Registrar’s message: assessment and management by telemedicine—crucial skills during the COVID-19 crisis
During this crisis, physicians have been called on to maintain their practice by operationalizing physical distancing through the use of telephone and video calls and seeing only a small minority of patients in-person. Uptake has been strong, and many physicians are now spending much of their clinic day communicating with patients remotely. Although usual care has been modified in many ways, the College reminds physicians that the use of technology does not alter the ethical, professional and legal requirements regarding appropriate medical care. In other words, medicine is medicine; the task of a physician does not vary by interface.
Physicians must continue to gather the information required to adequately address a patient’s presenting problem. For chronic stable conditions, medications may be renewed, and in-person reviews postponed. If a patient calls about a chronic or mild symptom, in most cases, it does not require definitive management. Triage and postponing will be a major part of patient care at this time.
Family physicians must avoid making specialist referrals via telemedicine without first fully assessing patients themselves. Most patients referred to specialists, such as gastroenterologists, cardiologists, and gynecologists, will require an in-person assessment before referral. The Telemedicine practice standard and Referral-Consultation Process professional guideline have been revised to clarify that patients who are referred to specialists via telemedicine must be adequately investigated and treated before the referral is sent.
Acute presentations require triage and clinical judgement. What can wait, must wait, but physicians must take care to ensure that patients know what to do if their condition does not improve. At present, that cannot be direction to simply go to a walk-in clinic or hospital.
The management of acute respiratory symptoms is clinic and community-specific and requires a particularly thoughtful approach. Direct contact between such patients and others must be minimized. Testing for COVID-19 is being selectively applied at present as both testing capacity and the personal protective equipment (PPE) required for patient assessment are limited. A minority of clinics and private practices are equipped and able to provide in-person patient assessments. In a growing number of communities, designated assessment sites have been created, where patients are referred after being triaged remotely by primary care providers.
The role of physicians managing patients remotely is one of triage and, where indicated, ongoing virtual reassessment and support. Physicians must make arrangements in advance if patients are directed to attend walk-in clinics, community clinics, assessment centres or emergency departments for higher levels of care.
Telemedicine assessments for acute respiratory illness must include two determinations:
- Whether care in hospital is required—essentially, whether the patient is decompensating. The threshold for referring for an in-person assessment may be higher than in usual circumstances, where those services have capacity and disease transmission is not an issue. Registrants must carefully consider the degree of respiratory impairment. Given that there is no specific treatment for COVID-19, a patient with a well-compensated viral syndrome should be advised to isolate in their home and treat their symptoms. The condition of some patients may deteriorate subsequently. Registrants must provide advice about calling back for further assessment and may need to take that initiative themselves. The task is similar to serial assessments of a patient in the emergency department and requires vigilance. Patients and families may be referred to the BC Ministry of Health’s COVID-19 Symptom Self-Assessment Tool to reinforce the advice of their physician.
- Whether the patient is a candidate for testing for COVID-19. Criteria for testing are posted on the BC Centre for Disease Control’s website here.
Resources for assessment of patients considered to be at risk of respiratory failure or candidates for outpatient testing vary by community. Registrants must familiarize themselves with local protocols. In many communities the local Division of Family Practice will have that information. Families of patients considered to be critically ill must be directed to call 911 without delay. Patients suitable for outpatient assessment must be put in touch with the appropriate clinic by telephone and directed not to present in person without an appointment.
Heidi M. Oetter, MD
Registrar and CEO
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