'We're in uncharted waters': Doctors adjust as virtual appointments become the new norm
Family doctors, specialists find ways to assess patients remotely during pandemic
Until a little more than a month ago, Edmonton family physician Dr. Krystle Kay-Pfau assessed only a handful of patients every week by video conference or over the phone.
The Alberta government's cap on billing for phone appointments was still being enforced and the coronavirus, while a growing public-health concern, had not upended daily life in the ways it has since.
Now, Kay-Pfau treats the vast majority of her patients virtually. Even the rare in-person appointment begins with a phone consultation.
"I think we're in uncharted waters for all physicians at this point," Kay-Pfau said. "None of us have gone through this, shifting from face-to-face care 95 per cent of the time to 95 per cent virtual care."
Most of her patients are happy with the convenience — and safety — virtual appointments afford, Kay-Pfau said. But she added there are drawbacks for both patients and their physicians, including her concern it is more difficult for doctors to convey their compassion through a screen.
Kay-Pfau is one of thousands of Alberta doctors forced to rapidly adapt their practices during the COVID-19 pandemic, treating patients from a distance when providing hands-on care isn't possible or worth the risk patients could be exposed to the coronavirus.
'I can't check the shoulder'
"I think all of us in the first few days were like, 'This is really challenging,'" said Dr. Terry Defreitas, sports medicine director at the Glen Sather Sports Medicine Clinic.
The first day of focusing on virtual care was especially disconcerting, Defreitas said, as she and her colleagues faced some of the limitations of virtual appointments.
"I can't put my hands on that knee. I can't check the shoulder," she said.
"But really, what we are trying to do right now is make sure people are safe at home and their injury is stabilized or maintained; it is not getting worse," Defreitas said. "We can improve [patients' conditions] somewhat because now our clinic is offering virtual physio as well."
Defreitas, who treats sports teams as part of her practice, said her clinic's pivot to virtual care began as she underwent self-isolation following her March 13 return from an Olympics qualifier event in Costa Rica. She called her patients and told them that for the time being, she would not be able to assess them in person.
Within days, the clinic had decided to launch a virtual care service — a "huge learning curve" at a practice where most had never done it before, she said.
In-person appointments when necessary
Defreitas said she and her colleagues now often rely on observing a patient's injury and range of motion through the patient's computer camera.
"If I am looking at a shoulder, for example, we will ask them to wear a T-shirt for the call, so we can see their arm and see their shoulder," she said. "We will ask them to wear shorts so we can see their knee, if we are looking at their knees," she said.
"And then we will ask them, 'You may need to demonstrate getting up from a chair, or a certain position, and we will try to describe it to you as best we can.'"
Kay-Pfau, the family physician, has had to find similar workarounds. If she is treating a patient previously diagnosed with high blood pressure, she said, she will get them to take three blood-pressure readings at home.
"We are on the phone so we can discuss what their current readings are like," Kay-Pfau said. "I will make sure that all of their lab work is up to date and if it is not up to date, I will make sure that it goes to the pharmacist with their prescription."
Like Defreitas, Kay-Pfau said she is still seeing patients in person when their symptoms indicate it is necessary.
"We try to do as much as we can over the phone," she said. "But if someone says, 'You know, my kid is really sick, they keep pulling at their ear,' well that probably needs an in-person assessment.
"We need to actually look in their ears, look in their throat, lay hands on the patient to make sure that something more sinister isn't going on," she said.
Concerns about fees for virtual visits
In March, as the COVID-19 pandemic worsened, the Alberta government introduced a new billing code for doctors that temporarily lifted the cap of 14 phone appointments per week.
Initially, family doctors were only able to bill $20 for a phone appointment with a patient, compared to the $38 they can charge for an in-person visit, even as the government touted a controversial new Telus Health app, Babylon, that allowed Albertans to meet with physicians in one-on-one video consultations through their smartphone. Doctors with Babylon are paid $38 for each consultation.
As doctors protested the fee disparity, the government introduced more new temporary billing codes and increased the fee to a flat rate of $38 for phone or secure video conference visits lasting longer than 10 minutes.
The new billing codes also cover some specialist phone visits with patients, and phone or online therapy for patients with mental-health problems. There is no cap on the number of virtual appointments doctors can charge for under the new codes.
The $38 rate "doesn't include any of the time spent prior to the phone call, reviewing the chart and [lab results], doing any charting or referrals that need to be done afterwards, calls to specialists," Kay-Pfau said. For in-person visits, "we can bill for all of that time."
Dr. Craig Hodgson, a Whitecourt family physician and president of the Alberta Medical Association's family medicine section, said while the new billing codes allow more flexibility to assess patients remotely, the flat rate, combined with lower patient volume during the pandemic, is placing a financial strain on many doctors' practices.
"Just like other businesses, they will adjust to what revenues they actually do have," Hodgson said.
"If at some point, you are actually having doctors' offices close entirely, or be available for bigger emergencies on a on-off basis but on a daily basis, not really be open," he added, "does that mean that all those extra patients will show up at emergency rooms? And I don't think that is what we want."
Doctors stress they are still there for patients
Hodgson said he wonders if the government will keep some of the changes around billing for virtual care, or revert to the "limited availability of virtual care that we had before."
A spokesperson for Health Minister Tyler Shandro did not respond to a query about virtual care billing.
Both Hodgson and the other physicians stressed that people should know their doctors are still there to treat them during the pandemic.
"From a continuity basis, we actually know who they are when we talk to them over the phone," Hodgson said. "We know the history behind [their health], we have access to the records that we have created over probably years.
"We would hate to have somebody waiting at home for something that they think, 'I'm going to hang on until after the pandemic is over,'" he said.