What do we lose
(and gain) with less
in-person care?
By Erin Howe
Jennifer Schultz was about to receive life-altering news. Then 43 years old, Schultz was sitting in her doctor’s office in a downtown Toronto hospital. She was about to find out she had Stage 3 lobular breast cancer, an invasive disease that can be difficult to diagnose.
The diagnosis would turn the world as she knew it upside down. It would lead to radiation, two surgeries and eight rounds of chemotherapy.
“When you give someone a serious diagnosis or let them know they have a chronic condition, their lives could be upended, even if it’s not life-threatening,” says Schultz, now 51 and in remission for six years.
Schultz decided to use her experiences as a cancer patient for good. She speaks regularly about patient-centred care in the Patient as Teacher program for the Temerty Faculty of Medicine’s surgical clerks. The program — set up in 2016 — provides third-year MD students in their surgery rotation with an opportunity to learn directly from patients.
“In moments like these, don’t underestimate the power of a gentle touch and asking, ‘Are you OK?’” she says.
For Schultz, it’s a chance to remind learners of the power of physicians to impact a patient in their most difficult moments.
Jennifer Schultz says in-person conversation can be a comfort to people receiving a difficult diagnosis. (23 sec)
The work Schultz does has become even more urgent to her as phone and virtual appointments become more ingrained in the health care system. Her experiences have made it clear to her that some discussions with health care providers should only happen in-person, and that the role of touch is crucial.
What Schultz is expressing is something that some health care practitioners are hearing more broadly across the board. The question of what is gained — and what is lost — in the advent of virtual care is of central importance to Canadian patients and the health care community.
By all accounts, the COVID-19 pandemic led to an unprecedented surge in virtual medical care. A 2022 report by the Canadian Medical Association, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada shows that rates of virtual care skyrocketed from 10 to 20 per cent of all health care visits in 2019 to 60 per cent in April 2020. By 2021, that percentage had fallen to 40 per cent of all visits, which is still significant.
“The [costs of physical contact] have been made manifest by the COVID-19 pandemic and have forced mass adoption of virtual care across Canada years ahead of schedule,” according to a 2020 C.D. Howe Institute report. “Virtual care will be a mainstay of clinical care in the future. There is the potential to transform the patient and provider experience, lower costs and improve care, particularly for those with chronic diseases.”
For a health care system with overwhelmed emergency rooms and rising wait times to see specialists —as well as a shortage of primary care doctors — virtual care could be seen as a way of leveraging resources.
But the rise of virtual care could also leave some people behind, says Tara Kiran (MD ’02), an associate professor in Temerty Medicine’s Department of Family and Community Medicine and the Fidani Chair in Improvement and Innovation.
In a study early in the pandemic, Kiran and colleagues found that people with a low income or poor health, or who had immigrated to Canada within the last 10 years had a stronger preference for in-person care. Issues such as language barriers and privacy concerns may have contributed to these feelings.
“If done right, virtual models can enhance equity and access care. But if not, we might inadvertently create additional barriers for some patients,” says Kiran, who practises family medicine at Unity Health’s St. Michael’s Hospital.
Further research by Kiran and others compared outcomes for patients who sought virtual care from their own physician with those who received care from a physician as part of a virtual-only care service, akin to a virtual walk-in clinic. People who saw their own doctor were less likely to visit the emergency room afterward than if they’d seen a doctor online who they had no prior relationship with and wouldn’t see again. While Kiran acknowledges that virtual care can have its advantages, she’s heard from many patients who want to see their doctor in-person.
Kiran was the principal investigator of the 2024 OurCare final report, the largest initiative to engage Canadians on the future of primary care. Over 16 months, Kiran and colleagues gathered more than 9,000 survey responses, and convened five provincial priorities panels and 10 community roundtables.
Kiran says that the findings show that most people still want to see their primary care clinician in-person. The majority of respondents also said they want virtual care in addition to office visits and the ability to make that choice themselves.
The finding doesn’t surprise Nazik Hammad (MSc ’95), a Temerty Medicine oncology professor. During treatment, there can be an information asymmetry between patients and physicians, she says, and being in the same room can help communication. Physicians understand the care plans for their patients, but the information can be a lot for people to take in, adds Hammad, a Unity Health oncologist.
“In person, I have extra opportunities to ensure my patients understand what I tell them,” Hammad says. “If I notice someone doesn’t take notes or ask questions, I might say something like, ‘I told you about this medication’s side effects. Would you be able to tell me what you remember from what we discussed?’”
Though patients may bring a family member or friend to their in-person appointments, Hammad points out that’s less likely to happen with phone appointments.
“Patients can benefit from having a support person who can help digest and remember information, advocate for them, and provide reminders to help ensure adherence to medication or other treatment plans,” says Hammad.
Virtual care can also help people before and after complex procedures, says Lisa Wickerson (BScPT ’93, MSc ’12, PhD ’19), an assistant professor in Temerty Medicine’s Department of Physical Therapy.
In 2019, Wickerson began researching hybrid rehabilitation programs to support people waiting for or recovering from a lung transplant. Before 2020, transplant patients attended hospital sessions three times a week pre- and post-procedure for supervised assessment and exercise training.
“When care is so specialized, in a way, that can be a rationale to keep it on site,” says Wickerson, who is also an affiliate scientist at University Health Network’s Ajmera Transplant Centre.
She now studies hybrid rehabilitation, in which patients receive both in-person and virtual care before and after a lung transplant, exploring how to assess and monitor a patient’s condition as they prepare for or recuperate from the surgery. Though a growing number of people already use wearable technology, such as a smartwatch, Wickerson says there is a need for accurate tools validated for at-home medical use.
Currently, Wickerson is finding ways to create program delivery models that can be personalized for individual needs and risk factors, which combine in-person and virtual care. She sees the promise in both approaches to help patients meet their needs.
“There’s no one-size-fits-all approach. We need different pathways for people based on their functional capabilities and medical status, in terms of what kinds of alerts, reminders and supervision they may need during preparation or recovery,” Wickerson says. The advantages of time management offered by virtual connection can extend to education as well.
In 2021, the Patient as Teacher program switched from an in-person model to online during the pandemic. Four years prior, the program had begun as a way of giving students an unvarnished view of the full experience of people with breast cancer. Over two sessions, cancer survivors came in-person to share their personal stories and perspectives with medical students.
The pandemic meant online sessions became necessary. At first, program founder and surgeon Jory Simpson (PGME ’12) says he was skeptical about how well online delivery of the program would work. But his skepticism lifted as he saw the program’s continued success with learners.
“It almost felt disrespectful because I believed so much in the in-person connection between patients and the learners. I worried it would be a negative experience for the patient-teachers,” says Simpson, an assistant professor in Temerty Medicine’s Department of Surgery, who launched the program.
Simpson says it didn’t take long to see the merits of moving things online.
“Students can engage with the patient-teachers in a professional and meaningful way. They can still gather in small breakout rooms for more intimate conversations,” says Simpson, who practises at Unity Health. “The students learn how to create online connections and get that practice with a patient population.”
Enabling volunteers to log in to their teaching sessions has also allowed a more diverse pool of cancer survivors to participate — including people who live outside of Toronto and people who have less financial privilege.
“We can recruit people from a wider range of geographic and socio-economic communities,” notes Simpson. “They don’t need extra time off work to travel, or worry about taking transit, or driving and finding parking in downtown Toronto.” Other Canadian medical schools have replicated the Patient as Teacher program, and online sessions are now available to postgraduate medical learners.
“We’ve seen learner perspectives of a surgeon’s most-important attributes shift dramatically,” says Simpson. “Before these sessions, all of the students ranked technical skills first. When asked again after the Patient as Teacher program, humanistic traits like compassion and the ability to provide comfort were given much more weight.”
Professor Danielle Martin says in-person and virtual interactions are both important in the relationship between family doctors and their patients. (44 sec)
And what if, as Danielle Martin (PGME ’05) puts it, it’s “not an ‘either/or situation, but a both/and’ approach?”
Relationships are the most valuable tool that family physicians have, says Martin, chair of the Temerty Medicine’s Department of Family and Community Medicine. She says that over time, primary care providers build trust, and learn to pick up on verbal and non-verbal cues to better gather information and sense when more is going on than a patient communicates or even realizes.
Martin, who is also a family physician at Women’s College Hospital, says the physical examination itself can help put patients at ease.
“When done well, it can be reassuring,” says Martin. “The respectful laying on of hands can help patients feel cared for, seen, and that their doctor is fully focused on them. The consent someone gives for physical touch in a joint pursuit of health is sacred.”
Despite this, Martin says virtual care has become a key part of the integrated relationship between doctors and patients. Connecting by phone to check in on how a treatment plan works for a patient, review test results or provide a requisition for a regular procedure such as a mammogram or blood work are all instances in which virtual care can be appropriate.
People who live in rural and remote areas or who belong to marginalized groups may also benefit.
Some people avoid the health care system because of negative past experiences or valid fears of racism, Martin says. Facilitating remote access, particularly if it enables access to a clinician from someone who belongs to the same community, for example, can help.
“There’s room for all the tools,” she continues. “They’re all manifestations of an ongoing commitment to the relationship between a health care team and the person in pursuit of good health.”
Schultz agrees. Though caring touch has its places, in real life so does the virtual empowerment of patients, she says. “Virtual care is just another way medicine is advancing. And it can help put patients in the forefront of their own care.” •