Updated September 16, 2020
(* indicates a newly added question)
We know physicians have questions and that those questions are evolving as the nature of this outbreak is evolving. Ideally, we would have clear answers on all aspects of this pandemic, the reality is that there will be decisions that require in the moment exercise of good professional judgement.
We know physicians are working hard to support each other and the public through this public health emergency. To help you continue this work, we’re keeping an updated list of frequently asked questions and answers. If we haven’t addressed your question, please contact us.
What are the current rules for providing in-person care?
At the beginning of the pandemic, the Chief Medical Officer of Health’s Directive #2 limited the provision of in-person care to only essential care.
That directive has since been updated to allow for the resumption of non-essential in-person care, provided that certain conditions set out in the province’s COVID-19 Operational Requirements: Health Sector Restart are met. This includes conducting a risk assessment before resuming in-person care, implementing a hierarchy of hazard controls, and implementing appropriate safeguards (e.g., physical (social) distancing, hand hygiene, etc.) in your practice.
This is not a return to pre-pandemic practice, but rather a move towards a cautious ‘new normal’ as we all adjust to the constantly evolving nature of the pandemic.
Decisions to provide in-person care must be thoughtful and made in a manner that: is proportionate to system capacity; minimizes harm or prioritizes mitigating the greatest risk of harm; is equitable; and supports those most burdened by the pandemic.
Should virtual care be the default?
The first hazard control set out by the province is elimination and substitution. This means prioritizing virtual encounters where it is possible, appropriate, and safe to do so.
However, it is not always possible to provide care virtually (e.g., where physical contact is needed) and even where it is technically possible, it may not be appropriate. As a result, physicians will need to provide a mix of in-person and virtual care, striking the right balance between the two options based on the nature of their practice and the needs of their patients.
For example, primary care physicians may find that they can provide a range of care virtually and reserving their in-person capacity for a subset of their practice. In contrast, the nature of care being provided to hospital inpatients is often best suited for in-person management, especially as patients have already left their home and are in-person, so many of the benefits of virtual care no longer apply.
In general, the College expects physicians providing care virtually to meet the same standard of practice that would apply to an in-person visit and to consider the appropriateness of providing care this way in each instance (see our Telemedicine policy).In addition to our policy, the Canadian Medical Association, Ontario Medical Association, OntarioMD, and the Quality Division of Ontario Health and Ontario Telemedicine Network all provide guidance to help physicians navigate this space.
A patient wants to see me in-person for care I can provide virtually — what should I do?
Not all patients are able or willing to receive care virtually and consideration to their unique circumstances will be needed in order to support their best interests.
You can sensitively explain the importance of receiving care virtually at this time, the supports you have in place to help them access care virtually, and that your in-person capacity is being triaged so it might take longer to receive care that way.
Ultimately, even if it’s safe and appropriate to provide care virtually, your patient’s best interests may be served by providing care in-person, provided the right safety precautions can be taken.
How do I decide whether and what to provide in-person?
The pandemic is ongoing and the changes to Directive #2 are not permission to return to a pre-pandemic practice environment. Decisions will need to be made regarding what and how much care to provide in-person. As part of this decision-making process, consider the following factors:
- Your patient’s needs, how they have changed or will change over time (e.g., negative outcomes from further delays), and what is in their best interest;
- The medical benefit or patient-perceived benefit of providing the care;
- The appropriateness of using resources to provide this care (e.g., PPE, medication in short supply, etc.) and whether other services in short or limited supply will be needed (e.g., risk of acute/critical care needs, in-person rehabilitation services, etc.);
- The risk of exposure/transmission based on the nature of the pandemic both locally and provincially;
- Whether another person, for example, a caregiver, will need to attend in-person and the additional risks associated with doing so; and
- Your ability to provide care safely with appropriate precautions to protect you, your staff, the patient, other patients, and the public more broadly (i.e., the Ministry of Health’s operational requirements and safety precautions highlighted below).
It’s important to remember that your decision is not just about what is possible or appropriate within your practice, but needs to be made with consideration to what is appropriate within the broader system.
What safety precautions do I need to take when providing in-person care?
The Ministry of Health’s COVID-19 Operational Requirements document sets out safety precautions that must be met as part of providing in-person care. It’s important that you follow guidance provided by the province or public health officials in order to implement safety precautions that are designed to protect everyone.
Physical (Social) Distancing: Set up your physical workspace and manage your practice in a way that enables staff and patients to observe physical (social) distancing (e.g., barriers at screening points, limited/separated seating in waiting rooms, assigning in/out routes with signs and/or visual markings, limiting the use of some examination rooms, having patients wait in their cars or outside the office (if possible/appropriate), reducing appointment availability, staggering shifts within group practices, etc.).
Hygiene: Have systems in place to support hand hygiene among staff (e.g., before/after every patient) and make hand sanitizing stations available to patients.
Screening: Screen all patients in advance (when possible, through video or telephone consultation), and at the point of care. If you are unable to safely isolate and/or provide care to patients with a positive screening result, redirect them to appropriate access points (e.g., emergency room if care is urgently needed). Also know where to direct patients who require testing and know when to report cases of COVID-19 to your local public health unit.
PPE: Follow public health guidelines regarding the appropriate PPE to use for the care being provided and avoid using more or higher levels of PPE than are required for the care being provided (e.g., airborne precautions if droplet precautions are recommended). The government has published guidelines to help physicians optimize their supply of PPE, access alternate sources through the PPE Supplier Directory when experiencing shortages through established supply channels, and request PPE from the provincial stockpile in emergency situations and when all other efforts have been exhausted.
Patient Safety: Tell patients in advance (e.g., at appointment booking) about the safety precautions you’ve put in place and ask them to bring and wear their own mask for their own safety and the safety of others, especially in instances where physical (social) distancing cannot be maintained. If patients do not have a mask, provide them with one or keep them isolated from other patients, and/or reschedule their appointment if necessary. Remember that some patients may have health conditions that make it difficult or unsafe to wear a mask.
Infection Prevention and Control: Infection prevention and control is more important than ever. Follow Public Health Ontario’s Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings and the sector specific guidance provided by the Ministry of Health. Public Health Ontario also has online learning resources available to help build or refresh core competencies in this area. The College has also worked with Public Health to develop a resource specifically for the Independent Health Facilities (IHF) and Out of Hospital Premises (OHP) environment.
Pandemic Related Practice Issues
*Patients are asking me to write notes or complete forms for COVID-related exemptions or clearances — what do I need to know?
Patients may ask you to write notes or complete forms exempting them from the requirement to wear a mask or return to work in-person or clearing them to return to work or school.
The College’s Third Party Reports policy sets out the general obligations that apply in these scenarios. Central among the policy expectations is the requirement that physicians be comprehensive, accurate, and objective when completing any notes or forms.
In these circumstances, your role is to provide and attest to information about the patient’s health care status or needs, and identify risks to their health, if relevant. Your role however is not to determine the outcome of the process, as it is the role of the third party (e.g., employer) to determine the outcome (e.g., whether the patient will be accommodated, etc.).
For example, this may include identifying the specific risks associated with wearing a mask or returning to work for your patient, or providing accurate information regarding your patient’s symptoms, such as whether they are the result of a pre-existing condition or are new.
This is an evolving issue and guidance to help physicians navigate each of the above scenarios is emerging.
The Ministry of Health and some public health units where masks are required have set out guidance on the limited circumstances where an individual would not be able to wear a mask. While there are variations in the specific guidance offered, broadly speaking it includes:
- any individual with a medical, mental, or cognitive condition or disability that prevents them from wearing a mask or a medical condition that makes it difficult to breathe;
- individuals who are unconscious or incapacitated;
- individuals who have a hearing impairment or work with those with a hearing impairment where the ability to see the mouth is essential for communication; and
- individuals who are unable to put on or remove a mask without assistance.
Some medical associations or specialty groups have developed recommendations regarding mask exemptions and guidance regarding specific conditions that may make it high risk for an individual to return to work in-person.
Finally, the Ministry of Health and Public Health have also set out criteria on when to discharge someone with probable or confirmed COVID-19 from isolation and considered them ‘resolved’.
Can I charge patients for any masks I provide or a fee to help cover the additional costs associated with additional safety precautions I need to take?
The College recognizes and appreciates the additional investments you are making to help serve your patients. These investments will help you provide care in the short- and long-term progression of the virus. The Ministry of Health has confirmed that infection prevention and control products or practices, including masks provided to patients, are constituent elements of the insured services physicians provide and so cannot be charged for.
What if a patient refuses to wear a mask?
If you encounter a situation where a patient declines to wear a mask, sensitively explain the expectation that they wear a mask and the importance of protecting public health by following the recommendations of public health organizations. Depending on your patient’s needs, your ability to safely isolate them from other patients, and your ability to safely provide care, you may need to defer or reschedule their appointment or redirect them to a setting that can safely provide care. Be aware that some patients have health conditions that make it difficult or uncomfortable to wear a mask, so plan ahead to help accommodate their needs and find ways to help them access care safely (e.g., providing as much care virtually, scheduling appointments during specific times, etc.).
Can I limit the number of issues addressed during in-person appointments?
It is generally not appropriate to limit the number of issues that can be addressed in an appointment at the outset (e.g., one issue per visit). Doing so can lead patients to self-triage, which is not appropriate. Instead, it’s best for you to identify their issues and prioritize accordingly. In our ‘new normal’ collect this information in advance and identify which issues can be treated virtually and which should be addressed in-person.
Be mindful that your patients may have been waiting for some time to see you and may have anxiety about addressing issues in a timely manner. Working with them to find the best way to provide care safely will be helpful.
Should I be reminding my patients that I’m available to them in-person and/or virtually?
It’s essential that patients continue to seek out care they need. Whether it’s an unexpected issue, a chronic condition that requires ongoing care, or providing general support during these times, it’s important for your patients to look after their health. An ongoing relationship with your patients means you know them well and can help them remain healthy and avoid negative outcomes that come from putting off care.
Consider letting your patients know you are available by, for example, telephone, video, or in-person as necessary. You might notify patients through your outgoing office voicemail, on your website, or through email.
*If I order a COVID-19 test for a patient, am I required to follow-up with patients on all test results, or can I rely on patients to access their results through Ontario Health’s online portal or other similar self-directed mechanisms?
Given the significance of a positive result and the imperative that patients isolate themselves, positive results must be communicated directly and promptly to all patients (in practice, this may often be done by public health). For positive results, it is not appropriate to rely on patients accessing their results via the online portal or any other mechanism that requires patients to confirm their test result on their own accord.
However, given the widespread and extensive testing that is underway, a “no news is good news” approach can be relied upon for negative results provided that:
- patients are informed that they will only be contacted regarding a positive result;
- patients are informed about how to access their results on their own accord, typically through the online portal; and
- it is confirmed that the patient is reasonably able to access their results on their own accord.
With respect to being able to access the online portal, this means the patient has a valid (green) Ontario health card, has internet access, and is able to understand and navigate a website in English. Other mechanisms for patients to access their results may vary across the province or by assessment center, and so what is needed to access these mechanisms will be specific to the circumstances.
For patients not reasonably able to access their results on their own, negative test results will need to be communicated to them directly.
Supporting the System Response
I have capacity to help, but don’t know where or how to get involved – is someone coordinating a system response?
Yes. Both the Ministry of Health and the Ontario Medical Association are working to get providers where they are needed the most. The Ministry of Health has launched a website to collect information from health care providers with capacity and institutions needing additional staffing and the Ontario Medical Association is using an app called BookJane (Apple or Android) where physicians can register with their OMA access code and create a profile to support redeployment in the system.
I have capacity to help, but doing so would mean practising outside my scope of practice – what do I need to know?
The College’s Public Health Emergencies policy enables physicians to practice outside their scope of practice during a public health emergency where urgent medical care is needed, another physician is not available to provide the care, and patients are not put at greater risk. For example, a paediatrician might help cover a colleague by seeing adult patients, or a hospital might temporarily grant privileges to a family physician to provide emergency department support. Physicians must always be mindful of the limits of their training and experience and use their professional judgment and work with colleagues to help determine how they can safely support patients.
Can I provide care or write prescriptions for myself, my family, or someone else close to me to help relieve pressure on the system?
The College’s Physician Treatment of Self, Family Members, or Others to Close Them policy sets out when it would be acceptable for physicians to provide care, including prescriptions, for themselves, their family, or other close to them. Generally speaking, it’s only permissible to do so for minor conditions or in an emergency, and when no other qualified health-care provider is readily available.
Early in the pandemic the pressure on the system was significant and the College acknowledged that departing from the policy expectation to provide recurring care for minor conditions was beneficial and helped to relieve pressure on the system. The nature of the pandemic has evolved such that this practice is no longer needed.
Should the nature of the pandemic significantly worsen going forward, there may once again be value in departing from the policy to provide recurring care for minor conditions. However, in these instances physicians must limit the care they provide to anyone with whom they are sexually or romantically involved with in order to avoid being subject to the sexual abuse provisions in the RHPA. In these instances, they must not provide recurring care. Additionally, physicians must never prescribe narcotics, controlled drugs or substances, monitored drugs, cannabis, or any drugs/substances that are addicting or habituating in any of these instances.
I am worried about my safety and I’m not currently able to see patients who require care. What should I do?
Given the broad roll-out of virtual care in the province, most physicians will be able to use virtual tools to help provide ongoing care that is needed. Additionally, provided that the right safety precautions are put in place, most physicians will be able to provide care in-person when it is needed.
However, every physician’s situation is unique and if you or your family are in a high-risk population you will have to consider the best way to manage your practice given your unique situation, the advice of public health officials, and the best evidence available at the time. In extenuating circumstances if you’re unable to provide care to your patients there are steps you can take to support them in accessing the care they need and avoid abandoning them at this stressful time:
- Use virtual care to provide what you can or help triage and re-direct patients as needed;
- Coordinate with colleagues to help provide coverage, either virtually or in-person;
- Engage with local pharmacists who may be able to assist with some types of care, like extending or renewing a prescription;
- As much as possible, avoid simply re-directing patients to the emergency department when these resources aren’t required, and instead do you best to help patients navigate the system to find the resources best suited for their care needs.
I’m self-isolating — what are my responsibilities?
If you are self-isolating due to, for example, unprotected exposure, a positive screening result, or returning from out-of-country it’s essential that you self-isolate. Follow the guidance above to help your patients as best you can while you wait out your self-isolation.
I don’t have the necessary personal protective equipment (PPE) to provide care safely — what do I do?
We know access to PPE continues to be a challenge in various parts of the system. It’s essential that you follow the current guidelines regarding PPE as they are changing as our understanding of the virus evolves.
We know that front-line physicians, especially those in hospital, may be faced with difficult decisions if PPE access does not improve. If you are no longer legitimately able to practice safely, it will be important to protect your health as much as possible to ensure you are available to support patients now and throughout the pandemic. You’ll need to exercise your judgment in each instance, considering:
- The need to support not just the patient before you, but future patients;
- The potential for harm, both to yourself and the patients before you; and
- Whether the patient is known to have COVID-19 or not, and the likelihood of exposure should you provide care.
In instances where potentially life-saving or life-sustaining treatment is needed, additional precautions are needed as this will typically involve performing high-risk aerosol-generating procedures. In these instances, consider:
- Whether the patient’s COVID-19 status is known, suspected, or unknown;
- The risk of exposure based on the specific procedures you would perform and the specific PPE that is currently not available to you; and
- The risk of harm to the patient of not performing the procedures and the likelihood that the intervention would be successful.
The College recognizes how difficult these decisions will be for physicians who are not normally in a position where they have to consider their own protection when serving patients, but it is important for physicians to strike the right balance that considers not just the patient before them, but their commitment to future patients as well.
I’ve read about some drugs that might prove beneficial in treating COVID-19: Should I be prescribing these drugs as a precautionary measure? Can I prescribe them for myself or family?
No. Many of these drugs have an intended use and prescribing them as a precautionary measure has or may contribute to drug shortages, compromising care for others. Should these or other drugs prove useful in combating COVID-19, their use will need to be carefully managed to support those who need them the most.
At a time where resources may be scarce, actions like those mentioned above dramatically depart from the core values of medical professionalism, undermine the public trust in the profession at a time where the public is most vulnerable, and may contravene the College’s Physician Treatment of Self, Family Members, or Others Close to Them policy.
How can I support patients who are isolating access medication?
Do not send patients who should be isolating to the pharmacy to access medication. Instead, tell patients to stay home, send the prescription to the patient’s pharmacy of choice, and explain the situation to the pharmacist. Physicians are permitted to share information about the patient’s COVID-19 status with the pharmacist as they are a member of the circle of care, and the information being shared is directly pertinent to the provision of care. The pharmacist and patient can then coordinate for the delivery or pick-up of the medication by someone other than themselves.
How can I send prescriptions if I’m working remotely?
By now most physicians will have adapted to practising in this new normal and be equipped to provide care from a remote practice. It is important that physicians continue to use established channels such as phone, fax, or e-prescribing systems to issue prescriptions. This helps to prevent fraud, avoid undue pressure on pharmacists, and to deliver safe and timely care to patients.
In exceptional circumstances, if you find yourself needing to work outside these established channels, make sure your prescriptions are complete, specific to your patient, include your and your patient’s identifying information, and coordinate in advance with your pharmacy colleagues as much as possible. If you are using unencrypted means of sharing prescriptions, ensure you have patient consent to do so as pharmacists may confirm with you that consent was obtained before they dispense the drugs prescribed.
I prescribe opioids for chronic pain/provide addictions treatment — how do I support physical (social) distancing with patients that are usually regularly seen?
The pandemic has created unique challenges for physicians working in these contexts. It is essential that all decisions be made in the best interests of the patient, and the pandemic requires a unique balancing of the risks inherent in opioid prescribing with those presented by the pandemic for each patient encounter.
The system has quickly adapted to help you navigate these difficult decisions:
- Virtual care may be a great tool to assist you in terms of counselling, assessing, or generally treating patients.
- Health Canada has made temporary changes to the Controlled Drugs and Substances Act that enable pharmacists to extend or transfer prescriptions, prescribers to issue verbal orders, and pharmacy employees to deliver controlled substances (see the Ontario College of Pharmacists and Health Canada for more information).
- The Centre for Addiction and Mental Health (CAMH) has also developed guidelines to help with the management of opioid agonist therapy in a time where prescribers may need to depart from normal practices to help protect all patients.
Professionalism and Complaints
What is the standard of care during a pandemic? How will the College respond to complaints that arise during this time?
The standard of care is always evaluated in context and the realities of providing care during a pandemic have the potential to alter how we understand the standard of care and that understanding will evolve with the nature of the pandemic.
Working with an evolving environment such as this can be challenging. It will be important for physicians to be mindful of and practice in accordance with any direction from the Chief Medical Officer of Health and hospital policies or procedures that are developed to address managing the pandemic.
While complaints may result during and as a consequence of the pandemic, we can reassure physicians that the College will address these complaints with consideration to the circumstances.
What should I be thinking about as I engage on social media about issues relating to the pandemic?
Physicians are reminded to be aware of how their actions on social media or other forms of communication could be viewed by others, especially during a pandemic. Your comments or actions can lead to patient/public harm if you are providing an opinion that does not align with information coming from public health or government. It is essential that the public receive a clear and consistent message. The College’s statement on Social Media – Appropriate Use by Physicians outlines general recommendations for physicians including acting in a manner that upholds their reputation, the reputation of the profession, and maintains public trust.
Registration and Licensure
I’m a recently retired physician/out of province physician/International Medical Graduate – what are my options to support the system response?
We’re doing everything we can to support those who want to get involved and contribute to the system’s response to the pandemic. The options available to you will depend on your circumstances.
Retired Physicians: If you’ve maintained your license, there’s no need to re-apply but be sure to check with CMPA about your coverage. Physicians who’ve not maintained their license will need to re-apply for licensure.
Out of province physicians: You can provide care virtually in line with our Telemedicine policy or, provided a state of emergency is still in effect, you can apply for a Short Duration certificate for 30 days with confirmation of employment from an approved facility, usually a hospital, and an identified supervisor.
International Medical Graduate: Provided that a state of emergency is still in effect and certain conditions are met, you may be eligible for a Short Duration certificate for 30 days. If you have not yet completed your residency, you must: have completed a medical degree of an accredited medical school; have practiced medicine full-time within the previous two years (including medical school); and have confirmation of employment from an approved facility, usually a hospital, and have an identified supervisor.Please note that we are only accepting applications for Short Duration certificates from those with confirmation of employment from public hospitals or other approved categories of facilities set out in the Medicine Act and with an identified supervisor. While the term of these certificates is only 30 days, they can be renewed. Please also note that future application for any other type of certification of registration will be considered in the usual course and independent of whether any Short Duration certificates were granted. Eligible applicants for the Short Duration certificates may not have the qualifications needed for any other type of certification.
If you have any questions please contact us at [email protected]