No vax, no visit? What to know and what to do with unvaccinated patients

Toronto - In the early days of COVID-19, the staff at the Canadian Medical Protective Association fielded numerous calls from doctors worried about the lack of personal protective equipment and ventilators, and about how patients are prioritized for care in overburdened emergency departments and clinics. Today, the calls to the CMPA are increasingly focused on COVID-19 vaccines and the patients who haven’t rolled up their sleeves to get the jab. “We are getting calls about what to do about vaccine-hesitant patients,” said Dr. Steven Bellemare, director of strategic engagement and advocacy at the CMPA, the national non-profit organization that provides legal help for Canadian doctors. Across the country, the regulatory bodies for doctors have issued reminders that unvaccinated patients are entitled to the same access to care as vaccinated patients. In a recent newsletter, the College of Physicians and Surgeons of British Columbia said it would be ethically “indefensible” for doctors to require documented proof of vaccination before allowing a patient into their clinic. Similarly the College of Physicians and Surgeons of Ontario stated clearly on its website that doctors cannot restrict in-person care only to patients who have been vaccinated or who recently tested negative for COVID-19. “In-person care can be provided safely — even in the absence of a negative test result or vaccination — by taking appropriate precautions, including screening patients and using necessary PPE,” wrote the CPSO. These messages are reiterated in black and white by the CMPA, with the additional caveat that refusing to provide care to unvaccinated patients could put doctors at risk of a college or human rights complaint, and potentially civil action. A debatable question we had to ask Yet when The Medical Post asked its readers in July if they would deny in-person appointment requests from patients who refuse COVID-19 vaccination, more than one out of every three respondents said they would treat these patients only by video, phone or email. The question also set off fierce—and in some cases hostile—debates amongst readers who chimed in with online comments. Some lashed out at those who stated they would refuse to see unvaxxed patients in-person, while others aired concerns about their staff and vulnerable patients. A few offered suggestions for mitigating risks from unvaccinated patients. While most doctors likely have a personal stance on the issue, ultimately it’s the legal, regulatory and ethical frameworks in the country that will decide what they can or cannot do with their unvaxxed patients. At the top of the can’t-do list is the restriction of unvaccinated patients to virtual care, said Dr. Heidi Oetter, registrar and CEO at CPSBC. “It would be important for physicians to know that virtual care has its place in clinical practice,” she said. “But the bottom line is, if a patient who is not vaccinated needs in-person care, then appropriate arrangements will have to be made.” Read: Doctors without vaccines A balancing act that calls for tough decisions Vanessa Gruben, associate professor at the University of Ottawa’s Centre for Health Law, Policy and Ethics, called the denial of in-person care for unvaccinated patients “punitive” and unfounded on any reasonable basis. But she acknowledged the tough decisions doctors face as they try to balance the needs and safety of their unvaccinated patients with those of other patients and staff. There’s also the matter of the doctor’s own safety. That’s where precautions and judgement come into play, said Dr. Bellemare at the CMPA. “When PPE is generally accessible and where it’s possible to protect oneself, the physician will have to consider what another reasonably prudent physician would do in the same circumstances,” he explained. “That’s the standard by which they will be judged should there be a complaint or lawsuit later on.” Dr. Nancy Whitmore, registrar and CEO at the CPSO, framed the argument within the context of Canadian physicians’ long history of treating contagious diseases. “We’ve been seeing patients with infectious illnesses forever,” she said. “COVID may be a new infectious illness, but it’s not the first one we’ve encountered.” This experience, combined with PPEs, disinfection protocols and safe distancing practices, should help doctors come up with effective approaches to managing patients who have not received, and perhaps have no plans to receive, COVID-19 vaccination. Read: Should we fire anti-vaxxer patients? The new reality: Adapting your day-to-day practice to mitigate risks Marie Carniello, president at Systemic Healthcare Solutions—a healthcare consulting firm in Niagara Falls, Ont.—offered a number of suggestions for managing unvaxxed patients in a clinical practice. These include dedicating blocks of time on the appointment calendar for non-vaccinated patients, preferably during parts of the day when they’re less likely to overlap with other patients or even with staff. “Maybe book them for the first two or three visits of the day and during lunch hour, without your staff having to be present,” said Carniello. Depending on the nature and location of the practice and the reason for the visit, appointments for unvaccinated patients could take place through a car window. Carniello noted that some clinics already ask all patients to wait in their cars until their appointment time. “Obviously you couldn’t do an in-car appointment with someone coming in for a PAP smear,” she said. “But it could work with a derm appointment.” To reduce the risk of potential transmission through gaps in plexiglass dividers, doctors might consider installing intercoms in their reception area. This will allow staff to communicate with patients from a safer distance, said Carniello. Another suggestion—albeit one that not many physicians will welcome—is to do more house calls, even if just on a temporary basis, with a particular focus on unvaccinated patients. “It’s not a really loved technique of delivering healthcare but there are companies out there that offer it as a third-party service,” she said. Doctors might also think about booking less appointments overall while increasing the level of over-the-phone triage, perhaps using medical directives to enable nurses or medical office assistants to take on more of the preliminary tasks for each visit. To further shorten exposure time, physicians could make better use of their EMRs to gather information from patients via secure email. Effective triaging: A new reality and way of life Comprehensive, pre-visit triaging of patients will now be ‘a way of life for physicians and their staff, said Dr. Oetter at the CPSBC. “We’ve got this new reality of effectively managing patient flow,” she said. “I would also offer the observation that with the new Delta variant, even vaccinated people can carry the virus. So effective triaging will be critical for everyone, not just unvaccinated patients.” While many physicians today may be grappling with how they can care for their unvaccinated patients while keeping themselves and everyone else safe, they will most certainly figure it out, said Dr. Oetter. “Doctors are bright people,” she said. “And I anticipate that public health will come out soon with best practices or advice on how to manage all this.” The story sounds much the same in Ontario. Dr. Whitmore at the CPSO said the college is expecting to get some direction, from the province’s medical officer of health, on in-person care for unvaccinated patients. In the meantime, she’s confident Ontario physicians will continue to make decisions that are in the best interest of their patients. “They know best, they’re in direct contact with patients,” she said. “And that gives them the opportunity to talk to patients about why they might want to be vaccinated. I think to not see those patients would be missing out on huge opportunities to inform them about the vaccine.” Read: COVID vaccinations—the next frontier

No vax, no visit? What to know and what to do with unvaccinated patients

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