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COVID-19 FAQs for Physicians

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Updated November 15, 2021

 

Physicians are working hard to support each other and the public through this pandemic. To help inform this work, we’re keeping an updated list of frequently asked questions and answers. Our goal is to provide clear information to help guide your decision-making, the unique challenges posed by COVID-19 you are asked to continue using your professional judgement. 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.

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.

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. 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.).

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, physicians have a responsibility to communicate any positive results  directly and promptly to all patients (in practice, this may often be done by public health). 

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 aware of and are reasonably able to access an online portal displaying their results (e.g., provincial online test results website, hospital patient portal, etc.). If patients are not reasonably able to access their results on their own, negative test results will need to be communicated to them directly. 

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 February 28, 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.

 

Providing Care

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’s the right balance between providing in-person and virtual care?

While virtual care can be a helpful tool to support access to care during the pandemic, the pressures that existed early in the pandemic that led to prioritizing the adoption of virtual care over in-person care (e.g., lack of PPE, severity of the pandemic) have now diminished and, in most instances, in-person care can now be provided safely and appropriately.

Physicians should now be resuming in-person visits based on both clinical need and patient preference. 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.

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.

We know that many physicians are striking the right balance, however, we are hearing about physicians’ offices that are not providing in-person care. Given broad vaccination coverage and fully accessible PPE, COVID-19 should no longer pose a barrier to in-person practice.

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 PhysiciansCanadian Medical AssociationOntario Medical AssociationOntarioMD, and the Quality Division of Ontario Health and Ontario Telemedicine Network.

What safety precautions do I need to take when 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. Public Health’s Infection Prevention and Control Key Principles for Clinical Office Practice During the COVID-19 Pandemic checklist can be used to assist with planning and preparing for providing in-person care. You can also inform patients about the safety precautions you’ve put in place to ensure compliance with these measures (e.g., advise patients to bring and wear a mask).

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, telephone , or using web-based/online technologies), and at the point of care. Follow Public Health guidance on what to do if a patient screens positive. 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.

Physical (Social) Distancing: Set up your physical workspace and manage your practice in a way that enables staff and patients to observe physical distancing, attempting to maintain at least 2 metres distance where possible (e.g., using barriers at screening points, spacing furniture, minimizing traffic flow with signage and/or markings, having patients wait outside the office (if possible/appropriate), staggering shifts within group practices, etc.). Where it is not possible to maintain at least 2 metres of distance, you should maximize distance and minimize contact and ensure proper masking is followed.

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.

Ventilation: Consider ways to optimize ventilation to maximize airflow in your workspace by reviewing Public Health Ontario’s resource on Heating, Ventilation and Air Conditioning (HVAC) Systems in Buildings and COVID-19.

 

COVID-19 Vaccines

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.

 

Physician Safety

I and/or my family are in a high-risk population and I’m worried about my safety. What should I do?

Provided that the right safety precautions are put in place, most physicians will be able to provide care in person when it is needed. Screening patients, both when scheduling appointments and at the point of entry to the office, will help determine the level of precautions you require when seeing patients in person.

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 where you are unable to provide care to your patients there are steps you can take to support them in accessing the care they need:

  • Use virtual care to provide what you can or help triage and re-direct patients as needed;
  • Coordinate with colleagues to help provide coverage for in-person care;
  • 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 directing patients to the emergency department when these resources aren’t required, and instead do your best to help patients navigate the system to find the resources best suited for their care needs.
 

Prescribing

How can I send prescriptions electronically when providing virtual care?

By this point in the pandemic, you should be equipped to provide care virtually when needed, including transmitting 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.

I prescribe opioids for chronic pain/provide addictions treatment — how do I provide appropriate access to care for patients?

Earlier in the pandemic, physicians adapted their practice and provided virtual care to patients using opioids. The Centre for Addiction and Mental Health (CAMH) developed COVID-19 Opioid Agonist Treatment (OAT) guidance to help with the management of OAT during the pandemic. However, as Ontario is reopening and normal health care services are resuming, physicians need to adapt their practices again, including by resuming more traditional approaches to carries and office visits, and notify patients that CAMH’s guidance no longer directly applies.

Health Canada has also 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).

 

Professionalism and Complaints

What is the standard of care during a pandemic?

While the standard of care is always evaluated in context, at this stage, many of the pressures that existed early in the pandemic have diminished and in most instances will not alter how we understand the standard of care.

As always, it will be important for physicians to be mindful of and practice in accordance with any direction from the Chief Medical Officer of Health, Ministry of Health, CPSO, and hospital policies or procedures that are developed to address managing the pandemic.

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

What does the MCCQE Part 2 Pandemic Exemption policy mean for residents?

In March 2021, CPSO Council approved a new registration policy permitting the Registration Committee to issue a certificate of registration authorizing independent practice to applicants who had not completed the MCCQE Part 2 where specific criteria are met. All applications will require review and approval by the Registration Committee and interested applicants will need to use CPSO’s online application portal.

In June 2021, the Medical Council of Canada (MCC) announced that they are stepping away from the delivery of the MCCQE Part 2 going forward. In October 2021, the Licentiate of the Medical Council of Canada (LMCC) policy was approved and is broader in its application given that the MCCQE Part 2 no longer exists.

More information about the exemption and new LMCC policy can be found by reviewing the policy or companion frequently asked questions. Any questions can be submitted via the Member Portal message center.