COVID-19 has put an enormous strain on the health care sector as wards and intensive care units fill up with patients. But the impacts of the pandemic have also spread to other parts of the health care system, including family physicians.
As part of the shift online, family physicians were encouraged to transition their practices to a virtual environment. This presented challenges in effectively conducting clinical care for patients, teaching for students, and assessing COVID-19.
Two sets of U of T researchers recently published papers in the journal Canadian Family Physician to address these challenges. The first team of researchers outlined a method for creating a virtual teaching clinic using the videoconferencing platform Zoom. A second team outlined the challenges with conducting COVID-19 assessments virtually.
A method for conducting virtual teaching clinics
A trio of researchers at U of T and Dalhousie University, including Dr. Sharon Domb, an assistant professor at the Department of Family & Community Medicine, described a method for creating a virtual teaching clinic using the Zoom for Healthcare or Zoom for Education application. Zoom for Healthcare is a specific package of the Zoom software for health care professionals that is designed to integrate with medical devices.
By using the existing features of the videoconferencing platform and relying solely on the physician as the host of the meeting to facilitate the clinic, this system was designed to be easy to learn and to use by medical residents, students, and patients.
In an interview with The Varsity, Domb explained how, with a new group of medical students starting in July 2020, they needed to know how to best teach and supervise new students virtually.
“That really created the impetus for us to say [that] we’ve got to figure out a way to do all of this with videos so that we can, as closely as possible, replicate the environment that we’ve got in the office,” explained Domb.
The virtual teaching clinic model includes three types of rooms. The first one serves as the clinic waiting room. The second type hosts the main teaching session, and the third type serves as the actual clinical space where students can interact with patients in multiple breakout rooms.
The supervising physician can navigate from the main session to the different breakout rooms to observe the interaction between learners and patients. “The real-time supervision was important to be able to provide good feedback,” said Domb.
Learners are also able to navigate between the main session and their respective breakout room. The navigation ability and the designated virtual rooms enable supervisors and learners to facilitate small group discussions.
The design of this model also allows patients to maintain their privacy when seeking care virtually. When patients enter the waiting room in Zoom, they are unable to see or learn information about the other individuals present. Supervisors are able to accept them into the main session one at a time and direct them into breakout rooms.
Zoom for Healthcare also provides patients with accessibility requirements with other means to attend virtual clinics. “There were options that made it accessible to patients who didn’t have the technology,” explained Domb. Patients can access the clinic using the free version of Zoom, with a computer, mobile device, or a landline telephone. Zoom for Healthcare also allows for patients to be called from the application.
Challenges with virtually assessing COVID-19
As family physicians were encouraged to provide virtual care for patients with COVID-19, a second paper from researchers at U of T and Mount Sinai Hospital outlined the challenges family physicians may encounter when virtually assessing patients.
In an interview with The Varsity, Dr. Warren McIsaac, an author of the paper and associate professor at the Department of Family & Community Medicine, explained that this paper was written at the beginning of the pandemic to highlight then-recent findings on the limits of assessment tools in identifying the severity of COVID-19 and, particularly, whether patients needed hospital admission.
The presence of pneumonia was identified as critical in differentiating between mild and moderate cases of COVID-19. It is recommended that patients with moderate or severe COVID-19 be hospitalized, so for physicians, it was important to be able to spot pneumonia.
“So [on] the whole, really deciding [whether] pneumonia [was] present… for at least at the initial phase of this illness, becomes a critical decision point,” explained McIsaac.
The researchers first looked at whether the characteristics of COVID-19 pneumonia among hospitalized adults could inform virtual assessments. These include, but are not limited to, fever, cough, and shortness of breath. It was initially proposed that these symptoms could be used in virtual assessments.
However, the symptoms of mild and severe pneumonia overlap quite a bit. While assessing patients virtually, physicians may not have access to chest imaging that would help distinguish between mild and severe COVID-19 pneumonia.
Measuring oxygen levels in the blood has also been proposed for virtual assessments, but the researchers’ review of the evidence concluded that this measurement has a limited role in differentiating between mild and moderate pneumonia.
McIsaac explained that by the time a patient’s oxygen saturation begins declining, the pneumonia could already be advanced and severe.
Clinical signs and symptoms alone may not be enough to rule out pneumonia without imaging. Guidelines from the American College of Chest Physicians have suggested that normal vital signs and clear findings on chest examinations could reduce the likelihood of pneumonia such that chest imaging might not be needed.
However, the U of T team showed that this would only apply to younger adults. For older adults whose vital signs appear normal, chest imaging would still be warranted given their elevated risk for pneumonia and heightened fatality rates.
The American Thoracic Society and Infectious Diseases Society of America guidelines recommend the use of a particular metrix, the Pneumonia Severity Index/Patient Outcomes Research Team score, to identify the severity of pneumonia in adults. However, this may not be applicable in the case of adults with community-acquired pneumonia associated with COVID-19, since low-risk adults with COVID-19 would not be receiving specific treatment. Data on this score is designed to reflect what could be expected if adults had taken antibiotic treatment.
Is there a way for COVID-19 to be diagnosed virtually?
Ultimately, it’s not clear whether a virtual clinic can easily diagnose COVID-19 without identifying the presence and severity of pneumonia, according to the researchers.
Furthermore, the fact remains that a virtual care environment comes with certain barriers, since some elements and practices of an in-person clinical setting cannot be replicated or transferred to a virtual clinic setting.
A video call between a physician and a patient certainly eliminates some barriers that a phone call would present. Both parties are able to see each other to build a rapport, and health care providers can instruct and correct patients as they conduct and report any self-tests. However, when self-tests and virtual tools come up short, and more rigorous assessment tools like medical imaging is needed, an in-person clinical setting is required to make decisions with certainty.
Nevertheless, a virtual clinic model can create more opportunities for patients to receive accessible care with a health care provider. The development of virtual health care models might help make the system more accessible in the future. But when rigorous tools are needed to make diagnoses with a degree of certainty, an in-person clinical environment will be hard to avoid until virtual diagnosis tools advance beyond their current capacities.
Disclosure: Shankeri Vijayakumar is the community outreach and sustainability director of the Woodsworth College Students’ Association’s Board of Directors.