Pandemic fears overshadowing need for primary care

Alex, a cancer patient, arrives at the emergency department (ED) with a fever and an elevated heart rate. The nurse, concerned about how sick Alex is, rushes to consult the doctor. It becomes apparent that Alex’s symptoms have been progressively worsening over the last several days. Asked why he waited so long to seek help, the medical team hears a familiar answer: “Because I was afraid to come into the hospital and get COVID-19.”

Within the hour, Alex no longer has a pulse. After performing CPR for 30 minutes, the medical staff’s efforts have been exhausted. Another life has been lost.

This is the reality faced in EDs across Canada during this pandemic. The illness and the outcomes may differ between cases but the issue is ultimately the same – people are waiting too long to seek medical attention. This excessive fear that results in significant stress and avoidance behaviours such as not visiting public, open or enclosed spaces where there is a perceived chance of contracting the virus is referred to as coronaphobia.

As of Feb. 4, there have been 20,355 related to COVID-19. But the number of preventable deaths that have occurred from delays in medical care because of restrictions imposed to prevent the spread of COVID-19 has yet to be tabulated.

The significant media coverage of restrictions and lockdowns and the overload of information and disinformation has made it a challenge for anyone to keep up. People have become so conditioned to fear COVID-19 that they are putting their own health at risk by ignoring symptoms and chronic health conditions as they fear that visiting a hospital will result in contracting COVID-19. The consequences became apparent across Canada last spring. Ontario, for example, noticed a sharp decline in the number of people presenting to the ED, with many hospitals seeing 20 to 50 per cent drops in volume. In response, health officials issued public announcements reminding everyone that hospitals are safe and encouraging them to visit for their urgent health needs.

Now, the tables have turned. In the midst of a second wave, many major hospitals are close to or exceeding full capacity and are at higher risk of delivering hallway healthcare. Exacerbating the situation, once again the majority of patients presenting to hospitals have delayed seeking care due to fears of contracting COVID-19 and are sicker. The impacts are evident: failure to intervene early is leading to patients facing irreversible damage, poorer health outcomes and untimely death.

From March to June 2020, the Ontario Chief Medical Officer of Health recommended that all non-essential and elective healthcare services be reduced to minimum levels or stopped completely, thus allowing hospitals to prepare for COVID-19 patients during the first wave and resulting in many primary care practices closing their doors.

Primary care practices are the entry point to the healthcare system and a continued place of return for all required healthcare services. When patients are unable to access their main primary care practice, the only other option is to visit the hospital ED. To allow continuity of primary care services, virtual appointments became the norm.

However, despite limitations being eased and non-essential and elective health services resuming, the Ministry of Health continues to recommend that primary care physicians see their patients virtually. The Ontario College of Family Physicians (OCFP) also has put forth recommendations for virtual care and clinic reopening. Many primary care practices are limiting in-person visits for some services beyond the OCFP’s recommendations. This is likely due to lack of office readiness as a recent poll by the Canadian Medical Association found that 54 per cent of physicians are experiencing challenges acquiring personal protective equipment (PPE) and 60 per cent find it too costly to acquire the necessary PPE. This continues to exacerbate the backlog of elective medical procedures, including surgery, routine preventative screening, acute care, diagnoses and treatment. The elective surgery backlog in Ontario between March 15 and June 13 was 148,364, with an estimated clearance time of 84 weeks. Further, there has been a 97 per cent decrease in screening mammograms and an 88 per cent decrease in Pap tests. Limiting the ability of patients to see their primary care provider in person reinforces the idea that the risk of catching COVID-19 is greater than the risk associated with a patient’s current or new health condition.

So how do we move forward? Ontario Public Health, and other governing bodies, should impress upon primary care physicians the importance of continuing routine screening (such as for various cancers) and increasing the availability of in-person primary care services. Provincial governments and health agencies must increase timely and affordable access to PPE for primary care practices, facilitating a safe return for patients into the facilities. And there should be clear messaging to the public, from healthcare professionals and government officials alike, indicating that it is OK to see your family doctor or go to a community health clinic if you are not feeling well. This will assist hospitals in avoiding hallway medicine and allow them to continue providing care for urgent needs and medical emergencies.

The appropriate supports must be put in place to ensure practices are ready to provide the timely primary care Canadians need. The priority of preventing the spread of COVID-19 should not be placed above the treatment of all other health conditions.