Picture of Tara Kiran

Tara Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team and the Fidani Chair of Improvement and Innovation at the University of Toronto.

In July 2020, I wrote a post on this blog to guide family doctors on how to ramp up in-person visits in their practices. A year later, the topic is still timely although the context is different: we are now fifteen months into the COVID-19 pandemic, a large proportion of the population is vaccinated against SARS-CoV-2 . How should primary care operate going forward?

Family medicine practices have been open and busy during the pandemic. National surveys and a survey done by our team in Toronto estimate that the vast majority of practices have continued to see patients in-person. Most are taking a virtual-first approach—seeing patients virtually first and then asking patients to come in-person if needed. Indeed, this is consistent with official guidance from Ministries of Health.

Administrative data along with data from physician and patient surveys suggest that most primary care visits are now virtual, mostly by phone, with some use of video and email or secure messaging. Only about one quarter to one third of visits have been in-person through the pandemic.

Patients seem to like virtual care. Results from a patient experience survey done at our 14 family medicine teaching practices at the University of Toronto found that over 90% of patients were comfortable with the privacy/security of virtual care. Most wanted virtual care to continue post-pandemic with 75% reporting they wanted phone visits to continue and 52% and 43% saying they wanted video and email/SMS to continue, respectively.

But, virtual care does not meet everyone’s needs. Our survey found that people who reported difficulty making ends meet, those who were new to Canada, and those who reported poor or fair health also reported lower levels of comfort with virtual care and were less likely to want virtual modes of care to continue after the pandemic.

We know a lot of care can be delivered safely and effectively through virtual modes. For example, virtual care can be used to enhance self-management of stable chronic conditions. Patients with diabetes can be taught how to keep track of their weight and blood pressure and check their own feet so that most care can be done virtually.

Yet some preventive care and screening has been missed or delayed, and some people with chronic conditions have likely not had appropriate review or management. Many have also experienced a worsening of mental health and addictions that requires empathy and therapeutic connection best delivered in person.

As of July 19 2021, 80% of eligible Canadians have had one dose of a COVID-19 vaccine and more than 50% are fully vaccinated. The Public Health Agency of Canada has released guidance allowing those who are fully vaccinated to have small gatherings indoors without masks or distancing. But, despite lower COVID case counts and the effectiveness of vaccines in reducing transmission, people who are unvaccinated will continue to be at-risk.

So how should primary care practices balance in-person and virtual visits going forward to deliver care that is timely, effective, patient-centred, and equitable but that also keeps patients and staff safe?

It’s time to move away from a virtual-first approach towards a patient-directed approach. In a virtual first-approach, clinicians are the first judge on what mode of care is appropriate. In a patient-directed approach, patients are the first judge of appropriateness. A patient-directed approach would support more equitable and efficient care.

When patients contact the office, they should be asked in an open-ended way whether they would prefer an in-person visit, a telephone visit, or a video visit. They could also be reassured about the vaccination status of the clinic staff, and that in-person visits are considered safe.

Clinicians can still help guide the visit choice, for example by recommending an in-person assessment following a virtual one or vice versa—or by sharing booking guidelines that outline which issues generally require in-person care. We can also embrace new modes of care, such as video and email, which will further support our ability to successfully balance in-person and virtual visits and meet patients differing needs. For example, video offers the ability to visualize bodily symptoms and better build therapeutic relationships and may in some circumstances obviate the need for an in-person follow-up, more so than phone calls.

Some  people may continue to prefer virtual appointments because these do not require taking time off work or paying for childcare or transportation. Other people, such as those with impaired hearing or language barriers, may prefer in-person care.

In a patient-directed approach, care is more efficient because there are fewer dual visits than when clinicians must assess every person on the phone before bringing them into the office (as is currently the case).

Some outpatient clinics have set arbitrary targets of 50% or 75% of visits being in-person during post-pandemic recovery. However, it’s unclear if those targets reflect patient preferences and needs. That’s why it’s important to start with a patient-directed approach, see if this aligns with provider and office capacity, and adjust accordingly.

Of course, as in-person visits ramp up, practices will need to be mindful to maintain a safe environment. Infection control practices such as symptom screening, masking, and hand hygiene should be implemented universally because differential practice policies for patients who are and are not vaccinated heighten shame and stigma. Given evidence of airborne spread of COVID-19, practices should take steps to ensure good ventilation  and aim to maintain physical distancing in waiting rooms by monitoring visit volumes and reducing unnecessary waiting. Most practices will not be able to operate at pre-pandemic in-person volumes. While patient preference is key, physicians may also have to consider which visit times to proactively prioritize. The following box provides a summary of proposed priorities for in-person assessment.

Proposed priorities for in-person assessment

  • New or worsening symptoms requiring in-person assessment including those with COVID-19 symptoms or issues related to mental health and addictions
  • Chronic conditions especially those with suboptimal condition or risk factor control, those who have difficulty engaging in virtual visits, and those who have not had an in-person assessment for more than one year. Special consideration should be given to people with mental health and addictions, especially those where it is difficult to build a therapeutic connection virtually
  • Prenatal care & routine childhood visits
  • COVID-19 vaccination (provision of vaccine and counselling for those who are difficult to engage virtually)
  • Pap tests, starting with those most at risk
  • Immunizations, starting with children, youth, and older adults

Providers will always need to prioritize office assessment of patient with new or worsening symptoms who need to be assessed in-person. Practices should accommodate patients who walk-in, a way to lower barriers to access for those who struggle to connect virtually.

Much chronic condition management can occur virtually for patients who are comfortable and have good disease and risk factor control. Patients with chronic conditions who have not been assessed in-person for one year or more should likely be asked to come for an in-person visit.

Catching up with missed preventive care should be a priority. Mammograms and colorectal cancer screening can be arranged virtually for most people. People overdue for Pap tests should be booked in-person in a staggered manner, starting with those most at-risk. Children overdue to receive routine immunizations should be prioritized. Many youth have missed out on school-based vaccination programs and depending on the local public health unit, catch-up may need to be done in primary care. Older adults are most at-risk from COVID-19 complications and also may not mount a robust immune response to the COVID-19 vaccine; vaccination for pneumonia and influenza are particularly important for this age group to avoid the risk of dual infections.

Well baby and prenatal visits will need to continue to be in person, as they have been throughout the pandemic. But the post-pandemic recovery is a good time to remind patients that “annual physicals” are not needed for most well adults.

Finally, primary care offices are poised to play an even more important role with COVID-19 vaccination as we enter the “last mile” of vaccination and contemplate boosters. Having COVID-19 vaccines in the office may allow for opportunistic persuasion of some Canadians who remain hesitant.

What about people who may have COVID-19? Given the planned closing of dedicated COVID assessment centres, primary care practices will need to become comfortable with assessing (and testing) patients with COVID-19 symptoms. Regulatory directives make clear that in-person care cannot be restricted to those who have been vaccinated or have a recent negative COVID-19 result. However, patients with COVID-19 symptoms should be separated in time and space from those without, for example, by having them come at the end of the day and wait and be seen in a separate exam room.

Virtual care is here to stay but has limitations. In the post-pandemic “new normal”, primary care practices need to continue to embrace new ways of doing things while prioritizing patient preferences, striving for equitable access, and catching up on missed care.