Virtual versus in-person consultation: getting the mix right

Early in the COVID-19 pandemic, Ontario saw a 5600% increase in virtual visits to health care practitioners, while in-office visits decreased by 79% from the previous year. In 2018, only 4% of family physicians in Canada were offering video visits while, at the peak of the pandemic, about 80% of primary care visits were being delivered virtually in Ontario.

Media reports at the time suggested patients were substituting emergency department (ED) visits when in-person consultations were unavailable, leading to additional strain on already stretched ED resources.

A research paper published in CMAJ looked at whether this shift in care was in fact taking place. Dr. Hemant Shah is an internal medicine physician and hepatologist at Toronto General Hospital and co-author of the study entitled Association between virtual primary care and emergency department use during the first year of the COVID-19 pandemic in Ontario, Canada.

On today’s episode, Dr. Shah discusses the study’s surprising findings with hosts Dr. Blair Bigham and Dr. Mojola Omole.  

Drs Omole and Bigham then speak with Toni Leamon, the CMA’s patient voice chair, a member of CMA's Virtual Care Taskforce and a co-author of the CMA's Virtual Care Companion for Patients. She offers the patient’s vision of high quality virtual care.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

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The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Mojola Omole: Hi, I'm Mojolo Omole.

Dr. Blair Bigham: I'm Blair Bigham. This is a CMAJ podcast.

So, Jola, today we get to talk about a controversy. Maybe it's not controversial. I think it's controversial, but maybe I'm just biased. We're talking about virtual care today and its impact on both family medicine and emergency medicine and the rest of us. You've had a transition to some virtual care. How does virtual care change surgical practice?

Dr. Mojola Omole: I feel like it depends on who you ask. A lot of other surgeons, they love it because now they get paid for what they were doing already. A lot of specialties, they were calling their patients anyways with their results. So that hasn't changed much. For me, from when I look at it from an equity lens, it makes sense that we have some aspect of that virtual care integrated into our healthcare because for follow-up of tests, renewal of prescriptions, I don't necessarily need to see you for that. A conversation over the phone is fine.

Dr. Blair Bigham: Yeah, it used to be that you had to go into an office or a clinic just for a 30-second interaction to get an update on something. That was just a huge waste of people's time, and for some people would've been a substantial hardship. But, at the same time, I guess there's a lot of conjecture and question about whether virtual care is, quote-unquote, "as good" as in-person care. Certainly, there's been a lot of emergency physicians who feel that we've been seeing a lot of family medicine patients who might not have been seen otherwise had they had better access to their family doctors. But we're probably conflating that with people who either don't have a family doctor or choose to use walk-in clinics because they're closer to home or more convenient. But certainly a lot of chatter about whether virtual care has helped or hindered the overall state of the healthcare system. And we're going to get into it today.

Dr. Mojola Omole: Yeah, for sure. And this paper that we're looking at, it is a research paper, and we're going to speak to one of the coauthors, Dr. Hemant Shah. The paper looks at has there been an increase in emergency room visits with patients now that we have virtual care? And they look specifically at patients who had an established relationship with their family physician. And it's really interesting the results of it.

We're also going to talk about another fundamental question that we're going to explore is from the patient perspective, because we have been hearing a lot from patients who felt as if they had less access to their doctor during the height of the pandemic, although you could argue that we're still in the height of the pandemic, so I'm not sure what that means. And we're talking to Toni Leamon, she's the chair of the CMA's Patient Voice working group to talk about the patients' perspective on virtual care.

Dr. Blair Bigham: Let's go ahead and jump right into it and talk to our expert before we get to our patient.

Dr. Hemant Shah is a co-author of the research paper in CMAJ looking at the association between the increased use of virtual care and emergency department use during the first year of the COVID-19 pandemic in Ontario. He's an internal medicine physician and hepatologist at Toronto General Hospital. Hemant, thanks so much for joining us today.

Dr. Hemant Shah: Thanks very much. Great to be here to talk about this controversial topic.

Dr. Blair Bigham: To say the least. So you're an internist and hepatologist at one of the best hospitals in the world. What made you want to look into this topic around primary care versus emergency department care utilization?

Dr. Hemant Shah: Yeah, it's a great question. So part of my non-academic life is spent as a physician advocate and leader. And this was work that actually came out of my role on the Ontario Medical Association Negotiations Task Force, where I served as vice-chair for our last physician services agreement negotiations round. That negotiations round took place through the COVID pandemic. And, as you might imagine, we went in with a plan about the priority topics for physicians that we were going to be negotiating with the ministry, and then the pandemic hit. And virtual care and its use, appropriateness, quality, payment structure, all of that, became very, very important and central to our negotiations.

So one of the great things about being part of a negotiations team at the OMA is we have a very analytic approach to everything we do. We have access to an enormous data warehouse, and we ask a lot of questions, research questions really, about things that are happening on the ground in the practice of medicine in Ontario. And so we were diving very deeply into this issue around virtual care, because you may remember this, there were a lot of media articles early on in the pandemic about how people can no longer see their doctors in person. And, as a result, they were going to the emergency rooms. I think many of our emergency physician colleagues were quoted in some of the papers.

Dr. Blair Bigham: We certainly felt that crush. We had people coming saying, "I can't see anyone else. I'm sorry I'm here. I just didn't know where else to go."

Dr. Hemant Shah: Right, and we were hearing a lot of that at the negotiations table on both sides. So we wanted to actually understand whether this was true or not, and whether there were certain types of virtual care that didn't result in increased emergency department utilization. So we began looking at this issue in the context of negotiations. And, as we dove deeply into it, it became obvious that we were exploring something that was relatively novel and worth disseminating. And as an academic physician, and I have other colleagues that were on that negotiations team on the physician side who are academics, we thought this has to get out there and be published. And that's what really led us to ask this question.

Dr. Blair Bigham: So what was it that made you suspicious that those frontline reports from the ER might not have been reflective of the whole picture?

Dr. Hemant Shah: Well, what made us suspicious that part of the picture was being missed, is that virtual care happens in many different contexts.

Dr. Blair Bigham: Sure.

Dr. Hemant Shah: So there's episodic virtual care, many of us may have had this through the last couple of years, with a physician or a healthcare worker that you don't have a continuous relationship with. That's one type of virtual care. And I think when people think about virtual care, that's often where their mind goes. The idea that you go onto your phone, click on an app and some person pops up on the screen that you have a healthcare encounter with. But there's a lot of other virtual care that happens in the system. And there have been papers published in the CMAJ itself about this, which is virtual care that happens within the context of a continuous patient physician relationship.

Dr. Blair Bigham: Like your surgeon following up with you or your family doctor checking in with you?

Dr. Hemant Shah: Absolutely. And the specific population we looked at in this study was patients in Ontario enrolled to family physicians. So these were their family physicians and they were getting virtual care from their own doctor. And we wanted to understand whether virtual care in that context actually increased emergency department utilization.

Dr. Blair Bigham: So I want to pay attention to the nuance here. Let's talk about patients who have a family doctor who are getting virtual care from their family doctor, what did you find in that group of people? First of all, before the pandemic, how many family doctors were doing that with their patients?

Dr. Hemant Shah: So prior to the pandemic in Ontario, and I know the most about Ontario's data, so I'll talk about that for the moment.

Dr. Blair Bigham: Sure.

Dr. Hemant Shah: Prior to the pandemic in Ontario, only 4% of family doctors in Ontario were giving any type of virtual care. And the total number of visits that were being performed virtually was well below 1%.

Dr. Blair Bigham: Okay.

Dr. Hemant Shah: In the initial months of the pandemic, there was like a 5600% rise in the amount of virtual care. We turned on a dime.

Dr. Blair Bigham: Quantify that a little differently for me. You had almost no virtual care, and then you had...

Dr. Hemant Shah: And at its peak in the early part of the pandemic, about 80% of primary care visits were being delivered virtually in Ontario.

Dr. Blair Bigham: I just want to stay in the nuance here, these are family doctors with their patients…preexisting therapeutic alliances that are being moved to a virtual platform?

Dr. Hemant Shah: Exactly. So Ontario has a lot of primary care that's delivered in what we call a patient enrollment model, which means the patient signs a form that says, "This is my family doctor." And there's an established relationship there, and we can actually measure and follow that at the level of the healthcare administrative datasets. So we looked at people who had an established relationship like that.

Dr. Blair Bigham: Okay. Staying in that category, when we say virtual, are we talking about video? Are we talking about phone? Are we talking about email?

Dr. Hemant Shah: So this study could only look at video and phone visits because that's what was being paid in Ontario.

Dr. Blair Bigham: Okay.

Dr. Hemant Shah: The nuance there, I like that you're talking about nuance because there's a further nuance here, which is the study period we looked at, there was actually no code that identified whether a visit was a video visit or a phone visit.

Dr. Blair Bigham: I see. Okay.

Dr. Hemant Shah: So we can't tell them apart in this study. However, I think based on everyone's knowledge of what was going on and experience at the time, the vast majority of these visits were phone. There was actually very little video.

Dr. Blair Bigham: Interesting. Okay.

Dr. Hemant Shah: So think about this as a study primarily of phone virtual care.

Dr. Blair Bigham: Okay. And so what did you find? How many people were going from the phone to the emergency department, for example?

Dr. Hemant Shah: Well, so what we did was we compared...we had two factors. We looked at the amount of virtual care happening in a practice controlled for a number of factors related to the physician practice, patient complexity, and then the outcome, which was emergency department utilization. And what we actually found in our unadjusted analysis was there's an inverse relationship. The more virtual care a physician was doing, the less their patients were utilizing the emergency department. And when you corrected for complexity - in Canada, we use something called the CTAS scores - we corrected for that…so that has to do with how severe the presentation was when a person comes to the emergency room.

When we corrected for all of those things, the relationship did not change, and it did not demonstrate that there was more ED utilization in practices that did more virtual care. So it actually looked like to us when virtual care was delivered in the context of a continuous patient physician relationship, it would not increase ED utilization. And, in fact, it might decrease ED utilization. And you could hypothesize why that might be the case. People may be able to access their physicians better, the ones that know them, and solve issues before they get to the point where they end up in the emergency room. So there are some plausible explanations for why this observation was found.

Dr. Blair Bigham: But so in a way, this sort of uproots-

Dr. Hemant Shah: It was novel.

Dr. Blair Bigham: Yeah. This totally busts a myth that I would've believed that…now I'm not a family doctor, but I assume that it's hard to diagnose someone over the phone. It's hard to know if chest pain or shortness of breath is worrisome. And as an emergency doctor, I just know the value that I place on being able to put a stethoscope on someone's chest or an echo probe on someone's chest and get a sense of what's actually happening. So I would just assume that family doctors would be inclined to say, "You know what? Someone needs to actually see you physically, lay hands on you and figure out if you need additional tests." But that is not the case in what you found in Ontario with family doctors who already had a relationship with their patients who were on the phone with them throughout the pandemic. It seems that those situations actually reduced ER utilization, or at least didn't increase it.

Dr. Hemant Shah: Well, I think what you're getting at is the appropriateness of virtual encounters. Where in our health healthcare system is it appropriate that there is utilization of virtual care, whether it's phone or video. And look, I practice longitudinal chronic care. I would say that when a patient calls my office and asks to be seen, I have a bit of knowledge about that patient already, that person, what their health complaint is at triage, which may be me or someone else in the office, and I can make a determination: is that appropriate to be done virtually or not? And that is to me, where virtual care fits into the system. Now I'm a specialist but family doctors have far more touchpoints with their patients. They understand and they know their patients very well. So when someone requests a virtual visit, I think they're actually able to determine using their professional judgment: is it appropriate or not? And when virtual care episodes take place after that determination is made, by a physician that knows you, it doesn't drive healthcare utilization. And I think that's a myth-bust here.

Dr. Mojola Omole: Even though the data shows that this is not what people were feeling, but people still had their feelings and there's still that perception that they were not able to access their family physician. And the ER docs also felt that they were seeing more patients. So what explains that phenomenon that people were experiencing?

Dr. Hemant Shah: It's a great question. I don't know the answer. I think that one of the things we could not look at was whether episodic virtual care was driving ED utilization, whether people were clicking on an app, getting some advice, and then going to the emergency room anyways after getting that advice, telling the emergency room staff, "I saw a doctor on video and I came into the emergency room anyways." That's something we couldn't look at because it's actually very difficult to untangle, with the administrative data in Ontario, whether a person doesn't have a relationship with a physician.

Dr. Blair Bigham: Oh.

Dr. Hemant Shah: Because there are people who have relationships with physicians that don't sign the form. It's a minority, but it confounds any analysis of a group of people that don't have an enrollment into a physician model. So it's a lot harder population to study. Now, if you look at the literature more broadly, work that other people have done, yes, there is some evidence that episodic virtual care - and this work primarily is predates the pandemic - that it does appear to increase healthcare utilization, whether it's just in-person visits in an clinic setting or in an emergency room. Again, that's something we couldn't look at in this study.

Dr. Blair Bigham: So certainly, the number of people in the ER these days who grab me by the wrist after I discharge them and say, "Will you please be my family doctor? I can't find one. I need a family doctor." It's just heartbreaking. I've never seen anything like that in residency. It's only been in the last year or so that people, they'll stop me in the hall, they'll say, "Oh, you seem nice. Will you be my mom's family doctor?" It's just outrageous. So there's a lot of people who are still struggling to get that family doctor access. Is there any other data out there that can help us understand that population, the people who don't have a family doctor, and how virtual care might help or hinder their efforts?

Dr. Hemant Shah: It's a great question. My wife is a family doctor.

Dr. Mojola Omole: And does she have any space?

Dr. Hemant Shah: I completely hear what you said.

Dr. Mojola Omole: My mom needs a family doctor.

Dr. Blair Bigham: I've got a list of people.

Dr. Mojola Omole: My mom needs a family doctor, so if she has any space please let me know.

Dr. Hemant Shah: I might have a family doctor for your mom.

Dr. Mojola Omole: Oh really? Thank you.

Dr. Blair Bigham: We'll have to edit that part out.

Dr. Hemant Shah: Like I said, we couldn't study this other kind of way that virtual care is delivered. I think there is a role for it in a healthcare system for people who can't otherwise access comprehensive primary care, but it cannot be the substitute for comprehensive primary care. I think everyone deserves a primary care provider who provides comprehensive care, ideally is part of a team, and works with other healthcare providers. That is the gold standard for healthcare for the population.

Dr. Blair Bigham: Right. And I want to go back to that population and ask another question about your data. Is it possible that, although the number of visits to an emergency department didn't go up with increased virtual care, is it possible, and again, this is the emerge doc bias in me, that when people did have to come to the ER, they were sicker because they hadn't been examined in person for a while? So even though the absolute numbers weren't up, the acuity was higher, the complexity was higher? I think all of us in the ER right now are just feeling crushed by the sheer complexity of the patients presenting. They're so sick, they don't have formal diagnoses, but I know they've got COPD and I know they've got heart failure and I know they've got uncontrolled diabetes just by meeting them. Is there any sense that things went off the rails in that regard, that people, maybe they weren't coming as often, but when they did show up, man, there was a lot of stuff that needed to get tuned up?

Dr. Hemant Shah: So you should be a reviewer for the CMAJ because this is a question that one of the reviewers asked us and it prompted us to do another analysis where we actually looked at the CTAS scores that patients were presenting with to the emergency room. So, it's not perfect but it gets at this question of whether people were presenting sicker, even though they were attending less often. And we saw no difference, when you looked at the CTAS scores for severity, in the way people were presenting before and after the study period started.

Dr. Blair Bigham: Okay. What about admission rates?

Dr. Hemant Shah: So as far as we can tell the severity of presentation hadn't changed, we did not look at admission rates. We don't have that data, unfortunately.

Dr. Mojola Omole: I guess we keep attributing the reason why patients are coming in sicker to them not physically seeing a family doctor, but only talking on the phone. And I don't necessarily think that that's true. Because even if someone has a lump, even if you felt it, you're still going to send them for imaging. Even if someone is telling you that every time they walk, they're having a hard time breathing or this is happening, you're going to be, "Okay, well, you need more imaging." So I guess that's just a little bit of my bias.

Dr. Hemant Shah: This is a really interesting discussion because at the negotiations table, we talked a lot about the value of the physical exam in modern medicine. And at the outset, I said we were very analytical in our approach. We actually did a systematic review on our side. Now I wish I published that too. But it's a really interesting issue about what the role is of that in-person encounter in a system where there are such sophisticated tests that can aid you in diagnosis and management of patients. I think this is a very live issue and one that our healthcare system is going to have to address, especially in the advent with of AI. If an AI can just order the echocardiogram, do you need a cardiologist? My best friend's a cardiologist, I hope he's not listening. But those are the issues that I think our healthcare system is going to have to address moving forward. And they're intersectional with virtual care.

Dr. Blair Bigham: So if you put on both your leader hat and look at this from a system perspective and your academic hat with the data systems that we have, what's-

Dr. Hemant Shah: That's a lot of hats you're asking me to wear.

Dr. Blair Bigham: I know. But give me your best guess. What's the next priority here for us to try to understand? How do we advance this topic and settle down this bickering that's going on between various physician groups and healthcare organizations to advance virtual care, we know we need the right amount of virtual care, without having these “one shot and done go see the emerge doc anyways”, types of systems that have also been brought to light?

Dr. Hemant Shah: I think to me there are three issues I would like to see the future of virtual care analysis and investigation dominated by. So the first is, what is appropriate virtual care? In what context does virtual care make sense in our healthcare system? The second is, what is a high quality virtual care encounter? Is that driven by the modality, whether it's video or phone or some other technology? Or are there other factors that would influence quality? And we have to embed those into the way virtual care is delivered. And the third one, a big one, to me, is how does virtual care impact equity and access to the healthcare system?

Dr. Blair Bigham: Hemant, you leave more questions than answers, which is exactly what we like on the podcast here. But clearly you've thought about this quite a bit and I need to think about it more as well and really embrace the nuance. And you've painted a really nice picture of the different areas of virtual care. Virtual care itself is not one thing. It's many different things. It can be done with high quality and low quality. So I think it's really interesting as we follow along to see how Canada's healthcare system adapts to this and how the pandemic's influence will accelerate the use of technology to make sure people get the care that they need when they need it. Thanks so much for joining us.

Dr. Hemant Shah: Thanks for having me.

Dr. Blair Bigham: Dr. Hemant Shah is an internal medicine physician and hepatologist at Toronto General Hospital.

Dr. Blair Bigham: Coming up after the break, we'll get a patient's perspective on virtual care.

COMMERCIAL BREAK:

Dr. Mojola Omole: We're going to turn now to what patients have to say about the increased use of virtual care. Toni Leamon is the patient voice chair for the CMA. She co-wrote the Virtual Care Companion for Patients, and she's a member of the CMA's Virtual Care Task Force. She's currently in St. John's, Newfoundland. Thank you so much for joining us, Toni.

Toni Leamon: Thank you so much for having me.

Dr. Mojola Omole: So let's just start off, from a patient's perspective, is the increase in the use of virtual care a good thing overall?

Toni Leamon: I definitely think it's a good thing overall. What we really need to think about is in the context of what the patient needs it for. So ultimately, I think virtual care allows for greater accessibility when it's done correctly. So, if more virtual care means more patients are accessing healthcare in the way that's right for them, then that's amazing. So in that way, I do view it as a really good thing.

Dr. Mojola Omole: So you are out in St. John's, Newfoundland, but you grew up in, I don't want to say it wrong, Port aux Basques.

Toni Leamon: Port aux Basques, yeah.

Dr. Mojola Omole: Port aux Basques.

Toni Leamon: Good job.

Dr. Mojola Omole: What's your experience with virtual care been?

Toni Leamon: Yeah, sure. So, growing up in a rural community like Port aux Basques before Covid, there wasn't a lot of virtual care around. Essentially if you needed access to healthcare that was more than a family doctor, it did require, and still does, to a certain extent, require a lot of travel. So, for example, growing up, I've always had to go see a dermatologist. And, unfortunately, depending on the year of my life, the dermatologist could have been two hours away, could have been six to eight hours away, or could have been 10 hours away. So I've done it all.

Dr. Mojola Omole: Wow.

Toni Leamon: So ultimately there was one specific story that I remember when I was growing up that I actually had to travel, it's approximately, depending on the weather, because that's another factor here, about eight hours to see a dermatologist for about five minutes for them to say, "Here's your prescription renewal. Have a great day."

Dr. Mojola Omole: Oh my gosh.

Toni Leamon: So that's a lot of time and money and effort and resources that I'm very lucky to have had to be able to attend. Where virtual care would've been the perfect thing for that. So since, I must say, it's definitely improved, there's so much more virtual care being used now in Port aux Basques and other rural communities. But it took COVID to get us there, unfortunately.

Dr. Mojola Omole: For sure. And when you think about it, and also from your work with the working group, what constitutes this high quality virtual care?

Toni Leamon: Yeah, that's a really good question because just because virtual care is there doesn't mean it's of great quality, unfortunately. So, ultimately, from a patient's perspective, quality virtual care really just has the same stipulations as quality in-person care. We just really want to be accessing the care that we need at the right time with the right provider. So high quality virtual care is really just when the care provider listens to the patient regarding what they need. And, when that's virtual care and both parties agree, "This is what we need, this is what's best for your care right now.", and this is what's best for the patient's accessibility requirements, that is amazing because everybody's listening to each other, everybody's supporting each other. Ultimately, it's just listening to each other, which is sometimes the big overview of what patients are always looking for in any of their care, is just being heard and collaboration. Because it can't always be one-sided. We need to make sure that the virtual care that people are receiving is the care that they need. So, essentially, not making it a requirement, but making it an option - and a really good option-  for patients and making it accessible that way.

Dr. Mojola Omole: So there's one thing that I find, I'm a specialist, I'm a general surgeon, and oftentimes patients will come in and say, "My family doctor sent me here and they didn't even examine me, they just talked over the phone and they sent me here." And sometimes I'm like, "Well, yeah, that makes sense because you were going to see me anyway, so it's not going to change." But I guess my question is, from a patient perspective, when should a physician prioritize seeing the patient in the clinic versus doing it virtually?

Toni Leamon: Yeah, I think that sometimes we don't need those in-person visits, and sometimes we do. But ultimately, I'd like to call patients experts in their own health. And I know that's sometimes a bit of a different view of it because you as physicians are the experts as well. But most of the time patients-

Dr. Mojola Omole: No, I'm an expert in a disease process. I'm not an expert on you.

Toni Leamon: That's a really good way to think about it. I really appreciate that, thank you. And patients would appreciate that perspective. So ultimately, patients know intuitively what's going on with their body, what they think needs to be seen in person. So, sometimes, if someone's really going through something and it's physically new to them, they're really going to want to be seen in person. So, by requesting that from their physician and having that as an option, is really beneficial to patients. Essentially, just knowing that the healthcare provider has a virtual option and an in-person option available. And it really helps when care providers are saying, "What do you think would suit your needs for this appointment?" Patients really just want that ability to choose. They really know what they want and they know what they need. So by having the option, I think it would really eliminate unnecessary in-person appointments as well as unnecessary virtual appointments.

Dr. Mojola Omole: So you were part of the team that co-wrote the Virtual Care Companion for Patients. What do you think they need to know about it to make it a positive experience?

Toni Leamon: What patients need to know about it?

Dr. Mojola Omole: What physicians need to know about it.

Toni Leamon: So I think what physicians need to know is that just like it's a learning process for physicians, it's also a learning process for patients. We're all learning how to access things online, on the phone. People are using very different platforms. So just being patient but also being informative. So, sometimes, if you get a link, no matter who we are, to something new and we're like, "Oh my goodness, I don't know what to do here." You need that extra time to figure it out. So just being transparent about what's going to happen and then giving patients the resources they need to access the type of care you're providing ultimately. And just by physicians knowing that this kind of care companion is an option, that is something that they can provide patients. It's a ready-made tool, "Here you go. Here's some things." Which really helps because, yeah, we all just need to realize that this is very new and it's so scary sometimes.

Dr. Mojola Omole: I can definitely imagine that.

Dr. Blair Bigham: Toni, you mentioned that this is a new thing for a lot of us, and we're all trying to navigate it. You've sat on the education subgroup for CMA's Task Force on Virtual Care. What do you think could be done to make that learning process easier so that we can all get into using virtual care more effectively and quickly going forward?

Toni Leamon: Yeah, we've come so far. People know about virtual care more. It's being integrated into medical learning more. But, ultimately, one of the big things we talked about in the report is updating and incorporating competencies for virtual care for learners. So, for the things that they do need to be competent in, to provide that care. So by having these updated, we're making sure that we're using the virtual care of the times and making sure that they're learning the correct things to provide the best top-notch virtual care they can.

So a lot of times, too, when we think about, as a patient, we do focus on what the patient needs, but patients are very supportive of what a physician needs. So, essentially, in this education working group, we really talked about supporting medical learners in the education that they're being provided about virtual care. So teaching medical learners how to use virtual care as tools for communication and relationship-building with patients, and just making sure that they have experience with it. We wouldn't ever, as a general surgeon, say, "Here you go. Let's do this surgery. You've never done it before. Have fun." So why should we do that with virtual care?

Dr. Mojola Omole: Honestly, there's so much on YouTube. I can teach you to how to a lot of surgeries.

Toni Leamon: You can do a tutorial.

Dr. Mojola Omole: Thank you so much, Toni. This has been really great.

Toni Leamon: Thank you both.

Dr. Mojola Omole: Toni Leamon is the patient voice chair for the CMA. She is in St. John's, Newfoundland.

Dr. Blair Bigham: All right, Jola, so there's clear cut times when someone does not need to physically come and see a doctor.

Dr. Mojola Omole: Yes. I would say... Okay, I'm going to say something that is probably controversial.

Dr. Blair Bigham: Ooh, do it.

Dr. Mojola Omole: Because so, to what Hemant was saying is - I do think we have to have that conversation - is how much do we need the physical exam in modern day medicine? Back in the day, in those days, they would diagnose a bowel obstruction based on the clinical exam because they heard some sort of sloshing. I don't even remember this physical sign. I just remember something about sloshing. But nowadays, I would never like... From my history, I'd be like, "Okay, that sounds like this." And then I'll get the imaging to confirm my diagnosis and also my physical exam.

Dr. Blair Bigham: But don't you think there's more to it than just a physical exam, though? We've heard a lot about people who work from home and how maybe that doesn't always work. Maybe company culture suffers. Maybe you don't have the same face-to-face interactions with people. Maybe just when you sit down face-to-face with a patient, you learn more about them, you communicate more, they tell you some more symptoms. I don't know. There's something about sitting down face-to-face, whether you're in healthcare or any other part of being human being, where sometimes face-to-face just gets things done. Maybe you build a better rapport, they trust you more. I don't know.

Dr. Mojola Omole: I agree with you. I don't necessarily know how I would feel accessing certain... for example, mental health. I don't know how I would feel if I had to go to my family doctor, who I love - let's say I'm having some sort of changes in my mental health…I would find it probably a little harder to describe to her in detail over the phone. Whereas in person, I might be able to discuss it with her a little bit better. So I completely hear that point. I think that part of this is having really framed conversations also with the public about maybe not the correct use of virtual care. Because sometimes patients want this for virtual care. And also discussing with physicians that actually this is not how you provide high quality care to patients if you don't do a physical exam for knee pain. I'm not sure. I just made that up.

Dr. Blair Bigham: Yeah. I think a really good point of Hemant was that there's a difference in certain types of virtual care, right? There's high quality virtual care. There's a nuance here. Not all virtual care belongs in the same bucket. And then the other thing that I really took away from Toni's interview was that patients want choice. They don't want to be told, "You have to do this virtually. You have to do this in person." For some people, they're going to want to come in and see you. For other people, they're like, "I don't have time for that or that's not accessible to me. Can we just talk on the phone?" And so matching up whatever the evolving evidence says about where do you actually get best care versus what patients want versus what physicians can reasonably give in a strained system, all of these things are interacting. It's way more complicated than I appreciated 25 minutes ago.

Dr. Mojola Omole: For sure.

Dr. Blair Bigham: Once again, more questions than answers, but we've run out of time. That's going to be it for this week's podcast. Please remember to like or share wherever you download your audio. We'd love to get the message out there and get more people listening and joining in on the conversation. I'm Blair Bigham.

Dr. Mojola Omole: And I'm Mojolo Omole. Until next time, be well.