Vincent Lam is the co-author of The Flu Pandemic and You. He is a practising physician, a faculty member at the University of Toronto, and the medical director of the Coderix Medical Clinic.
Imagine you want to bake a lot of bread. More than 30 million loaves. Would you go to a busy baker who already produces millions of loaves? Or would you give the job to a fancy pastry chef, and tell the bread maker to wait and maybe pitch in later?
Primary care providers – family doctors and nurse practitioners – have long been public health’s strongest partner at getting vaccines to their patients. They are the experts at reaching those whom public health misses. Canada’s COVID-19 vaccination rollout needs to leverage their skill and capacity. In 2019, 40.2 per cent of flu shots were given in primary care offices. Only 4.9 per cent of flu shots were administered in the type of temporary vaccination clinics that every province is now scrambling to create for COVID-19 vaccines. Meanwhile, Ontario’s COVID-19 Vaccination Task Force includes a retired police chief and, until she resigned for travelling outside the country, the chief executive of a car parts supplier, but no family physician. Canada’s National Advisory Committee on Immunization has no family physician members, though it does have one as a liaison.
Provincial vaccine rollout plans call for a phased approach. First priority are people who are most likely to have severe outcomes from COVID-19 such as those in long-term care, and those who are most likely to contract the coronavirus such as health care workers. In the short term, the rollout will be constrained by supply of COVID-19 vaccines. The present reliance on teams going into long-term care homes and hospital-based vaccination clinics for vulnerable health care workers makes sense because it focuses scarce vaccine. Even so, delays that have left doses languishing in freezers have already shown the hazards of reinventing the wheel.
Meanwhile, ask your family doctor when they might be able to give a COVID-19 vaccine. They will tell you that at this time, despite having given hundreds or thousands of vaccines in their career, they know as much as you do. The provincial planning schematics all say that at some point the COVID-19 vaccine will be “widely available” in clinics. Although local, grassroots groups of family doctors have already begun to educate one another on the vaccine so that they can be prepared to answer their patients’ questions, no one has told them how they will be part of the rollout. Nor should they be told late in the game how to do what they already do best. Family doctors need to be at the planning tables now, in order to improve the rollout plans and integrate them into primary care.
In later phases of the rollout, the aim will be to reach larger groups of people, but still in sequential groups for many months. Relying principally on a new structure separate from primary care would mean that many eligible Canadians are not vaccinated.
The 55 per cent of Canadians who said in a December, 2020, poll that, if offered, they would take COVID-19 vaccine immediately are likely to attend the planned mass vaccination clinics once opened. The 10 per cent who don’t want vaccine at all cannot be forced to get a jab. Crucially, 36 per cent of respondents wanted to wait. This group, more than a third of Canadians, likely has reasonable questions about a new vaccine and would like to talk to someone about it first. As with any new health care intervention, patients should be able to receive knowledgeable answers about the COVID-19 vaccine from a trusted health care provider who can give them the shot. An April, 2020, poll found that 92 per cent of Canadians trusted their family doctor or nurse. Only 81 per cent trusted public-health officials.
No one knows what percentage of the population must be vaccinated to achieve herd immunity from COVID-19. For measles it is 95 per cent. For polio it is 80 per cent. No one is guessing that 55 per cent will be enough for COVID-19. Mass vaccination clinics will be important and I intend to work in one, but if we wish to vaccinate enough people to have a reasonable chance at achieving herd immunity, family doctors must be front and centre to reach their undecided patients. They’re ready! They’ve been on top of their patients’ sugar levels, blood pressure and missing shots for years.
And how to reach out? Though sorely needed, Canada does not have a centralized electronic health record system. Some provinces have a better provincial database than others, but most Canadians’ health records exist in a tangled disarray of siloed information systems that do not talk to one another. When a provincial plan proposes a sequence in which people over 80 who live in the community will be the next group, followed by those over 75, then 70 and so on, or wishes to identify people with chronic diseases and health problems in order to prioritize them, officials are just crossing their fingers that these Canadians regularly scan for public-health announcements and immediately do what is suggested.
Thus far, challenges with adherence to COVID-19 public-health measures such as masking and physical distancing make it clear that public-health direction does not immediately translate into universal action.
There is no master list to call the people in designated rollout sequences, or even to see if they have turned up for a vaccine. Primary emphasis on public-health announcements and mass vaccination clinics, which is the theme of current rollout plans, will mean that the principles of equity and fairness that all government bodies say are meant to underlie the COVID-19 vaccine distribution framework will not apply to those who have less health literacy, less family to advocate for them and are not “plugged in.”
The Canadian health record system may be fractured and dysfunctional, but right now we have to figure out how best to use it. To this end: The doctor best positioned to identify high-risk patients and give them a friendly phone call, which would be far more effective than any media campaign, is the one who has already built a trusting relationship with that patient. Family doctors need to be brought into the planning now, so that they can look through their charts – some are still paper – and begin the conversations now with these groups of patients. Family physicians are experts at moving people from “I’m thinking about it” to “sounds good, doc,” but it takes a little time. These conversations should start now, while we are waiting for doses to actually arrive. Family doctors are eager to do this, but the bread maker needs to know the size of the order to start baking.
Many family physicians have unique relationships of trust with groups of patients who are hesitant to use other parts of the health care system, often from BIPOC or other disadvantaged communities. One lesson of the pandemic has been that these groups overrepresent both the ranks of essential workers and those who have already died from COVID-19. I work in addictions medicine, and the already horrendous overdose death rates of my patients have been worsened by the isolation and societal disruption of COVID-19. Yet, many people who have suffered the most during this pandemic will be slow to trust an impersonal system that offers a vaccine. With years of care and trust between myself and my patients, I will have a much better chance of success at reaching them with a COVID-19 vaccine than either a media blitz or a doctor whom they have never met.
It is crucial to create information systems that allow family doctors to know which of their patients has already received a vaccine, and who needs a phone call. If a family doctor has 1,000 patients in their practice and 550 have received a COVID-19 vaccine at a mass vaccination clinic, the doctor needs to know who they are – so that they can focus their efforts on tracking down the remaining 450. The current Ontario database of COVID-19 vaccination is not available to primary care providers or anyone in the health care system outside of the vaccine machine. Imagine being a doctor, trying to figure out whether the non-English speaking breathless patient in front of you has heart failure or COVID-19, and having to guess whether they have been vaccinated? Once again, more vulnerable patients will be disadvantaged.
This is a massive forehead-slapping problem that would have been identified earlier if someone had asked a family doctor. The time to fix it is now. We are fortunate to have 43,500 highly trained, dedicated family doctors in this country who care deeply about their patients. We must both innovate and leverage the strengths of our existing primary care relationships, institutions and systems rather than treating them as an afterthought. Our entire health care system is predicated upon a primary care system that can accelerate the end of the pandemic if it is actively brought into the vaccine rollout plan. The National Advisory Committee on Immunization and every province’s COVID-19 vaccine rollout plan need to have family doctors centrally engaged in the leadership, planning and communication of this crucial project. Pastry chefs are more than welcome to help, but Canada needs the bread makers to do what they do best.
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