November 5, 2021
Dr. Kieran Moore
Chief Medical Officer of Health
Ministry of Health
Mr. Patrick Dicerni
Assistant Deputy Minister
OHIP, Pharmaceuticals and Devices Division, Ministry of Health
Dr. Nancy Whitmore
Registrar and CEO
College of Physicians and Surgeons of Ontario
Dear Dr. Moore, Mr. Dicerni, and Dr. Whitmore:
On behalf of the Ontario Association of Cardiologists (OAC), we are writing to express concerns over your recent letter to Ontario physicians regarding the provision of in-person and virtual care at this stage of the COVID-19 pandemic. Specifically, we take issue with (1) your assertion that COVID-19 no longer poses a barrier to in-person practice; (2) your contention that physicians’ offices are not providing in-person care; and, (3) the implied threat of disciplinary action that may be taken against physicians if they do not see patients in-person.
While hospitalizations and incidents of severe illness have dropped recently in Ontario, COVID-19 remains a concern for all front-line doctors, including cardiologists, who must continue to vigilantly operate their clinical practices in ways that ensure the protection of their patients and staff when seeing vaccinated and unvaccinated patients. While not insurmountable, it must be acknowledged that COVID-19 continues to present important barriers to in-person practice.
Ontario’s cardiologists have remained accessible to their patients since the beginning of the COVID-19 pandemic by keeping their offices open for in-person visits as well as through virtual care appointments. Throughout all stages of the pandemic, cardiologists worked hard to strike a suitable balance between providing in-person and virtual care services taking into account such factors as PPE availability, social distancing protocols, staffing requirements, patient preferences, vaccination rates, and much more. In so doing, we succeeded in ensuring that patients had access to elective and emergency cardiac care in the community and hospitals all across the province.
Your letter asserts that the standard of care is often difficult to meet in a virtual environment. We disagree. In the Cardiology specialty, a significant amount of objective information comparing past and present test results is used along with an updated history from the patient, which can readily be obtained virtually. In fact, cardiologists have found that having several family members present in the patient residence at the time of a video or telephone virtual visit results in a more robust and reliable history about matters such as functional status and symptoms. There are many circumstances in our specialty in which virtual care is superior to an in-office visit.
Cardiac patients are often extremely elderly with advanced poly-morbidities. These factors as well as their cardiac condition itself put them at great risk from exposure to viral pathogens like COVID-19 and others such as Influenza. Conducting virtual visits, where clinically appropriate, and avoiding crowded waiting rooms reduces their exposure to these pathogens.
Virtual care expansion in the province has also improved access to specialist care for patients who live in remote areas, reducing the need to travel many hours to urban centres for routine cardiovascular care. This expansion in reach and scope of services is an important enhancement to the provision of cardiovascular care across the province. Furthermore, the response from the general public has been very positive. Patients are pleased to receive care in their own locations without the need to travel or wait in crowded waiting rooms. Primary care physicians in remote areas have also indicated that their access to cardiology specialty support has improved during the pandemic due to new virtual care options.
The OAC agrees that in-person care is essential for certain conditions or where physical assessments are necessary to make an appropriate diagnosis or treatment decision; however, the COVID-19 pandemic has taught us that the standard of care can be met without an in-office visit in certain circumstances. When used properly and responsibly, virtual care can be an extremely effective way to provide excellent care that reduces COVID risk to all patients and staff regardless of vaccination status.
Our profession must live up to the responsibility of providing timely and appropriate care for patients. Cardiologists in Ontario believe we have done this, and we object to a generalization that we may not have done so. If it is the case that some patients no longer have reasonable access to care (virtual or in-person) then the Ministry of Health and/or the College of Physicians and Surgeons of Ontario should develop a mechanism to quantify and address the problem on a specialty-by-specialty basis. As individual practitioners in specialty practice, cardiologists have heard many patients state they feel abandoned with respect to certain aspects of their care. We encourage the College, the Ministry and the OMA to explore this in more detail. Best practice guidelines for virtual care are long overdue and will benefit many Ontario patients. We encourage our leaders to develop such guidelines, and stand ready to provide our clinical expertise and experience to help accomplish this.
Finally, Ontario physicians are best suited to decide which patient visit is appropriate to do virtually and which requires in-person assessment. To assist cardiologists in making these decisions, the OAC is developing a guideline framework outlining the appropriate circumstances for in-person and virtual visits for meeting the standard of cardiac patient care. We believe this timely initiative will improve patient outcomes, protect physicians and staff, and meet broader public health objectives. We look forward to working with you to improve Ontario’s virtual care framework and ensure it is used appropriately and in a way that improves access to, and the safety of, health care for all Ontario residents.
John D. Parker, MD, FRCPC Richard Davies, MD, PhD, FRCPC
Board Member Board Member
c.c. Dr. Adam Kassam, OMA President