Getting back to in-person

Across the country, governments and colleges are evolving their recommendations on in-person and telemedicine in primary care, as physicians try to find the right balance in their own practices. While viewpoints differ and debates get heated, most agree it’s going to take time to create a system that takes advantage of the benefits of virtual care and minimizes its risks and limitations. In September, Ontario’s Patient Ombudsman and College of Physicians and Surgeons both reported they’d received complaints from patients who had trouble getting in to see their family physicians and/or were finding virtual care appointments insufficient. Meanwhile, emergency departments were seeing a significant increase in the number of patients who had symptoms normally attended to by family physicians, now available for fewer in-person visits. In a letter issued to physicians in mid-October, Ontario Health and the college asked doctors to care for patients in person now that COVID-19 vaccination rates are high and PPE is readily available. “There are limits to what can be done virtually and the standard of care is often difficult to meet in a virtual-care environment,” the letter said. Other ministries and colleges have similar messages. The College of Physicians and Surgeons of Manitoba recently called for a “blended model of care balancing in-person and virtual medicine,” and the B.C. health ministry encouraged doctors to opt for in-person visits. The messages got a mixed reaction. “I’m fed up to the teeth with others calling on all family doctors to get back to the office. Most of us never left and have been crushed with more work, lower priority for vaccination, and less pay,” said Toronto FP Dr. Chris Sun. “(But) I have heard from many specialists and ER colleagues whose patients have told them their family doctor isn’t seeing anyone in person, and I’ve heard this myself from a few of my new patients.” Read: What does the current job market tell us about family medicine’s future in Ontario? Dr. Sun has witnessed the limitations—and even dangers—of virtual care and said his greatest concern is the quality of the care patients are receiving especially if they are getting treatment from online clinics as opposed to their regular family doctor. In his own family practice and when working online clinics himself, he is surprised by the care some patients have received, whether it’s missed diagnoses or inappropriate antibiotic prescriptions. “The sheer volume of instances of inappropriate care is concerning,” he said. “Practice standards for telemedicine need to be established and enforced. Sore throats and UTIs being prescribed antibiotics without even an attempt to get a test doesn’t even meet the standard of care for a walk-in clinic.” SYSTEM OVERWHELMED Dr. Rod Lim is the site chief of the pediatric emergency department at the Children’s Hospital at London Health Sciences Centre, in London, Ont. He commends his family physician colleagues for adapting to virtual care but also for continuing to see patients. “The pandemic has accelerated virtual care’s development and taught us it has a lot of good uses. It has also taught us the utility of timely physical exams,” he said. “I think there are many (FPs) who have been very considerate and adapted quickly to the changing situation during the pandemic.” At the same time, he said, “there is a large backlog of routine visits that require in-person exams, and I believe a significantly reduced capacity to see patients with infectious symptoms.” Dr. Lim said he and his ER colleagues see large numbers of patients who say they have reached out to their primary care providers but were unable to have an in-person appointment. “It has been a huge challenge for us to keep a safe environment to be able to access larger numbers and higher acuity patients in our department. We have staffing challenges because people have become burnt out over the past 18 months.” Across the country, physicians are facing similar challenges. Read: Why are we still under-diagnosing the second-most fatal disease in the country? “All parts of the system are overwhelmed, and access to timely care remains a challenge,” said Vancouver family physician Dr. Eric Cadesky. “The emergency room remains a low-barrier entry point for the five million Canadians who do not have a family doctor and the millions more who cannot get timely access due to systemic issues.” Dr. Cadesky said his clinic has always offered telemedicine. “Most doctors I know are using virtual care to improve access for our patients with geographical, social, physical and other barriers to care.” DELAYED ASSESSMENTS Dr. Alan Drummond is an ER doctor in Perth, Ont., and co-chair of the public affairs committee of the Canadian Association of Emergency Physicians. He says the problem is not patients with relatively minor injuries clogging up the ER, but patients getting delayed assessments for major illnesses, like heart disease, stroke and pneumonia. “That’s the bigger concern for us—that patients are not able to access their family physician sometimes for months, and people end up showing up in our departments with advanced stage carcinomas. And that’s just not frankly acceptable. It’s troubling,” Dr. Drummond said. “I don’t think it’s so much, ‘What is the impact on the ER department?’ so much as, ‘What is the impact on the patient?’ It’s important to combat the myths of inappropriate patient visits overwhelming emergency departments. The number of people that come in has gone up. Part of that increase is among people who are frankly fed up, being told that they can’t see their family doctor for six weeks. The only problem is that they’re going to end up waiting a long time for a comparatively minor illness. if they don’t mind the wait, then we don’t mind looking after them." HARNESSING THE GOOD OF VIRTUAL CARE Dr. Onil Bhattacharyya is a family physician and director of the Centre for Digital Health Evaluation at Women’s College Hospital in Toronto. He said that during the pandemic he became acutely aware of some of the deficits with the pre-COVID model of care and some advantages of virtual care. Read: Negation driving many Ontario family doctors to distraction First, he realized that pre-COVID, physicians would see patients who could get through on the phone and make their way to the clinic. “We saw many people in person who didn’t need to be in-clinic, and we did not see people who lived far away, had mobility issues, or who weren’t feeling well enough to come in,” he said. “During COVID, we triaged incoming calls to see who needed to be seen in person, and we asked people to send blood pressures or photos of wounds in advance of their visits to decide on next steps,” he said, adding that virtual care has made it easier to monitor patients to see if they are improving, responding to treatment, or having side-effects. ‘MORE WORK’ For Dr. Bhattacharyya and his colleagues, virtual care “has become the default mode of interaction, but it has also become more work because we have not fundamentally redesigned care to achieve its potential.” Despite complaints about increased workload for FPs and ER doctors, an uneven compensation model, and other practical considerations, physicians, governments and colleges are primarily concerned that as the health system evolves, it will better serve the patients. “The pandemic has revealed and exacerbated many of the cracks in our healthcare system including the need to support primary care to improve access and attachment,” said Dr. Cadesky. Dr. Drummond agrees and believes a period of reflection in terms of all facets of healthcare delivery is necessary. “There’s no magic bullet that’s going to fix this tomorrow. I think the regulatory authorities across the country are concerned and don’t want patients to be 100% virtual for very good reasons. So, we’re just going to have to come to some understanding of where it fits and where it doesn’t. That may take a couple of years of reflection as a profession.” Virtual care is here to stay, said Dr. Bhattacharyya. “But we have barely scratched the surface in terms of achieving its potential. This will require lots of upfront work which has only really begun.” Read: The Recovery: BMJ launches podcast on sustainable healthcare

Getting back to in-person

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