Virtu(al) and vice: 22 thoughts on care in 2022

Does virtual care lead to a devilish erosion of our bedside skills? Or is it a godsend connecting patients with their doctors? Does it encourage convenience and low acuity encounters or does it improve access to quality care? The answer to all of these questions is yes, maybe. As provinces like Ontario and B.C. grapple with how to balance the promise and perils of virtual care, we can see how far it has come and where it is going. So, in the spirit of our digital world where the attention economy is measured 280 characters at a time, here are 22 thoughts on virtual care in 2022: Read: Dr. Soreya Dhanji: How e-prescribing has helped me find balance between in-person and virtual care Virtual care has been here since the late 1800s when Alexander Graham Bell called his doctor to ask if insulin had been invented yet. Now we have video, email, text and other messaging to provide care remotely. While different platforms since have had varying degrees of success, the pandemic accelerated virtual care to the point of ubiquity. With such widespread uptake in healthcare and use by patients—i.e., voters—it’s here to stay. “Is virtual care good or bad?” is no longer the question; “how do we best use and support virtual care?” is. With respect to Marshall McLuhan, if medium is the message the virtual care is a tool. It can be used to connect patients to the doctors and care teams that know them. It can also be used by platforms that work as virtual walk-in clinics providing low-acuity, high-volume care outside of an established relationship. Again, virtual health is just a tool. Convenience is a pejorative word. What virtual care can provide is access. Five million Canadians don't have a family doctor; of those that do, only 43% can contact them the same or next day. We can’t have strong primary care without attachment and access. Patient experience is part of the Triple Aim, and access is an important part of experience. Think of the access inherent in Amazon and Netflix and Spotify, but also consider if you would rather call/email/text your accountant/lawyer/travel agent or if you would accept having to see them in person for every issue. In fee-for-service systems, prices reflect our values. (Yes, I know fee-for-service is an immensely broken part of our immensely healthcare system, but bear with me.) If we value access and bringing care to patients then all virtual care of medically-necessary services should be in the fee schedule as a publicly-insured service. (Cosmetic, travel and other nonessential services should continue outside of the public system whether done virtually or in-person. Again, virtual care = tool.) Access is important, but so too is what we access. In an emergency we will take the first available doctor. But the evidence base for care within a relationship is incontrovertible. If we value longitudinal care as we should, then the fee paid for a visit within an existing relationship should be higher than that of episodic care. The difference in these values should be enough to incentivize appropriate use and encourage doctors to provide longitudinal care while also allowing access to any care for the five million Canadians who are still unattached or those who cannot reasonably access their doctor or healthcare team at a given time. Should fees differ for in-person versus virtual care? What is done matters more than where it is done? If we want the right care at the right time in the right place then we have to recognize that the best care is situational and having options allows maximum access. This fee conversation may be moot as more doctors wish to move to alternative payments like salary and capitation; in these systems virtual care is one of many services offered to patients, just another tool that doctors that use to provide care. A preference to pay more for video visits compared to in-person or phone calls is inequitable (with the exception that a doctor has to travel to a facility to access reliable and secure telecommunications.) For example, visually-impaired patients prefer phone to video. So do many (but not all) of my older patients. Some patients in rural areas may not have access to the highspeed internet required for video. If this seems like a sudden change of how care is delivered then get ready for the next conversation: widespread asynchronous communication like texts and emails—the ones you likely use already for most of your personal communication. B.C. already responded to the pandemic by adding asynchronous communication within fee-for-service and it could be provided easily and securely in an alternative payment model. The shift towards virtual care has been swift, especially as it became a lifeline for us to care for patients sheltering at home. Not everyone was ready. Yet like others in society many of us doctors quickly learned how to use Zoom and other platforms and many hospitals and health authorities mobilized to provide professional subscriptions to virtual communication platforms. Others like Signal remain free and secure. We have to be careful not to further burden doctors who are already overrun with EMRs and administrative tasks that take us away from the care of patients and cause moral injury, especially with 20% of us already on the edge of leaving practice. Doctors need intuitive virtual care tools that fit into our workflow and improve our efficiency. We in turn must be flexible and allow for work/life integration that builds in time for patients with urgent issues and those who need both in-person and virtual care. COVID blasted open the Pandora’s Box. We are beyond good and evil and need to focus on getting user-friendly platforms, technical support, and payment models that recognize the time and expertise involved in quality care to provide the best care we can, virtual or not. Eric Cadesky is a full-service family physician in Vancouver.

Virtu(al) and vice: 22 thoughts on care in 2022

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