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‘What’s the appropriate amount of virtual care? It’s not zero, and it’s not 100’

As provincial governments in B.C. and Ontario urge family doctors to resume routine in-person visits, some are pushing back.

In response to the COVID-19 pandemic, provincial and territorial governments and medical associations moved quickly to fund virtual care, defined as any remote, technology-based interaction between a health-care provider and a patient or patient representative. It can be a phone call, videoconference, email exchange or a text.

While this tool has been essential in reducing the risk of viral transmission, providing care for patients who need ongoing medical attention and conserving personal protective equipment, it is also having unintended consequences, according to provincial ministry officials who say the trend is now increasing pressure on hospital emergency rooms and may be leading to poorer health outcomes.

“While these tools have advantages for certain patient care needs, including providing necessary virtual pathways to care in remote and Indigenous communities, the pandemic experience has also reinforced the vital importance of hands-on in-person care … With appropriate measures in place, we expect all practitioners to resume routine in-person visits,” the B.C. Ministry of Health wrote in a Sept. 3 statement.

Ontario followed with a similar statement on Oct. 13: “There are limits to what can be done virtually and the standard of care is often difficult to meet in a virtual care environment…. It is the joint position of the Chief Medical Officer of Health, Ministry of Health and the College of Physicians and Surgeons of Ontario that in-person care can be provided safely and appropriately and it is expected that all physicians are providing in-person care based on clinical needs and patient preference.”

But doctors are pushing back, saying virtual care needs to be more fully developed and standardized. During the September federal election campaign, the College of Family Physicians of Canada (CFPC) said that virtual care tools “enhance access,” and called for “drafting and adopting national standards for virtual care.” The CFPC’s position is that “virtual care is the new reality for most family physicians and their patients.”

In a February health policy document, the CFPC outlined advantages to virtual care, including improving access to care, especially for patients who cannot easily travel to a clinic; simplifying the coordination of care for those with chronic or complex conditions who often require several care providers; and saving patients travel time and the cost of missing work or making caregiving arrangements.

However, there is concern over virtual care’s ability to diagnose illness. A U.S. article in May called virtual health a “double-edged sword” in that it presents the opportunity to improve care, but also makes the potential for mistakes “exponentially greater.” Ontario pediatric neurosurgeon Sheila Singh recently wrote about the limited ability of virtual care to diagnose serious illnesses, stating, “Seeing a patient on a screen is nothing like examining a child in person.”

The Canadian Medical Association has committed $2.5 million to study the impacts of virtual care, equity of access to care and its outcomes, its evolution during the pandemic and its future in a post-pandemic world.

In the meantime, health ministries are hoping that more face-to-face visits will help people receive preventive care and earlier diagnoses, as well as curb unnecessary visits to the emergency room. “Many think that there are a lot of offices still closed for in-person visits,” the Canadian Association of Emergency Physicians said in an email statement, “leading to many coming to the (ER) because it’s the only way to get an exam.”

Ontario ER physician Jessica Robinson has seen this first-hand. She saw one middle-aged man after he had spent months complaining of abdominal pain over the phone to his GP, who had responded with reassurance. “And then I walked into the room – the man was bronze from his jaundice.” She diagnosed him with advanced cancer and broke the bad news to his wife over a conference call.

There is concern over virtual care’s ability to diagnose illness.

“I think (patients) are getting very frustrated with their primary care people because I’ve had so many of them apologize to me for coming to the emergency department,” said Robinson.

Pre-pandemic, family physicians were not paid for phone calls, with few exceptions. For example, according to a B.C. billing guide from 2018, they could earn $20 to manage a limited number of patients, or $6.77 to give advice about blood thinners over the phone, compared to over $30 for an in-person visit.

After March 2020, many provinces, including B.C. and Ontario, allowed family doctors to earn the same amounts for phone calls as they would for in-person visits. This enabled the public to continue “seeing” their physicians without exposing them to the risk of catching or spreading disease in clinics.

Since the virtual care shift, its uptake has exploded. A study of Ontario data revealed that pandemic usage of virtual care was up 56-fold in early 2020. Figures from the B.C. Ministry of Health showed that from 2019-20 to 2020-21, virtual care delivered by family physicians increased from less than 6 per cent of all visits to nearly 52 per cent.

Vancouver family physician and researcher Rita McCracken provides care both in person and virtually; she says that virtual care has enabled her to keep tabs on patients with chaotic lives who otherwise would have avoided the family doctor. Poverty, insecure housing and mental health issues such as substance use disorders hamper their ability to attend the clinic, she says.

McCracken also stresses that while vaccines and masks offer protection from COVID-19, family doctors are still anxious about their risk from in-person care – “Especially with what we know with COVID being aerosolized,” she said. The government has not provided her clinic with any guidance on how to make structural upgrades to make it more COVID-safe or consulted an engineer to help optimize ventilation. Most of her clinic’s staff also have children in school to protect.

No one knows which direction virtual care is going, and it will take time for our health-care system’s competing interests to find a new balance. Meanwhile, family doctors like McCracken will continue to ask one question.

“What is the most appropriate amount of virtual care to provide? It’s not zero, and it’s not 100 per cent.”

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  • Richard P says:

    Definitely experienced this first hand. Was diagnosed virtually incorrectly couple times. Until had to go into ER. Personally I think first onset of symptoms should be an in person visit. Subsequent followup of the same health condition can be virtual. This would strike the perfect balance between in person and virtual care.

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Anthony Fong

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Anthony Fong is an emergency physician in Vancouver and clinical assistant professor at the University of British Columbia Faculty of Medicine.

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