COVID Blog: Stories from the Frontlines

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The COVID-19 pandemic has required extensive education, flexibility, and adaptation in order to keep our patients, staff, and learners safe, while ensuring that we continue to provide the excellent resident education and care that our patients count on. Here, we highlight the strategies we undertook at our academic family health team to maintain high quality patient care and resident training.

1. Supporting Wellness

Early on, wellness was prioritized by incorporating two chief residents, one from each training cohort, on our COVID Leadership Committee to promote resident empowerment. This committee met three times a week to discuss COVID’s impact on clinic operations. Residents and faculty had an open line of communication to provide the resident perspective on virtual clinics, safe clinic operations, and social distancing measures.

Continue reading on the CFPC website >>

Everywhere around me, I see signs of physician burnout.

Clinical volumes are rising. Patients who had deferred care are coming in now with important concerns. We see the impact of COVID-19 on some of those left most vulnerable and hold the space as they share their struggles.

We are trying to keep up with rapidly changing COVID-19 guidance but the onslaught of communication is exhausting and oftentimes confusing.

Continue reading on CMAJ Blogs >>

She had taken off her sweater for me to examine her painful shoulder when I noticed the irregular black mole on her upper back.

He was here to discuss his back pain, but the smell of cigarettes on his breath filled the room. I think of how I am going to bring up his mood in our discussion- always the trigger for his smoking.

‘I think it’s probably another flare of my gout’ he states, as he bends down to take off his shoes. His left hand has a tremor that I am sure I would have seen before, had it been there.

She came in to discuss birth control, but as she is holding her baby I notice faint bruises on her arms.

Observation is a powerful tool that we, as family physicians, learn to master. We are constantly looking, assessing and examining our patients, both for the things they are concerned about, and for things that we notice based on our extensive training. It is a skill that is developed over time and experience. Clinical observation has been a central part of medicine dating back to the time of the ancient Greeks and Hippocrates when the value of examining the body became apparent. Looking after our patient’s physical, mental, social health by directly observing them during our encounters and analyzing their interactions with us as we examine them, we pick up on signs and non-verbal cues that lead us to best diagnose and treat them. As William Osler once said “the whole art of medicine is in observation”,“learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become experts”. 

Continue reading on the CFPC website >>

Race and health are deeply intertwined in our country. Race plays a role in health and health care because structures, for various reasons, exclude racial groups.

We are in the midst of what I think is the largest civil rights movement in human history: Black Lives Matter and her Turtle Island sister movement, Indigenous Lives Matter.

As an Indigenous and Black woman, physician and mother, these movements are intensely personal to me. The pandemic poses an existential threat to Indigenous and Black communities. It reveals the intimate connection between race, racism, health and income.

Continue reading in U of T Med Magazine (Summer 2020) >>

Since April, more than 875 people with COVID-19 have lived in two Toronto hotels set up so that those experiencing homelessness could quarantine safely. The recovery sites continue to operate.

The pandemic is affecting all of us in different ways. Before COVID, there were about a hundred doctors, including myself, working with Inner City Health Associates at different practice sites.

At the beginning of the pandemic, before we launched two recovery sites at city hotels, I’ll never forget trying to wrap my head around the number of people we knew were homeless or vulnerably housed in our city. I had a sinking feeling that Inner City Health Associates was just not big enough.

That changed.

Continue reading in U of T Med Magazine (Summer 2020) >>

With COVID, it’s important to bring an equity lens when working with people who are homeless. At the recovery sites, we provide clinical support for people simply because they belong to a population that society doesn’t support.

If you approach people with the traditional “I deal with an individual in isolation, that’s it,” you’re really missing the story. That’s not why they’re sitting in front of a health care provider.

They sit in front of me, a lead physician for the two recovery sites, because society has failed them. Society has failed to put the right social supports in place to deal with the health pressures they’re facing.

Continue reading in U of T Med Magazine (Summer 2020) >>

I work at a busy family medicine clinic in downtown Toronto that kept operating when lockdown began early in the pandemic. Early on, in-person patient appointments were discouraged, so we provided care online or by phone.

One of the challenges with providing care this way is the disparity that exists between patients who have access to a phone and the internet, and those who don’t.

Some of my patients are very transient.

I worry a lot about the patients I haven’t been able to reach.

Continue reading in U of T Med Magazine (Summer 2020) >>

Weekends have lost some of their meaning during the COVID-19 pandemic. The structure of the week is one casualty of the pandemic. One Saturday evening, I received a text that one of my patients had come into the hospital in early labour*. She had been into triage a few days earlier but at that time, she had not been in labour so we sent her home. She said was not equipped to cope with pain. Understandable perhaps, given that she was a single mom with an unwanted pregnancy from a partner she considered less than desirable and on whom she had a restraining order. I’ve been her doctor since I delivered her daughter sixteen years ago. She’s funny and resilient and, over the time I had known her, I had gained her trust enough to have seen her smile on occasion.

The night progressed and so did her labour. By dawn she was 7cm dilated with bulging membranes. She was visibly grateful when I arrived, despite my masked appearance. She held my hand tightly (a breach of the social boundaries in the outside world) and asked me not to leave. The resident that had followed her pregnancy with me had also come in to the hospital, partly because she realized, as I did, that this patient had almost no one else she could rely on. When we asked her how she would be getting home the next day, she responded that a friend had agreed to call her an uber.

Continue reading on CMAJ Blogs >>

In January 2019 we were excited to be asked to participate in a Quality Improvement Course, “Improving Joy in Work.” Finally! A QI project that didn’t make my (Jennifer’s) eyes glaze over. We completed the lessons, participated in discussions, and met to plan how to bring more Joy to our team in palliative care. A few months later we were asked to serve as Wellness Leads for our division at the U of T. Yes! A new focus for academic work was born that excited us both. As both of us are working moms, summer plans, start of a new school year, and busy clinical practices continuously crept into our schedules. Planning on how best to thoughtfully implement ideas and programs for our site and the Division took longer than we expected. Looking back, that time was a luxury. Healthcare has changed dramatically since we started on this project over a year ago. And figuring out how to reach out to our colleagues is a task that now brings a sense of urgency. Thankfully wellness and support are now recognized as important for physicians. We no longer are expected to deny or ignore our own needs, or the consequence caring for others has on our lives. Compassion begins with accepting our own humanness and extending kindness to ourselves and others.

We have started a virtual support group for physicians in our Division. Connecting with our colleagues has helped us more than we imagined. have been inspired by our colleagues working in the community who have been inundated with patients dying at home who fear coming into hospital. We know the homecare palliative care doctors are managing caseloads of extreme numbers. We are in awe of our colleagues working in Palliative Care units who are working to support patients and families faced with restrictive visitor policies due to Covid. Providing inpatient palliative care consults, we have been struggling with how to advise families with loved ones at end of life. Where with high symptom burden we typically wouldn’t hesitate to recommend a transfer to a palliative care unit, we are now working outside the box to see if a death at home could be comfortable so that patients can be with their loved ones in their finals days. For many that simply isn’t an option.

Working with other Wellness leads in the hospital, we have heard from our colleagues across divisions of the struggles they are going through; from our peers in oncology who have had to treat patients with chemotherapy while their surgeries for operable malignancies are delayed, to our peers in vascular surgery who have no OR time for limb saving surgery. It is clear that Covid has affected each one of us, irrespective of our field of practice. Can it also bring us together? We have used this opportunity to reach out to colleagues within our division, as well as throughout the faculty of medicine. Our experiences share common themes. As we navigate the practice of medicine in the world with COVID, let’s keep building bridges and supporting each other. Its connections that help to get us through each day and that will help us come out of this stronger.

Sarah Torabi and Jennifer Moore
Palliative Care Physicians, Sunnybrook Health Sciences Centre

Submitted June 16, 2020

As the number of new cases of COVID-19 decreases in most provinces, government and professional associations are providing guidance on the reopening of clinical services to a “new normal”. Much of the specific advice is focused on restarting surgeries and procedures. There has been little guidance for family practices, typically the first point of contact in our healthcare system.

Over the last two months, family practices have dramatically changed how we deliver care. Our volumes have dropped by about 30-50% and more than 80% of the “visits” we are now doing are virtual. Many of us are assessing rashes and foot ulcers using video or photos. We are more likely to prescribe an antibiotic for a sore throat or ear without an in-person exam. Non-essential visits have been postponed including routine visits for chronic diseases or cancer screening. We are renewing blood pressure and diabetes medications without the usual office assessments, relying on home measurements when available. We are supporting an increasing number of people with mental health concerns, a challenge on the phone and video is not always possible.

Continue reading on CMAJ Blogs >>

Tara Kiran
Family Physician and Fidani Chair of Improvement and Innovation at DFCM

Since my first day as a family physician, I’ve looked after frail seniors living in long-term care (LTC) settings. I remain fascinated by the complex nature of their multiple medical conditions and the resiliency that accompanies them. I’m a strong supporter of interdisciplinary team-based care and the multitude of skills required to meet the daily care needs of this population. I’ve cared for many Canadian veterans from the Second World War and Korean War and have been touched by the personal stories they have shared.

It therefore saddened me greatly to hear about the devastating impact that the COVID-19 pandemic has inflicted on seniors’ homes. Over 80% of all fatalities in Canada have been linked to these settings and, in Ontario alone, there have been about 250 institutional outbreaks. Challenges associated with physical distancing, difficulty isolating symptomatic residents with cognitive impairment, and staff working at multiple facilities have all been contributing factors.

Continue reading on CMAJ Blogs >>

Allan Grill
Chief, Department of Family Medicine at Markham Stouffville Hospital and Associate Professor at DFCM

As my city braced for our local COVID-19 onslaught, I had the strange experience of facilitating the final session of this academic year’s undergraduate reflective curriculum. As part of this curriculum, my assigned group of medical students and I had been meeting regularly for the better part of two years, coming together to reflect and commiserate on their most poignant and challenging training experiences. Over that time, I had been repeatedly impressed by the students’ insight and candor, and grew to anticipate our often-transformative discussions.

That last afternoon clearly felt different to us all. In adherence to novel social distancing requirements, we congregated virtually, making use of one of a number of increasingly popular online meeting platforms. Instead of crowding around a small table, elbow-to-elbow, in a sunny room on campus, each of us huddled in solitude at our personal computer screen, gazing at familiar faces against unfamiliar backdrops – kitchens, bedrooms, a backyard. It was awkward and bizarre, and I was struck by how deflated the students seem. Having completed their required clinical rotations and examinations, they are on the cusp of graduation and the beginning of residency.

Continue reading on CMAJ Blogs >>

Diana Toubassi
Family Physician and Assistant Professor at DFCM

“The personal impact of this pandemic has been pretty significant. I have a three year old and a three month old at home. As we’re having this conversation, one daughter is napping in her bedroom, and I’m rocking the other one in my arms. This rarely happens, where they’re both asleep at the same time. It’s hard not to worry about their future, especially now.

My nephew is now three weeks old – I haven’t gotten to meet him. These pieces are a reminder that life is continuing to happen. People are getting married, and babies are being born.

These things that we’re used to celebrate collectively – we’re finding ways to connect with each other despite social distancing, until we can actually physically gather.

Continue reading on Healthy Debate >>

This is a profile on faculty member Danyaal Raza by Arnav Agarwal.

Dear Colleagues,

Today is National Doctor’s Day and I salute you all in the incredible work that you do. Being a doctor is truly a privilege, and we are privileged to be entrusted with the care of people in their most vulnerable moments. Our cause is a noble one, our feats often outstanding, and we work with an admirable ethic, tirelessly to meet the unending need.

We are heroes.

A hero, by definition, is “a person admired or idealized for courage, outstanding achievements, or noble qualities”. Some heroes, in fiction, are superhuman.

We are heroes, but we are not superhuman.

Continue listening to the rest of the letter on Soundcloud >>

Sarah Kim
Family Physician at St. Joseph's Health Centre

Several of Dr. Nadine Laraya's colleagues wanted to send her a shout-out for being a hero on the front line of the COVID-19 pandemic.

Laraya is a family physician and the community family medicine liaison for St. Joseph's Health Centre in Toronto.

One of her colleagues, Dr. Edward Weiss, says she's been instrumental in ensuring all medical professionals — from family physicians to emergency doctors — in the community have the latest developments when it comes to tackling the crisis.

Continue reading on CBC's website >> 

I am a family medicine resident in my third year of the Integrated 3 Year Residency Program.  My residency includes the core family medicine residency in addition to a concurrent Master’s in Science from the Institute of Health Policy Management and Evaluation.  Next year, I will be completing an additional year of training in Care of the Elderly at Baycrest Health Sciences.

I have been working in a COVID Assessment Centre and I am presently on the medicine wards at my site hospital.  In addition, I have continued to provide longitudinal virtual care to my family medicine patients.

It’s hard to believe that it has only been six weeks of the pandemic. I thought I would share some of my observations from my perspective of being both a family medicine resident and a health policy master’s student: 

1. COVID involves a collective effort.  I have seen the Department of Family and Community Medicine unite amongst staff physicians, residents, and administrators.  There has been fantastic leadership with great communication from the Department of Family and Community Medicine as well as my hospital, family health team, and postgraduate medicine. 
2. We need to ensure that we are looking after those in our shelter systems.  These people are some of the most marginalized in our community and they are disproportionally impacted by this pandemic.
3. Elderly patients are especially vulnerable.  There have been countless outbreaks in long-term care and these patients are at a significantly higher risk of death.  We need to continue to find solutions and ways to support these patients and their health care workers.
4. Robust testing is an important epidemiological tool to understand the penetrance of the virus and to evaluate the mitigation strategies.
5. It is important to use a critical lens when interpreting any COVID studies.  Even if it is from a reputable journal, you need to critically appraise each study’s methodology and conclusions.
6. This pandemic is a new virus and so is its evidence.  Therefore, recommendations and policies can change with time, and it is important that we swiftly adapt.
7. Education can be delivered in innovative ways. I had the privilege to take a master’s course on Education Technology for Health Practitioner Education last semester through the Department of Family and Community Medicine.  Now more than ever, we need to find ways to deliver medical education from the safety of our homes during this pandemic.
8. Virtual care has grown exponentially due to COVID.  Through virtual care, family physicians can manage their patients’ chronic conditions, check in on their mental health, and avoid hospitalizations. 
9. Spouses and loved ones of our front-line workers are underappreciated during this pandemic and we need to support physicians families. 
10. A pandemic is a marathon and not a sprint.  Physical distancing is working, and we need to continue to stay home so we can flatten the curve. 

Elliot Lass
PGY-3 Resident

Submitted April 21, 2020

My practice "sits" in a walk-in clinic. While I run a regular family practice with appointments and full care the majority of the 22 rooms are for the adult and paediatric walk-in. Over the years there is the occasional very agitated patient who shouts at the front desk staff. Mall security is often called. I believe it was getting particularly bad with one patient one day and he threw a pop can at the staff.

That was 6 months ago and after ++ complaints the owner of the clinic finally erected a plexiglass wall to form a barrier between staff and the waiting room. It took about 2-3 weeks to figure out how to communicate through the barrier. We needed to add a microphone and speaker system but by the start of February 2020 it was working well (from the staff point of view- the patients hated it).

Then came March and COVID19. One day a patient came into the walk-in. He was a 70-year-old man and had recently travelled from England. He said he had abdominal pain, no fever and no cough. At that time only China was on the list of countries to screen positive. Staff screened him through the glass, had him sit in a special area of the waiting room over 20 metres away from the rest of the patients. Through the glass the MD working assessed the patient, then determined he needed to go to the hospital. Transfer was arranged. We found out later through Public Health that after the Patient went to hospital and was sent home, he returned the next day, was admitted and was one of the first Toronto deaths from COVOD-19.

To every cloud there is a sliver lining. The belligerent patient who tormented the front staff and mall security for weeks likely saved them from being exposed to COVID-19.

Risa Bordman
Family Physician at North York General Hospital-community site

Submitted April 17, 2020

It’s hard to believe that our practice lives have been upended for just over a month. I am measuring the time past in units of learners lost. My first casualty was a PGY2 who scheduled a 4 week elective last month. Owing to an out of country trip, he was on 2 weeks of quarantine. By the time the final week came, our clinic was 80% virtual and there was little I could offer in the way of patient care. He was deployed to another service. The second casualty was a 3rd year clinical clerk scheduled for selective 2 weeks from now. Due to the impacts of COVID-19, the MD program has cancelled all 3rd year elective placements. For many of us, our days are now filled with Virtual Visits by phone or video. We are socially distancing from our colleagues and staff. The loss of our learners is felt deeply. The enthusiasm of our learners , the joy of mentoring and the thrill of observing new skills acquired is a loss for both myself and my patients. After 35 years of supervision, my patients actually look forward to their role in helping to train new doctors. I don’t know when we will return to more normal practice, but I am certain I will be more mindful of the joys of sharing my practice with our learners.

Audrey Karlinsky
Family Physician at Sinai Family Health Team and Bedford Family Health Organization

Submitted April 16, 2020

I have never been so grateful to be part of a team.

Every day, I feel overwhelmed by the mountain of information coming to me via the newspaper, radio, social media, and worst of all, my own email inbox. Sifting through what is important and deciding how to change practice often seems like an impossible task. But thankfully it’s one I don’t need to do alone.

In my clinical practice, I have the luxury of being a follower.

In the last month, our primary care team has rallied to change the way we deliver care several times over. Like others, our focus has been on providing accessible, equitable patient care while keeping patients and staff safe. These changes have only been possible because of the leadership of many.

Continue Reading on CMAJ Blogs >>

Tara Kiran
Family Physician and Fidani Chair of Improvement and Innovation at DFCM

"It does not take much to realize that it all adds up to a dangerous and explosive concoction if the Coronavirus arrives here. Vulnerable communities like this are most likely to drop even further into poverty if the virus hits. It is virtually impossible for them to social distance so it could spread like a wildfire.

Now into February, the Coronavirus was now a main topic all over the globe.  But unfortunately, this is still not a main concern for the people in the areas where I work. No one really understands what the big deal is about handwashing and hygiene.

Each day we see three-year-olds walking around with constant runny noses, open sores, ringworm. Kids are all sharing cups and spoons, there are no wipes or tissues for coughs and, of course, there is very little handwashing in most locations."

Continue reading on their personal blog >>

Sunyata Choyce
Past participant in Global Health Program

Welcome to the Medical Residency Twilight Zone:

There are no medical students. Academic half-days are virtual. Research projects are delayed indefinitely. Your oral presentation at the conference is cancelled. The entire conference is cancelled. Oh, that’s because flights are also cancelled. Licensing examinations are delayed. Clinics are cancelled. Where did all the patients go? You can hear a pin drop in the emergency department.

My hands are raw. No, I am not moisturizing them during the day and, yes, they are showing cracks. I am turning reptilian. These masks make me so hot, I can barely breathe. My glasses are constantly foggy. Oh hey, I didn’t recognize you with the mask on. Leaving the hospital and coming home are newly ritualized. Wash hands (arms, neck?), then take off scrubs, then take off shoes, wash hands again, put street clothing on… wait did I miss a step? Did I contaminate myself? Will I contaminate my home? Get my wife sick? I don’t know. I have internal monologues about how often to sanitize my equipment. Is my cell phone going to survive all this virox? It is the least of my worries right now, but it would really suck if I broke it.

Continue Reading on CMAJ Blogs >>

Gray Moonen
PGY-1 Resident

I am a family physician. I work in the COVID-19 Assessment centres. It is difficult. I am used to working in a context where I am able to greet my patient, smile to offer a sense of comfort, listen to their concerns and worries and collectively come up with a plan on how to manage their identified issues. I was not able to do any of those things. I am rarely closer than one meter to my patient, so I am certainly not able to shake their hand or put a comforting hand on their shoulder. The nurses on the team remind me not to get too close, otherwise, I will need to change my personal protective equipment and we do not have enough to change between every patient. I look like an astronaut, covered from head to toe in a gown, gloves, and a face mask and shield; maybe they can see the concern in my eyes through the face shield and my glasses? Patients are scared, of course they are, it is an unprecedented time. We are still here for you.

Archna Gupta 
Family Physician and Adjunct Assistant Clinical Professor, DFM, McMaster University

Submitted April 2, 2020.

In Toronto, as in many other cities in Canada and the United States, the coronavirus crisis is twinned with a different crisis: homelessness.

Sometimes all it takes is one person to illustrate how the system is failing.

Miriam* has struggled with housing for years. A couple of years ago, when her landlord ended her lease, she was unable to find another apartment that she could afford. Despite days and days on the phone with central intake, she could not get into a city shelter in Toronto. She was eventually advised by a housing worker to go to London, Ontario (a city of about 400,000 two hours drive away) – where she still could not get a shelter bed. She spent several nights in a McDonald’s until she was taken in by a local church.

Continue reading on CMAJ Blogs >>

Tara Kiran
Family Physician and Fidani Chair of Improvement and Innovation at DFCM

The two of us – married with 3 children, one a family physician and the other a general internist – left for a family vacation to Panama on March 7th. It is not an exaggeration to say that health care in Canada changed more during the 2 weeks we were away than it did during the 2 decades since we were medical students.

The COVID-19 pandemic will go on for many months, and we hope to share our thoughts here each week. In this initial blog, we will share our thoughts about travel, based largely on our recent experience in Panama, Miami and Toronto.

In Panama, the government decided to shut down all international travel just 10 days after its first COVID-19 case. When we heard the news, we hustled to get an earlier flight home. 

Continue reading on CMAJ Blogs >>

Tara Kiran
Family Physician and Fidani Chair of Improvement and Innovation at DFCM

If you are feeling like the information about COVID-19 is coming fast, changing quickly and overall…overwhelming. Join the club, we all do. Yes, even health care workers. My brother is a paramedic and has been working endless hours at the Toronto Paramedic Command Centre. He has passed on this great resource all about the facts, just the facts with the Canadian facts first. As the information changes, so do we. We have to continually change our behaviours. Let’s talk about CHANGE.

Continue reading on Wellsense >>

Julia Alleyne
Associate Program Director, Academic Fellowship and Graduate Studies at DFCM

Wellsense is a blog created by faculty Dr. Julia Alleyne with daily messages to maintain wellness, but with a common sense, evidence-based approach.