Trust Takes Years to Build. Our Health System Breaks It Overnight.

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William Carlos Williams, the early 20th-century physician-poet, wrote that a poem lies within every patient. It is the doctor’s job to listen for it. I read those words when I was a young man weighing career options, and they made a deep impression on me. That idea still shapes my practice.

Family medicine provides care for every stage of life, from birth to the very end. I have welcomed newborns into the world, watched them grow into adults with children of their own, and sat with patients in their final days. Some people are with me briefly, others for decades. It is a privilege to be trusted with the most intimate aspects of their lives, and those relationships keep me going.

In other specialties, care can be episodic and less comprehensive. In primary care, trust between patient and family doctor ensures better care, improved health outcomes, and higher degrees of both patient and professional satisfaction.

A lifelong primary care relationship is the ultimate expression of continuity of care. Trust between patients and primary care teams is a critical component of a well-functioning health ecosystem. Yet, the priorities hard-wired into the U.S. health care system often conspire to undermine it.

When Insurance Churn Breaks Continuity of Care

Establishing trust takes time, and our insurance framework disrupts that delicate process. Loss of insurance usually means loss of a primary care relationship. Changes in insurance plans — even for patients who remain insured — can sever a patient’s connection with their primary care clinician due to misalignments between plans and provider networks.

In a perverse manifestation of this phenomenon, some of my long-term Medi-Cal patients who had the good fortune to gain full-time employment with health benefits were then forced to leave my practice because their private workplace plan does not include my clinic in its network. 

The bureaucratic rules for Medi-Cal coverage can be equally vexing. In California, if a Medi-Cal enrollee moves across county lines, they may have to change plans and providers. Continuity of care is important, and sometimes I’m able to get special permission from the new county to continue caring for a person with complex needs. But that sort of workaround takes time, resources, and foresight. 

For patients and clinicians, this high rate of churn is problematic. The lack of continuity undermines relationships and leads to poorer health outcomes. When a patient must see a new provider, they are put in the vulnerable position of starting over. Medical history may get lost during transfers. Meanwhile, clinicians feel a sense of loss when a familiar patient disappears into another system.

The Work That Only Trust Allows

Relationships matter. Understanding a patient as a unique, whole person makes a relationship trusting and trustworthy.

A relationship with a young mother I have known since she was a child helps me to tune in to a developmental problem emerging in her toddler so we can work together to navigate the services her child needs.

As patients enter their sunset years, we have conversations about their goals for their lives and health care. Some patients say they are fighters and wish to receive intensive and often uncomfortable treatment for a serious illness. I do my best to advocate for them to receive care that meets those goals. Others say that they have had enough with hospitals and invasive treatments, and we discuss options for comfort care and hospice.

This advocacy is especially important for patients who come from marginalized communities that historically have been mistreated by medical professionals. These individuals are less likely to trust and engage with the system, despite having a higher incidence of chronic disease and complex care needs. That’s why a relationship with a longtime trusted primary care clinician can help ensure those patients are treated equitably and with dignity.

Trusted patient–provider relationships combat health misinformation embedded in the vast flow of media content reaching the public. A patient with diabetes who sees advertisements for a new medication can bring that information to their trusted family physician and collaborate with the doctor to determine whether the drug is a good fit. A patient reluctant to get a recommended vaccination often is willing to consider it after a conversation with a longtime physician who has earned their confidence. 

Closing the Primary Care Investment Gap

Primary care in California and nationwide is facing a crisis of underinvestment. Primary care clinicians receive lower compensation compared to specialists, and that incentivizes medical students and trainees in other disciplines to enter specialty fields, especially when students are carrying significant student loan debt.

The lack of funding for primary care team members such as behavioral health specialists, clinical pharmacists, and community health workers makes things worse. Robust staffing of the primary care team reduces clinician burnout and makes it possible to deliver the comprehensive, whole-person care patients deserve.

In my practice, it often isn’t until the end of my time-limited session that I realize a patient may have depression, anxiety, or another mental health issue. With full team staffing, I can give a warm handoff to our behavioral health professional and know the patient is in good hands. Without that infrastructure, it becomes more difficult to ensure my patient receives needed care, and that makes primary care harder to do well.

These hurdles exacerbate recruitment challenges I faced for years as head of UCSF’s Department of Family and Community Medicine. Despite having wonderful physician faculty teachers and role models, academic medicine’s specialty-oriented culture meant few of our graduating students became family physicians. High turnover rates among primary care clinicians also intensify the state’s dire primary care workforce shortage, which further disrupts patient-clinician relationships.

The consequences of fewer primary care clinicians will be poorer access to care and longer wait times for people who have complex care needs, reside in rural areas, or come from marginalized communities. With the burgeoning population of older adults and patients with chronic medical needs, these conditions are a recipe for system failure.

Recent CHCF polling found that Californians with regular primary care providers are more likely to trust the health care system. Most Californians trust their primary care clinicians. At the same time, fewer than half of people surveyed said they trust hospitals, insurers, or pharmaceutical companies. These findings suggest that providing relationship-based primary care will strengthen public confidence in the health care system.

To build public trust in health care, we must change the way we position and value primary care. The California Office of Health Care Affordability has adopted a goal of doubling the share of total health spending devoted to primary care by 2034.

This is a welcome, major step toward invigorating the field and facilitating team-based primary care services centered on trusted relationships. All Californians have common cause in ensuring successful implementation of the state’s primary care investment policy to ensure that high-quality, team-based primary care moves from aspirational best practice to the standard of care statewide.