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Health care workers don personal protective equipment before entering a negative pressure room to care for a COVID-19 patient on a ventilator at the Humber River Hospital in Toronto on Dec. 9, 2020.Nathan Denette/The Canadian Press

Virtual doctor’s appointments have become the norm since the start of the pandemic, but as Ontario starts to emerge from the worst of COVID-19, there is mounting tension over the role virtual care should play going forward.

Some emergency physicians say a small number of family doctors are taking advantage of the system by only taking virtual appointments, forcing patients to seek in-person care in the emergency room, which is causing huge bottlenecks and ballooning wait times.

The problem is serious enough that it prompted the province’s Ministry of Health, regulatory college and Chief Medical Officer of Health to issue a rare joint statement last week calling on doctors to resume more in-person patient visits.

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“We know that many physicians are striking the right balance between virtual and in-person care – however, collectively we are increasingly hearing about physicians’ offices that are not providing in-person care,” the letter said. “There are limits to what can be done virtually and the standard of care is often difficult to meet in a virtual care environment.”

But many family physicians say the resulting narrative – which contends doctors are eschewing the responsibility to see patients in person when it is clearly warranted, forcing them to seek emergency care – is a simplistic take that can obscure serious problems facing the profession. They say family medicine has been facing a long-standing crisis in Ontario – one that has been exacerbated by the pandemic – and that without investment in better care, the situation will likely only worsen.

According to Ontario’s Ministry of Health, in-person appointments accounted for about 50 per cent of all primary-care physician visits in the past year, increasing to nearly 60 per cent by August.

But it appears a small minority of family doctors are primarily conducting virtual appointments, which could help explain the spillover effect being seen in emergency rooms. Data from Ontario Health show that 9 per cent of primary-care physicians in Ontario were doing 75 per cent or more of their visits virtually as of June.

Liz Muggah, president of the Ontario College of Family Physicians, said she believes the number of doctors doing more in-person visits will continue to climb, now that there is widespread access to personal protective equipment and vaccines.

“We can accept that there is a small subset who may well be overindexing on virtual care,” she said. “We need to understand why – and there’s a complexity in the why.”

Going forward, the challenge will be how to best balance virtual and in-person care, as well as to better connect family doctors to the broader health system, which is not as integrated as it could be, she added.

In the meantime, emergency rooms in Ontario are struggling to keep up with a substantial increase in visits from patients who haven’t been able to secure an in-person appointment with their family doctor. Several emergency room physicians say they are consistently treating the patients of a small handful of family doctors.

Steve Flindall, an emergency physician in York Region, said patients are often apologetic for coming to the emergency room, but say they didn’t know where else to turn after their doctor refused to see them in person.

“A lot of patients are suffering because they’re not accessing their family physicians in the appropriate manner in the last year and a half,” he said.

Dr. Flindall said he recently treated a man with severe abdominal pain who was repeatedly refused an in-person visit by his family doctor.

“As soon as I laid a hand on the guy, I realized he was sick and I was on the phone with a surgeon,” Dr. Flindall said.

The man was in the operating room shortly after to treat a perforated colon. It shouldn’t have taken a trip to the emergency room to properly diagnose him, Dr. Flindall said, but such instances have become all too commonplace, as a small minority of doctors are still refusing in-person visits. He said that because doctors can charge the same amount for a virtual appointment as an in-person visit, a few appear to be taking advantage of the situation as there’s no incentive for them to return to seeing patients at the office.

At the start of the pandemic, the Ontario government introduced several new temporary billing codes to allow physicians to get paid for virtual and telephone appointments. While there was an existing telemedicine billing code in Ontario, many physicians say the system was too clunky and complicated to be widely adopted. The government recently announced that the temporary billing codes have been extended until Sept. 30, 2022.

For Irene Zouros, an emergency physician in Brockville, Ont., the province’s recent letter urging family doctors to resume more in-person visits was a welcome relief, as she and her colleagues struggle to meet the demand from patients in the emergency room who say they couldn’t get an in-person appointment with their family doctor.

“I think it will be a wake-up call for many family physicians to revamp their practice,” Dr. Zouros said. “It’s been a long time coming.”

Dr. Zouros said she has seen several tragic situations unfold as a result of patients not being able to see their doctor in person.

Many family doctors say they support the province’s push toward in-person visits. While virtual care has an important role to play, patients also need access to face-to-face appointments, said Tara Kiran, a family physician at St. Michael’s Hospital academic family health team in Toronto.

But part of the challenge is that family doctors are also being swamped with requests from patients who delayed seeking care during the pandemic, making wait times for appointments unusually long in some cases. COVID-19 protocols mean doctor’s offices can only accommodate a fraction of the patients they did pre-pandemic, adding to wait times. In some cases, patients simply can’t – or won’t – wait for an appointment, said Alan Drummond, a physician and spokesperson for the Canadian Association of Emergency Physicians.

And in some cases, patients may mistakenly believe their doctors aren’t conducting in-person visits, perhaps because of outdated or confusing information on websites or voice-mail messages. Dr. Kiran did a survey of Toronto doctors in January, before vaccines were widely available in Canada, and found 93 per cent were conducting in-person visits, as well as virtual ones.

“I think there are obviously some folks who are not seeing people in person, but I think that’s actually a slim factor in that narrative that’s building,” said Dr. Kiran. “Many doctors have struggled with timely access before the pandemic, and now you have this backlog of needs.”

Allan Grill, chief of family medicine at Markham Stouffville Hospital, said the issue of patients seeking care in the emergency room because of issues accessing family physicians existed long before the pandemic. But the challenges of COVID-19 have made the situation worse, and in order to fix it, the root problems need to be addressed, he said.

“If you ask for too much and you don’t put the resources that are required in the community to manage patients that are not … in the hospital, it’s very challenging.”

The consensus among many physicians is that virtual care has an important role to play in Canada’s health care system, but more work needs to be done to spell out what that should look like.

Adam Kassam, president of the Ontario Medical Association, said his organization is in talks with the province about making virtual care permanent – but there are still unanswered questions about how to integrate it into the overall health care system.

“It requires a better analysis and understanding in the system about need, appropriateness, access, as well as safety,” Dr. Kassam said. “So all of those factors are still being grappled with as we move through this pandemic.”

Despite the province’s letter to doctors about moving to in-person visits, Health Minister Christine Elliott said on Tuesday that there is a role for some virtual care in the health care system.

”This is a way, I believe, that people can have greater access to medical services when they need them in a very timely manner. And so there is more work to be done to expand some of these virtual services across the province,” she said.

”This is part of entering into the 21st century of medicine.”

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