Primary Care in the face of COVID-19
How a group of family physicians led a COVID-Assessment Centre through the depths and heights of a pandemic
When the COVID-19 pandemic began, the entire healthcare system was shaken. Cancelled surgeries threatened to delay important procedures, healthcare providers struggled to balance caregiving for their children as schools closed, and patients hesitated to access their physicians’ offices. Perhaps the most overwhelmed group of physicians was family doctors – the foundation of the entire healthcare system.
As a family physician, working during an ‘unknown’ pandemic was scary, stressful, and challenging. Making decisions about which patients to bring in for exams and which ones to conduct virtual visits with was daunting. Even with an air filter and proper personal protective equipment (PPE), how could we bring in a patient who tested positive for COVID-19 into the clinic, where immunocompromised patients also visited? At the same time, these patients needed assessment. While virtual care was useful, there were times when it was clear that a patient who had upper respiratory system symptoms needed to be seen in-person. How could we achieve this in a safe and efficient manner?
Our team of physicians got to work. Under the lead of Dr. Sohal Goyal, a Ministry of Health funded initiative began to open a COVID-19 Assessment Centre (CAC) in the heart of Mississauga, Ontario. This was no easy feat; there were numerous logistics to be sorted out: everything from obtaining enough PPE, hiring nurses and administrative staff, getting air filters, organizing the flow of patients in a typical day, documenting symptoms and plans of care, communicating with the public, and more.
The CAC first opened in January 2022. At first, patients could simply walk-in for an assessment, regardless of their COVID-19 status. Many times, patients presented to the clinic with symptoms such as sore throat, fever, cough, etc. and had not taken a Rapid Antigen Test (RAT). We tested them using the PCR machine if they met the Ministry criteria (which changed several times over the course of the pandemic, further challenging us to use our resources wisely). At other times, patients presented with positive RATs, but they were not being seen by their own family doctors to avoid spreading infection. In this case, we conducted focussed physical exams and provided counselling or treatment as necessary. In some cases, patients had to be sent to the emergency room due to low oxygen saturations, severe symptoms, signs of deterioration, etc. At other times, we provided education around symptom-control and conservative treatment, knowing that most COVID-19 cases responded well to this. Of course, we always counselled patients about when to present to the emergency room, and our nurses also provided patients with a handout on isolation precautions (which, again, changed several times through the pandemic!).
As the pandemic unfolded, treatments for COVID-19 emerged. In the outpatient department, Paxlovid became available under certain circumstances. Our CAC responded to the call and began prescribing and dispensing Paxlovid to eligible patients. This required us to make several changes to our workflow; we obtained a point-of-care machine that gave us an approximate estimate of a patient’s kidney function, as Paxlovid doses changed according to this. We onboarded a group of pharmacists who helped us obtain medication reviews for patients and manage drug interactions between Paxlovid and the patient’s routine medications. We provided education to patients taking Paxlovid, and our team called patients each day during their treatment to follow-up, inquire about symptom changes, ensure the medication was being taken correctly, etc. Meanwhile, our physicians sent updated notes to the patient’s family physician to ensure that this was kept on their charts. And – unsurprisingly – as the criteria for eligibility for Paxlovid changed, our CAC changed, too. We had to constantly adapt and shift our processes to serve our communities well.
What began as a ‘COVID Assessment Centre’ turned into a safe haven for many patients who were unable to access their healthcare providers for assessment. Not all our patients had COVID-19, but many of them required urgent assessment, triaging, and treatment. From simple illnesses such as otitis media in children to complicated cases such as severe COPD exacerbations – our team responded to the call during a raging and dangerous pandemic. Patients would come in frightened, frantic, and sick; they would leave with praise for our team and gratitude that we examined them and provided appropriate management. If it were not for our team, many patients told us, they would have gone to the emergency room and waited for hours – or they would not have gone to get examined at all. As family physicians, we knew this to be all too-true: our CAC was decreasing the burden on emergency rooms, getting patients the treatment and healthcare advice they needed, and essentially - saving lives.
Our CAC remained open for approximately two years, during which we assessed and managed about 40 patients per day among 2-3 physicians. Our team of nurses and pharmacists assisted us in triaging and managing complex cases, and our administrative staff worked extremely hard to schedule patients as the number of people presenting for care increased.
As a family physician who worked both in the CAC and in my own clinic, I witnessed first-hand the impact that the CAC was making the community. When patients called in to my clinic and reported that they were either experiencing upper respiratory symptoms and/or tested positive for COVID-19, I now had a resource to refer them to: the CAC. When a patient presented to the clinic and we could not examine them in-person, we sent them to our team at the CAC. Patients who presented to our family medicine clinic who were potentially eligible for Paxlovid were then referred to the CAC for possible treatment. The CAC was indeed a powerful and impactful resources to depend on as a family physician – and patients appreciated that they were examined by a physician within 1-2 days (depending on need, patient load, etc.) at the CAC. Countless patients reported that the care they received at the CAC was excellent, timely, and reassuring. They extended their gratitude about not having to wait in the emergency room for hours to get their child’s fever examined, for having a physician listen to their lungs and prescribe the appropriate treatment, for being seen in a timely manner when their own physician was not seeing people in person, and more.
As the number of patients with COVID-19 decreased and vaccination rates increased, our patient volumes began to drop. More physicians were reopening their clinics, so patients were able to access their primary care providers for assessment. As a result, the CAC closed in January 2023. This was a sad goodbye for our team of healthcare providers – we had formed strong bonds among one another, supporting each other as we managed sick patients. We had asked one another for expertise on medication dosing, triaging, and more; we had all worked with patients who were very ill and/or anxious. Reminiscing on how our model of work at the CAC evolved over time brought tears to our eyes: we began as a humble centre that managed patients with upper respiratory system symptoms and positive COVID-19 tests; we adapted to the constantly-changing criteria for which patients were eligible for COVID PCR testing; and we adjusted our model to prescribing and monitoring patients on Paxlovid. The news of our closing also shook the community – many individuals without a family doctor had depended on our centre to be examined when local walk-ins were closed; other patients reported that their own family doctors were not seeing people in-person; even my own family-practice patients reported their gratitude that the CAC existed during the height of the pandemic.
The impact of our CAC affected patients, healthcare providers in the community, emergency room departments, and the greater Public Health system. Although it was saddening to see it close, I recognized that this is what family doctors do – we adapt to changing circumstances around us, advocate for our patients, and develop plans to serve our communities according to the best-available evidence. When resources are tight, we seek out connections and relationships to boost our capacity to help our patients. We support one another through emotional and stressful situations, and we work with other healthcare providers to promote health and prevent disease. Appropriate and adequate funding from governments for our healthcare providers are assets that promote our ability as family physicians to make impactful changes. I am blessed to have gotten the opportunity to work in the CAC and witness the incredible work that we were able to do during the three years of the pandemic.
If another pandemic were to come our way, I have no doubt that the lessons and experiences from this CAC will inform future practices and make improvements in how healthcare providers manage emergency health issues. I often think back to my shifts at the CAC, dressed in PPE with a stethoscope in my hand, ready to examine the next patient with a positive COVID-19 test. Was I anxious about contracting the virus myself? Certainly. Was I worried about the severity of illness that the patients presented with? Of course. But was I fortunate to have this opportunity to make an impact in the healthcare system, to potentially save lives, and to support our communities through an unknown and challenging pandemic? Definitely. Would I do it again? Without a doubt.
Dr. Marina Malak is a family physician in Mississauga, Ontario and a lecturer and
faculty member at the University of Toronto and McMaster University. She holds the
position of Assistant Director of Programs at the Foundation of Medical Practice Education
(FMPE), and is also the Primary Care Physician Lead for Continuing Medical Education
at Trillium Health Partners (THP).As part of her advocacy work, she is a board member of the Mississauga Primary Care
Network (PCN). She is also a member of the National Committee of Continuing Professional
Development at the College of Family Physicians of Canada (CFPC).She is passionate about patient care; medical education; and promoting mental, physical,
and emotional wellness. She enjoys reading, writing, public speaking, badminton and
basketball, puzzles, and doodling in her bullet journal and Procreate app.