Summer 2020 (Volume 30, Number 2)
Virtual Care in Rheumatology:
The Sequel ‒ Thoughts as of March 2020
By Philip A. Baer, MDCM, FRCPC, FACR
“Never let a good crisis go to waste.”
– Variously attributed to Winston Churchill, Rahm Emanuel and Saul Alinsky.
(M. F. Weiner Medical Economics 1976: “Don’t Waste a Crisis — Your Patient’s or Your Own”)
I didn’t think I would be revisiting
this topic so soon, but COVID-19
has changed many plans. Amid all
the bad news, the restrictions on face-to-
face interaction have upended our
working world, potentially with some
longer-term benefits to us and our patients.
Fresh off a typically excellent CRA
Annual Scientific Meeting, extensively
covered in this issue of the CRAJ,
I had high hopes for March 2020 in
real life. My wife and I were booked to
speak on a continuing medical education
(CME) tour of Morocco for two
weeks: that was cancelled with three
days to go, preventing us from being
stranded in Casablanca when Morocco
closed its airspace. I pivoted to attend
a medical meeting in Vancouver: cancelled again, after
I already had checked in for my flight online. No problem:
I obtained a cancellation slot for needed cataract surgery.
Again, that was cancelled with less than 24 hours notice
due to COVID-19.
Meanwhile, every booked medical meeting, Journal Club,
CME, and industry contact has been postponed, cancelled
or moved online. With social distancing the new norm, our
local Disaster Psychiatry interest group did remind us that
emotional connectedness was even more important than
usual. In this wired world, that is easier than ever, even
when physical separation is necessary. In Ontario, it was
gratifying to see our tight-knit rheumatology community
working together, in small groups and through the ORA,
to support each other in this very unfamiliar environment.
While helping each other, we also were confronted with
how to meet the needs of our patients with rheumatic diseases.
While many of us are not thrilled with our electronic
medical records (EMRs) on a day-to-day basis, the benefits
of having one over paper charts in this situation are clear.
We can work from anywhere, at least
as long as the electricity keeps flowing
and the internet is functioning. Provincial
governments moved quickly to enable
billing for telephone visits, which
we last used during SARS in 2003, and
expanded the options for video visits
to more platforms. With some medical
buildings closed, and some physicians
healthy but in self-isolation after travel,
care could continue to be delivered.
Of course, adjustments are needed
in any new work environment. EMR
adoption is not synonymous with EMR
optimization, as I quickly learned. We
had never favoured emailing with patients
because of privacy and timeliness
of response concerns. Now, we
suddenly wanted everyone’s emails in
order to scan and send them lab requisitions and other
documents, as most patients do not have fax access, and
snail mail could be eliminated at any moment. E-prescribe
options look better than ever when available; for everyone
else getting a virtual visit, recording their pharmacy’s name
and fax number was a new requirement.
My first few telephone visits included this new administrative
work, but otherwise went surprisingly well. Routine
follow-up visits of stable patients work well in this format,
saving some patients long commutes to my office. We also
handled patients who were in self-isolation after travel, who
would have had to delay their visits. Video visits for the
tech-savvy will manage other patients: rashes and obviously
swollen joints can be seen; home blood pressure readings
can be obtained from patients; but subtler findings
will clearly go unrecognized. Patients proved quite adept at
doing their own tender joint counts, and our paper Multidimensional
Health Assessment Questionnaires (MDHAQs)
were replaced by verbal versions.
Issues do persist. Joint injections and biologic infusions
cannot be done virtually. Patients who are not doing well
require in-person examination in many cases. New consults
also are difficult to handle virtually, other than those related
to incidental abnormalities on imaging and lab tests,
many of which should not have been ordered in the first
place. Patients with new-onset vasculitis, rheumatoid arthritis
and systemic lupus erythematosus (SLE) must be
seen and treated urgently. Lab monitoring intervals can be
spaced out, but those tests are still required.
For those visiting the office, there are new realities:
Locked office doors, social distancing in the waiting room,
restrictions on accompanying persons and drop-in visits,
and the use of personal protective equipment when necessary.
All patients are now screened based on travel history,
contacts with COVID-19 patients, fever, and other
worrisome symptoms. My secretary has a new script for reminder
phone calls, and the signage on our front door and
throughout our medical building is ever evolving.
Tantalizing therapeutic questions remain to be answered.
Should ibuprofen be avoided? Will the promise of anti-malarials,
baricitinib and IL-6 inhibitors as COVID-19 treatments be
realized? Will there be a vaccine? Will this be the last ever pandemic?
That one is easy, the answer is NO. What will the new
normal look like after this pandemic runs its course? I predict
virtual medicine is here to stay. As Canada’s chief public health
officer Dr. Theresa Tam stated: “People are using innovations
to try and get care to people in different ways. That includes
. . . having billing codes for physicians who are doing these
consultations remotely. So what you’re trying to do is increase
the maximum . . . capacity for the health system to treat those
who have more serious presentations of the COVID virus.
They are using telemedicine in a way that I feel to be maybe a
legacy of the outbreak itself.”
If you have COVID-19 tips, experiences or stories to
share, feel free to send them to us at the CRAJ for possible
publication in print and/or online in future issues.
Philip A. Baer, MDCM, FRCPC, FACR