‘In Dialogue’ Episode 5: Drs. Karen Saperson and Sarah Reid
In episode five of “In Dialogue,” CPSO Policy Director Craig Roxborough speaks to Dr. Karen Saperson, a psychiatrist specializing in geriatric psychiatry, and Dr. Sarah Reid, a pediatric emergency physician, about virtual care and the College’s new policy approved at its June 2022 Council meeting, as well as physician burnout and maintaining the delivery of quality health care.
Dr. Saperson is the academic representative for McMaster University on CPSO’s Council. She’s also a professor of psychiatry in the Department of Psychiatry and Behavioural Neurosciences at McMaster, as well its Academic Head of the Division of Geriatric Psychiatry, and the current chair-elect of the Royal College Geriatric Psychiatry Specialty Committee. Her research focuses on medical education, particularly in the area of assessment and education policy development.
Dr. Reid is an elected professional member for district 7 on CPSO’s Council. She is an Assistant Professor in the Departments of Pediatrics and Emergency Medicine at the University of Ottawa, and a Clinical Investigator at the CHEO (Children’s Hospital of Eastern Ontario) Research Institute. Her main academic interest lies in improving the care of children seen in general emergency departments across Canada.
Related eDialogue Articles
- Virtual Care Expectations
- Virtual Care
- Virtual Care and Post-Pandemic Practice
- Privacy and the Virtual Care Visit
- COVID-19 Raises Profile of Virtual Care
- Post-Pandemic Care
- Reclaiming Herself
- Reaching Out for Help
- Pandemic and Mental Health
- Physician Burnout and COVID-19
- Patient Bias, Physician Burnout
- Pandemic-induced Mental Health Distress
- Dr. Sarah Reid’s Council Award feature
- Canadian Medical Association (CMA), College of Family Physicians of Canada (CFPC), and Royal College of Physicians and Surgeons of Canada (RCPSC): Virtual Care Playbook (updated Mar. 2021)
- CMA, CFPC, and RCPSC: Virtual Care Guide for Patients (Jun. 2020)
- Canadian Medical Protective Association (CMPA): Telehealth and virtual care (webpage w/CMPA resources; updated Mar. 2022)
- Thinking of working with virtual clinics? Consider these medical-legal issues (revised Apr. 2021)
- Practising telehealth (reviewed Sep. 2021)
- Protecting patient privacy when delivering care virtually (revised Dec. 2021)
- Virtual care: What about consent? (microlearning activity)
- Information and Privacy Commissioner of Ontario (IPC): Privacy and security considerations for virtual health care visits (2021)
- Ontario Health: Verified Virtual Visit Solutions – Vendor List
- OntarioMD: Privacy & Security Training and Resources
CPSO presents In Dialogue, a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.
Craig Roxborough, CPSO Director of Policy (CR):
Hello, and thank you for joining us In Dialogue. My name is Craig Roxborough, and I’m the Director of Policy here at the CPSO. I’m really excited to host this episode on a topic that’s relevant to all aspects of health care and has been especially crucial in these past two years. The pandemic has been extremely challenging for all of us, for patients and for physicians, but an unexpected silver lining may be that it forced some much-needed innovation in the way that we deliver care.
We’re pleased to have today’s experienced guests here to talk about virtual care and how it’s changing the health care system. So, with that, I’d like to welcome Dr. Karen Saperson, psychiatrist, and Dr. Sarah Reid, a pediatric emergency physician, to this important discussion around the delivery of patient care. In addition to their practice and teaching roles, both are members of CPSO Council and the working group for the College’s new Virtual Care policy. Let’s start with some brief introductions to tell our listeners a bit about your practice and how you got involved in the College’s work.
So, Karen, let’s start with you. You have a background in psychiatry, both clinical and teaching and mentorship positions, and you’ve done extensive work in the field of Geriatric Psychiatry. But tell us a bit more about your career, your research and academic focus, and some of your joys being a physician educator in Ontario.
Dr. Karen Saperson, Psychiatrist and CPSO Council Member (KS):
Thank you very much for inviting me to talk about this really important topic, which is also very close to my heart. As you mentioned, Craig, I am a psychiatrist practicing in geriatric psychiatry at McMaster University. I’ve been there for about 25 years, and my entire career has been in academic medicine, where I really love the teaching/supervision aspect of curriculum development, and also relationships with other bodies important to the College and to the profession, like the Royal College. I am the academic rep for McMaster for the medical school on the Council, and have really enjoyed my work at the College, where I’ve been able to learn more about bridging that divide between academia, clinical practice, policy, government, etc.
CR: Great. And Sarah, would you please tell us a bit more about your work at the Children’s Hospital of Eastern Ontario or CHEO for short, where you work in pediatric emergency medicine? And also your role as an associate professor in pediatrics and emergency medicine at the University of Ottawa? What are some of the reasons you were drawn to this field and some of the highlights of your chosen path?
Dr. Sarah Reid, pediatric emergency physician and CPSO Council Member (SR):
Thanks a lot, Craig. It’s great to be here. Yeah, I’ve been working at CHEO for almost 20 years. And I actually trained there as well. It was very clear to me from early, early on that I was going to do pediatrics — once you know that you never sway from it. And then I was really drawn to acute care. So peds emerge just seemed a great fit for that. And it has been, it’s offered me lots of different opportunities for teaching and educating. One of the things that I love to do is to talk to docs who work outside of academic centres and provide care to children all across Canada. So, that’s been just a really amazing part of what I’ve been able to do. Over the course of my career, getting involved in Council was sort of just happenstance To be honest, the election was coming up, and somebody asked me if that might be something I’d like to do — it hadn’t been something that I’d even thought about. But it’s proven to be really interesting work that I wouldn’t have pictured myself doing. It sort of allows you to really see the inside of how this whole machinery works, and how regulation impacts physicians, something that you might have read a few things about CPSO during your training or, you know, worried about it a little bit, but there’s actually so much more that happens at the College in terms of policy development, and that sort of thing. So it’s really been a very interesting side aspect to my career that I wouldn’t have thought that I would have gotten involved in but I’m very, very delighted that I’ve been able to have the opportunity.
CR: Thanks, Karen. Thanks, Sarah. One of the reasons that we wanted to discuss virtual care with you is because you’ve both implemented or ramped up its use in your practice during the pandemic, and you’ve been an integral part of the development of CPSO’s new Virtual Care policy, formerly called Telemedicine. I’m wondering if you can reflect a bit on how you’ve incorporated virtual methods of providing care into your practice and into your academic roles. Karen, maybe we’ll start with you.
KS: Thank you, Craig. So, it’s important to remember that in mental health psychiatry, virtual care was established decades ago as a very viable alternative to in-person psychiatric services, where virtual care was able to begin to address some of the increasingly unmet service needs for mental health to remote areas, but sometimes even local areas were being able to provide that care virtually ensured that patients had care rather than no care. With the pandemic, I’ve been absolutely amazed at how the whole system has been able to pivot to adopt some of these strategies to remove barriers to care — regulatory barriers were removed rapidly and I think the College played a role in helping move that forward.
But it also happened at a time when technology was exploding and the option of using more secure platforms became available, and the use of EMRs. Where being able to stay at home at one’s computer and have access to labs and pharmacy and all of those things that are important to patient care. For my population, which is the older adult population, I think it was twofold. So there were challenges, certainly in terms of the technology, because many of that generation — and I see patients in their 90s, and some who are over 100 — don’t have that tech-savvy knowledge. And sometimes those with severe mental illness don’t have family or others to help. So, I think there were those and so for that population, there was always a need to continue seeing in-person as safely as possible. But for the vast majority of seniors who either had some technology or who had family to help, being a vulnerable population and helping to avoid coming into the hospital or coming anywhere where there are other patients and risking COVID; it has been a real bonus to be able to see them on video, particularly knowing that there is already a body of literature that suggests that the kind of work we do in psychiatry can be effectively delivered for the most part, virtually.
There are still always going to be instances where patients need to be seen in-person and, you know, certainly we can elaborate on that later on where judgment is important. But I think it has been a good thing and patients appreciate not having to — because access, there’s the tech access for older adults, which can be a challenge. But before that, the access to coming into the hospital paying for parking, getting a ride, all of those barriers were removed.
CR: You’ve touched on this a little bit already, that by working with an older patient population, there may be unique challenges that they experienced as it relates to utilizing virtual care. You commented a bit about seeing some of those folks in-person. But I’m wondering whether or not you were able to help those individuals overcome some of those technical challenges to take advantage of the benefits that you’ve also articulated?
KS: So yes, and I think, you know, the buzzword is “flexibility.” And I think the care has to be driven by patient need. If you can put that front and centre, you know, the rest will follow naturally. And I did, also, before I address your question directly want is distinguish that within virtual care, there are various kinds of care there’s telephone, there’s video. And obviously video is better, because we need our eyes to see things that can be things that perhaps patients don’t report, but which are nevertheless important to their clinical condition. So, we talked about family and utilizing family, and for us in geriatric psychiatry, it is a family-based specialty where family is almost always involved, if available, with the patient’s care. We are a team-based specialty and we utilize team members. So, there have always been throughout the pandemic members of our interdisciplinary team who are critical to the delivery of care, who continue to do home visits when necessary. Our patient population is also in assisted living facilities, where we help them come on board with the technology. So, I think it’s just a variety of options to help our patients do that. And when all else fails, the telephone — it is less ideal, but it is better than no care.
CR: And Sarah, your context is quite different in a high-intensity, fast-paced emergency department. How is virtual care being rolled out in that sort of context? Or what’s your experience been like during the pandemic and integrating virtual care into your practice?
SR: Yeah, I mean, pre-pandemic, I can think of the fact that we do telephone consultation with physicians from all over our catchment area, many times, all shift, we’re talking to people on the phone about cases they’re seeing and helping them deliver care and, you know, talking about transferring the patient, etc., if necessary. We have a follow up nurse who talks to families about results and next steps every single day, so that that sort of care was already happening. But early on in the pandemic, you know, I’m sure that a lot of the listeners will remember it when things got really quiet in peds emerges across the country, like recently, so down 50-60 percent of normal volumes, and we understood that that was social distancing, etc., that we drop our viral kind of population, but we weren’t seeing the Leukemia and the DKA and the appendicitis and so, where did all the kids go kind of thing and very concerned that we were missing patients and there was some published data on morbidity around late presentations and that sort of thing.
So, within sort of April, April 2020 I guess it was, we piggybacked on to work that had already been done at our centre to develop a video platform within our EMR to do ambulatory care. And our IT team was just incredible. And just completely, as Karen said, just the pivot and the innovation was just really something. When you work in healthcare, you don’t think that can happen, but apparently we are able to do it. So, it’s amazing. And within a month, we had launched a pediatric emergency department virtually, with the hopes that we would be able to safely reach out to a population that might not be coming when they actually needed to come, and to have an option for care for families who are really, really scared to come into the emergency department. And so that ran for many months; unfortunately, we were not able to continue that service more recently, just because the in-person volume in the emergency departments across the country have just absolutely exploded, so we need everybody working in house, but I think it did bridge a gap for families during a time when they were very anxious about having to bring their child into the emergency department. It was a video-based platform, because as Karen mentioned, eyes-on particularly impedes that sort of gestalt of the well child versus the ill child, especially in a population that we don’t have a pre-existing relationship with the patient. So, very different than a long-standing relationship with a patient that you know well that you can talk to them on the phone. And that’s a perfectly safe thing to do.
But just from a risk perspective, we really felt like a video interaction was going to be very helpful and provide us with information that we wouldn’t get over the phone. And it was fascinating to see what you can actually do from a physical examination perspective, video wise — you can have a child bouncing on the bed behind and assess their abdominal pain sort of virtually — it was quite fascinating. But I do think we saw that we could assess kids in a way that was safe, we saw that somewhere around 17 percent actually needed to be reassured and sent in-house to have something done, like a full physical exam or a test or something.
And that, from a quality perspective, it really seemed like it was very safe: we had long months of follow up, no significant missed cases, no significant morbidity associated with the service. So, a lot of the children’s hospitals across the country subsequently developed their own program. So, this is something that can be done. There’s lots of ways to do it. And we have to be thinking about quality measures and making sure that it’s safe. And there’s always an option for an in-person assessment, just because that still needs to happen in some circumstances. So, I think for all those reasons, it was really such an interesting time to see what the innovation can do for us, how we can use technology, how we can partner with families, how they can help us to assess the service and to change it and to evolve. Yeah, I mean, it certainly was an exciting time and I think we filled a gap that was really there and it was necessary for us to do something different.
CR: Something that I’m reflecting on as I listened to both of you is the observation that the beginnings of the virtual care that we turned out to use during the pandemic really did exist prior to. Karen, you talked about how in psychiatry, there’s long-standing recognition that this is a way to overcome some barriers, geographic, in particular. Sarah, you reflected on the observation that virtual care is more than just delivering care directly to a patient, it’s also engaging with other health care providers and helping to extend the reach of the specialty that you’re in. So, the past two years have really been challenging for health providers, as well as for patients. But it’s also been a time of remarkable transformation, evolution and innovation. And both of you have reflected on this already. But I’m wondering if we can dig in a little bit deeper and explore some of the real benefits of virtual care, but also some of the real limitations or disadvantages or challenges that come from integrating virtual care into a medical practice. Sarah, maybe this time we’ll start with you.
SR: Yeah, sure. I mean, I think when we were doing the virtual ED, families loved it. And I think Karen already spoke to this, I think as docs, we underestimate the impact of coming to the office, missing work, organizing daycare for other children, paying a ridiculous amount for parking, and then waiting for hours to have this appointment that you have been looking forward to — it has a big impact on people. And I think it’s not always necessary. I think that that’s the reality that we have to look at — when does an in-person appointment actually need to occur? And when could you do this virtually? And are there more creative ways of providing care that don’t have such impacts on the patient?
So, I think that’s an important concept. I think that we have to be mindful of groups that are not going to be able to access this kind of technology. The digital divide is something we need to be aware of. In order to be able to come to the emerg, you had to have Wi-Fi that was reasonable. You had to be able to navigate being able to access a Zoom meeting, and many people don’t actually have that expertise. And you know, if English is not their first language, or in our case English or French, they wouldn’t have been able to access the service because we just didn’t have the opportunity to have translation available. So, all of these things, in some ways, there’s an access issue that’s helped by virtual care. But there’s another piece for more vulnerable populations, that perhaps it exacerbates their difficulty accessing care.
Another thing that I think has come to light for me and my practice now — I mean, of course, I’ve been seeing patients in-person during the whole pandemic — we do see quite a lot of families who have accessed virtual care for their child and been given a diagnosis that would really have required an in person physical exam. A good example are things that antibiotics are prescribed for, so like ear infections, strep throat, that sort of thing. And then the patient’s still symptomatic, or they’ve had a side effect to an antibiotic that they perhaps didn’t require in the first place. And I think antibiotic stewardship is just one piece — is virtual care always high-quality care? And I’m not sure about that. And that is something that we’re seeing in my shop a lot. And I think that’s something that we all need to think about and make sure that in-person assessments are occurring when they need to, in order to be able to provide high quality care.
CR: I like the way that you talked about the benefits around access, but also that there’s equity in terms of how we understand access. The challenges of coming to an in-person visit are real and there’s an equity issue at play there. And being able to overcome some of those challenges actually just introduces a different set of equity considerations in terms of how we access virtual care. And so it sounds like there’s a real balancing act that needs to go on in terms of how we utilize and support each population that needs to be supported. Does that resonate with you, Sarah?
SR: Yeah, I mean, I think so. I think the more you dig into this issue, the more complexity that is uncovered. If we talk about our policy, that’s why we sort of tried to have these really relying on physician judgment, because that’s what we’re doing every day, all day. And I think that we have to empower physicians to apply their own judgment. But yeah, I think it’s important to highlight some of these issues that might not come to mind, depending on the population you serve and the practice that you have, you might not always be thinking about the fact that there could be some negative consequences for certain patient populations and that sort of thing. So, I think working on the policy made me realize, my gosh, this is a bit of a minefield, to be honest. And we really need to be careful about how we apply this, how it evolves over time. And I think it’s going to be a very useful tool into the future. And I don’t think it’s going to be going away. I just would hope that we all think about how we best can offer high quality care and how we can just ensure that patients are getting what they need when they need it.
CR: There’s some nice segue there, but I’m going to park it for just a moment. We’ll talk about the policy development process and where we’re landing with that in just a second. But Karen, I want to give you a chance to reflect on your experience of both the benefits, and then the limitations or challenges of virtual care.
KS: So, I think Sarah has raised some incredibly important principles. And I think the one that I would see at the core of all of this is physician judgment. We serve as a physician population of Ontario, we serve a hugely diverse population with very diverse needs. And we don’t yet have criteria about who should be seen for virtual care and who should be seen in-person. So that’s also to be parked for another iteration of the policy, perhaps, and something to be worked out within specialties. There are studies demonstrating evidence — and in medicine, we fall back on the evidence — that there are studies, reasonably robust body of literature supporting the evidence of virtual care with the provisors of using physician judgment for those factors.
But just a few small advantages in my own practice, which is an outpatient practice. And I spent about 50 percent of my time doing virtual care and 50 percent in-person because I also do ECT, which, of course, has to be delivered in-person. But for the outpatient practice, at the start of the pandemic and up until now, it has been largely virtual with slowly, slowly changing to more in-person care when required. A reduction, a huge reduction in no show rates, for example, because you always can catch patients when you’re delivering virtual care. So, from that point of view, the access — and Sarah mentioned earlier in the emergency room, you don’t have a relationship — in our practice, we do. We follow patients with severe mental illness, where a telephone call for somebody you know can provide a lot of really valuable information and is better than missing their clinic appointment.
Waitlist times and efficiency, certainly when many of my colleagues do outreach, they go from patient home to patient home or to assisted living — that, as you can imagine, takes a lot of time. And with the increasing numbers of patients on waitlist, that’s a less efficient way of seeing care than doing it virtually, where you can go from one to the other. So, these are some of the examples. I think, all of the — I’m not going to repeat the important points that Sarah made about access and technology proficiency versus the transportation, travel time costs, etc. I think there are always going to be two sides of the scale in weighing the benefits versus the disadvantages, and the equity issue for patients who are not tech savvy. But I think that we have examples in psychiatry where you’re going to need to see people, in-person patients for example, who have sensory challenges, hearing impairment, where we need to use translators — that’s much less efficient in a virtual setting than in real. And depending on the acuity of illness for patients who, for example, have rapidly deteriorated and are floridly psychotic, one needs to be able to see them and be in the room and have that kind of experience with the patient. And quite frankly, many of our patients are very lonely and isolated, and that human contact is necessary.
And I think the other important aspect of considering virtual versus in-person — most of us work in teams and team morale, it certainly can be fragmented and take a hit when we’re all in our own little spaces. And that team morale is important for doing good work for patients and achieving good clinical outcomes for our patients. So, I think it’s a very nuanced discussion. Flexibility for me is important and for physicians to be able to develop their judgment in understanding more. And for the literature now, because much of the literature was done where virtual care was studied, where it was either virtual care or no care. And so now we need to look at different sorts of studies where we compare within a population, randomly, outcomes with virtual versus in-person care.
SR: Yeah, just further to what Karen was speaking about, it’s brought up a couple of things for me. And interestingly, as part of our virtual immersion in our pediatric population, we did have some mental health patients, because, of course, we see a lot of mental health presentations in emerg. And so we studied that actually. And, you know, it proved to be really difficult to do that properly. They were offered a 30-minute slot, so you can imagine trying to interview a teenager with severe anxiety, for example, that you’ve never met before, establish a therapeutic alliance or rapport, and then finish in half-an-hour and make sure you’ve done an appropriate risk assessment. And so we partnered with our crisis intervention workers and developed an offering that seemed to work when we had a lot of support from our team. But alone as a peds emergency physician trying to do that assessment virtually in 30 minutes, didn’t feel good for us as providers and I’m not sure that it felt very good as the patient.
Another piece that came up with that particular population, and I’m sure some physicians who are doing virtual care will attest to this, is that — and maybe even Karen can speak to this — is that when you’re doing the assessment, for sensitive issues, for example, you’re not really sure who else is in the room. And so the privacy issues are significant. I had a patient’s mum recently disclose to me about some difficulties at home. And she’s followed by a mental health provider, but it’s only seeing that provider virtually, and hasn’t been able to really disclose the issue because the person who she’s having a difficulty with lives in the house. So, I think that there’s all these things that we need to think about. So again, just speaking to the complexity and really it’s that sort of risk benefit analysis. And again, the physician judgment is so key for all of us.
CR: I think both of you have commented on the real benefits, the real challenges, the real limitations, the need for physician judgment, the need for some flexibility, and what it sounds like is an almost case-by-case assessment of the appropriateness for the patient, for the individual, for the context. During the pandemic, we saw the pendulum swing really hard and necessarily towards prioritizing virtual care, perhaps even to sort of the limits of what would be reasonable to do. And I think now, what we’re seeing is a recalibration going on to make sure that physicians are striking the right balance and using the right modality that sort of fit the purpose. I wonder if you can reflect on how — and Sarah you touched on this a little bit, even in that mental health example — how you’ve been engaging in a recalibration, or what a recalibration between the mix of virtual and in-person has looked like for you and what it might need to look like for the system as we’re going forward.
SR: Yeah, I mean, unfortunately, just the realities of the pressures on the system right now have made it impossible for us to continue virtual care, because the bricks and mortar emerg is just bursting at the seams. So, it’s just not feasible for us to have another platform that has to be staffed, for example, which is, I think, a real shame. And I think that looking into the future, if we ever kind of get back to a steady state that’s manageable — and I’m hopeful that will happen — that I think we need to look at this again in order to see is there a way that virtual care, for example, is in an acute care setting? Is it a way to decant some patients? Is it a way to offer patients another offering that will allow them to access urgent care that perhaps does not need to be seen in an emergency department? I think we need to just be mindful of people’s access to primary care, people’s access after-hours, on weekends, that sort of thing. And we need to look at this, obviously, this is all part of a bigger system reboot that’s going to need to happen in order to be able to offer care at the time it’s needed by the person that should be giving it in the way that it should be offered. And in my case, that’s making sure that families have access to care for their children when their children are sick, not three weeks down the road. That’s the reality of when parents want their kid to be seen is at the time that the kid is unwell. And if the only shop in town is the emergency department, that’s where they come. And I think we can all understand that.
CR: I mean, you’ve reflected already on this idea that virtual care can be used to help triage or redirect or reallocate people to the right places to ensure that they’re receiving the care from the right sort of provider at the right time to the right issue. I think you’ve also reflected on the potential risk when other parts of the system have not got the calibration in the right kind of way. And then you, as an emergency room physician, end up seeing the consequences of patients who should have been seen in person, but didn’t get seen in person and they show up in the emergency room. Is that fair? Is that something that we might want to reflect on?
SR: Yeah, no, I think that we definitely saw lots of examples of parents who had sought care in other venues through virtual care and being provided with the diagnosis or treatment plan, etc. And ultimately, then still had to be seen in person by someone. And so it ended up being sort of twice the visits or twice the cost to the system for sort of half the care. And I think that doesn’t feel like high quality. And that would be something that I think we just need to be really careful about, the recalibration of what that should look like. Because I think that there’s lots of good virtual care happening. But I do think that there’s some that is sort of trying to circumvent the actual in-person assessment that should take place and ultimately just delays care. And I think that we need to make sure that we’re not having a lot of redundancy, unnecessary kinds of things happening that actually they’re not value added for the patient.
CR: Now Karen, the recalibration or the striking the right balance between virtual and in-person, I suspect that it might be specialty specific, in many ways that the right balance is going to look different for different specialties. And, you know, your practice might look quite different than somebody else. And I wonder if you might reflect on that balance for you or for other specialties as well.
KS: Thanks for the for the question, Craig. I think is so important to highlight the diverse and heterogeneous nature of our profession. I just want to reflect on something Sarah has said — years before the pandemic, I went to a talk by Andre Picard, where he talked about the Canadian healthcare system and the fact that one of the huge reasons that things were not as they should be is that the emergency room is the front door of the health care system. And then he highlighted other countries where it is not so and how things are. So, I think the emergency room has taken a particular toll as that front door, the sort of place where people go after they’ve either not received care or haven’t received ideal care. It is different, I think, in psychiatry, and, you know, we’ve talked about some of the examples where people have to be seen in person. But I think also, it’s important to learn the pandemic has shown us what is possible, and many of the things we would not have imagined being possible. We need to hang on to what was good and what worked, and we need to be flexible in recognizing the need to develop criteria for when in-person care is really, really needed. You know, we haven’t talked much about physician burnout, but I think that’s an important question and part of all of this — because physicians are human beings — were also a limited resource. Our goal is to provide the best care possible for our patients. We have to be here to do it. And so how do we achieve that balance?
CR: As we think about the recalibration, and the role of professional judgment in helping to make sure that we’re making the right kinds of decisions, I’m wondering, have you in your practices encountered situations where patients have been skeptical about receiving care virtually, and whether you’ve had to do any work to try to help overcome some of that skepticism?
KS: Sorry, can I quickly add something to what I said before? I wanted to raise the issue of medical education and virtual care. And I want to emphasize the point that medical students, residents have to see and have to do in order to learn. So the impact of virtual care on the education, particularly in shorter residencies, like family medicine, where you don’t have extended time, some family medicine residents have done their entire residency during the time of virtual care. And I think the toll on that, and the impact on that, is going to be felt in different ways for years to come. So, I felt that that’s an important point to mention.
SR: Yeah, I would agree totally with that, Karen. I mean, it’s sort of twofold, right? So, the one side is that many of those residents may not have just had the in-person experience that they would have had, hands on the patient kind of experience. And then the other piece is that we need to be training residents to be able to do virtual care, right? Like we need to develop curriculum and develop a wave to teach the skill because it is a skill set. I felt initially, gosh, our group was so nervous to do this, how can we even conceive that we’re gonna be able to see a patient over video? And how is that going to feel? Does that feel safe, particularly, as I mentioned before, when you don’t have a previous relationship with the family or the child, so you get comfortable, you get good at it. But we’re speaking about experienced physicians who’ve been in practice for years kind of thing — it’s different to start out your practice and then be required to do something that really, you know, is a whole different way of practicing medicine.
CR: Are there specific things that you’ve learned from your experience delivering care virtually, where you’ve had to change the way that you delivered care or change the way that you engage with the patient in order to suit or fit the virtual modality?
KS: Oh, definitely. Definitely, I can think of many examples. I mentioned earlier that very early on, we learned that — I didn’t know before that — for example, patients who had difficulty hearing — and that’s many older adults — could not be assessed appropriately and adequately over certain kinds of virtual care. So, telephone is out and for video, certain enhancements had to be made and some equipment used to make it easier for the patient. So, that’s one example. When there are very large families who want to be involved, modifications have to be made. The technology has also improved over the course of the pandemic, so that has helped, certainly. But I think knowing, learning as we go along, helps to anticipate and helps to put certain things in place. Using translators, for example, for people whose first language is different than English.
SR: Yeah, I mean, I would say for our side, you did definitely learn how to modify your physical exam to do some maneuvers, having parents involved, creativity was paramount. I think the other thing was the counseling was different, right? Because you have to talk, you have to be very upfront about what this can do and what this can’t do. And that’s part of the consent piece at the beginning of the interaction, but also at the end, when the discharge instructions were different, because you had to be very upfront about what you weren’t able to assess. And really explicit discharge instructions, like we emailed written discharge instructions to every patient, and they were probably more explicit or had different content than they would have had there been the more traditional in-person assessment, certainly.
KS: And just to add, also, just a very important example from psychiatry is doing a new assessment on a patient where there’s a concern about risk. So, for example, suicidality and anticipating that one might have to issue a Mental Health Act form. There are particular implications there in delivering virtual care, as compared obviously to in-person, so to take that into consideration and anticipate wherever possible.
SR: Yeah, and one other thing that we had set up with our program was I had mentioned that 17 percent or so of the children had to be sent in for an in-patient assessment or testing and that sort of thing. So we had a pathway that was developed wherein the communication with the in-person emerg, the patient was an unexpected patient, any testing could be ordered ahead of time, streamlining the pathway for the family. And so they understood how that would work. But again, it sort of goes to having a process by which you can organize an in-person assessment, if during the virtual assessment, you realize, gee, this is more than I thought, or there’s something that we really do need to do in person, like you do have to have a mechanism for that. I think that’s really important.
CR: So I’m hearing that there’s been a lot of learning in the past couple of years about what we can do, what we ought to do, how to best do it, and how to structure and support the team, the institution, and patients and families as a part of the delivery of care. And that there’s a lot of work still ahead of us. I think, in terms of taking those learnings, operationalizing them, implementing them into our processes, and then adopting or integrating them into our medical education programs so that these skills are taught and these learnings are sort of entrenched in our new generation of practitioners. Is that a fair reflection?
SR: Yeah, for sure.
CR: I wondered then, maybe we might segue a little bit and talk about our new Virtual Care policy and your role contributing to the development process. The Virtual Care policy aims to guide physicians in navigating this rapidly growing space. And you both had an opportunity to be members of the working group that helped to shape the direction and the expectations that we set out in that policy. I’m wondering if you might share what some of your findings were as a part of this process in developing the policy, and what some of your recommendations were as a part of the working group to make sure that CPSO landed in the right space with this particular policy?
SR: Yeah, I mean, I think that it was such interesting work. I think one of the highlights for me is that we have public members of Council on the working group and so to hear a patient’s perspective was really critical. Just speaking to that sort of access issue, how much the in-person assessment can have an impact on work and life in general, and to just be sensitized to that; we sort of normalized it in our minds, I think, and it’s really important to have a patient perspective, in terms of what that feels like to be from the patient’s side of things. So, I think that that was really key. I think that we really tried to centre this on the standard of care — what should be sort of all our goal, we should always have that in mind, whether it’s in person, whether it’s virtual care, it should always be the same.
I think if we ground ourselves with that sort of goal in mind, that can really go a long way to understanding where the physician judgment comes in. If you keep the patient central to that decision-making, than I think it should be no different than any other care that you’re providing to be perfectly honest. And we tried to not exceptionalize this too much, because it actually is like any of the care that you’ve provided, that you put the patient in the centre, and try and offer care that is of most benefit to them, acknowledging that there may be patient preferences, there may be issues around access, there may be other things that come up, and then you together have to do some shared decision-making around the risks and benefits of the way that the care is going to be provided. And just ensure that there’s a safe mechanism by which you might need to shift gears as necessary.
KS: I would agree with Sarah and that keeping that principle of the standard of care front and centre and, within that, reminding ourselves that because of the diverse work that we do, the geography of the diverse regions of our province, there was a need to have broad principles, providing guidance, but not being proscriptive. I think the advice documents that go along with our policies are very, very helpful for me, as a physician, reading this to see how this policy fits my particular work. In addition to the value of the public members, I think the stakeholder engagement has been such an important process of every policy development. And I’ve been really surprised by how the responses and how that makes one think and rethink one’s own position on some aspects of the policy and the language that we use. Some of the important principles that we’ve raised before in this discussion, things are going to come down in some instances to judgment, there are always going to be outliers and unique situations. But keeping those sort of broad principles in mind, but avoiding the pitfalls of being absolutely proscriptive.
SR: Yeah, I mean, I think that’s true. Karen, just as you were talking, I was thinking that it’s a very humbling exercise to work on these policies, because you sort of come in with your own idea of what this should look like, etc. And then the consultation process that happens sort of twice over the time that the policy is getting developed, the background work that’s done by staff in terms of trying to look at best practices from across the country in terms of an environmental scan and that sort of thing, it really makes you realize the complexity of this issue. And I can say, “Oh, yes, in the peds emerg, this is what we did.” But I’m not a primary care provider with a large practice of patients that I know well, where the application of this would be completely different. And I think we need to come into the policy process with that kind of blank slate, understanding that this is very diverse population, diverse physicians, diverse specialties. The application of this is really going to depend very much on who and where and how you practice, and acknowledging that it’s really important.
We want to be centred around providing high quality care, but I think we really need to acknowledge that at the end of the day, physicians do know what they need to do. They know best actually. We can provide — it’s important for us to provide guidance, but I think we need to respect the autonomy of the physician and respect the judgment that is involved in medical practice.
KS: And the thoughtfulness also that went into policy development around principles related to EDI was very, very educational and informative for me, being mindful of those principles in which the College, of necessity, is moving in the direction of was a huge learning curve for me too. And I think that those principles apply to the Virtual Care policy as they do to every policy.
One of the other things that came to mind was the discussion in the policy development that patient preference is not always best care. And so patient preference is important, it’s one factor in several factors and should always be thought about as a principle, but isn’t necessarily the way to deliver the best care and where the physician judgment really comes in.
CR: You both have talked about the way that the policy has been drafted to try to be principle-based. And given all of the learnings that we’ve had over the past couple of years and the evolution that’s likely to occur in the future. Karen, you commented on this a little bit earlier in the conversation about the need for practice guidelines, or specialty associations to come together and help to articulate what is or is not appropriate. And the policy, I think, I think we tried to find a space where the policy is flexible enough to leave it open for future work to be done. How do you see the next couple of years playing out in that space, if I can put you on the spot?
KS: Well, back to the issue of how much we’ve learned during this pandemic, which has really driven a lot of the change around virtual care and the way in which organizations think about it, and including the College and the way in which we’ve drafted the policy, I think organizations have to also show that flexibility. I know that I’m diverting from the question that you’ve asked, but I would like to talk about physician burnout. And the way in which this — the virtual care — relates to physician burnout, and the way in which organizations are going to take up various approaches, standards and policies. Because I think it’s really, really important. And Sarah and I have had some discussions around this, we see this a little differently. So, for me, virtual care and the flexibility around virtual care is something that can address the epidemic of physician burnout. I think the numbers around burnout are staggering, even pre-pandemic. And many of the studies and surveys that have been done during the pandemic are just quite alarming and shocking with respect to physician and other health care providers — but I’m most familiar with the numbers around physician burnout — I think allowing that flexibility to deliver care in a way that meets the standard of care for patients and also allows physicians to be human.
Just an example, during the pandemic, physicians are also parents and physicians are also caregivers for aging relatives, and having to deal with their own issues around perhaps having disorders that make them vulnerable to COVID. And being able to negotiate the way in which care is still delivered to patients, and also protecting themselves and their families where the standard can be met is very, very important. I know that many physicians of my generation still see medicine as a calling. I think physicians now are much better educated, where there’s formal training and education around burnout and wellness and protecting oneself. So, I think just highlighting the fact that physicians are human with human needs is a very important factor in addressing burnout. The whole issue of personal resilience is a hot potato in the question of physician burnout. And I think there’s an absolute need for organizations to adopt cultural change, which includes flexibility around how care is delivered, rather than the onus being on physicians themselves to develop their personal resilience.
CR: So, Karen, you bring up a really important issue. The College along with many other health system partners like the OMA, the CMA, the CMPA, we have all made physician burnout an area of focus. It was an issue that existed, obviously, pre-pandemic, but the pandemic has really, I think, started to intensify some of those feelings. And if I’m hearing you correctly, virtual care might be one of the tools that we can implement collectively to help address some of the issues that physicians are feeling from a burnout perspective. Sarah, how do you see physician burnout affecting practice? What sort of strategies have you personally put in place? Or how do you think the College can help to support this important issue?
SR: Yeah, I mean, maybe I could just say one thing related to Karen’s comments. I agree. I think this is a tool that we can use to have some flexibility in our practices to perhaps mitigate some of the issues around burnout, have physicians be able to design a practice that’s sustainable for them. I do think that there’s one piece of virtual care, which includes, for example, direct messaging with patients around results management and that sort of thing through EMRs, that I hear from a lot of colleagues as a major driver of burnout, to be honest. So, I think we need to be careful about some of these tools and results being released to patients prior to you being able to discuss with the patient, and then, suddenly, there’s many hours added to your work week because you’re doing that kind of EMR management. So I think, just like all the things that we’ve talked about today, there’s a plus and a minus to these things. And so, I think we could have a whole discussion about EMR, like lots of benefits, but lots of extra administrative tasks downloaded to physicians. So, I just thought I’d make a little point about that.
Yeah, I mean, it’s a huge crisis. Let’s face it, in my own specialty, whether it’s peds emerg or emergency medicine, in the next few years are going to be very, very difficult as we move into whatever this next phase is going to look like — there’s major overhaul of our system that’s well overdue. And for many physicians, I’ve never heard as many people talk about what they’re doing next after their medical careers are over in their mid-40s. That’s a pretty shocking thing to hear for people that have trained for many years, for whom, in many cases, this was a childhood dream, to have this job, and who feels still very connected to their patients and the privilege of practicing medicine, and yet cannot see past the next few years in terms of what that career might look like. And that to me is really devastating to think about that, when I think about my colleagues, and what it was like when we trained and what we thought our careers were going to look like.,
So, what can we do about this big, hairy, practical problem? I agree with Karen. I think it’s very easy for people to talk about personal resilience and I don’t think that is fair. These are not people who are not resilient; these are people who work in a system, which is very broken, and the moral injury associated with working in a system and trying to provide care to a patient that you can’t provide because of system issues — can’t provide in a way that you feel is reflective of what you would want to offer the patient is — it’s a hard place to be. There’s no easy answer. I would say that for my own practice, depending on the day, I feel differently. I have luckily got a raft around me of colleagues, and wider friends and family that support me to be able to do this job and that’s critical. And so, I think for those out there, trainees or people at the beginning of this job, it’s a wonderful job, it’s a humbling job and it’s a very meaningful job, but it is a very difficult job. And so to build some kind of support system around yourself as you embark on this career and progress through this career, I think it’s critical. I mean, it’s not so different than lots of other jobs and what we know about life, that having that kind of structure around you that can provide you with the support that you may need at times when things are tough, has just been really life changing for me and for many others. That’s what keeps things afloat.
CR: And Karen, I have to imagine given your specialty, you have some thoughts on how this can be so challenging both individually and as a collective, as a profession. I wonder if you have some thoughts to share as well?
KS: Absolutely. I think Sarah has raised such important points. There is no other career that I would rather have chosen. I have loved every day pretty much going into work and, yet, it’s hard. People are exhausted. I feel exhausted. I think people are angry. Our patients are angry because they are exhausted too and I think people will refer to the mental health epidemic, which is likely to follow the physical health issues of COVID. And I think we’re in it. People are frightened, exhausted, sad, lonely, isolated — it’s a very, very difficult time to be human and to be part of the physician workforce, where Sarah has talked about the moral injury working in this system, where our hearts are there to provide the best possible care and it’s hard because system issues, over which most physicians feel they have no control over. — I think it’s very important to remember that when we’re talking about the issue of physician burnout, it’s clearly linked to poor patient outcomes and we have to address it, we have to address it in the best way that we can and the College through our policies is one of the ways to provide guidance, at least within this broken system.
And Sarah, I think you’ve highlighted the issue of not only the burnout, but the resultant physicians leaving the workforce. I hear it among our residents, which is really frightening, because they’re at the very, very start of their career. And I think, as I said, the younger generation is much better informed. They’re better informed to advocate for their needs and to set limits. And yet, how are we going to meet the population need?
One of the ways certainly talking about psychiatry, Craig, is that how can we address the stigma in with respect to seeking help for mental health among physicians. I think the College has taken steps in that regard, even in the way the questions on the annual renewal have changed and evolved over the years. So that’s one small example. I think the messaging from the CEO, from Nancy, to the profession has been very supportive, the tone has been encouraging. And while the College, clearly the mandate of the College is to protect the public, there has also been expressions of support and clear guidance for the profession during the pandemic. So, I think steps like that help. It’s important for organizations also to take steps in that way in terms of the tone of communications, and in the clarity of the guidance that is provided.
And I think virtual care, coming back to our policy, is an example of demonstrating a necessary flexibility or nimbleness within the healthcare system. And we have to be able to be nimble and to adapt in a system like this where things feel sometimes as if they’re crumbling around us, and we need to do that while still holding fast to standards. And to be able to use where there is evidence, and there’s not evidence for everything, but where there is best available evidence to guide our actions.
SR: I think it’s very important in the policies to acknowledge physician judgment. I think it’s really important that these policies go out for consultation so that physicians in the province, as well as non-physicians, have a chance to have their voice heard and to really encourage people to take part in that type of process. And to know that those comments are taken very seriously, as these policies go through their iterative changes. I think people will see that that’s happened, even in the virtual care when there were a lot of really big engagement with our end users and it’s evolved in terms of what it looks like now versus what it looked like at the beginning.
From a regulation perspective, of course, a lot of this is entrenched in legislation, the way this whole thing works in terms of the College’s role and how medical care is regulated in the province. But I think that decreasing the red tape, using this idea of right-touch regulation, wherein you’re not using the same heavy hammer for low level complaints, you’ve created an alternate dispute resolution process that can address maybe, even up to sort of 40-50 percent of complaints that come through the College, instead of having to apply the same kind of regulatory force to every single complaint. That just makes sense, you know, the quick turnaround in terms of how those low-level complaints are dealt with, I think that has a big role to play in terms of how physicians experienced that and the stress or strain of a complaint that goes on for many months can’t be overstated. So, I think having a mechanism by which low level complaints are dealt with in a more nimble and quick manner — of course, you’ve got to make sure both parties are happy with the outcome. But I think all of these sorts of changes are important. It’s all ways of trying to decrease unnecessary stress on physicians when we understand where people are at right now, because we need to protect this incredible group of docs in the province. Nobody went into this profession thinking, in 10 years I’m out. So, we really, I think, need to be very mindful about ways in which we can soften some of this and make some changes to system factors that we have control over that will make the onus a little bit less and the burden less on physicians who are practicing.
CR: So Sarah, in those comments, you were reflecting a little bit on some of the changes that CPSO has made in the past few years and identified those as ways that we can help address some of the challenges that practicing physicians are experiencing, even in their interaction with us and how that can contribute to reducing burnout, or at least addressing some of the experiences that they’ve had with us in the past. You’ve both been at CPSO for a number of years now, working in a few different capacities, on committees, on council, on the policy working group. What have you learned about the health system? And how has your time here impacted the way that you approach your clinical and academic roles? Karen, maybe I can start with you.
KS: Yeah, thanks for the question, Craig, because I think it’s an important one. Through my role as the Faculty of Health Sciences Rep at McMaster, I also learned a lot through the education outreach process, where I think it’s important to demystify many of the College processes right from the beginning, starting with I know medical students are not governed by the College, but when they come in, an introduction to the College and throughout their residency, introducing residents to some of the policies and processes and complaints process of the College early on. In terms of how this has impacted my work, I see my clinical work with a different lens. Of course, where we do our best work for patients and try to provide evidence informed care, I also see things now through the regulatory lens, looking at the legal issues and how our work intersect the care that we deliver, how that intersects not only with regulatory, with the law, but also with government, government policy, and how all of the organizations involved in the practice of medicine come together and impact on that care. And I think it has also made me approach my clinical work with a quality improvement lens, looking at how processes can be improved and efficiencies improved in the delivery of care, passing that on to learners who are there as well.
SR: I agree with Karen completely. I mean, I take the experiences that I’ve had at CPSO into other roles that I have, both academically and clinically.
CR: Well, thank you both. Any last closing thoughts or messages that you want to leave for Ontario physicians, the learners and others that might be listening to this podcast?
SR: I would say one thing without trying to be too Pollyanna-ish, because I definitely work in the system and I know what it’s like these days. I would say, what I tell my learners is yes, there’s 60 patients waiting to be seen in an eight-hour wait, which seems insurmountable, but just try and connect with the patient in front of you and give them your best. That switch in my situational awareness to the system down to the individual patient has actually been quite helpful to sort of reconnect me with the reason I wanted to do this job and the privilege of doing this job. And sometimes that can feel like a welcome kind of reprieve from when you’re working in a system that feels so overwhelmed, that if you can just connect with that patient one-on-one, do your best, move on to the next patient, do your best. And that has helped me in the last particularly six months when things have really exploded, that has helped me to reconnect with how I felt as a as a kid when I said what I wanted to do when I grew up.
KS: I think that’s a creed to live by Sarah is to just in the moment, be there for our patients and do the very best we can. And I would add to that, where one can, each of us, it’s so important to support each other — that that’s part of what makes this an incredible profession is the camaraderie that adds to the morale of our physician group. And it’s important for our learners to see that, to have it modeled rather than to hear about a dinner in a formal session or seminar. So, with the little energy that we have leftover after serving our patients, the best we can do is to be there to support each other.
CR: Karen, Sarah, thank you for joining us. We always appreciate your expertise, your experiences and your thoughtful words. Thank you for listening. We hope you’ve enjoyed this episode of In Dialogue.
Thank you for joining us, please visit www.CPSODIalogue.ca for more in-depth discussions about health care.