Chair's Column: Virtual Via Zoom - The New Normal?

Before 2020, I had only heard the term “zooming” as it referred to racing around very fast. And, of course, in Aretha Franklin’s song Who’s Zoomin’ Who? Something tells me she wasn’t talking about the video chatting we are now engaged in day and night.

Video chatting and virtual care seem to be ubiquitous now. Our 2020-2024 Departmental Strategic Plan (the formal release of which has been pushed back due to COVID-19) addresses virtual care as a burgeoning area that requires our attention as both physicians and medical educators. One of our aspirational goals is to ensure that the way we train physicians to practice medicine reflects the rapid evolution of artificial intelligence in clinical decision making and digital technologies in care provision that we are witnessing. The newly released Royal College Task Force Report on Artificial Intelligence and Emerging Digital Technologies aligns with this goal. An unintended, but positive, consequence of the COVID pandemic is that we have begun to make rapid strides towards this goal.  

I recently reached out to you for your updates and perspectives on virtual care, including teaching in the context of virtual care. You sent me a ton of information, and it continues to flood in! Clearly, the stresses of the COVID pandemic have not dampened your innovative spirit! I cannot do justice in this column to the enormity of the work you have done and are doing, but will instead provide a high-level summary of what you’ve told me.

Clinical practices have pivoted rapidly to provision of ambulatory care via the telephone, telemedicine and other technologies. It hasn’t been easy. The Ontario Telemedicine Network (OTN) platform was not built to handle the current volumes (improvements are ongoing), but a number of third-party tools such as Zoom, MS Teams, WebX, etc., have expanded their networks to meet the demand. The Ministry of Health introduced long-overdue billing codes for the provision of virtual care, although they will not be processing these billings until June. Whether or not these will remain beyond COVID pandemic, however, is unclear.

New programs have also been developed in a targeted response to address specific clinical stresses of the COVID pandemic. For example, Infectious Diseases at Sunnybrook launched COVIDEO to provide follow-up care to COVID-positive patients in their homes. GIM and Palliative Medicine have partnered with colleagues in Family Medicine to launch Long-Term Care +. Leveraging their data analytic and QI expertise, GIM consults and additional ancillary services, like STAT labs and mobile diagnostic imaging, are being provided to support primary care physicians to provide high quality care in long-term care facilities.

Most of you told me that virtual care is good for your patients. It offers a patient-centered alternative that saves patients time (e.g. from work) and money (e.g. parking), allows families and caregivers to participate, and helps patients feel safe during the pandemic. You also told me it was good for you as a care provider. Patients have access to useful information during the appointment, like the names of drugs and their calendar. There are fewer patient cancellations and no-shows, and overall, patients seem happy to receive a virtual visit in their home. Virtual care may be particularly useful for ‘high-frequency, low-touch’ encounters, like endocrinology patients who require frequent insulin and thyroid dose adjustments. A recent Personal Health Navigator article by Paul Taylor in Healthy Debate took a deep dive into changing practices as virtual care became the norm almost overnight, including many of its benefits and challenges. When COVID finally passes, we may see virtual care become more common in areas where it could be most beneficial and convenient for patients and providers alike.

To get a patient’s take on this, I also asked one of our DoM Patient Advisors about their own experience receiving virtual care, and this is what they told me:

I have previously had correspondence with one of my care providers when I was not feeling well. I was able to give my symptoms, blood pressure readings and temperature readings which helped my doctor send out a requisition to a lab nearby for me to do some blood work. I was able to get some peace of mind that I was doing okay. My doctor then gave me further instructions as to how I was to deal with what I was experiencing. That example of “virtual care,” to me, is an example of how reaching patients virtually can help high-risk patients and the doctors who care for them keep on top of their care and help people stay healthy.

But there are also limitations to virtual care. Many of you commented on how much can be gleaned from seeing your patient’s face when you are meeting with them. Others remarked that not all patients have access to technology, and those who do may be unable to use it due to cognitive or other disabilities. For many specialties, including my own, diagnosis and management remain very dependent on the physical examination. Technical glitches or a poor internet connection can also undermine the success of these methods. But, remarkably, you are busy figuring out how to overcome these challenges!

You are innovating on ‘virtual’ patient assessments. For example, Neurology has developed a virtual neurological examination manuscript and educational videos. PM&R faculty and residents have broadcast national webinars on aspects of virtual care, including ways to mitigate legal risks. They’ve also developed an online reference library of materials, though they have yet to figure out how to do a virtual EMG! Dermatology has patients email a picture of their skin lesions in advance of a consult using a secure hospital mailbox that staff physicians can access either from home via VPN or from the hospital. Endocrinology has developed check lists for administrative staff, physicians and patients to guide and optimize virtual care.

You are also working hard to identify the most efficient and effective ways to incorporate learners into the virtual care platforms, whether through OTN, Zoom or another platform. Most are inviting resident participation in an OTN virtual visit as a guest or having the resident call the patient and speak to the patient by phone, then conference in the staff after review. Educational sessions, even morning reports, are being conducted virtually. Some are finding the virtual format has improved attendance and enabled presentation to a much larger audience. Geriatric Medicine residents have been quick to embrace a QI initiative to track the outcomes of patients they are seeing using telemedicine and are using this opportunity to learn creative ways to show autonomy. GIM faculty and residents are developing a rotation for Core IM residents in virtual care.

Using your expertise in QI, education and research, you are evaluating models of virtual care and virtual education, and disseminating your findings, including through peer-reviewed publications. For example, the Neurology Quality and Innovation Lab has developed a cross-site working group to increase virtual care capacity through dissemination of information, relevant resources, such as billing practices and providing support to colleagues in setting up a virtual practice. Together, they are championing modifications to the EMRs to better capture virtual care encounters. They have put together a manuscript and video series on the virtual neurological examination, which has been submitted for publication.

These are but a few of the incredibly impressive virtual care initiatives underway, and this hasn’t even begun to scratch to surface of what’s happening across our hospitals.

I think it’s fair to say that digital technologies are here to stay and will be integral to how we continue to care for patients, teach, learn and meet in academic medicine. Let me close with some advice from an article from the BBC entitled “The reason Zoom calls drain your energy”. I strongly recommend you read it. Their recommendations to alleviate Zoom fatigue are as follows:

• Limit video calls to those necessary. If info can be shared other ways, do so;
• Don’t require the camera to be on all the time (it can be more stressful when on), and when it is, shift where your screen is relative to you (it’s easier to concentrate when off-centre); and,
• Build 'free' time before and after meetings for friendly banter or to disconnect completely.

It can almost go without saying now that this has been an incredibly unprecedented and disruptive time. Thank you for your courage and dedication to patient care during this scary and uncertain period. I am so very honoured to work with all of you. I also want to extend a special acknowledgement to those of you who responded to my request for information, and to those who are still to respond! If you have anything else you’d like to share about your approaches to virtual care, don’t hesitate to get in touch.

Thank you! Keep well, keep safe.