title: In search of attachment: a qualitative study of chronically ill women transitioning between family physicians in rural Ontario, Canada.
abstract: BACKGROUND
  Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support.
  
  
  METHODS
  Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience.
  
  
  RESULTS
  Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician.
  
  
  CONCLUSIONS
  Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants' accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery.
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada. erandall@shaw.ca
authors.forename: Ellen
authors.initials: E
authors.lastname: Randall
authors.forename: Valorie A
authors.initials: VA
authors.lastname: Crooks
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Goldsmith
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health; D002908:Chronic Disease / Q000523:psychology*; D003266:Continuity of Patient Care; D005194:Family Practice; D005260:Female; D006801:Humans; D008875:Middle Aged; D009769:Object Attachment; D009864:Ontario; D062209:Patient Handoff; D010817:Physician-Patient Relations; D036301:Qualitative Research; D012017:Referral and Consultation; D012216:Rheumatic Diseases / Q000523:psychology; D012424:Rural Population