Why millions of Canadians are still waiting for a doctor with Dr. Danielle Martin
Join Dr. Tara Kiran as she explores just how bad the primary care crisis is in Canada and the history of exactly how we got here. To do that, she phones her friend (and boss), Dr. Danielle Martin, to dissect the foundational elements of Canada's healthcare system, discuss why the system is grappling with significant gaps, and to ask the thorny question of where accountability lies, and who exactly should bear the responsibility for the system’s shortcomings.
Tara and Danielle also reflect on their own experiences as family doctors and they unpack both the challenges and rewards of family medicine in Canada, from administrative burdens leading to burnout, to the magic that comes with being trusted to care for Canadian patients.
Resources mentioned in the episode:
Danielle’s book “Better Now: Six Big Ideas to Improve Health Care for All Canadians”
Danielle’s now viral testimony to a US Senate Committee on healthcare
Related articles you might like:
Canada has more family doctors than ever. Why is it so hard to see them? By Kelly Grant, Globe and Mail 2022
Keeping the front door open: ensuring access to primary care for all in Canada by Tara Kiran, Canadian Medical Association Journal 2022
We need bold reform to fix family health care by Tara Kiran, Globe and Mail 2023
More about Primary Focus:
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Learn about the OurCare Standard
Do you have an idea for an episode? Email primary.focus@unityhealth.to
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Why millions of Canadians are still waiting for a doctor with Dr. Danielle Martin
Primary Focus Podcast — Episode 1
Pre-Show: Calling Danielle
Dr. Danielle Martin (00:05) Hey Tara, how's it going?
Dr. Tara Kiran Hey Danielle, so glad I caught you. I have a favour to ask. I am starting my own podcast.
Dr. Danielle Martin What?
Dr. Tara Kiran Yeah. I've been thinking about it for a while, and I'm going to do it. Guess what the podcast is about?
Dr. Danielle Martin I mean, I hope it's not about fixing cars, because I can't help you very much with that. If it's got something to do with family medicine and primary care, I'm probably pretty good for it.
Dr. Tara Kiran Yes, it is about primary care. And I wonder if you would be my first guest.
Dr. Danielle Martin Are you serious?
Dr. Danielle Martin Absolutely.
Dr. Danielle Martin I'm honoured to be your first guest. Thank you for inviting me. What's it called?
Dr. Tara Kiran It's called Primary Focus.
Dr. Danielle Martin Count me in.
Introduction
Dr. Tara Kiran (00:56) Welcome to Primary Focus. I'm Dr. Tara Kiran. I'm a family doctor and a researcher who is passionate about building a stronger, more equitable primary care system in Canada. I'm the Fidani Chair in Improvement and Innovation at the University of Toronto, and I practice at St. Michael's Hospital, Unity Health Toronto, where I'm also a scientist at the MAP Centre for Urban Health Solutions.
In my research and practice, I try to find and test solutions to make healthcare more inclusive and effective. Back in 2022, I launched Our Care, a national initiative to co-create a blueprint for primary care reform together with patients and the public. And now I'm launching this podcast to spark a national conversation about the current primary care crisis in Canada and how we're going to solve it. For more on this podcast and our mission, click over and listen to the trailer.
For this episode, I've asked my friend and colleague — and she's actually also my boss — Dr. Danielle Martin, to help me catch you up on how primary care works in this country and map out the current crisis we're facing.
If you've never met her before, let me introduce you. She's the kind of person who can make you feel inspired just by hearing about her work. She was the head of our National Medical Students Association and the provincial residency organization in Ontario. She founded Canadian Doctors for Medicare. She spent eight years as a senior hospital executive at Women's College Hospital. And of course, in 2017, she wrote the book Better Now: Six Big Ideas to Improve Health Care for All Canadians.
Today she's the Chair of Family and Community Medicine at the University of Toronto — the largest department of family medicine in the world. She's still a practicing family doctor and a mentor to many aspiring young leaders. She is a bold thinker, an unapologetic champion of access to care for all, and I'm proud to call her a friend.
So today Danielle and I are talking about how healthcare in Canada is organized, how it's funded and delivered, and who — if anyone — is being held accountable for our current crisis in primary care.
I just happened to be chatting with Danielle just hours after the Ontario government announced $1.8 billion for primary care, with a goal to connect all Ontarians with a family doctor or primary care team in the next four years. We'll definitely be talking more about that in a future episode.
Setting the Scene
Dr. Tara Kiran (03:21) Big announcement today. Not bad.
Dr. Danielle Martin Yeah, it's pretty amazing. Good day for primary care, and I'm pretty happy. There's gonna be so much good work we can do now over the next year or two or four.
Dr. Tara Kiran So thanks for joining me, Danielle, for this first episode. I'm excited to have you on. We wanted to start off setting the ground level — what is primary care all about, what is it like in Canada, where are we right now, what are some of the deep issues we're facing, and where can we go? And I thought, who better to ask all these questions than you?
So I guess to start, Danielle — can you define for me what primary care actually is?
Dr. Danielle Martin The easiest way to think about it, really, is that primary care is the front door to the health system. It's the place where people enter the care that they need. It's a place where you have a relationship over time with a clinician — often a family doctor, but not always. It could be another healthcare professional who knows you, who sees you as a whole person. And it also becomes the entry point into other healthcare services, whether that's imaging, lab tests, specialist interactions, or importantly, community supports and other kinds of social supports that might be required for health.
It's also the place, hopefully, from which we can engage not just with individual people, but with groups and communities, to think about how we create healthier environments more broadly. It's the first entry point into healthcare, and therefore it forms the foundation of health within healthcare systems. When it works well, it can be really beautiful. When it's not working, it can be really, really challenging for people to access the care they need.
It's also — and I know we'll talk about this more — way more expensive and way less satisfying when people have to enter the health system through places other than a strong foundation of primary care.
Dr. Tara Kiran (05:40) Yeah — you use the word "foundation," and I think that's another analogy I like to use: it's like the foundation of a home. If the foundation starts to have cracks, or there's a problem with the foundation, then everything else falls apart, because it's really what's keeping that home intact.
I think what you've just described is what we often talk about as the four C's: primary care is the place you first go when you need help — first contact. It's also where you get continuous care: you can see the same person over time who really gets to know you. The family doctor or primary care team coordinates your care, and importantly, they look after the whole picture — it's comprehensive. It's not just the mind or the body.
One misnomer people often have is thinking about what family doctors do and assuming it's mostly physical stuff. But I'd say probably a third of what we do is actually mental health care — depression, anxiety, all of those things. And another thing we experience in family medicine is that it's all of those things at once.
I was in clinic this morning with a medical student. Two of the patients she saw had prevention needs — due for an immunization or a mammogram — plus some acute needs like a sore knee, but also had recently been seen by a specialist and came back to kind of "decode" what the specialist had recommended. It becomes a trusted place that people return to. "The specialist said I should do this — but you know me. Should I really take this medication?"
And so it's the mental health, it's the physical health, it's also sharing that "my mom had a stroke and it's really causing me stress, and maybe that's why my blood pressure is up a little — and do I really need to take this additional pill?" So it's mental health, physical health, social environment, family issues, all at once. And it's that weaving together of those different elements that builds trust and relationship over time.
What do you think about how primary care is organized? Do we even have a system in Canada?
The History of Canadian Medicare
Dr. Danielle Martin (08:01) To get into this in the Canadian context, we kind of have to go way back in time — to the beginnings of Canadian Medicare, when famously Tommy Douglas, then the Premier of Saskatchewan, wanted to eliminate financial barriers for people who needed healthcare. This was based on his own experience as a child. He had osteomyelitis, a very serious foot infection, and was eventually treated only because his parents agreed to have him taken on as a teaching case. His family faced this stark reality — the choice between medical care for their child and, in their case, losing their farm. Paying rent, buying groceries, or accessing healthcare: that's a choice people have to make all the time, all over the world. He didn't think it was right, and he set out to fix that for the people of Saskatchewan.
First he put in place public insurance for hospitals, and then he came to want to include doctors in that. And the doctors of Saskatchewan — although many may have individually supported the concept — organized medicine in Saskatchewan was not on board. The doctors actually went on a very famous, very bitter strike, to try to preserve their right to bill patients directly for care and to bill private insurance.
In the end, they reached a compromise — what's now known as the Saskatoon Agreement — where effectively doctors agreed they would not bill patients for medically necessary services; they would bill the public insurance plan. But they would remain independent practitioners. So the deal was: you're still an independent business owner, you still make your own choices about how you're going to organize your clinic and your life, hire your secretary, run your charts, do all the ins and outs of your business as a completely independent business owner — but instead of sending the bill to the patient, you'll send your bill to the government.
That Saskatoon Agreement formed the basis of family medicine in Canada today. It continues to rest really on that model, where the defining aspect of Canadian Medicare — that people should access care according to their need, not their ability to pay, which is a very deeply held value among Canadians — is honoured. And yet our doctors are not employed by the health system. We don't have a national health service. We don't really have much of a system to speak of. We don't tell healthcare providers where they should work, what neighbourhood they should work in, how many patients they should see. We don't offer them a pension, we don't give them benefits, they don't have paid sick leave or paid vacation. They're completely independent, but they send their bill to the government.
So I would say it's not really a system in that sense — it's an insurance plan. And there are some family doctors and other folks across Canada who continue to believe that's a good thing: that it gives us maximum independence and flexibility as healthcare providers, the ability to respond to the needs of our communities without having to run everything past the government. There's a grain of truth in that, of course. But it's also true that where we see big gaps in access to care, it's very hard for government to fix those gaps, even though the people whose taxes are paying for that care kind of expect their governments to fix it.
So there's a mismatch between what people expect government should be able to do, and what government can actually do in that space. I think that creates some of the tensions we see today. Here we find ourselves in 2025, with six and a half million people — as your excellent research has shown — who don't have a family doctor or any real access to primary care in Canada. And we're trying to figure out how to modernize these systems to meet the needs of today, in an environment where the systems were not really built for that kind of capacity-building or oversight. It's a tension that kind of defines the way primary care is set up in Canada, for better and for worse.
Dr. Tara Kiran (12:37) Yeah, for sure. The other thing I think about in terms of the legacy of Medicare is that of course it laid out funding for hospitals and doctors as part of that insurance plan, but not much else. And in an ideal world, to keep people healthy, primary care would include more than just doctors and hospitals. It would include funding for mental health care, dental care, eye care, all of those things. And we heard that from people we spoke to across the country — they felt all those things were important, but were frustrated they weren't covered.
I think reflecting on what you've said, the question that comes to me is: who is accountable? Is there anyone who's even accountable? When six and a half million people in Canada don't have access to primary care, is that the federal government we hold to account? Is it provincial governments? Individual doctors? The doctors' associations?
Dr. Danielle Martin Yeah, that's the tension. I would say that the Canada Health Act — and if you ask Canadians, they sort of expect this, because access to care based on need not ability to pay is seen as a defining Canadian value — many Canadians do think it's the job of the federal government to fix these problems. I understand that. I actually think it's quite beautiful that it's a Canadian value. But actually, the federal government doesn't really have the levers to fix these problems on the ground.
So there is a mismatch between where we intuitively feel accountability should reside and where the power actually resides. I'm reminded of something — I think it was Tony Blair who once said, when he was Prime Minister in the UK, that he arrived in office and spent many months pulling on the levers of power before he realized they weren't attached to anything. I'm pretty sure I have that quote more or less right. And I think that must be what it feels like to be a federal minister of health. You think you're pulling on these levers, and they're not attached to anything.
Dr. Tara Kiran (15:00) Yeah. And from the public's point of view, they want access to primary care. They want a family doctor, a nurse practitioner, or a team who can see them on an ongoing basis, who they can rely on, build that relationship with, trust, and come back to again and again. So I think we continue to have this issue of so many people in Canada without access to primary care. And I think it's actually apt to call this a crisis — when more than one in five people don't have access to the front door of the system, I think we're in a crisis.
So why are we in this mess? I obviously have my own thoughts, but I'd love to hear yours.
Why We're in a Crisis
Dr. Danielle Martin Yeah, I agree it's a crisis. I've even gone so far as to call it a state of emergency — although not the kind where the army is coming in. Definitely not that. But it does feel that acute.
I will say parenthetically that in the twenty years I've been at this, I've never had as much support from my specialist colleagues as I feel right now. Because as you say, this crisis is spilling over into our emergency departments and hospital wards — specialists seeing very complex patients with a lot of needs in the dermatology clinic, with nobody to send them back to to deal with their complex chronic illnesses. It's being felt in every part of the healthcare system, and it gives me no pleasure to have those conversations with specialist colleagues, but I feel like the whole system is feeling this crisis in a way it perhaps hasn't before.
Why are we here? How much time have we got? So many decisions — and non-decisions — have led us to this point. Everything from difficulty recruiting new graduates to practice comprehensive family medicine in the community, to the non-existence of infrastructure for interprofessional teams, to the aging of the population — which includes the population of family doctors, with people retiring and hanging up their stethoscopes with huge practices and no one to hand them over to.
The pandemic, of course, accelerated that phenomenon, with people retiring from family medicine practice in the community while continuing to practice medicine in other ways — those focused-practice environments you named. And then there's just the increasing complexity of the work, combined with what people are calling administrative burden or paperwork — and I have some ambivalence about how we label that work.
Some of the administrative work we do in family medicine and primary care is just straight-up our jobs. Everybody has paperwork. I live with a lawyer — everyone has email, everyone has things they need to fill out that they wish they didn't have to do. But the absence of good systems to deal with referrals to specialists, timely access to imaging, employer requirements for documentation — these things, which are symptoms of underinvestment in appropriate systems of flow in healthcare — all come back to the family doctor's desk. And that's a recipe for burnout.
I don't mind filling out somebody's disability forms, because that's the difference between that person getting income or not. I am the only person who knows enough to describe in detail the degree of their medical disability, and I consider it a sacred duty to do it, even though some of those forms are super annoying and too long. But I am not amused to have to re-refer the same patient three times to different specialists to get them the care they need — because it turns out this doctor only sees the left foot, not the right foot, or they retired and won't pass your referral along, or the wait list is so long they've simply closed to new patients. And you're tearing your hair out trying to get somebody something you know they legitimately need. That's not a good use of my time. That's the kind of administrative work that leads to burnout.
And of course, it's also true that in most Canadian provinces and territories, family doctors earn less money than other medical specialties. That is a driving force in career choices for new graduates and experienced family doctors alike. If you can earn more money by doing a job where you work hard for a few weeks and then clock out with no ongoing responsibilities and obligations, that's hard to compete with.
All of these factors and more contribute. But I am less interested in how we got here, or in how hard it is, than in hope. And where it is that we need to go.
Dr. Tara Kiran (21:00) I agree. The beauty of our jobs. I totally agree. At the same time, I think it's important that we understand the issues so that we can tackle them. In quality improvement, we always talk about how understanding the problem is the thing a lot of people don't take enough time to do. I think we do have a good sense of why we're in this crisis. You named so many things.
I kind of think about it as demand and supply. On the demand side, there are more patients because of a growing population, and each patient takes more time because they have more complex chronic conditions and more social issues. That's unfortunately to be expected with an aging population unless we do a really, really good job keeping people healthy through health promotion and prevention.
But then there's also the supply side, which is what you spent a lot of time talking about. I'll add just one thing that's crystallized for me recently: we have a lot fewer doctors per capita than many peer countries. We're actually just short on doctors. And within the doctor group, fewer people are going into family medicine — many are leaving family medicine, or training in family medicine and then choosing to do something else.
Dr. Danielle Martin Yeah, there's been such hot debate about this. What's the right number of doctors per population? And of course, in Canada there's the very particular issue of distribution — something many of our comparator countries don't experience with the same level of acuity. So we would actually need even more doctors. And yet in the Netherlands or Denmark, they have 1.6 times the number of doctors we have. That's pretty substantial.
Some people like using the analogy of family doctors being the Swiss Army knife of the healthcare system — someone who can do lots of different things — so of course they're going to be used in different ways throughout the healthcare system too.
But yeah, you've pointed to so many of the other things: not enough pay, system inefficiencies, society changing over the years. Nobody wants to work the way people worked thirty years ago. People want more work-life balance.
But what was so important is that you mentioned hope — that you still love being a family doctor. And I know I love being a family doctor. I honestly still think it's the greatest job on earth. I can't say enough about the magic when it works, when you're doing what you're there to do. I say this as someone who's not especially spiritual: I do believe it's sacred. Like it does feel that way to me. The trust that runs both ways.
The Magic of the Relationship
Dr. Tara Kiran When I think about my patients who I've known and taken care of for twenty years and the way we relate to each other — that relationship is, I do think, actually magic. And we don't spend enough time talking about that. Is there a story that comes to mind?
Dr. Danielle Martin (24:21) I'll share one patient just because it's fresh in my mind — I spoke to her on the phone just last week. I called her to check in, because she's older, she's got a whole bunch of medical problems, she'd come in after a fall, and I was worried and just wanted to follow up. She's pushing 80 and is an incredibly active person — always taking courses at the university. I know her daughter, I know her granddaughter. We have this beautiful relationship, and she's exactly what we all should picture when we think about healthy aging: an extraordinary, intellectually and physically engaged person.
I called her, and she said, "You know, I was just thinking about you — wondering how your daughter's doing." Because she's known me since I was pregnant. My daughter is now 15 and barely speaks to me, but only in an age-appropriate kind of way. She remembers when I was pregnant. And so that way that we care for each other — I was thinking about her, and I called because I was thinking about her, but she had also, for whatever reason, been thinking about me. In what other job do you get that?
It was a small example, but one that sticks out because that was just Wednesday in my job.
Dr. Tara Kiran Yeah, it's truly a special thing to build a relationship with someone over time. Funnily enough, I also have patients who ask me about my children. For many years they would ask me how old my baby was — and my baby is now eleven years old. In their mind, the time has gone very slowly, so they still ask, "How's your baby doing?" And I'm like — eleven! What? Anyway —
What you're saying rings so true, because it's a relationship that's not one-sided. You're holding space and being there for patients, but there's so much they also trust you with. It feels very special to know things they've disclosed to you that they haven't disclosed to anyone else — to enter these private worlds that you'd never have access to in your social life, to be part of something so intimate, to have people trust you and help them navigate some of their most difficult times, and the most special and beautiful times in their lives too. And then if something happens to you, they know it and they ask about it.
It's a very special thing, this relationship. The secret sauce, as you say.
Dr. Danielle Martin Secret sauce.
Dr. Tara Kiran We both are fans of putting more of that secret sauce into the healthcare system. We've talked to people across Canada for the last couple of years, and we've pulled together everything we heard into the Our Care standard, looking to that as the beacon. Thinking about the future and the hope — what do you think we should be doing? Where should we be acting?
What Needs to Change
Dr. Danielle Martin You know, there was something in the media just a week or two ago: a new family doctor opened the doors to his practice in Walkerton, Ontario. He would be rostering 500 people. It was cold and snowy — we're doing this podcast in January — and people started lining up at two o'clock in the morning outside the Rotary Club, or wherever it was they were signing people up. And the newspapers came and the TV cameras came, as if to say: this is what we've come to in Canada. People lining up starting at two in the morning in the snow to try to get a family doctor. This is not a Taylor Swift concert ticket lineup.
The media were interviewing people in line, and so many of them — such a Canadian sentiment — people saying, "I'm so overjoyed that I made it to the front of the line, and I feel like I won the lottery getting a family doctor, which should just be the right of every resident of this country. But I'm also worried, because I know there are people who couldn't line up, and I feel a bit badly that maybe I took the spot of somebody who needs it more, because I could line up."
Such a Canadian sentiment — my neighbours worrying about who else isn't in the line, who couldn't make it, and what that means for somebody else.
To me, that's what Our Care is about. The power of the work that you've done is not to think about what we need to do from the perspective of academics or system leaders who study this stuff, but to think about it from the perspective of the people who use the system, the owners of the system — the public. And those folks in Walkerton understand what it's about and why it matters. That's why they lined up. They get that this is the core, the foundation — the alpha and the omega.
So we take our cue from them. What do we need to do? We need to make the investments. We underspend on primary care as a proportion of health expenditures compared to other OECD countries, so we need to right-size the budgets. We need to put in place interprofessional teams so that it's not a doctor-only show. That's part of how we're going to get over the undersupply and maldistribution of physicians — by not thinking of this as only a physician thing. You can do a lot more with a doctor when that doctor is working in a team with a pharmacist, a social worker, an addictions worker, a nurse, a nurse practitioner, a physician assistant, a peer worker. You put those people together, you've got real power to take care of people. And that's going to cost money.
But also all of those infrastructure pieces we've been talking about are going to be really important. As the diseases and the medical aspects get more complex, the system ratchets up its own complexity. And if it's the job of individual family physicians to try to navigate that complexity on their own for people, we will burn them out. We need those system fixes — like central intake for specialty care and advanced imaging, as one example I'm quite obsessed with, though there are other examples as well.
We have to begin from those principles. We have to declare the goal. I'm very happy that in Ontario we finally declared the goal: a hundred percent of the population — everybody — should be attached in a meaningful relationship to a primary care clinician, supported by a team. That's the goal for everyone. And usually that clinician will be a family doctor, but not always. That's where we begin — and then there are all kinds of enabling things we need to put in place.
Dr. Tara Kiran Yeah, I totally agree that it starts with articulating the goal very clearly. Unfortunately, not as many jurisdictions across Canada have done this as I would like. But in Ontario they've declared the goal, and I think also in PEI and a few other places — declaring the goal of everybody having access, and then directing the money toward that goal, is really the foundation. And all the other things you mentioned follow from that.
I love the anecdote about Walkerton. When I think about the stories I've read and heard, I was also struck by just the kindness and community orientation of the people standing in that line — how they talked about how everyone was so nice and supportive, and held space for each other when someone needed to use the bathroom or get the person from the car whose spot they were holding. When I think about hope, that's what gives me hope: that people in Canada really care about each other, care about their neighbours, and want everybody else to have that access. They want it for themselves, but they also want it for other people. And that's the way forward — to listen to them and design around what they say they need.
Any last thoughts you want to share with us, Danielle?
Dr. Danielle Martin I'm just very heartened and excited that you're doing this work, Tara. I think it's incredible. I know there's a lot we can learn from our international comparators, and you're going to be talking to lots of very smart people who can describe what gets done well in other systems. There's a lot we can pick up and take from those places.
But I also think — like you, I've traveled and seen other health systems, read about other health systems, and spoken to experts in other countries — what you're describing about that community orientation, that view that the health system is a defining characteristic of what it means to be Canadian, is actually quite unique. Even in health systems that do a better job of delivering on it than we do — and there are more than a few — that commitment to the values is not shared in the same way, as a core, nation-building concept.
And I think that is special and needs to be honoured. It may actually be what we have to teach the world. It's our contribution.
Dr. Tara Kiran Yeah — it's what we can give to the world. I love that.
Closing
Dr. Tara Kiran Thank you so much for coming. That was fun.
Dr. Danielle Martin (35:43) Thank you. I hope it was okay — I know you had to rush here from clinic, and it's always a million things happening. But I hope it was good.
Dr. Tara Kiran It was. You did a great job.
Dr. Danielle Martin You're an amazing interviewer.
Dr. Tara Kiran I'm a little self-conscious about that right now.
Dr. Danielle Martin No, you did amazing. Thank you. Okay, I better go — I'm, of course, late for my next meeting, but it was so great to chat with you. Thanks for including me.
Dr. Tara Kiran Thanks, Danielle.
Dr. Danielle Martin Okay, bye.
Dr. Tara Kiran Bye.
Credits
Primary Focus was created by Dr. Tara Kiran and is made possible by a grant from the St. Michael's Foundation. Maryam Danesh is our research assistant. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
Primary Focus is supported by a grant from the St. Michael's Foundation. Dr. Kiran is supported as the Fidani Chair in Improvement and Innovation at the University of Toronto, and as a scientist by the Departments of Family and Community Medicine at St. Michael's Hospital and the University of Toronto.
If you'd like to read more content from Dr. Kiran about Canada's primary care system, join the Substack newsletter at primaryfocus.substack.com, or visit primaryfocus.ca. For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca.
The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.