Why continuity of care in general practice matters, especially when the system does not value it.
Every GP knows the patients who get labelled “difficult” – unwanted, marginalised, complex.
They are often the ones moved between waiting lists and referral pathways. They are also the ones most likely to fall through the cracks.
General practice is uniquely placed to care for them. It offers continuity, local understanding, and an ongoing presence in people’s lives. Yet bureaucracy and fragmented systems can erode this role, particularly in rural communities where resources are already limited.
I love general practice not just for what it is, but for what it allows me to be. I see patients in my consulting room, in aged care facilities, in emergency departments, on hospital wards, in their homes, and anywhere I can reach them.
Even speaking to a community group about dementia, mental health, or public health is clinical work. It is part of the same continuum, even if it is not an appointment or a billing opportunity.
Not everything of value can be measured in dollars, but every meaningful interaction can be measured in fulfilment.
Some of the most important moments in medicine do not happen in structured appointments. They happen at the bedside – at the end of life, when you are breaking bad news, when you are helping someone through an acute crisis, and when organising transfer to a tertiary centre.
That is when you are closest to your patients, and when your skills matter most.
Patients living with severe, chronic mental illness carry a disproportionate burden. They navigate fragmented systems, limited access, and inconsistent care. If we are honest, they can become what many clinicians describe as “heart-sink” patients. They are hard to engage and even harder to care for over the long term.
What keeps me energised in general practice is not what we usually talk about.
As a rural GP, long drives are part of the job. Some of my favourite conversations happen on those drives with my family, talking about life and work.
This story came from one of those conversations. My daughter said, “You should write this.” So I did.
I want to share the story of Sam (name changed for privacy).
Sam is a young man living with severe mental illness. He has a history of childhood trauma, intermittent substance use, repeated conflict with clinicians and services, poor medication adherence, and frequent encounters with hospitals, ambulances, and police. These are not occasional events. They are part of his everyday life.
By most definitions, he is “difficult”. And yet, with me, something was different. Not always, but often enough.
He would listen. He would apologise afterwards. He would thank me for my patience.
I made a deliberate decision. I would show up for him.
My practice team knew that if Sam needed to be seen, we would make space, even when there was no vacancy. If necessary, I would see him ahead of others who could safely wait.
In the emergency department, I made sure he had food. If he was transferred elsewhere, I checked that he had a way to get home. At times, I worked with local services to help with basic needs like clothing.
I had a soft spot for him. And I suspect he knew I was someone he could trust.
As often happens, things took a turn.
He was involved in a motor vehicle accident. He sustained a limb injury. He was overprescribed opioids. He disengaged from physiotherapy. His condition deteriorated, and eventually, he became wheelchair-bound.
Local services reached their limit. The default response was predictable – “too complex”. Send him to Melbourne.
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But that was not going to happen. He did not have the means, and his situation was worsening, both physically and mentally.
So we tried something different.
I reached out to orthopaedic colleagues and we organised surgery locally. The operation went well.
He did not attend formal follow-ups, but we worked around that. We kept the relationship going. We engaged local physiotherapy. We built small, manageable steps.
Slowly, things changed.
Today, he is walking, with no aids, and no longer dependent on opioid pain medications.
One day, he came to see me in my consulting room. He was teary. He thanked me, genuinely and deeply, for “putting up with his crap”. Then he handed me a printed A4 sheet with a short thank you note.
I put it up on my wall in the consulting room.
At his next visit, he noticed it and asked: “Is this the only thank you note you’ve received?”
I took him to the staff room and showed him a wall full of cards from other patients.
He looked back at me and asked: “Then why is my cheap-looking printout more important than all of these?”
I showed him a few things in my room: a rainbow magnet my daughter gave me; a Sydney Swans scarf from my son. Everything else is clinical or professional.
Then I told him this: Your note is different. Helping you navigate this journey, getting you from where you were to where you are now, is one of the most meaningful things I have done. More meaningful than many other achievements.
You are special. Your note is not just a piece of paper. It sits in the most important place in my consulting room, and in my heart.
He broke down in tears. I did too, quietly.
But in that moment, there was a deep sense of fulfilment. The kind that no funding model, no metric, no system can ever truly capture.
This is the spark of general practice. This is why continuity of care matters. This is why we work hard to be better doctors. This is why we show up every day, despite the bureaucracy and the noise.
And that is what keeps me going.
This is not an isolated story in rural general practice. We see this more often than people realise.
Associate Professor Alam Yoosuff is a rural generalist GP, chair of the Murrumbidgee PHN, and a board director for the Murrumbidgee LHD. He is a clinical academic at the University of Notre Dame.
This article was first published on Professor Yoosuff’s substack. Read the original here.
