The Doctor Is In, Virtually. But for How Long?

At 6 p.m. most evenings, a Vancouver family doctor sits down at her laptop and hangs her virtual shingle: the doctor is in. While complying with pandemic-mandated social distancing rules, she expertly juggles her young children, a physician spouse and a career in a rapidly changing care environment.

This is the only time she can reliably carve out to see patients. After two dozen video-based visits and phone calls, she spends the rest of her evenings updating charts, following up on test results and setting reminders for health issues that need to be dealt with in person once COVID-19 restrictions on office visits have eased.

In the stretch of 12 weeks, Canada — and much of the world — has seen one of the biggest shifts in how we provide primary health care ever.

For most family physicians like me, virtual visits, which are usually facilitated by either phone or videoconferencing, now comprise at least 80 per cent of interactions with patients. Seeing patients remotely has been one of the only ways to adhere to social distancing orders while still providing care to people who remain more likely to be sick from something other than the coronavirus.

Encouragingly, there’s evidence that virtual visits are not just a necessary adaptation but can facilitate good quality and cost-effective care. In B.C., where virtual visits have been funded since 2012, a study found that patients who visited their doctors virtually were overwhelmingly satisfied with their care. Those same patients also went on to cost the system less money — but only if they had a pre-existing relationship with the doctor.

There were conversations about enabling better virtual care in Canada before the crisis. We were lagging behind other industrialized countries and high-functioning health systems. In 2015, at least half of U.S. health giant Kaiser Permanente’s visits were done virtually; at the same time, less than one per cent of physician billable services in Canada were virtual.

This February, the Virtual Care Task Force, a collaboration between several major doctors’ groups, called for more national leadership to increase virtual care and urged provinces to address legislative and policy obstacles. Even before this, the importance of increasing virtual care was a major focus of discussion for doctors and patients at meetings across the country.

But despite the promise of technology and artificial intelligence to improve care and outcomes for patients, the pace of change — or at least effective change — has been glacial. It took a global pandemic to pitch us out of the ice age.

Before, private operators had the edge

For years, both here and in the U.S., proponents of virtual medicine have struggled to help it realize its full potential. Hindered by technological snafus, payment barriers and patients who simply prefer old-fashioned, in-person medicine, progress has been slow. Virtual care has been largely used as the exception rather than the rule, such as for provision of specialist care to people in rural and remote communities.

In some cases, the barriers have been mutually reinforcing: provincial payment programs often only cover in-person visits; patients therefore come to expect and insist on them.

While the public system has dragged its feet, the private system has pounced on opportunity. For example, Telus Health, a subsidiary of the telecom behemoth, has rapidly expanded into this space. On the heels of its AI-powered symptom checker (which has sparked questions about privacy and efficacy), it has opened a virtual walk-in clinic accessible by any patient through a computer or phone app. To attract physicians, Telus Health pays a salary and does much of the back-end administrative work.

But it takes doctors out of the primary care system and experts are rightly worried about the potential of what they call “episodic care” to undermine long-term primary care relationships.

Luckily, the public system has come a long way in a few months. Since mid-March most doctor’s offices have been open only for visits that can’t be done virtually, such as prenatal visits to measure the size and heart rate of a growing fetus.

This rapid evolution has been necessary. Across Canada, regulatory colleges have mandated that doctors comply with social distancing orders: like anyone else, we are subject to public health directives limiting all but essential in-person services. And like anyone operating a small business, doctors have experienced tremendous stress and uncertainty: overhead costs and obligations to pay staff have largely remained the same, while office visits, which for most doctors are the only way to generate revenue, have dropped off precipitously.

Provinces have, to varying degrees, helped accelerate the pace of practice change. Most have updated billing codes to allow doctors to get paid for seeing patients remotely, though some, like Ontario, have had technological hiccups that left many providers in the lurch.

Federally, Prime Minister Justin Trudeau announced in early May over $240 million in funding to make it easier for patients to reach their doctors through video, text and phone, as well as funding for virtual mental health services.

Virtual potential

Virtual care has the potential to address access problems in our system. It could help a pediatric respirologist in Saskatoon observe the wheezing and chest retractions of a child with asthma in a small town, where residents have scant access to a family doctor, much less a pediatric specialist. It would help those with mobility issues or those unable to pay for transportation to a far-away clinic. And it’s convenient for patients, too. Recently, one of my patients on dialysis for kidney disease lamented that the travel and long periods in waiting rooms made it pretty much impossible to do anything else.

Access and distance to health care are significant barriers to people trying to take care of their basic health needs. I recently covered the practice of a Vancouver-based doctor. In one week I had visits from patients who lived in Ladysmith, Whistler and Kelowna. When I asked my patient from Ladysmith why he continued the 10-hour round-trip despite having moved away a few years back, he shrugged: he couldn’t find a family doctor taking patients in his new town, and he’d known this one for more than 20 years. The patient’s doctor had become a trusted confidante. It didn’t make sense to go anywhere else.

But research shows that longer times spent travelling to seek health care may be harmful. For people like my patient on dialysis, who drives to the hospital three times per week for the procedure, research has shown that longer travel times negatively affect patients’ quality of life. Globally, women who live in rural areas are more likely to be diagnosed with later stage breast cancers than those in urban areas. One factor is likely the longer travel time to access mammography screening, which can catch cancers in an earlier and potentially more curable stage.

There are also health issues that can be just as well managed, or even better managed, virtually. Some of the most common issues that doctors treat, such as high blood pressure and diabetes, are also conditions where a patient’s numbers during a particular visit don’t necessarily reflect their day-to-day control. To manage chronic conditions like these, remote home monitoring devices or more regular home measurements, coupled with virtual checkups, can be more effective.

Of course, the pandemic has exacerbated some medical problems. Mandated isolation at home, lost jobs and a free-falling economy have compounded many of the mental health problems we already saw in our practices. Pre-COVID, it was already a challenge to get a patient in to see a psychiatrist. Luckily, research has shown that psychiatrists treating depression are just as effective over video as they are in person. Scaling this up to help reach vulnerable people who can’t come in as a result of geography or stigma could make all the difference in helping them regain their mental health.

The drawbacks

Relationships are the secret sauce of quality primary care. Decades of research shows us that the best primary care is delivered in the context of an ongoing doctor-patient relationship. This makes intuitive sense: a doctor who knows your medical conditions and has worked with you in the past is going to be better able to apply their clinical acumen to your present medical problems.

Walk-in style virtual care casts this notion aside completely, instead encouraging patients to be seen by a doctor they will likely never know in person. Some U.S. states, recognizing this problem, require a patient to have been seen and examined by a doctor before a virtual visit is allowed.

All of this isn’t to say that in-person visits aren’t sometimes necessary. You can’t gauge body language and affect in the same way virtually. While the physical examination is far from perfect, physicians still rely on it to help make or break a diagnosis such as worsening heart failure.

Technological barriers to virtual care exist for those who lack updated computers and rapid internet connections. To address this, some systems are working to give their patients equal footing: for example, U.S. primary care provider ChenMed drops off internet-ready iPads at the homes of patients who wouldn’t otherwise be able to get online.

For doctors, seeing patients from a makeshift home office can prove a mixed bag. It can allow for flexibility and reduce overhead costs if they have fewer days in costly offices and work a day or two from home.

The system might also benefit. In one large study, people who had virtual visits to treat high blood pressure needed fewer subsequent in-person visits. In many big cities, where doctors struggle to pay for rising overhead costs, and governments are stretched thin trying to pay doctors, these may be important pieces that help longitudinal primary care stay afloat.

Many physicians, like other now-virtual workers, are also exhausted by the long days spent in front of the computer. A Nanaimo-based doctor remarked that he now goes through the days with considerably less enthusiasm: doctors are mostly social creatures and in-person interactions bring them joy and satisfaction and can mitigate the difficulties of practice. Another colleague confided that she desperately missed seeing her patients in real life: “I didn’t go into medicine so that I could diagnose and treat people over a screen.”

Across the country, as communities begin the process of opening back up, doctors’ offices will follow suit. As with many aspects of daily life, the new normal will only loosely resemble the old. Most physicians say they anticipate continuing to provide care virtually, as long as the system supports them to do so.

Out of the lockdown has come inevitable change, and an opportunity to reconsider the need for the face-to-face visit. A change, we hope, for the better.