Updated March 23, 2022
Physicians are working hard to support each other and the public through this pandemic. Our goal is to provide clear information to help guide you as you exercise professional judgement to practice in this environment. If your question is not addressed here or if you need further support beyond the information provided below, please don't hesitate to contact us
How do I balance providing in-person and virtual care to my patients?
Every practice is unique and finding the right balance will require judgment on the part of the physician to consider the merits of virtual vs. in-person visits and to determine which approach is in the patient’s best interest. Physicians should be continuing to utilize both in-person and virtual visits based on clinical need. It is critically important that the standard of care is always met, which means in many cases, care will need to be provided in-person.
Not all patients will be able to get the care they need virtually as there are limits to what can be done virtually. In-person care is essential for many conditions and some patients do not have adequate access to virtual care. For example, where patients have difficulty communicating virtually, where physical contact is necessary to provide care and services (e.g., newborn care, prenatal care, vaccine administration) and other diagnostic and therapeutic procedures (e.g., Pap smears and biopsies), or where physical assessments are necessary to make an appropriate diagnosis or treatment decision (e.g., infectious conditions, post-operative care, chronic disease management), patients need to be seen in person.
It is important to remember that the standard of care must always be met. As CPSO’s Telemedicine policy states, physicians are expected to consider the appropriateness of providing care virtually in each instance, and if virtual care is provided, the care must meet the same standard of practice as would apply in person. In addition to our policy, helpful resources regarding the limits and appropriateness of using virtual care have been developed by the Ontario College of Family Physicians, Canadian Medical Association, Ontario Medical Association, OntarioMD, and the Quality Division of Ontario Health and Ontario Telemedicine Network.
The government has ended the mask mandates for most settings, what does this mean for my practice?
As of March 21, 2022, masking requirements have been removed in most indoor settings in the province with the exception of public transit, long-term care and retirement homes, shelters and other congregate care settings, and health-care settings (including hospitals, psychiatric facilities, and doctors’ offices).
Physicians are still expected to take appropriate safety precautions when providing care to patients based on their assessment of each patient’s needs and requirements.
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 in your practice setting is that they wear a mask to protect themselves and other patients on site. Public Health guidance specifies that patients who are symptomatic for COVID-19 or have a recent exposure must wear a surgical/procedure mask. However, for other patients, by donning appropriate PPE and safely isolating them from other patients, you may still be able to safely provide care. If an in-person visit is not needed to meet the standard of care, you could alternatively offer virtual 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 restrict in-person care to only those patients who have been vaccinated or have a recent negative COVID-19 test result?
No. In-person care can be provided safely — even in the absence of a negative test result or vaccination — by taking appropriate precautions, including screening patients and using necessary PPE. While you can encourage eligible patients to get vaccinated, patients cannot be denied access to necessary in-person care based solely on their vaccination status. Similarly, it is not appropriate to deny in-person care to patients who screen positive, but have not yet had a COVID-19 test if in-person care is needed and adequate safety precautions can be implemented. The Ministry of Health has identified one exception, namely, that in areas where community transmission of COVID-19 is not low, patients who are scheduled to undergo a surgical procedure requiring a general anaesthetic and are not fully vaccinated should be tested, and non-urgent procedures should be delayed if the test is positive.
If you have questions about the precautions you should be following while providing in-person care, please refer to the FAQ below, “What safety precautions do I need to take when providing in-person care?” CPSO also recognizes that in rare instances, physicians in high-risk populations may need to limit access to in-person care. For more guidance, please see the FAQ below, “I am worried about my safety and I’m not currently able to see patients who require care. What should I do?
How should I manage patients with symptoms of COVID-19 seeking care?
Some symptoms of COVID-19 are similar to many other conditions (e.g., flu, COPD, sinusitis). Public health guidance states that physicians should not delay assessment and treatment of issues which have symptoms that overlap with those of COVID-19 but are clinically evident of a different diagnosis. Physicians will need to use their clinical judgement, taking into account local epidemiology and exposure history, to assess and treat these types of issues in a timely manner. While patients with these symptoms should be referred for testing and need to be told to self-isolate until a negative result is received, access to appropriate care should not be denied (including access to necessary in-person care, providing appropriate precautions can be taken), even if the patient has not yet been tested.
What safety precautions do I need to take when providing in-person care?
The Ministry of Health continues to provide guidance on how to safely provide care during each stage of the pandemic. The most up to date information can be found on the Ministry of Health's website, where guidance is provided for different sectors within the health care system.
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. You can also inform patients about the safety precautions you’ve put in place to ensure compliance with these measures.
Pandemic-Related Practice Issues
Patients are asking me to write notes supporting a medical exemption from COVID-19 vaccines — what do I need to know?
Patients may ask you to write notes or complete forms exempting them from getting vaccinated. If you are asked by your patient to provide information supporting a medical exemption from receiving a COVID-19 vaccine, your patient must have a legitimate medical condition that would warrant an exemption.
The National Advisory Committee on Immunization (NACI), the Ministry of Health, and some public health units have provided guidance regarding contraindications for COVID-19 vaccines. The Ministry of Health has also provided guidance about medical exemptions in the Medical Exemptions to COVID-19 Vaccination document, and guidance for specific allergy populations in the COVID-19 Vaccination: Allergy Form document.
Generally speaking, there are very few acceptable medical exemptions to the COVID-19 vaccination (examples include an allergist/immunologist-confirmed severe allergy or anaphylactic reaction to a previous dose of a COVID-19 vaccine or to any of its components that cannot be mitigated, or a diagnosed episode of myocarditis/pericarditis after receipt of an mRNA vaccine).
Given the rarity of these exceptions, and in light of the fact that vaccines have been proven to be both safe and effective, any notes written for patients who qualify for a medical exemption need to clearly specify:
- the reason they cannot be vaccinated against COVID-19 (i.e., document clear medical information that supports the exemption); and
- the effective time period for the medical reason (i.e., permanent or time-limited).
While physicians are generally required to complete third party medical reports for patients when requested, the circumstances of the pandemic support physicians declining to write notes or complete forms when the patient making the request does not have a medical condition that warrants an exemption. If you find yourself in this situation, clearly and sensitively explain to your patient that you cannot provide them with a note or form, along with the reasons why.
It is also important that physicians work with their patients to manage anxieties related to the vaccine and not enable avoidance behaviour. In cases of serious concern, responsible use of prescription medications and/or referral to psychotherapy are available options. Overall, physicians have a responsibility to allow their patients to be properly informed about vaccines and not have those anxieties empowered by an exemption.
The Centre for Addiction and Mental Health (CAMH) has a COVID vaccine clinic that has been adapted to better support individuals with mental illness, substance use disorders, dementia and other neurodiversity. CAMH offers specialized care, for example, by ensuring that there is no visible medical equipment in the clinic or at the vaccination station, and allowing extra time between appointments for more questions and counselling if needed.
What do I do if a patient has an expired health card or a red and white health card?
Due to COVID-19, the Ministry of Health has extended recently expired health cards (on or after March 1, 2020) and red and white health cards so that they remain valid. You should still be accepting these health cards from Ontario residents at this time until the extension period ends on September 30, 2022. If a patient does not have a valid Ontario health card, you should not turn them away. You can use the billing codes identified by the Ministry of Health for those without OHIP or another provincial health plan.
Why should physicians get vaccinated?
Having a fully vaccinated health-care profession is critical to minimizing the risk of COVID-19 transmission and/or outbreaks in offices, clinics and hospitals. Even if you do not feel sick, asymptomatic infection and subsequent transmission is possible. The COVID-19 vaccine reduces your chance of becoming infected and is the best way to control the spread of the virus, and so getting vaccinated is an essential step to protecting your own health, the health of your patients, and the community at large.
This pandemic offers physicians an opportunity to lead by example. By getting vaccinated, physicians can help relieve the strain on our health-care system and support the health, safety, and well-being of the people of Ontario.
COVID-19 – now a vaccine preventable disease – is among the leading causes of death globally and known to have prolonged, wide-ranging impacts. High vaccination rates are important because they help achieve herd immunity and protect people who cannot be vaccinated.
While the College recognizes that some physicians cannot get vaccinated due to medical contraindications, those physicians can still provide strong leadership on COVID-19 prevention and continue to advocate for full vaccination of all those eligible.
How can I send prescriptions electronically when providing virtual care?
Given the nature of practising through a pandemic, most physicians are well-equipped to provide care virtually when needed and should be in a position to transmit prescriptions to pharmacies using secure and established channels such as telephone, fax or e-prescribing systems. Sending electronic prescriptions directly to patients increases the risk of fraud, places undue pressure on pharmacists to verify the authenticity of prescriptions and impedes the delivery of safe and timely care.
As always, work with your patients to identify their pharmacy of choice, and then coordinate with the pharmacist to determine how best to transmit the prescription securely. If you encounter any challenges, collaborate with your pharmacist colleagues to find the right solution for everyone.
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 and need access to 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.
Professionalism and Complaints
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.