Why relationships in primary care matter now more than ever (hint: virtual health care isn’t everything)

This guest blog, by Dr. Arundhati Dhara, was re-published with permission from the Nova Scotia Health Ethics Network

Does virtual care really work?

To state the obvious, COVID has been hard for everyone. For health care providers, there is a sense of discombobulation. We are experiencing the same anxiety and depression as other Nova Scotians, while also trying to help our patients address their mental health and wellness. We are treating those with COVID 19 and those without it with many of the same precautions. It is an enormous effort.  At the same time, we are dealing with the sensation that our own lives – both professional and personal – are barely hanging on by a thread as we wait for the other shoe to drop. We have not addressed the blurring of the personal and the professional, the fears of bringing home COVID 19 to our families, and the guilt that comes from that fear. We need an honest conversation that acknowledges how messy (and even impossible) it has been to actually heal people during a pandemic.

I read somewhere that COVID is the Great Exacerbator. This moniker applies just as much to health care providers as it does for the patients we care for. Early in the pandemic, Nova Scotia moved most of the delivery of primary care away from in-person visits towards telephone calls, and then to virtual platforms. On the face of it, this represents the very best of what we can do – responding quickly, being nimble and flexible while continuing to provide good care to patients. We congratulated ourselves on our ingenuity and ‘seamless’ care transitions. But the unexpected consequence was that we further downgraded the relational work of family medicine at a critical moment.

Initially patients got their prescriptions refilled, their children attended to, and their fears about the novel coronavirus allayed. Phone visits were able to meet some basic health care needs. By this I mean that defined problems with defined solutions were well suited to virtual care. But as the pandemic has gone on (and on and on), the cracks in our new model are starting to show for patients and providers alike. This is especially true in domains like mental health where the problems are more nuanced and the solutions complex. It will come as no surprise that COVID has taken a profound toll on the mental health of Nova Scotians. While Nova Scotia has seen some of the lowest rates of COVID 19 in the country, we are not immune to the suffering. Paradoxically, depression and anxiety rates (due to the pandemic) are higher here than anywhere in the country (https://researchns.ca/2020/10/01/mhrc-release/). 

Why relationships matter

COVID 19 and the mostly necessary move to virtual visits highlights how little we value the real work of healing in medicine. Family doctors will often talk about the ways that we ‘walk with our patients’ through their lives and experiences. Zoom calls do not allow us to do that. In fact, for many patients, internet availability or unreliable access to phones or mobile phone minutes means that it is hard to even attend such an appointment.  And even for those whose internet connections are stable, “Zoom fatigue” is real, to the detriment of us all. 

Health and wellness are not linear and caring for patients requires a great deal of finesse. Providing effective care during COVID depends on the relational work of family medicine, especially to mitigate the mental health effects of the pandemic. The relationships between family physicians and their patients are a form of social capital from which we have been drawing throughout the pandemic. These investments allow us to offer care over the telephone for patients we know well, but it is near impossible to build anything new. 

We’ve been getting by with virtual care, and during the pandemic, it may be the best option possible given the many constraints we are facing. But we need to recognize and value the relational effort that makes virtual care function. Ultimately, family medicine is built on relationships. It is relationships, in the clinic and in our communities that will get us through this pandemic.

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