role is undergoing transformation. The cumulative effect of these changes can

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impact the confidence and competence interprofessional team members have in their
abilities to perform well and manage their workload. As demands for service increase,
and capacity of the team decreases, one way of coping for interprofessional team
members is to focus more narrowly on specific tasks for patients, instead of performing to
the broadest scope of their practice ability. These practices that recur as high demand for
care of complex patients persists result in greater adherence to specialized knowledge,
rather than a shift towards generalism. This can hinder the development of a broad base
of generalist practice by interprofessional team members, which is one of the desired
outcomes of team-based care. Instead, it may reinforce professional silos, encumbering
efforts of the health authority’s intent to dismantle such silos with transformational
change in primary care delivery.
As interprofessional team members establish their own practices of connection to
facilitate therapeutic relationships with patients, four situations are identified that may
help to uncover some of the advantages of team-based care that have not previously been
considered. These situations can be defined as “valuing discontinuity”, “explaining the
system”, “making suggestions”, and “checking in”, and are in addition to the more clearly
defined roles and functions expected of an interprofessional team. These situations are
distinct in that they likely would not transpire within the patient-provider dyad, they take
into account some of the factors that affect the therapeutic relationship between patient
and interprofessional team member, such as setting, and draw on the ways in which
interprofessional team members apply clinical judgment to the patient’s particular
situation in a manner that is different from primary care providers.

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By “valuing discontinuity”, it can be understood that there may be times that a
health issue is only uncovered when the patient has a chance to step outside the
boundaries of how she is known within the confines of the patient-provider dyad. Rather
than always viewing the repeating of health history as duplication, it can be understood as
an opportunity to share different information. This is an important finding to add to the
discourse of continuity which is often discussed as an assumed good. Understanding that
patients may value access to the interprofessional team in order to see a different health
care professional who is unknown to them or who can know the patient differently, is
also a consideration for primary care providers who are gatekeepers to the rest of the
interprofessional team.
Interprofessional team members become involved in a patient’s care specifically
because existing strategies, supports, resources, and interventions available to the patient
and primary care provider have been optimized. The role of the interprofessional team
member may be in part to know about other resources and supports or strategies within
the community and health system that can help to restore or maintain the health of a
patient or family member. “Explaining the system” is one aspect of how interprofessional
team members are able to engage patients to increase patient or family understanding of
how to access, use, and navigate different resources or supports. With knowledge and
understanding of many formal and informal supports or resources both within and outside
the health system, interprofessional team members can help patients understand and
improve their journey and experience through a complex network of discrete services.
Interprofessional team members often see patients in their home environment, and
this can contribute to interprofessional team members evaluating the health of the patient

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comprehensively, incorporating understanding of social and medical facets of health.
Interprofessional team members are able to assess the patient’s living situation, income
status and stability, family or relationship dynamics, and hobbies or interests, both tacitly
and explicitly. This accumulation of knowledge helps interprofessional team members to
anticipate in part the trajectory of a patient’s health and make suggestions for future care.
These suggestions are how interprofessional team members consider the situation of the
patient by taking into account the factors that currently influence the patient’s health. The
suggestions also offer opportunity for patients to foresee how the interprofessional team
members may have a continued or future role in the patient’s care that will be different
from the role of the primary care provider.
“Making suggestions” is also a type of anticipatory guidance that gently reminds
some patients that their reliance on supports and resources within the community and the
health system may increase over time. In this way patients may align their expectations
regarding their prognosis with the knowledge of the interprofessional team member.
“Making suggestions” is also a strategy of care planning that explicitly involves the
patient and incorporates patient preferences at a juncture that is early enough in the
patient’s illness trajectory that the patient can be actively involved in decision-making
about their future care.
Finally, interprofessional team members engage in practices of connection by
“checking in” with patients. This is a practice that intentionally incorporates the temporal
variation of involvement in patient care with the interprofessional team. It is also the
practice that most clearly identifies how an interprofessional team can provide primary
health care.

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“Checking in” might be by phone or in person, and with one team member
visiting to report back to the broader team, or the patient may receive a visit by multiple
interprofessional team members at once. The purpose of “checking in” might be to assess
how the patient is tolerating changes to medication, if the safety bars installed are being
used correctly, or if family members have fulfilled their promise to the homebound
patient of dropping off groceries. During these “check ins”, interprofessional team
members assess the patient’s particular situation and engage in therapeutic dialogue to
help determine what intensity, duration, or type of care may be required at a particular
point in time. The variability of these encounters attest to the abilities of the
interprofessional team to be flexible and adaptive based on needs of patients, and to
deliver responsive, comprehensive care that addresses many of the determinants of
patients’ health. In this way the interprofessional team may be able to move beyond
limitations of primary care to improve a patient’s health, and rather shifts care of the
patient into the realm of primary health care.
The four situations described here demonstrate how team-based care goes beyond
what was initially promoted to primary care providers by the health authority (Northern
Health, n.d.) regarding services of the interprofessional team. In addition to performing
the regular and expected functions of their roles, interprofessional team members can
deliver primary health care. With a broad conceptualization of health understood in the
context of a patient’s everyday life, interprofessional team members help to improve the
conditions of a person’s particular situation in order to improve health outcomes.

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Chapter Eight: Contributions of Knowing in Team-Based Primary Care
The preceding chapters have uncovered and explored how knowing patients and
team members influences aspects of negotiating team-based primary care. The research
questions of this study were addressed through distinguishing the detail of practices from
the whole of team-based primary care. This final chapter will frame discussion in order to
draw out implications of the study. How practices of connection facilitate key aspects of
feeling known, and how these practices can ultimately influence team-based primary care
attributes and outcomes, is the focus of this last chapter.
The key findings of this study revolve around feeling known and how knowing
contributes to understanding who needs team-based primary care. First, although team
members may already know one another, transitions or changes in practice structure and
process can disrupt established relationships. Second, the way in which patients feel
known, and primary care provider practices of knowing patients, influences how and
when the interprofessional team may be involved in the patient’s care. This impacts how
primary care is negotiated in terms of who is provided with team-based care.
The findings illustrate that even when primary care providers know patients very
well, this information may not be shared with interprofessional team members. How
primary care providers and interprofessional team members know and understand one
another can influence what and how information is shared, which can affect how care is
planned and coordinated. Finally, the results of this study help to illuminate how
interprofessional team members know patients differently than primary care providers,
and that while all professionals involved in a patient’s care establish therapeutic
relationship through practices of connection, this is achieved differently based on the

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role, function, duration, frequency, setting, purpose, and understanding of the relationship
between a health care professional and patient. Understanding these nuanced differences
helps to demonstrate how interprofessional teams can provide primary health care for and
with patients through negotiation of team-based care.
To explicate these findings and explore implications, what follows is not an
explanation or narrative, but rather interpretation of the circumstances uncovered in this
study (Moules et al., 2015) in light of the areas of attunement for this research in addition
to some of the principles of team-based primary care. Possibilities for future education,
practice, and research are presented for consideration.
Knowing the Team
The findings of this research highlight the extent to which previously existing
professional relationships can be disrupted by changes to role, organizational structure,
and the process by which providers and team members interact with one another. Even
when team members already know and like one another, when there is a significant
change to the way in which different team members will perform their role, increased
opportunities to informally and formally negotiate new relationship boundaries and
understanding through conversations are necessary. When teams are not co-located,
misunderstandings about the role or performance of team members can influence primary
care provider practices in terms of connecting patients with the interprofessional team.
These practices may remain unchanged for long periods of time when teams are not colocated, because there is little chance for or comfort with dialogue between primary care
providers and team members to correct or address errors in interpretations of role,
function, or expectations.

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When providers and interprofessional team members do not know one another,
there may be concern about involving an unknown professional in a patient’s care.
Primary care providers wish to understand what the role, abilities, clinical judgment, and
level of responsibility interprofessional team members have in sharing care for a patient.
Not knowing team members may cause delays in involving the interprofessional team in
a patient’s care, and it can affect what information is shared about the patient. Providers
who know little about team members may feel hesitant to share sensitive patient
information. A secondary issue is that providers who are uncertain of the specific role of
different team members may be unsure what information is most relevant to assist the
team in caring for the patient. These issues can significantly impact the timeliness and
effectiveness of patient care, highlighting the necessity of providers and interprofessional
team members being able to get to know one another in their professional role.
In contrast to not knowing, when clinicians understand “each other’s world”, it
can enhance communication and information sharing. When team members know one
another it increases the likelihood of informal dialogue amongst the team. While this
seems a rather simplistic finding, it deserves special consideration when teams are not colocated, as opportunities for informal dialogue may have to be deliberately sought. In this
study, there were few opportunities for the two “sides” of the team to learn about one
another.
For continued planned implementation of interprofessional teams, efforts to
encourage, plan, and allow primary care providers and interprofessional team members to
learn and know about one another through a variety of mechanisms can be helpful.
Ongoing opportunities for team members to have frequent, informal, shared

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communication are critical factors to the success and sustainability of interprofessional
collaboration and practice in primary care teams (Morgan et al., 2015). Joint visits
(Brown et al., 2016), joint case conferences, and either planned or spontaneous drop ins
at the primary care providers’ offices may be helpful to get to know one another’s
strengths, preferences, and system of relevances (Wagner, 1970). When team members
and primary care providers learn about each other’s ways of working in primary care, it
becomes easier to understand what information about patient care is meaningful to
different team members, and this can improve the relevance of information sharing or
transfer in planning and delivering patient care.
In the context of early implementation of team-based primary care, issues of
communication and feedback loops can be understood to be related in part to how
clinicians know one another. It is anticipated and hoped that some of these issues resolve
as team-based primary care becomes established, through the efforts of interprofessional
team members and primary care providers to understand each other’s practice world. The
implications and understandings discussed in the remainder of this chapter, however, are
relevant regardless of the stage of primary care transformation. The discussion is now
broadened to consider how knowing patients and understanding who needs a team can
help to create and sustain a high quality primary care system.
Knowing in the Patient-Provider Dyad
People who feel healthy tend to take this state of being for granted (Gadamer,
1996). Through everyday living, individuals are socializing, working, playing, and
engaging in other thinking and actions in an environment that helps them maintain health
without even noticing. When this equilibrium becomes disturbed, health or ill-health is

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noticed. People take action to restore health based on their capacity and agency to do so.
Actions to restore health reflect a number of inter-related factors such as their perceived
health status, their previous experiences with the health system, and their personal health
practices (Andersen, 1995). Individuals in this study activated support systems, strategies,
and/or resources to restore health, such as relying on friends or family, or engaging in
health promoting practices such as attending a fitness class. These actions may
satisfactorily achieve the goal of restoring or maintaining health. Alternately, an
individual may seek primary care. Primary care is also a support and resource to people,
but it is a formal entry to the health system, and this is where people transition to the role
of patient.
The role of the patient is an alteration to the identity of an individual. Giddens
(1991) suggests securing identity begins with the formation of basic trust. Being able to
trust is a safeguard against chaos, and creates a framework for ontological security (p.
44). This security and trust in the world is reinforced through ritualistic day-to-day life,
so that our daily routines in effect offer coping mechanisms through which we are able to
socially manage our anxiety about the world (Giddens). Trust is a social practice
(Solomon & Flores, 2001). Through this lens, it can be appreciated that the primary care
encounter is a unique situation that may be rife with uncertainty for an individual in the
role of patient, yet it is seldom explicitly considered in this way in everyday practice.
Issues of trust and identity influence care-seeking practices of patients, for example
Adam, who sees his primary care provider only if he has physical injury.
In establishing self-identity, individuals maintain a particular narrative (Giddens,
1991): who they are, the roles they enact, and the memberships they have in their various

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communities. Schutz identifies these components as an individual’s biographically
determined situation (Wagner, 1970). In attending a primary care encounter, these
components, represented by both ontological security and self-identity have the potential
to be threatened or disrupted.
For many individuals, deciding to consult a primary care provider about a
particular concern is not part of routine day-to-day life. This in itself may cause an
increase in anxiety, and anxiety may be exacerbated if the primary care provider is a
relative stranger. Based on the work of Giddens (1991), it then becomes necessary to
achieve trust, so that anxiety can be overcome, ontological security can be re-established,
and the encounter can be productive. These findings were echoed in this study through
Diane’s interview, as she discussed the process of her decision-making that led to
disclosure of her eating disorder.
The tensions that were navigated in the primary care encounters in this study
include protecting or continuing a self-narrative, managing power imbalances, and
maintaining or projecting a particular role and identity. These tensions are complex, yet
tend to be completely taken-for-granted, and remain covered up in most patient-provider
interactions. The potential for these complex tensions to be uncovered or addressed
within a patient-provider encounter are determined by the tasks of achieving trust and
maintaining the patient’s ontological security through therapeutic dialogue. This was
observed throughout the patient-provider encounters of this study, for example the way in
which Isaac talked with his patient about her alcohol use to help her sleep. The way in
which primary care providers engage in conversation with patients to help patients feel
known may be central to determining not only the outcome of a single visit but also

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subsequent plans for seeking care and attempts of the patient to maintain or restore
health.
While it has been previously acknowledged that patients desire a trusted clinician
who knows them well (Cheraghi-Sohi et al., 2008; Phillips-Salimi et al., 2011), the
practices that providers engage in with patients to help patients feel known have been
largely overlooked. In this study, patients identified four qualities embodied and enacted
by physicians that contribute to feeling known. Patients who feel known describe that
their physicians display a personable manner, patients are treated as partners to the extent
they wish to be included in their care, the physician discloses some amount of personal
narrative during an encounter, and the personhood of patients is acknowledged through
methods of inquiry into, for example, hobbies or family. These qualities can be
understood as a way of knowing through conversation to validate identity as part of the
social practice of the primary care encounter. Practices of connection enacted in part
through language and conversation demonstrate particular skills that are experienced by
patients as patient-centred practices that can help to relieve uncertainty and facilitate
provision of high quality primary care.
In analyzing how these four qualities enacted through practices of connection may
be important precursors to delivery of high quality primary care, further examination is
required to articulate how knowing in the patient-provider relationship can have
implications towards improving core attributes of primary care: access,
comprehensiveness, continuity, and coordination. These attributes are selected as they
represent key pillars of the GPSC (2016) PMH model, and remain the pillars that can be
directly influenced through patient-provider encounters. Others have identified equity as

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an important attribute of primary care (Haggerty et al., 2007; Wong et al., 2014), and
although it is not included in the PMH model, equity is included here to capture some of
the significance in thinking about who may benefit from interprofessional team-based
care.
If knowing patients is considered a starting point, and improving health outcomes
and patient experience is the desired end point, the space between these points is the
patient-centred primary care encounter. This study, with its focus on practices, allowed
for direct observation of the negotiation of primary care. The primary care consultation
transpires whereby aspects of patient satisfaction and improved outcomes at an affordable
cost are determined while providing the patient some degree of access,
comprehensiveness, continuity, equity, and coordination of care.
Access
Access is not foregrounded in this study, although the care-seeking practices
(Andersen, 1995; Andersen et al., 2011; Dunn, Hammond, & Roberts, 2009) of patients
are taken under consideration in terms of acknowledging how patients may activate their
own “team” that may or may not initially include primary care providers when seeking to
restore or maintain health. For patients who seek primary care at the office of the primary
care providers of this study, access is addressed through offering same day appointments
and longer time slots for those with complex needs. While this approach may have
originated as a way to improve efficiency of the practice, there is an equal benefit to
patients. This approach to booking in conjunction with MOAs who know the patients
well helps to accommodate patients who may have preferences for particular times of day
or difficulties such as securing transportation to and from the office.

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Although patients of the primary care provider office in this study followed the
established routine in the community of accessing either walk-in, after-hours clinic, or the
emergency department when the office is closed, it is notable that patients of these
providers did not wait days or weeks for appointments. A shorter wait for patients to
access their regular primary care provider has potential health system benefits, as patients
do not need to delay care-seeking to the point where they become so unwell they must
seek help through the emergency department. In terms of patient satisfaction, on the day
of their primary care appointment, patients did not languish in the waiting room long past
their appointment time to see their provider. The role of the MOA, the structure of the
practice, and the process of seeing patients may help patients feel their time is of value,
and can improve patient experience in primary care. This in turn impacts future decisionmaking about care-seeking and personal beliefs in the value of including the primary care
provider as part of the patient’s “team” in helping to restore or maintain health.
Comprehensiveness, continuity, and patient-centredness
The pillars of comprehensiveness and continuity are tended to within the patientprovider encounter. The degree of comprehensiveness of care and continuity is related in
part to therapeutic relationship (Hjortdahl & Laerum, 1992; Hjortdahl & Borchgrevnik,
1991; McWhinney, 1998). Therapeutic relationship can be understood to develop in the
context of an encounter where the primary care provider embodies the four qualities
identified above by patients as contributing to feeling known: Primary care providers are
personable, they treat patients as partners, they disclose or are willing to disclose some
personal narrative, and they are interested in the patient as a person. Skill in enacting
these qualities through practices of connection can help to create conditions for further

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therapeutic dialogue that may result in therapeutic relationship being established,
however these practices alone will not necessarily result in a therapeutic relationship
being established or maintained.
The second question of this research concerned how therapeutic relationships
between patients and primary care providers can be developed and sustained. The
findings of this study indicate that therapeutic relationships that incorporate key features
of being safe, longitudinal, and patient-centred may rely on consistent and intentional
aspects of therapeutic dialogue. Specific features of effective therapeutic dialogue used
by primary care providers that were observed in this research include: asking patients
specific questions about their habits, hobbies, and preferences; not only seeking causes
but asking about reasons; not “glossing” over patient statements; apologizing for
misunderstandings; willingness to address sensitive topics or issues; not interrupting if
the patient is tangential; using a conversational style versus a rigid interview style; asking
about the patient’s goals.
Practices of connection that foster therapeutic dialogue are valuable to assist
providers to successfully integrate components of the patient-centred clinical method
(Stewart et al., 2014) into primary care encounters. As such, exploring health, disease,
and the illness experience; understanding the whole person; and finding common ground
(Stewart et al.) can be achieved through practices of connection that foster therapeutic
dialogue. The features of therapeutic dialogue rely on the primary care providers’ use,
choice, and timing of language, and can serve to incorporate the fourth component of the
patient-centred clinical method, which is to enhance the patient-clinician relationship
(Stewart et al.).

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The nuance or prominence of particular features of therapeutic dialogue is
expected to be different with different patients. Engaging in therapeutic dialogue relies on
the interest and ability of the primary care provider to have a genuine conversation with
the patient. Gadamer (1960/2011) described how people fall into conversation without
knowing in advance what might come out of it, and that “a genuine conversation is never
the one we wanted to conduct” (p. 385).
Therapeutic dialogue requires primary care providers to consider their own biases
and agenda for a primary care encounter in order to meaningfully interpret what the
patient says. The possibility for therapeutic dialogue to take place calls on the skill of the
primary care provider to enact the features of therapeutic dialogue as well as the ability to
remain open to what the patient is saying. When the patient’s agenda is addressed in a
way that helps alleviate a patient’s uncertainty about their health or the reason for their
visit, understanding can be reached and care can effectively be planned to assist the
patient to restore or maintain their health.
The way in which primary care providers remain open to a patient during a
primary care encounter is through consistent application of clinical judgment in tangent
with their stock of knowledge at-hand (Wagner, 1970), which includes the different types
of knowledge a primary care provider has at-hand in a given situation. Drawing on these
ways of knowing, primary care providers are distinguishing and choosing among
possibilities (Gadamer 1960/2011) in how the patient’s particular situation addresses
them. Through conversation, primary care providers are seeking to understand the salient
details of a patient’s circumstances and history at a particular point in time. Primary care
providers must choose when to be silent and when to probe, whether to explore multiple

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issues or prioritize among issues. These decisions are made in light of the primary care
provider’s horizon in terms of past experiences with the patient, the overall structure of
the provider’s day, such as time pressures, and other internal processes, such as energy
level or feeling hungry, or being pre-occupied with a previous patient’s issues.
The information that is uncovered by a primary care provider within a primary
care encounter must be sorted and requires rapid decision-making as well as
demonstrating some type of reaction to the patient. This process of distinguishing does
not conclude with ending the conversation with the patient, but carries through to help
determine an appropriate plan of care for the patient that must take into account best
available evidence, patient preferences and choices, as well as other system and context
factors such as health benefit coverage and availability of specialized resources.
Through the unfolding of these complex features taking place within a primary
care encounter, primary care providers engage in practices of connection through which
patients determine whether or not they feel known. Feeling known can influence what
patients choose to disclose in a visit. This in turn affects how primary care providers
engage in therapeutic dialogue, and determines the extent to which genuine conversation
may occur. Genuine conversation has the potential to further help patients feel known and
resolve uncertainties about their health. Genuine conversation resulting from therapeutic
dialogue fosters therapeutic relationship, and over time, therapeutic relationships can
contribute to improving key aspects of primary care for patients, such as
comprehensiveness and continuity.

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Coordination
Coordination is the fourth pillar of high quality primary care that can be directly
influenced by patient-provider interaction. While all the pillars discussed in this section
are inter-related (e.g. access will influence continuity), it is continuity, especially
management and informational continuity, that most directly overlap with coordination.
Informational continuity underpins coordination (Banfield et al., 2013), which is why
effective, timely coordination of team-based primary care is connected to primary care
providers having a therapeutic relationship with patients. Ongoing therapeutic
relationship helps to foster better understanding of a patient’s situation over time, and this
allows more information about the patient, in areas beyond the biomedical realm, to be
known. It is this information that will cue the provider to identify when team involvement
is necessary, and it is the information that can be shared with the team to help coordinate
care. This research helps to articulate how therapeutic relationship impacts coordination
of care.
Over time, coordination has been devalued at the expense of disease management
(Bayliss, Balasubramianian, Gill, & Stange, 2014); another indication we may have
allowed the evidence-based medicine paradigm to dominate too much of the planning and
delivery of primary care. This is beginning to shift, however, as there is increasing
realization that multiple chronic conditions cannot be treated in one patient as distinct
occurrences, and as the need for team-based care increases. With more attention to
coordination, there have been numerous attempts to define it, and debate continues over
how to measure it (Schulz et al., 2013).

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For the purposes of this discussion, coordination is defined as the “deliberate
organization of patient care activities between two or more participants (including the
patient) involved in a patient's care to facilitate the appropriate delivery of health care
services. Organizing care involves the marshalling of personnel and other resources
needed to carry out all required patient care activities and is often managed by the
exchange of information among participants responsible for different aspects of care”
(McDonald et al. 2007, para 1). This definition is chosen in part because it is being used
by Northern Health as attempts to improve coordination in primary care are undertaken.
Primary care providers in this study, who are the gatekeepers to the interprofessional
primary care team, must make decisions not only when to involve the interprofessional
team, but also what information to share. Coordination is not achieved passively by
simply having the right information. The appropriate and timely sharing of information
relies on the practices of first the primary care provider, and then the interprofessional
team.
It is noted that patients experience continuity as opposed to coordination; when
patients feel confident and supported, they assume clinicians involved in their care are
communicating (Haggerty et al., 2013). It is only when there is a disruption experienced
that patients become aware that clinicians may not be sharing the relevant information
(Haggerty et al.). Both these situations were experienced by patients in this study.
As the supports and resources offered by primary care providers are increasingly
optimized by patients who require more support, the interprofessional team will likely
become involved in the patient’s care. In team-based primary care, involvement of the
interprofessional team is an occurrence necessitating coordination and sharing of

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information. Here we see that coordination hinges not only on what information is
known, but also what is done with it.
In coordinating care, patients do not expect their care to be seamless (Haggerty et
al., 2013). However, involvement of the interprofessional team represents a transition in
care for the patient. Thus, it is timely to elucidate some discussion about how knowing
patients and team members can influence negotiation of primary care, particularly in
terms of coordinating care within an interprofessional team.
Information in transition
Data collected for this research took place during the early stages of
implementation of Northern Health’s first interprofesssional primary care teams.
Structurally, many issues impeded transfer and sharing of information. Some of these
issues, such as the interoperability of the nine information systems used in various
primary care settings, continue to be pervasive and will require prolonged efforts to
reconcile and resolve. Other issues, such as inconsistent feedback loops, and the Service
Request process, are persistently monitored and evaluated with efforts to improve the
process over the short term. These issues are a reminder about how structures and
processes do significantly impact practices of documentation and information sharing.
When the primary care provider and patient make a decision that it is time to
involve the interprofessional team, information about the patient is transferred to the
interprofessional team. The word “transfer” is more appropriate than “share” in this case,
because the information moves from one “side” of the team to the other without
interpersonal involvement. There is very rarely a conversation between the primary care
provider and interprofessional team to give context to the information or to augment the

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information that is written down, as can be observed in “hallway consultations”, for
example, to discuss unarticulated concerns. Instead, the information transfer is passive.
The practices of primary care providers recording information to be transferred to
the interprofessional team are widely variable, despite the designated process of the
Service Request. Forms and processes alone cannot change practices. This may be
particularly true when the impact of practices, e.g. transferring inadequate or insufficient
information, remains invisible to the practitioner.
Rather than attempting to name a cause of inadequate information transfer, this
research helps to articulate some of the reasons why the information transfer process does
not consistently facilitate coordination of care. These reasons are identified primarily by
observing practices. Although the issue that primary care providers and interprofessional
team members have little chance to share information through conversation is important,
there are other reasons contributing to poor informational continuity, that influences
coordination of primary care. One reason is time constraints; when primary care
providers fill out a Service Request quickly between seeing patients, the information that
is written, selected, or “tagged” to be included with the Service Request may be less
compared to when providers do not feel rushed.
Patient privacy is another reason primary care providers may avoid including
some patient information, particularly around topics usually considered sensitive, such as
finances, or family dynamics. Complicating this issue is if the primary care provider does
not know the team member well; there may be additional concern about how the team
member might incorporate this information with the patient, and the provider may wish to
avoid the patient’s dismay or shock realizing a team member the patient has not met

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before is privy to intimate details of his life. The obverse to this, of course, is that issues
of financial capability, or difficult family dynamics, frequently prompt team involvement
in the first place. Much of the guessing and uncertainty about what might happen to
information that is transferred could be eliminated with conversation between primary
care providers and team members.
A final reason that inadequate information may be transferred to the team, which
is to say the information is known by at least the primary care provider but not shared
with the team, comes from a distinct manner of making decisions about sharing
information pertaining to a patient’s care. The primary care provider may not include
information that a patient, for example, copes with an adult son who drinks too much and
refuses to move out. This type of information may rarely be the sole focus of a primary
care visit, and so while a primary care provider may be aware of this dynamic, it may be
information that fades to the background of the primary care provider’s awareness and is
not included on a Service Request. Yet for an interprofessional team member who will
visit the home, knowing that the son lives at home or may be intoxicated during a visit is
information that is desirable to receive in advance of a visit to the home.
This last reason helps to explicate why the ability of providers and
interprofessional team members to “know each other’s world” is fundamental to
coordinating care. Primary care providers rely in part on clinical judgment to distinguish
between all the information they know about a patient to discern what might be the most
useful information for the team to receive, rather than framing it as the most useful
information that can be provided from the primary care provider’s perspective. To
provide coherent and connected care, especially for a patient transitioning from primary

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care to team-based care, understanding and providing the information another team
member would find useful and pertinent is important. In other words, primary care
providers may need to learn to think like a team member.
Sharing information that is most relevant to the team member who will see the
patient next can be applied bi-directionally. As team members become involved in a
patient’s care, they will need to determine what information the primary care provider
may find helpful in planning and staying updated about the patient’s ongoing plan of
care. It can be expected that there may be both principles to guide understanding of
sharing relevant information within a non-co-located team, and also idiosyncrasies. This
is to say that while most team members will appreciate relevant social information about
the patient to be shared, there may be some team members who believe it does not change
their approach. Similarly, while most primary care providers wish to be apprised of
changes or new information regarding a patient’s health or plan for care, there will be
some who prefer to ask the patient themselves.
To address the idiosyncrasies so that care can be optimally planned and
coordinated, clinical leadership is required to establish principles for sharing information,
as well as to persistently ask what is best for the patient. Principles to sharing information
can guide a process to facilitate practices so that patients do not have to repeat their story
or receive conflicting advice. This will help ensure care is coordinated and patientcentred, rather than sharing information based only individual team member or primary
care provider preferences.
When the interprofessional team becomes involved in the care of a patient, it is
not only the practices, but also the timing of information transfer that facilitates

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coordination. When a primary care provider sends a request for team involvement it must
contain adequate information, but it is also beneficial, when possible, to send the request
at a time before the patient deteriorates or is in crisis. If the team meets a patient for the
first time when the patient is in crisis, it is very hard to get to know the patient, there is no
“baseline” to evaluate to what degree a patient is returning to “his old self”, and making
sense of the plethora of information that is usually forthcoming when a patient has a
health care crisis is time consuming. If the primary care provider is able to anticipate that
team involvement may be necessary in the future for a patient, it is prudent for the
primary care provider to consider the timing of this information transfer. With adequate
advance notice, the primary care provider, interprofessional team, and patient may be
able to more deliberately prioritize and plan for increasing care needs in the future.
When informational continuity is not maintained, the consequences can affect
patient experience, engagement, and outcomes. These consequences may be amplified
when the patient is in transition, between receiving care within the patient-provider dyad,
to participating in care as as part of an interprofessional team. Appropriate clinical
judgment and decision-making when applied to coordination of care, means knowing and
selecting the information that is relevant to the team member(s) receiving the patient and
sending the information at a time before the patient is in crisis, when possible.
Equity
Provision of equitable care in a patient-provider encounter can be a natural
outcome of comprehensive, continuous, and coordinated care. With adequate
understanding of patient circumstances, providers can identify inequities and take action
to address them. This is one way that involving an interprofessional team helps to

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Figure 2 helps to illustrate the dynamic process whereby knowing patients
influences how primary care can be negotiated within a dyadic relationship. The features
described here are based on the findings of this study, and could be helpful within many
patient-clinician relationships. However, a key difference in considering this Figure as
representing the patient-provider dyad is how each feature: Practices of Connection,
Helping Patients Feel Known, Fostering Therapeutic Dialogue, and Fostering Therapeutic
Relationship, can be strengthened over time to improve delivery of primary care in a way
that aligns with the key attributes of primary care: Access, Comprehensiveness,
Continuity, Coordination, and Equity.
As patients and primary care providers know each other over time, the different
features of the Figure may be reinforced or overlooked, and a change experienced by the
patient in any of the features will affect the overall process, experience, and outcome. The
process illustrated in Figure 2 represents how the relationship between the patient and
provider, as well as the relationship between practices of connection and negotiation of
primary care, are always “in play” (Grondin, 2015), and how many taken-for-granted
features of knowing patients within a primary care encounter are inextricably linked to
outcomes.
The way in which primary care providers know patients influences how decisions
are made to involve the interprofessional team. This in turn greatly influences the way in
which the PCH model is operationalized. Before shifting the discussion to explicate the
care that team members provide within the PCH, it is prudent to consider how the PCH
model could provide a very different type of care if the importance of knowing patients
was overlooked or underestimated.

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Not Knowing the Patient
In this study, the way in which primary care providers know patients is largely
tacit. This is, in part, what makes the patient experience of care so nuanced. To explore
how primary care experience and delivery can be affected when patients are not known,
some barriers to knowing the patient within the primary care encounter are considered.
First, practices of connection can be impeded if a primary care provider’s clinical
judgment is inadequate. Poor clinical judgment detracts from the provider’s ability to
recognize what is salient about a patient’s situation, and this can hinder therapeutic
dialogue. While there are many facets influencing how clinical judgment is developed
and exercised, ranging from the personal, such as biases that clinicians bring to
encounters (for example see Bloch, Rozmovits, & Giambrone, 2011), to structural, such
as time pressures (for example, see Sharman et al., 2010), clinical judgment is rarely
articulated in discussions of therapeutic relationship. It remains covered up and perhaps
even devalued due to the predominant discourse of evidence-based medicine (Epstein,
1999; Peile, 2014). Understanding how to develop and maintain therapeutic relationship
with patients might be better aligned with drawing on the same skills used to make a
diagnosis versus setting it apart from the clinical reasoning process whereby patient
feelings or expectations may be assessed, but not acted upon or incorporated into a plan
of care.
The second barrier to knowing the patient in primary care is lack of attention to,
or failure to recognize the importance of the therapeutic relationship. A recent news
article featured Scott Robertson, a health researcher, claiming that access is more
important than seeing the same primary care provider (Canadian Broadcasting

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Corporation, Oct. 31, 2016). The access versus continuity debate is long-standing (Gerard
et al., 2008; Haggerty et al., 2008; Locatelli et al., 2014; Stange, 2011). Delving into the
claims made by Mr. Robertson, he draws on American examples of patients who seem to
be accessing team-based care in a manner that is intended to address a demand / capacity
gap, rather than provide patient-centred care. Specifically, patients might visit or call in to
have a particular issue addressed but the “level” of the issue is addressed by the team
member with the narrowest applicable scope of practice first. Only as problems are more
complex or unresolved might they be “elevated” to the attention of a primary care
provider. The argument made by Robertson is that this approach allows all team members
to work to the full scope of their practice. Implicit in the article that is not transferable to
many Canadian contexts is that these teams are likely very large, they are likely colocated, and they likely share an EMR or have high interoperability of their information
systems. Assertions that primary care “tasks” might be delegated or otherwise spread out
among different team members may not be applicable or desirable within the PCH or the
PMH model.
Others have proposed similar solutions to improving team-based care delivery in
ways that overlook the therapeutic relationship of the patient-provider dyad.
Bodenheimer and Smith (2013) propose that non-clinician and non-licensed personnel are
“seriously underused” (p. 1882). This statement is accurate in many ways, but the
framing of the statement is worrisome. Bodenheimer and Smith suggest aspects of
primary care such as education, coaching, medication refills, and other routine reasons for
primary care visits can be tasks assigned to team members whether through standing
orders or regulated scope of practice. They advocate for “kiosks” of treatment of

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competent adults with uncomplicated urinary tract infections (p. 1884). No human effort
required. This presents a number of new problems in the primary care environment.
If uncomplicated patients are “out-sourced” to team members who are not the
primary care provider, there is a question of when do primary care providers get to know
the patient. Waiting until they have multiple chronic conditions or are in crisis is not
advantageous for patient or provider. Patients want to know that their primary care
providers have a vested interest in them and know them, so that care can be tailored and
meaningful. An approach to team-based care that neglects the primacy of the patientprovider dyad may initially reflect through metrics that it is high performing primary
care, but it may not be high quality primary care. To increasingly ensure that the lowest
paid and least educated members of the team spend the most time with patients is not
equitable care. With this approach, comprehensiveness, continuity, and coordination may
suffer.
The approach promoted by Bodenheimer and Smith (2013) is not a vision of
team-based care to endorse; it is reverse-engineered primary care. Ensuring multiple
people see patients for issues normally addressed within a patient-provider encounter is
not effective team-based care, and prompts questions about how much primary care can
be cleaved from a visit to be distributed through a multiple-provider model. Attention to
the value of therapeutic relationship within a patient-provider dyad may lessen the
temptation to chop primary care delivery into small pieces, and maintain the worthwhile
pursuit of generalism (Reeve et al., 2013).
When circumstances impair the robust application of clinical judgment in a
patient-provider encounter, or when the value of the therapeutic relationship becomes

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covered up, patients experience care differently. Based on these findings in this research,
strict attention to evidence-based medicine may be a barrier to genuine conversation
within the patient-provider encounter. As patients develop multiple chronic conditions,
time in an encounter may be increasingly taken up with attention to screening, explaining
results of regularly ordered investigations, monitoring and adjusting treatments according
to evidence. There is likely a trade-off between adhering to evidence-informed practice
and knowing a patient by, in part, exhibiting qualities such as expressing interest in the
patient as a person.
To resolve such quandaries that may in fact contribute to moral distress (Pauly,
Storch, & Varcoe, 2011) or personal dissatisfaction with the role of primary care provider
(Bodenheimer & Sinsky, 2014), Greenhalgh, Howick, & Maskrey (2014) offer important
advice about “real” evidence-based medicine. Real evidence-based medicine asks, “what
is the best course of action for this patient, in these circumstances, at this point in their
illness or condition” (Montgomery in Greenhalgh et al., p. 3). Real evidence-based
medicine tends to ethics and morality, finding out patient values and preferences, and
takes patient agency into account (Greenhalgh et al.). Rather than adherence to the
“rules” of evidence-based medicine, real evidence-based medicine includes application of
judgment, imagination, and common sense, while valuing continuity, empathy, and the
patient-provider relationship (Greenhalgh et al.).
The suggestions offered by Greenhalgh, et al. (2014) demonstrate the possibilities
of incorporating both evidence-based medicine and therapeutic relationship into
encounters with minimal trade-offs. The ability to draw on sufficient clinical judgment to

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achieve this balance appears necessary. Accomplishing this may be challenging for many
primary care providers, yet evidence of these skills are reassuringly present in this study.
Regardless of the type or cause of the barrier that may hamper knowing the
patient, the consequences are two-sided. First, the patient may feel known to a lesser
extent. This in turn may influence care-seeking practices, or what the patient chooses to
disclose during an encounter.
The second consequence of not knowing patients well is that the primary care
provider will understand less about the patient. Decreased awareness of patient agency,
resources, supports, or interests will result in a different understanding of the patient’s
health. This may then delay the involvement of the interprofessional team, particularly if
the issue is primarily in the social realm of health. Further, care plans for the patient may
be less robust, with less tailoring to the patient’s preferences and values. When the
primary care provider is not fully aware of the patient’s circumstances, less information
will be available to share with the team.
Practices of connection that are limited by inadequate clinical judgment, poor
therapeutic relationship, or over-emphasis on biomedical aspects of the patient’s
presentation can prevent comprehensiveness, impair continuity, and impede coordination
for the patient to receive team-based primary care. In addition to provider-level attributes,
structural attributes that devalue the patient-provider relationship can also shape the way
primary care is negotiated and delivered, as with models that seek to divide aspects of
primary care among numerous clinicians. In this study, however, practices of connection
in the patient-provider relationship and the structural reforms informed by characteristics
of the PMH and the PCH model led to the interprofessional team being involved in a

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particular way, that can best be articulated through describing how team-based primary
care is offered and delivered to patients.
Team-Based Care
Initial access to the interprofessional team for patients in primary care is through
the primary care provider. Considering the patient’s journey between encountering ill
health and seeking care, Andersen’s (1995) Health Belief Model helps draw attention to
how patients engage in restoring or maintaining health prior to seeking primary care.
Andersen’s model highlights how it is the patient’s perceived or evaluated health status,
predisposing characteristics, or personal practices that influences care-seeking. This is
true in describing how patients access primary care services. However, the decision to
seek care from an interprofessional team is a step beyond accessing primary care. Thus, it
becomes the primary care provider’s perception of the patient’s status, the provider’s
predisposing characteristics, and the personal practices of the provider that primarily
determines team involvement for the patient. This is one reason it may be of increasing
necessity to uncover practices and decision-making of primary care providers, towards
improving the effectiveness and understanding the operationalization of team-based
primary care.
Access to the interprofessional team is requested for a wide variety of reasons. It
would be misleading to only identify what is written on the Service Request to
summarize why interprofessional teams become involved in patient care. While some of
the Service Requests do hint at the complexity involved with the patient’s care, others
might simply read “help with meds”, or “Lifeline”. The key to understanding who needs
a team is looking beneath these requests to consider why the patient requires help with

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their medication or the Lifeline service installed. During the period of data collection, the
interprofessional team regularly addressed issues of guardianship, power of attorney,
housing, disability, uncontrolled disease, decreasing competence, financial capability,
mental health, addictions, self-care, home support, family dynamics, medication
interactions or side effects, mobility, differing levels of service involvement for different
diagnoses, transportation, and safety.
The interprofessional team addresses all aspects of health, understood broadly to
incorporate medical and social dimensions. The interprofessional team becomes involved
to assist patients through major transitions in recovering or maintaining health, and
sometimes in the transition of increasing burden of illness to death. Thus, the patients
who need a team are those who are no longer best served by delivery of high quality
primary care; the answer to who needs a team is those who require primary health care.
This understanding of team-based primary care as part of a primary care home
sets the interprofessional team deliberately outside the patient-provider dyad. This can
result in more appropriate use of the interprofessional team versus a model that advocates
for many primary care services such as medication refills or coaching or chronic disease
management to be performed by the team and not the primary care provider. The
interprofessional team is not an extension of the primary care provider, implemented to
relieve the burden of the primary care provider in caring for complex patients. Rather, the
interprofessional team is an added layer of skill and expertise that is poised in the
community setting to help patients with complex co-morbid conditions continue to care
for themselves by addressing health issues that can extend far into the social realm.



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Considering how patients define “team” in relation to what helps patients restore
and maintain health, Figure 3 attempts to represent why upstream initiatives outside the
formal health system to assist patients need to be of continued interest and investment to
health care planners. Helping people to develop and optimize both their own agency, as
well as formal and informal supports and resources, such as sense of belonging and
community, stable housing and employment, or friendships and hobbies, can help
individuals maintain their health, sometimes without entering the formal health system.
Such initiatives can also bolster primary care services in terms of primary care providers
having a greater pool of resources and supports to draw on, to help patients with limited
agency or awareness of available resources that may help to restore health. A population
orientation is necessary to conceptualize and operationalize a successful model of
primary care.
Next, Figure 3 illustrates primary care as a service that can be delivered in
conjunction with patients drawing on their supports and resources. Primary care also
overlaps with care provided by the interprofessional team, yet primary care providers
remain on a distinct “level” within the Figure. In part, this is to distinguish that not all
patients need an interprofessional team, and many attributes of high quality primary care
can be delivered by the primary care provider in the context of therapeutic relationship
with patients who feel known.
Although numbers of patients with multiple chronic conditions are expected to
increase over time, the levers to ameliorate the complexity that these patients will present
to primary care providers should not be such that they disrupt the longitudinal therapeutic
relationship between a patient and their primary care provider. Rather, efforts to increase

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job satisfaction of primary care providers are necessary. These efforts do not necessarily
need to be tied to financial incentives (Denis et al., 2013). Systems that reward through
provision of external goods “risk undermining those goods internal to the practice and
ultimately the practice itself” (Kesselring et al., 2010, p. 8). Primary care providers are
most satisfied when they believe they have done well by their patient (Bodenheimer &
Sinsky, 2014), and when they are able to be part of patients’ lives over time (Stange et al.,
2014).
To preserve the value of knowing patients and therapeutic relationship, efforts
could instead be directed towards removing or re-assigning tasks that are not associated
with direct patient care, and allowing for increased time to engage in activities primary
care providers find meaningful (Halvorsen, Edwards, Aaraas, Aasland, & Kristiansen,
2013). Future research might further examine what practice-level activities primary care
providers do or do not find meaningful. Direct observational methods may be valuable in
these endeavours (Epstein, 1999; Morgan et al., 2015), to uncover the real time spent on
activities such as coordination or information transfer. Results from such researches can
help inform meaningful structural changes at an organization level.
Observation of practices can also assist in understanding how primary care
providers make decisions about how and where to spend their time in everyday practice.
Cognitive science has a role in primary care research. Future studies can help to explicate
practices that contribute to primary care provider satisfaction, as well as uncover
decision-making processes involved regarding involvement of interprofessional teams.
To return now to the last “level” of Figure 3 is to turn attention to the
interprofessional team. The interprofessional team becomes involved when the strategies,

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supports, and resources pooled by the patient and primary care provider no longer suffice
to help the patient maintain or restore health. Figure 3 illustrates that the interprofessional
team is not an extension of the primary care provider office. The interprofessional team is
a group of professionals who provide care to the patients who are the most complex and
require the most in terms of time and service. The time and resources it takes to provide
primary health care to patients with complex health and social needs is an alert to again
recognize that the more that patients can be helped to maintain or restore health earlier in
their illness trajectory, the more capacity there will be for the interprofessional team to
care for those who are unable to achieve this.
Capacity within the interprofessional team is a significant concern. Beginning
with the initial Service Request, interprofessional team members begin the work to
distinguish the care the patient will require. When there is insufficient information
transferred via the Service Request, team members will spend extra time attempting to
create a clinical picture of the patient. Information being sought from one another or
those on the team who might already know the patient is centred on understanding patient
agency, and access to or use of existing resources and supports.
Questions the interprofessional team members may ask one another as they plan
care for patients are inquiries that focus on understanding patient agency, which
demonstrates team members’ use of clinical judgment to inform their assessment of how
patients may be able to engage in care that is planned or offered. Second, these
conversations indicate how the interprofessional team is able to work as a team,
synthesizing information to refine and improve coordination of care for the patient. Yet,

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increased demands on the team that decreases capacity negatively influences these
practices.
The interprofessional team have knowledge of one another’s roles, areas of
expertise, and preferences. The practices of team members that are a result of knowing
one another contribute to improving attributes of primary care for patients. The patient
has an access point to an interprofessional team member, often through the team member
visiting the patient at home. Comprehensiveness is improved when the team member is
able to inquire about the patient’s health or function outside the team member’s particular
scope, such as when the occupational therapist asks a patient if they are managing their
medication, or when the mental health clinician notices there might be a fall risk for a
patient. This in turn facilitates management continuity, as the team member can share the
information learned during the visit with another team member to determine if further
action is necessary. The resulting plan of care is then coordinated for the patient, and it is
done so in an anticipatory manner, for example when the occupational therapist can visit
the patient to help install a raised toilet seat before the patient falls.
The practices enacted when team members know one another are muted when
interprofessional team members are overwhelmed with high patient volume, as the
findings of this study demonstrate. This may have a lasting deleterious effect on the
confidence and competence of the interprofessional team to fulfill their roles and meet
patient care needs effectively. Increased demands on the interprofessional team for
service from primary care providers raises questions about the appropriate duration and
intensity of team involvement in patient care. While there have been some initial studies
to examine what the appropriate panel size for a primary care provider might be

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(Muldoon, Dahrouge, Russell, Hogg, & Ward, 2012), there is scant literature to guide
thinking about empanelment of patients for interprofessional primary care teams, or how
team members might optimally structure their workday or plan to see patients. For
example, there is work underway to help identify patients at risk for frailty by Wong,
Williamson, and Katz (BC Primary Health Care Research Network, 2016), but this may
be of marginal benefit to interprofessional teams such as the one in this study, given that
a significant amount of team member resources are used to address mental health and
social issues of patients, who may also be frail. Problem-focused identification of patients
suitable for interprofessional team involvement may be of limited helpfulness in
identifying the actual scope of work required with many patients who have multiple
chronic conditions.
When patients become involved with the interprofessional team, it is between the
patient and team member(s) to determine the length and intensity of team involvement;
the primary care provider is minimally involved in this negotiation. However, as demands
on interprofessional team members increase related to patient volume and need, team
members are distressed about the type and amount of care they want to offer patients, and
what they are able to provide. As demand outstrips capacity, questions about repatriation
to the primary care provider arise. There is again very little evidence to inform
coordination of the patient’s transition from an interprofessional team when it is
determined that the patient’s health is restored to a degree that primary care services,
rather than primary health care services, will suffice.
If health is not restored, and ongoing interprofessional team involvement is
required, further questions arise about the nature of therapeutic relationship between

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patient and team member. Considering the features of therapeutic relationship within the
patient-provider dyad, there are different structural influences to examine within
longitudinal therapeutic relationships between team members and patients over time.
First, interprofessional team members are unionized employees of the health authority.
As such, high turnover within and throughout interprofessional teams is expected and is
already taking place. This impairs the development and maintenance of therapeutic
relationship between patient and team member over time.
The second structural aspect that maintains differences in therapeutic relationship
compared to the patient-provider dyad is the functionality of the EMR. The overarching
care plan for each patient resides in the patient’s PCH, where primary care providers are
located. Thus, while interprofessional team members may be closely involved in the care
of a patient, it is intended to be for an aspect of the patient’s care, such as mental health.
Attending to just one or two aspects of a patient’s care may not be how the
interprofessional team functions in practice, yet interprofessional team members do not
have access to all other components of the patient’s care plan. For example, care or
advice provided by specialty services, or care provided by the primary care provider, is
not easily available to the interprofessional team unless it is explicitly shared by the
primary care provider. Based on these two structural influences, and the amount of
information that can be gained or lost through staff turnover or the way information is
stored affects how team members know patients in a therapeutic relationship. Some of the
features of therapeutic relationship may be more difficult to attain for interprofessional
team members compared to a primary care provider with a stable practice over many
years and access to a fulsome longitudinal record of the patient’s care.

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The transition of repatriation from interprofessional team to primary care is of
special interest to interprofessional primary care teams, because the information that is
learned about a patient and known by interprofessional team members may be very
helpful to primary care providers, yet there is not always a clear understanding or process
to share this information. This situation is complicated for teams that are not co-located
because primary care providers and interprofessional team members have little
opportunity to have conversations with each other. Of particular interest in terms of
knowing the patient is the fact that interprofessional team members commonly see
patients in their home environment.
A change in setting or context of care frequently offers up new information about
the patient’s situation that could change how decisions are made for the patient’s care, yet
primary care providers may be unaware of information or changes to the patient’s
situation as assessed by interprofessional team members. Further work to refine processes
of information sharing beyond the time of initial interprofessional team involvement is
necessary. Feedback loops and information sharing during intervals of team involvement
and during any transition (Haggerty et al., 2013) are essential for primary care providers
to be able to maintain understanding of the patient’s situation.
Patient participants in this study had minimal opportunity to interact with the
interprofessional team as it was so newly implemented. As more patients have access to
team-based care, further inquiry into patient experiences of feeling known and sustaining
therapeutic relationship with team members, as well as outcomes of team-based care, will
be useful to determine future health service planning and delivery. The family experience
will also be important to consider in future research, as many patients of the

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interprofessional team can be expected to be quite ill and may not be able to report fully
about their experiences or satisfaction with team-based primary care.
As interprofessional primary care teams continue to be implemented in Northern
Health and elsewhere, vision and intent is required at an organizational level to promote
the sustainability and effectiveness of these teams. With ongoing concerns about capacity
and demand, it may be tempting to address these concerns by limiting or restricting the
activities of interprofessional team members through policies and protocols. The risk of
implementing protocols to guide a health care professional’s practice is that knowledge
can no longer be applied to the concrete case. Instead, a protocol is designed to ensure the
same care is provided uniformly to all patients.
Limiting the ability of interprofessional team members to engage in situational
decision-making erodes the equitable base of primary health care. “As all work in modern
life becomes organized as a business, increasing rational forms correspond to neglected
ability and autonomy of formation of judgment and action … The more strongly the
sphere of application becomes rationalized, the more does exercise of judgment along
with practical experience in the proper sense of the term fail to take place” (Gadamer,
1996, p. 17). In health care, proper exercise of judgment cannot be over-estimated as it is
a base from which practices are developed and enacted.
One reason it can be tempting to organize and standardize processes that might
otherwise be determined through professional judgment is that it offers a means to cope
with uncertainty. As the health care system and patient needs become increasingly
complex, seeking approaches to reduce uncertainty may be appealing to patients,
providers, regulators, and health care planners. Current thinking and approaches,

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however, tend to land within an existing paradigm that continues to embrace positivism.
As such, adherence to evidence-based guidelines, benchmarking against performance
measures, and treating disease-specific conditions are dominant practices within our
current system to attempt to address uncertainty and reassure ourselves that we are doing
the right sorts of things, even if outcomes do not reflect the cost or intensity of such
efforts.
The findings of this study draw attention to aspects of negotiating primary care
that are already in place, but have not been articulated very well or paid as much attention
in current primary care research or practice. Through practices of connection, this
research illuminated how feeling known, and the development of therapeutic relationship
can facilitate understanding of the way team-based primary care is negotiated. The
findings of this research explicate the value and implications of knowing patients and
knowing one another as part of an interprofessional team.
Practices of connection help people to feel known. Feeling known creates space
for genuine conversation, and through genuine conversation relationships can be
maintained that help address uncertainty during times of change and transition. Feeling
known also contributes to the way primary care is negotiated, in terms of how key
attributes of primary care can be influenced, as well as guiding decision-making about
who needs team-based care. Finally, the degree to which patients feel known and are able
to maintain therapeutic relationships with their primary care provider impacts the type of
care that can be provided by an interprofessional team. When patients receive
comprehensive primary care from their primary care provider, interprofessional team
members are able to address patients’ health and social needs beyond primary care, in the

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realm of primary health care. Operationalization of the PCH model in this way may have
benefits beyond the original conceptualization of the model.
Lessons for Moving Forward and Summary of Implications
The implications of this research summarized below may be helpful to health care
professionals, educators, health care planners, and researchers. The implications are
intended to be helpful to specific groups, however there are also several key lessons
learned from this study that are of broad interest to those planning initial or next steps in
implementing and integrating interprofessional teams as part of the PCH model. The
lessons will be outlined first, followed by the implications.
Key messages
This study demonstrated how practices of connection help people to feel known.
Feeling known matters for patients and within teams. For patients, feeling known
influences decisions about when to seek care. Further attention to care-seeking practices
of patients is needed. This may include redefining access to incorporate what patients
may access in terms of resources for health at the community level prior to or in
conjunction with accessing primary care.
Between primary care providers and team members, feeling known influences
decisions about when to involve the team in a patient’s care, and when the patient might
be repatriated to the primary care provider. In this way, feeling known can influence how
patient-centredness, access, continuity, and equity are enacted in primary care delivery.
Knowing team members also increases trust. Efforts to identify mistrust and address it
while affirming professional identities can help team members and primary care
providers to feel known, particularly during times of transition.

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The ability of team members and primary care providers to know patients and one
another is influenced by personal, organizational, and structural factors. These factors
affect how information that is known about a patient is shared between team members.
When team members are not co-located, there is risk for the gap between what is known
and what is shared to widen, and intentional strategies to reduce this gap are necessary to
improve coordination of care. Strategies can be multi-faceted but need to include face-toface time for conversation between all team members.
Attention to skill mix within interprofessional teams is important, to balance
experience and workload of individual team members. Ongoing evidence-informed
evaluation of workload demands and the capacity of interprofessional teams is essential
to measuring success and preventing team dysfunction. Critically, understanding of the
teams’ anticipated and actual function is necessary.
To integrate interprofessional teams successfully, clear understanding of the
primary care provider workforce is necessary, as team roles and function is influenced by
the services requested by primary care providers. For teams with primary care providers
who are experienced and provide full service primary care, interprofessional teams may
be more likely to be called upon to care for patients who are medically and socially
complex. Other primary care providers may anticipate drawing on the team to perform
primary care tasks to “free up” the time of the primary care provider to attend to a higher
volume of patients. These parallel views of team-based primary care are of philosophical
and practical significance in terms of achieving transformation of a primary care system.
Further discussion of shared vision in this area needs to take place to improve successful
integration of team-based care.

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Implications for health care professionals
Health care professionals working as part of an interprofessional team can engage
in practices of connection with patients and one another. Practices of connection are
evident in action, but also in language and text. Primary care providers and team
members can be intentional about planning opportunities for conversation, both formal
and informal. This is especially important if teams are not co-located.
Ideas for planning face to face dialogue include attending a joint visit or joint
home visit together, making preferences known, for example asking team members to
text when requesting a quick telephone conversation, and also planning for periodic
rounds or case conferences for shared patients. Health care professionals can learn to
“think like a team member” so that information about patient agency, or what supports
and resources a patient has tried or is currently engaged with, can be useful for team
members who do not know the patient.
All members of the interprofessional team should participate, with assistance of
organizational leadership as necessary, in discussing and coming to an understanding
about preferences for timing, style, and consistency in sharing information and
documenting patient care or plans for care. Although EMR interoperability can be a
barrier, opportunities to improve the content, relevance, and timeliness in terms of
communication feedback loops can be deliberately sought. Principles for documenting
and sharing information particularly during times of patient transition is key.

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Efforts towards primary care providers and team members being able to know one
another are important, especially for teams that may have high turnover or other causes of
instability. Discussions of what having a shared vision actually means, as well as
attention to team members’ strengths, preferences, competencies, and scope of practice
will facilitate understanding of how to provide high quality care to patients.
In terms of patient care, primary care providers and team members can
intentionally strengthen practices of connection to help patients feel known. Attention to
features of therapeutic dialogue in conjunction with ongoing reflection of how to
maintain therapeutic relationship with patients that are safe and patient-centred is helpful.
Thinking about what patients may feel uncertain about can assist health care
professionals in considering how particular practices of connection may address some
uncertainties for patients.
Implications for educators
A shift to the PCH model of interprofessional team-based care has significant
implications for educators. Despite increasing recognition of the value of
interprofessional education, it can be difficult to find appropriate timing in a curriculum
as well as a group of students who are near the same level in their professional education
to learn together about team-based primary care. Efforts to increase opportunities for
interprofessional education, for example through case-based simulations with different
professions represented as team members, may help to better prepare future health care
professionals working in a community-based team environment.
Further attention is needed in education to help students of the health professions
to understand one another’s scope of practice and expectations for role within an

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interprofessional primary care team. As team-based primary care becomes the norm in
Canada, the functions of particular roles can be expected to change, and educators may
need to revise course content to keep up with the evolution of team in practice. For
example, in nursing, courses continue to be taught by topic area, such as mental health, or
pediatrics. Nurses who are currently novices to the profession in BC have had very little
preparation to work as a team member in a primary care setting, where the expectation is
to be a competent generalist.
Lastly, educators interested in preparing students to work in interprofessional
primary care environments may wish to look closely at clinical sites chosen for student
placements. It is timely to re-visit the way in which preceptors are selected and
remunerated in primary care for all professions. “High standards need strong sources”
(Taylor, 1992, p. 516), and in terms of selecting preceptors, students deserve access to
preceptors who are interested in teaching, providing meaningful feedback, and helping to
perpetuate practices of connection in primary care.
Implications for health care planners
At the organizational level, there is great uncertainty during a time of
transformational change. Middle managers and leaders of health care organizations can
expect to be called upon to address uncertainties that will persistently arise from various
groups and locations. In anticipation of this, managers may identify that knowing team
members and the value of genuine conversation to address uncertainty can be helpful
outside the patient care setting. In order for managers to create space for genuine
conversation, a significant degree of openness to others in conversation is necessary, and

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this may take more time compared to meetings where the primary objective is to convey
information or a particular agenda.
Engaging in conversation to address uncertainty requires managers to be skilled in
understanding the organizational vision while recognizing the everyday pressures of
clinicians. Managers often have an overview of the workflow of interprofessional team
members, and they may recognize when imbalances are occurring between how much
time team members are learning new processes and workflows versus how much time is
spent seeing patients. Managers can be key in helping to determine scheduling structure
and capacity of team members. Better understanding of how much time team members
should spend at meetings, seeing patients, or on other administrative tasks is critical to
facilitating optimal team capacity, satisfaction, and success. For example, managers can
help to determine the amount of duplication in documentation by team members, and if it
is found to be significant, elevate this issue to a level of priority to be addressed at an
organizational level.
Managers can help to address the uncertainty of team members that is
accompanied by significant change in terms of planning orientation of new team
members. During early implementation, much of the orientation process was not planned.
However, in planning for staff turnover, it is timely to attend to a process by which new
team members can be introduced and get to know the other team members, including
primary care providers. Currently, it may be that team members are not given enough
time to orient into their new position while learning new documentation practices, new
electronic systems, and meeting all new patients.

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Moving beyond the level of managers to a broader health planning level, it is
important to mention the requirement for interprofessional teams to have access to
interoperable electronic medical records. Although it is a tremendous task to require that
information systems be linked or have a satisfactory degree of interoperability, this
cannot be overlooked as a recommendation. It is well known that health information
technology lags far behind the private sector, and while it may be somewhat accepted that
electronic systems are not as functional as they should be, this is not a reason to
normalize it. Along with issues of interoperability, concerns about privacy and
confidentiality on a non-co-located team require further analysis and discussion.
For health planners at the system level, there is still much to be done to
understand and improve team-based primary care that is sustainable, effective, and
satisfactory to patients and providers. To begin, the value of “upstream” initiatives should
not be lost in the conversation about primary care reform. Public health was absent from
the interprofessional team in this study, and a population orientation is needed to achieve
lasting, equitable health outcomes.
The extent to which individuals and families can be assisted to stay healthy in the
community setting with minimal health system intervention is a desirable goal. Deciding
on initiatives that promote health and increase the availability of supports and resources
to individuals and families will be context-specific. However, these initiatives may be
more effective when a broad, social definition of health is used to inform initiatives.
Thus, strategies such as increasing minimum wage, providing financial assistance to
family members who are caregivers of an aging parent or dependent adult child, offering
universal coverage for daycare, or innovations to decrease social isolation and foster

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belonging at the community level are currently relevant to the population’s needs and
may be worth analyzing further. Strategies such as these can provide increased supports
and resources for patients and may also act as an adjuvant to enhance patient agency.
Implications for researchers
The findings of this study can help to advance the primary care research agenda in
Canada. Further study that incorporates direct observation of patient-provider interactions
may be helpful to improve understanding of social and structural influences on decisionmaking and practices. Direct observation of health care professionals working in primary
care can also help to identify reasons and causes of clinician dissatisfaction and practices
that detract from effective primary care delivery. Improved understanding of how health
care professionals inform their decision-making in primary care can help to illuminate
why gaps in care persist. This work may then contribute to knowledge mobilization that
addresses how to reduce such gaps to improve health outcomes or patient experience.
Meaningful measurement in primary care research is an important topic area that
was not addressed through the design or findings of this study. However, this research
does draw attention to aspects of primary care delivery that deserves further discussion in
considering indicators to assess effective team-based care. Currently, there are two major
projects underway attempting to consolidate primary care measures in evaluating primary
care, with the hope that such measures could be applied consistently (Brooks et al., 2016;
Burge et al., 2016). It is not yet known how or to what extent measures that assess being
known from the perspective of patients or clinicians may be incorporated, although
Brooks et al. did identify that “being known” was a measure of importance according to
the clinician stakeholders of that study.

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In 2006, the Canadian Institute for Health Information (CIHI) published a report
containing 105 indicators to measure primary health care. Of 105 indicators, only 25 were
possible to measure even in part with existing data sources. In 2012, CIHI reduced the
number of indicators to 51, but by 2016 only 16 of the 51 indicators had data to support
rigorous measurement (CIHI). None of those 16 indicators were related to patient
experience of primary care or the role of relationship or feeling known.
With the significant work being undertaken in measurement by Burge et al.
(2016) and Brooks et al. (2016), it is hopeful that appropriate measures can be identified
to assess the role of therapeutic relationship and feeling known in relation to providing
effective team-based care. Other measures may also prove useful yet appear to be
overlooked, particularly in the process domain, such as who offers home visits to which
patients and how frequently, or what is an appropriate panel size of patients for
interprofessional team members, or how to assess coordination of care through patient
transitions. Further investigation will be necessary to identify, develop, and refine data
sources for these and other measures of interest.
Many data sources for current indicators of primary care performance draw on
administrative data, survey data, or interview data. While each of these sources have
strengths, and may in some cases be appropriate to evaluate patient experience and
feeling known in primary care, these methods will not uncover the reasons that patient
experience and outcomes are positive or not. Continued observation of practices and
further inquiry into patient-provider interactions, in addition to increased uptake of
patient-reported outcomes, is necessary to explicate the reasons behind the findings of
any indicator of primary care performance. With these strategies augmenting traditional

217
measurement approaches, practices can be identified that help to improve team-based
primary care and outcomes.
Conclusion
In BC, transformation to the PCH model of delivering team-based primary care is
just beginning, and implementation of the first interprofessional teams are withstanding
scrutiny as others consider how the PCH model can be operationalized. Yet, as
Hirschman pointed out, “the architect of social change can never have a reliable
blueprint. What can be most usefully conveyed is an understanding of the experience that
made it at all possible to build under trying circumstances” (Hirschman, 1970/1987 p.
194). This study provides a nuanced understanding of how negotiation of team-based
primary care occurs within the PCH model, and how knowing patients and team members
influences key attributes in delivering primary care.
Implications that draw on the findings of this research are actionable at the
provider, organizational, and system level. There is potential for improving team-based
care through further examination of relationship and processes for decision-making at the
practice level. Articulating practices of connection can amplify facets of primary care and
protect aspects of relationship-based care that may otherwise be neglected.
This study calls for increased attention to understanding and articulating practices
as a way to protect the foundational value to feeling known in primary care. Practices of
connection that help patients and team members feel known influences decision-making
and alleviates uncertainty. In this way, knowing and feeling known can substantially
change the way team-based care happens.

218
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Appendix A: Interview Guide
Questions for Patients

Questions for Providers

1.How long have you lived in this
community? When did you first start attending
the clinic for health care?
Probes:
What brought you here?
Have you experienced changes in your health
over time?

1. How long have you lived in this
community? How long have you been
practicing?
Probes:
What brought you here?
Has the team (# of providers, different types of
providers) changed over time? What has your
experience been of this?
Can you think of a time when a particular
provider began working here? Can you tell me
about that experience? (Orientation, fitting in
with other team members, seeing patients,
communication etc).

2. Who do you see when you go to the clinic?
Has this changed over time?
Probes:
Can you tell me about a time and what
happened when you decided to see someone
else OR request the same person for follow
up?
Have you had any difficulty in seeing whom
you might request when you call the clinic?
Can you tell me about a time when that
happened?

2. Do you have experience working on other
health care teams? Who is part of your current
team?
Probes:
Can you give me an example of how you work
with other health care providers as part of a
team?
Can you think of an example of a time with a
patient where you realized you had to involve
other team members? Can you tell me more
about that?

3. Is there a health care professional who
knows you best? What is it about that person
who makes you feel known?
Probes:
What is it that he or she does? Can you
describe a visit where that happened?
If you don’t feel known, can you describe
some of the things that have happened to you
where your experience was that the provider
did not know or understand you?

3. What are your thoughts about team-based
care? What do you think is going well? What
could be different or improved?
Probes:
Can you give me an example of a time
working as a team went well? In what ways
did it go well? What else influenced why this
worked well?
What about an example of a time when
attempting to provide team-based care it did
not go well? Tell me what happened. How did
your actions influence events in this example?

4. How would you describe your treatment at
the clinic over the past year? Over the past 5
or 10 years? Is there a time when someone

4. Tell me a little bit about how you prepare
for your days in the office. What do you
consider before seeing or talking with

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really made a difference? Is there a time that is
particularly memorable?
Probes:
Can you tell me more about that? Can you
think of an example?

patients? What is important for you to know
about the patients you see?
Probes:
Can you think of a patient with chronic illness
and tell me how you might prepare to see
them?
What about a patient with mental illness?
Multimorbidity?
Can you tell me about the last time you met a
patient new to the practice? What did you do
before, during or after that visit?

5. If you could imagine a difference in the way
some things worked about health care in your
community, what would you change?
Probe:
Can you tell me a little bit about your
experience that has influenced your
suggestions?

5. Tell me about the documentation system
used in the practice. Would you change
anything about it?
Probes:
Tell me about a time when the documentation
helped improve the care the patient received.
Can you think of a time when the chart
reflected conflicting information about the
patient, or it appeared a patient received
conflicting advice?

6. Can you describe your experience the last
time you attended the clinic for a health care
concern?

6. Are there patients in the practice you
consider to know very well? Tell me about
that.
Probes:
Can you give an example of one patient you
know well and describe the events of how you
came to know that person?

7. Thinking about a time you did not have
your health, what was significant to helping
you feel better?
Probes:
What did health care providers do?
What did others in the community do?
Is there a specific occurrence that signified
your realization that you were getting better?
Can you tell me more about that?

7. Are there patients you have found it difficult
to get to know? What do you think makes it
difficult to know some patients?
Probes:
Can you describe a recent encounter with a
patient you don’t know very well?
Can you think of a patient you have seen in
practice multiple times but do not know very
well? Thinking of the last time you saw that
patient, how did the visit go?

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Appendix B: Ethical Approval

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