University of Toronto Family Medicine Report - Stronger Together: Caring Through Crisis by Department of Family and Community Medicine at the University of Toronto

UNIVERSITY OF TORONTO FAMILY MEDICINE REPORT

Stronger Together: Caring Through Crisis

2021

EDITORIAL COMMITTEE Faculty Dr. Karen Tu Dr. Catherine Ji Dr. Catherine Varner Dr. Sumeet Sodhi Dr. Michelle Greiver Dr. Peter Selby Dr. Ross Upshur Staff Ms. Amy Noise Dr. Ellen Stephenson Ms. Alicia Fung Ms. Jemisha Apajee Ms. Allison Williams

IN DEDICATION The 2021 University of Toronto Family Medicine Report is dedicated to all those affected by the COVID-19 pandemic – those who have lost their lives and the lives of loved ones, the family doctors, primary care providers and all those who have made huge personal sacrifices in the service of others, as well as the families and friends who have made these sacrifices possible.

SUGGESTED CITATION Tu, K., Ji, C., Varner, C., Sodhi, S., Noise, A., Stephenson, E., Greiver, M., Selby, P., Upshur, R. (2021). The University of Toronto Family Medicine Report: Stronger Together: Caring Through Crisis. Toronto, Ontario: Department of Family and Community Medicine.

We wish to acknowledge this land on which the University of Toronto operates. For thousands of years it has been the traditional land of the Huron-Wendat, the Seneca, and the Mississaugas of the Credit. Today, this meeting place is still the home to many Indigenous people from across Turtle Island and we are grateful to have the opportunity to work on this land.

ISBN: 978-1-9990809-2-1

Contents 31

Chapter 4 Family medicine leadership

Building the ship as you’re sailing it: How to lead in a pandemic

Chapter 1 Caring through COVID-19

The crucial role of primary care: Distributive leadership in action

Eyes closed, arms folded: Inside a long-term care rescue operation

Emergency medicine leadership during the pandemic

Chapter 5 Teaching that matters, care that makes a difference

Learning as a community during COVID-19

Crisis and opportunity: The present and future of virtual care and education

Excellence in virtual teaching

Innovation as the solution

Teaching that matters, care that makes a difference

Committing to social accountability

Message from the Chairs

DFCM in numbers

Understanding care experiences: DFCM COVID-19 patient experience survey

Caring for homebound patients during the COVID-19 pandemic

Shield and protect: Helping shelters support their clients

COVIDCare@Home

Providing palliative care during COVID-19

Chapter 2 Responding to the pandemic: Supporting communities

Community First: COVID-19 response in Nunavut

Rich culture and resilience: Reflections on Operation Remote Immunity

Vaccine hesitancy among Black Canadians during COVID-19

Chapter 6 Research to improve care 45

An INTRePID international research journey

Using UTOPIAN data to improve primary care for our patients

Chapter 3 Staying connected

Emergency medicine research during a global emergency

Pandemic Pregnancy Guide: The virtual frontline for perinatal support

Palliative care research through COVID-19 and beyond

Looking ahead: Message from the Chair

Communicating during COVID-19: Health journalism in the pandemic

#StrongerTogether: Unifying two clinics with a common goal

Stronger Together: Caring Through Crisis

Message from the Chairs When COVID-19 was officially declared a pandemic in March 2020, few of us could have imagined what the coming months would look like.

University of Toronto Family Medicine Report

Since then, we have seen over 400,000 cases, 19,700 hospitalizations and 6,100 deaths, plus a slew of associated health issues in the Greater Toronto Area (GTA) alone*. For family doctors and other primary care providers the crisis has added multiple layers of stress and exhaustion to already-challenging roles. Despite the transition to virtual care, overburdened hospitals, remote learning and separation from loved ones, family doctors have kept clinic doors open – physically and virtually – and our communities safe while driving forward critical COVID-19 research and ensuring learners receive the best possible educational experiences.

circumstances. This work is broad, far reaching and, in many cases, ongoing. The 2021 University of Toronto Family Medicine Report is a celebration of this work, of family medicine as a whole and collaborative spirit that defines our profession. Submitted by members of the broad DFCM community, the stories and anecdotes are personal reflections from our faculty, learners and colleagues. Of course, this is just a snapshot of the incredible work happening across our department. There are many other groups and individuals providing outstanding leadership, care, research and education at DFCM. Thank you to you all.

Dr. David Tannenbaum It has been hard, but the stamina, optimism and adaptability Vice-Chair, Operations, Interim Chair (April 2020 of family doctors have shone through. Our Department of – September 2021) and Associate Professor, U Family and Community Medicine (DFCM) colleagues have of T DFCM; family doctor, Sinai Health System led the extraordinary COVID-19 swabbing and mass vaccination efforts, advocated for remote and under-served Dr. Danielle Martin communities, inspired vaccine confidence and stepped Chair and Associate Professor, U of T DFCM; in with compassion and creativity in unprecedented family doctor, Women’s College Hospital *Public Health Ontario for Toronto, Peel, York, Halton and Durham Public Health Units as of November 23, 2021

DFCM in Numbers People

1,952

The University of Toronto Department of Family and Community Medicine (DFCM) is one of the largest family medicine departments in the world. Our faculty, staff and learners are dedicated to excellence in patient-centred family medicine education, research and clinical care. PLACES

377

1,000+ 38

Faculty Members

Family Medicine Residents

MD Learners

Graduate Students

40+

Continuing Education Students

Staff

Core Teaching Sites

40+ Teaching Practice Sites

Integrated Community Streams RESEARCH

$40.5M In Research Grant Funding*

UTOPIAN The University of Toronto Practice Based Research Network (UTOPIAN) uses a database of electronic medical records to study and answer important healthcare questions. UTOPIAN includes:

Physicians

Clinical Sites in the GTA and Beyond

411,201 Patients**

Faculty & learner data from 2020-21 academic year. *Total amount of Principal or Co-Principal Investigator grants received by researchers affiliated with DFCM in 2019. **Estimates of care provided in 2020 included throughout this report are based on data from 411,201 patients.

Stronger Together: Caring Through Crisis

392

University of Toronto Family Medicine Report

Chapter 1

Caring through COVID-19

CARING THROUGH COVID-19

Eyes closed, arms folded: Inside a longterm care rescue operation Dr. Ann Li is a family doctor and Lead for Long-Term Care at North York General Hospital and an Assistant Professor at U of T DFCM On Christmas morning, I entered a long-term care home ravaged by COVID-19. Medical and nursing staff were at a critical shortage. My hospital had tasked me with aiding the home’s medical team. Silence pervaded the entire home. Some residents lay in bed, hardly breathing, eyes closed, arms folded, like Snow White in her glass coffin. For them, we were too late. Others were quiet but moving limbs. There was hope! Searching for staff, I found one nurse on a 50-bed unit. Unprocessed orders were still flagged from three days prior. We needed to act fast.

Supporting long-term care: Dr. Anne Pyper and Dr. David Silver

Communication was a huge barrier. More than 90% of residents were Chinese speaking only, but the staff available were unable to converse in Chinese. No family were allowed in. Dr. S. felt, “It’s important to speak in a patient’s mother tongue to truly understand their suffering. I had a patient who refused to eat all day, but once we put her daughter on FaceTime, she ate her whole meal!” Dr. M. noted, “Residents languished alone, some in their confusion thinking they had been abandoned by their loved ones.” We called every family, every day in an attempt to provide some comfort, totalling about 200 calls per day in addition to all the other duties.

In response to urgent calls, family doctors and specialists from emergency, surgery, laboratory medicine, pediatrics, “Silence is not golden,” reflected Dr. T. “We, the health care internal medicine, psychiatry, anesthesia and radiology, workers, witnessed many horrific incidents of residents converged from as far as Ottawa, London and Guelph. not being cared for properly. … We need to speak up for We even had a firefighter. Our team of three quickly those who are socially disadvantaged and who could not grew to 45. speak up for themselves.” Dr. F.* recalled how well we came together on short notice to provide the best medical care we could in an unbelievably challenging environment.

Armed with COVID-19 protocols and determination, the physicians offered every humanitarian service including clinical rounding, feeding, personal care of residents, supplies management, housekeeping and even offer- By the time we departed in February 2021, 189 residents ing to cook. Shifts ranged from two-to-nine hours a had contracted COVID-19. Sadly, 81 had died. Without day, followed by hours of remote charting from homes the herculean efforts of the rest of the team, it could and hotel rooms. Stamina was pushed to the limit for have been many more. fear of contamination – “I don’t want to drink or eat so I won’t have to pee,” insisted Dr. L. We now know we can By the Grace of God, no team member contracted COVIDwork nine hours without food or bathroom breaks, but 19. My heartfelt thanks to everyone involved. this – alongside the emotional burden – took its toll on our personal health. *Physician names have been abbreviated for privacy.

Stronger Together: Caring Through Crisis

On New Year's Day, we formed a Chinese-speaking physicians’ roster to provide virtual encouragement in communication for staff, colleagues, residents and families. In just two months, Family Council participation rose from one person to more than 30 as families became more actively engaged in care.

CARING THROUGH COVID-19

Understanding care experiences: DFCM COVID-19 patient experience survey

Improving the patient experience is central to improving quality in primary care. Patients want care that is accessible and centred on their needs, but the pandemic has posed new challenges in delivering care. PATIENT EXPERIENCE SURVEY

University of Toronto Family Medicine Report

In June 2020, the University of Toronto’s 14 family medicine teaching clinics launched a patient experience survey to understand patient perspectives during COVID-19. 7,532 patients and caregivers took part in the first wave of the survey which was sent electronically between June and September 2020. 65% of those who responded were women, 71% were born in Canada and 9% had difficulty making ends meet.

The Patient Experience Survey was a collaborative effort enabled by Quality Improvement Directors across DFCM sites and led by Drs. Payal Agarwal and Tara Kiran. Dr. Payal Agarwal is a family doctor at Women's College Hospital and a Lecturer at U of T DFCM Dr. Tara Kiran is a family doctor at St. Michael’s Hospital, Unity Health Toronto, the Fidani Chair in Improvement & Innovation and an Associate Professor at U of T DFCM

KEY FINDINGS

87%

82%

87%

83%

felt involved in their care decisions and treatment plan

were able to get an appointment within a reasonable time

would recommend their clinic to another friend or family member

received care by phone and would like to continue connecting virtually with their providers

91%

are comfortable with the level of privacy and security of phone, video or email care

However, patients with different backgrounds reported different experiences. For example, those who had difficulty making ends meet, were born outside of Canada or reported poor/fair health were less comfortable with the privacy and security of phone, video and email care.

The survey is sent to patients every quarter, and clinic teams meet regularly to discuss the results. We are working to include more diverse perspectives to better understand the care needs of all patients. For example, the survey is now being sent in English, French and Mandarin.

The information gathered from the survey is shaping how family doctors provide care, now and in the future. We are working to improve care by:

Ensuring the way we deliver care meets everyone’s needs

For more information or to take part in the survey, please contact dfcm.quality@utoronto.ca or visit tinyurl.com/DFCMPtExp

Exploring best practices for adopting email and video in our clinics

Stronger Together: Caring Through Crisis

Ensuring timely care for those who need it

University of Toronto Family Medicine Report

CARING THROUGH COVID-19

Caring for homebound patients during the COVID-19 pandemic

2,579 1,313

house calls for

patients in 2020 UTOPIAN data, 2020

In June 2020, Buzz – a 90-year-old homebound patient of ours – had been tired for several days and was too weak to bear weight. His son, Don Neal – a family doctor living out of town – worried that Buzz might have contracted COVID-19, but his father was too weak to visit a COVID-19 assessment centre. After hearing about Buzz's situation, our home visit team stepped into action.

At the heart of our team’s philosophy of care is the importance of patient-centred care: What are the patient’s goals and wishes? Some of our homebound patients continue with active medical treatment, seeing specialists and going to hospital when such care would improve their function or quality of life. Others want only comfort-based care at home.

Our team is a group of three family doctors, a nurse practitioner, a clinical pharmacist and a LHIN (local health integration network) co-ordinator. We serve a high number of seniors living alone in some of the lowest income postal codes in the city.

Uncertainty is part of our culture in family medicine, even more so in caring for older patients.

This uncertainty is particularly challenging when making shared decisions in the absence of clear guidelines for the care of homebound patients with COVID-19. We had to Don was relieved that "someone was willing to ‘PPE- consider: If a patient deteriorated, should we provide the up’, go in to do a swab and get an early diagnosis." His medications that were being used in long-term care? Do instincts were correct: Buzz had COVID-19. We put in we order oxygen to keep on hand at home or should they supports to manage him at home with minimal contact call 911 immediately? These are questions we grappled and provided an oxygen saturation monitor with instruc- with in caring for patients with COVID-19. tions on when to call. Buzz initially seemed to recover well from COVID-19. Early in the pandemic, we saw that virtual care wasn’t However, on day 14, a personal support worker reported going to work for our patients. Most don’t have computers, Buzz's pupils were strangely dilated. He had suffered a and some don’t even have a phone. Many have dementia haemorrhagic stroke, a known complication of COVID-19, or severe hearing loss. To meet our patients’ needs in this and was transferred to hospital. new environment, we quickly developed protocols for using personal protective equipment (PPE), testing and The family strongly wished to bring him home to die. It monitoring patients with COVID-19. We also accessed would take days to arrange a palliative team, but the COVID-19-focused goals of care discussion guides and family wanted him home as soon as possible. Our team created an end-of-life symptom management kit with delivered a symptom management kit and cared for him at home until the formal palliative care team arrived. He special consideration for patients who live alone. died peacefully at home.

St. Michael's home visiting team setting out to vaccinate! (L to R) Dr. Doret Cheng, pharmacist; Dr. Amy Freedman, family doctor; Lorna McDougall, nurse practitioner; Dr. Ann Stewart, family doctor

A hybrid health model

Caring for frail patients – a population hit particularly hard by the pandemic – at home has been challenging, We have said goodbye to many much-loved patients. Ultimately, however, the pleasure of caring for people in their homes has sustained us during a difficult year. Our most recent shift has been to lead the vaccination of homebound patients and their caregivers who are served by the Downtown East Ontario Health Team. We have been delighted to share the joy of this work with other family doctors and nurse practitioners as we bring vaccines into the home. The team thanks Dr. Don Neal, Goderich, Ontario for permission to share his father’s story.

In response to the pandemic, the Get Well Clinic in North York pivoted to a custom virtual care platform (built on open-source software) within a week to maintain access to primary care. Early on, 85% of our virtual visits were secure video-enabled. Within one year, we registered over 2,000 patients on our platform, alleviating the volume of in-person appointments. This more than doubled the number of appointments we could provide and helped maintain mental health, diabetic and cardiovascular disease patient care. A hybrid model and expanding family doctor team allowed us to better care for the community and expand efforts to train aspiring doctors through medical school electives and our pre-medical volunteer program.

Dr. Ann Stewart is a family doctor at St. Michael’s Hospital, Unity Health Toronto and an Assistant Professor at U of T DFCM Lorna McDougall is a Nurse Practitioner at St. Michael’s Hospital, Unity Health Toronto and an Adjunct Lecturer at Lawrence S. Bloomberg Faculty of Nursing

We also expanded our mental health program and became a COVID-19 vaccination clinic, vaccinating 2,500 patients to date.

Dr. Kevin Lai is a family doctor at Get Well Clinic and North York General Hospital and a Lecturer at U of T DFCM

Stronger Together: Caring Through Crisis

Dr. Amy Freedman is a family doctor at St. Michael’s Hospital, Unity Health Toronto and Baycrest and an Assistant Professor at U of T DFCM

CARING THROUGH COVID-19

Shield and protect: Helping shelters support their clients

University of Toronto Family Medicine Report

COVID-19 hit Toronto’s homeless population hard and fast. Those relying on shelters found it increasingly hard to find a space, while those who made their livelihood on the streets lost their income. Homeless individuals were 20 times more likely to get admitted to hospital with COVID-19 and five times more likely to die than their housed counterparts.

Just like you would in a family, we then helped shelters shield and protect the most vulnerable, while managing risk among those with lower-support needs. We helped identify who should be moved into one of the in-demand hotel rooms and we provided crisis management teams to respond rapidly to COVID-19 outbreaks and data reports to help shelters assess and personalize protocols for outbreak prevention, contact tracing and immunization While COVID-19 is a virus uniquely armed to harm under- based on their clients. served populations, these populations are not homogeneous. Led by Drs. Stefan Baral, Tomislav Svoboda and myself, Most people experiencing homelessness do so for a one- CARE is implemented by a team of population health off period of less than six months. Though a relatively nurses and made possible by an interdisciplinary team low percentage of the population experiences chronic including family and public health physicians, data homelessness, their health conditions are often complex, analysts, health promoters and community partners. requiring diverse medical and social supports. A crisis Introduced to address the crisis at hand, i.e., COVID-19, further complicates their care. CARE created an unprecedented picture of the people served by the shelter system, producing invaluable At Inner City Health Associates (ICHA) – the largest home- epidemiological insights to harness at any time and for less health organization in Canada – we have been working many ends. It will continue to provide resources and on data-driven care services for a long time. As COVID-19 real-time data to inform improvements in clients’ care hit, we launched CARE, a COVID-Alert Risk Evaluation and and population health. Management tool to help the homeless-serving sector identify their highest-need clients and find and allocate Homelessness is not a health problem, and it is not a resources to those who would benefit most. social problem – it is both. COVID-19 has highlighted this inextricable link and shown how family medicine is a cruOur team of nurses, medical and nursing students and cial part of community-focused care that embraces both. other clinical volunteers worked one-to-one with shelter management and staff to build a database of clients and identify their risk-level, health status, history and behaviour. This is as manual as epidemiology gets. We Dr. Aaron Orkin is a family doctor, Inner City assessed 4,624 individuals at 144 shelters, of whom Health Associates Population Health Lead and 67.3% were low risk, 24.2% medium risk and 5% high risk. an Assistant Professor at U of T DFCM

Balancing psychiatric and COVID-19 care

Pandemic eating disorder care

When the pandemic hit, the Centre for Addiction and Mental Health (CAMH) pivoted to ensure ongoing psychiatric care for inpatients, while safely managing patients with COVID-19. A unit was created for psychiatric inpatients with COVID-19 and our 10-person hospitalist team rose to the challenge, adapting our skill set and expanding our clinical role. This involved significant teamwork, conducting daily rounds that focused on COVID-19 patients and adding weekend hospitalist coverage.

Eating disorders have skyrocketed during the pandemic, with children, teens and young adults hit particularly hard. For these individuals, regular monitoring of eating habits, weight and blood pressure is a central part of care and recovery. But the shift to virtual care left many without essential support. While self-monitoring is a useful tool for many conditions, asking people with eating disorders to monitor their own weight and vitals can have dangerous medical implications. When COVID-19 hit, we started seeing patients with eating disorders deteriorating and ending up in the emergency room.

Working closely with our psychiatry colleagues, we worked on strategies to care for our patients’ medical needs while also providing mental health supports. This has been particularly crucial as many patients have experi- In this time of need, local family enced heightened psychiatric distress doctors stepped up to lend a hand. and isolation related to the pandemic. These comprehensive primary care providers are providing the necessary medical monitoring for children, Dr. Jennifer Nicolle is a hospitalist teens and young adults in Southlake’s within the Division of Medicine eating disorder program. These regin Psychiatry at the Centre for ular in-office checks, supported by Addictions and Mental Health the interprofessional eating disorand a Lecturer at U of T DFCM der team, are essential for keeping patients stable, out of hospital and, ultimately, alive.

HIV testing, FAST

Due to COVID-19, many clinics have reduced their services, particularly those around HIV and sexually transmitted infection testing, in an effort to redirect resources to the frontline of the COVID-19 response. The FAST HIV (Feasible, Accessible, Standard Testing for HIV in the emergency department) project has been working to implement in-house HIV testing, with a turnaround time of threeto-four hours, at University Health Network for emergency department (ED) patients. We are excited to launch ED testing in the coming months, addressing this public health priority and ensuring Canadians have opportunities to know their HIV status.

Dr. Megan Landes is an emergency medicine doctor at University Health Network and an Associate Professor at U of T DFCM

Dr. David Makary is a family doctor, Chief of Family Medicine at Southlake Regional Health Centre and a Lecturer at U of T DFCM

Sherri Miller is the Manager of Child and Adolescent Mental Health at Southlake Regional Health Centre

Stronger Together: Caring Through Crisis

Dr. Mahdi Memarpour is a psychiatrist and Chief of Psychiatry at Southlake Regional Health Centre

Sensitive examinations in a virtual world

CARING THROUGH COVID-19

COVIDCare@Home

Sensitive physical examinations are, as their name suggests, sensitive. Family doctors are trained to conduct these safely and respectfully, but doing so using photos and video calls is entirely new and presents unique challenges. At the start of the COVID-19 pandemic, the St. Joseph’s Urban Family Health Team quickly realized that conducting sensitive exams virtually might cause harm, especially to patients with a history of trauma. To help providers decide when and how to conduct sensitive exams using virtual tools, we devised a trauma-informed age-based clinical decision tool and a step-by-step guide (tinyurl.com/SensitiveExams). We hope this new approach will keep our patients both physically and emotionally safe.

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Dr. Lilian Robinson is a PGY1 family medicine resident at St. Joseph’s Health Centre, Unity Health Toronto and U of T DFCM

Caring for the most at-risk patients COVIDCare@Home (CC@H) is a remote monitoring program that cares for home-based patients with COVID-19. The primary care-based model was developed in partnership with Women’s College Hospital, Sinai Health and DFCM. Care is provided to patient homes through frequent telephone and video visits, with the optional delivery of monitoring devices including a pulse oximeter. An interdisciplinary team including members from nursing, pharmacy, social work, physiotherapy, occupational therapy and respirology collaborate with primary care providers to support the clinical needs and social determinants of health of patients. Patients showed appreciation for this approach, with one patient stating, “The team set me up with a social worker who connected me to a permanent family doctor, which is part of why I’m raving about the program.” Since April 2020, CC@H has cared for 2,500 patients, spanning more than 7,500 visits. Patients are of a diverse range of ages, with almost a quarter having no current attachment to a primary care provider. CC@H has continually responded to the changing needs of the pandemic. In wave two, the referral base was expanded to serve regions with high infection rates, including direct referrals from Scarborough. In wave three, care pathways were created to accept discharged obstetrics and medicine patients who required home oxygen support from Mount Sinai Hospital. Continuous evaluation was embedded into the program, resulting in four peer-reviewed papers to share lessons learned. The CC@H program will continue to care for the most at-risk and marginalized patients diagnosed with COVID-19 with a strong focus on dealing with the complex intersections of medical and social factors. Dr. Payal Agarwal is a family doctor at Women's College Hospital, COVIDCare@Home Medical Director and a Lecturer at U of T DFCM

Supporting resident education During the COVID-19 pandemic, as family doctors switched to providing care virtually, training practices and educational opportunities for family medicine residents needed to be adapted. We conducted an evaluation of residents working as part of the COVIDCare@Home team to understand the impact of the switch to virtual care on educational experiences.

RESULTS: →

Family medicine residents can effectively transfer their in-person visit skills to deliver effective care virtually. "The physical and medical knowledge and skills are no different than what you would have to do for in-person care. It's more about learning how to navigate the technology efficiently, safely and adequately."

→

Our results, reflected by the residents’ quotes, show that virtual care models are supportive of residency training practices and are not perceived as a constraint to learning.

The experience of residents at the clinic helped them better understand family care practice principles. "The COVIDCare@Home Clinic has really emphasized the benefit for some patients of having a team-based approach where you are able to refer to social work or pharmacy and pull in those experts to provide holistic care." "It is like a microcosm of primary care that really shows how it can work really well for patients."

→

Residents were able to outline the attributes necessary for developing an effective rapport with their patients virtually.

Dr. David Rojas is an evaluation scientist, Director of Program Evaluation in the MD Program at Temerty Faculty of Medicine and an Assistant Professor at U of T Department of Obstetrics & Gynaecology

Stronger Together: Caring Through Crisis

"You need to be able to listen and to communicate appropriately with the patient to obtain accurate information from them; you also need to listen to their cues or whatever they're trying to tell you to do an accurate assessment."

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CARING THROUGH COVID-19

Providing palliative care during COVID-19

Palliative care provides essential care doctors started an embedded end-of-life care while also ensuring ICU-GIM model of care. Finally, we quality of life and dignity for patients collaborated with obstetrics and and families who are living with a critical care to provide psychosocial life-limiting illness – from the time support to mothers with COVID-19 in of diagnosis, through managing pain the intensive care unit. and addressing active issues to helping patients and families cope with The inpatient palliative care team loss and grief. is part of the larger Temmy Latner Centre for Palliative Care program During the COVID-19 pandemic, there which provides 24-7 care to patients has been an increased need for guid- in the community through homeance from palliative care experts. Our based services. Throughout the panteam from the Temmy Latner Centre demic, the need for both outpatient for Palliative Care at Mount Sinai and home-based care increased as Hospital has provided support for many patients chose to remain at patients in the emergency department, home. Both teams augmented their the intensive care unit, and the inter- in-person and virtual care offerings to meet the increasing demand for nal medicine and obstetrical floors. palliative care at home. Our COVID-19 efforts in the Mount Sinai Hospital Emergency Department began Reflecting on this last year, the panin April 2020. The emergency depart- demic enabled massive collaboration ment was caring for many patients with and in support of colleagues who from nursing homes impacted by don’t typically work together. The COVID-19 outbreaks, and our palliative basis of all these models was always care team made themselves available the provision of relationship-based 24/7 to assist with communicating medicine — a pillar of family medicine. with patients’ families about goals of care, while also lending expertise to provide supportive care. Based on the lessons and impact in the emergency department, our palliative care team continued to lead partnerships to support long-term care homes during outbreaks. In addition, the Mount Sinai Hospital palliative

Dr. Ramona Mahtani is a palliative care doctor and In-hospital Care Lead in the Temmy Latner Centre for Palliative Care at Sinai Health and an Assistant Professor at U of T DFCM

2,032 683

palliative care visits for

patients in 2020 UTOPIAN data, 2020

Stronger Together: Caring Through Crisis

University of Toronto Family Medicine Report

Chapter 2

Responding to the pandemic: Supporting communities

RESPONDING TO THE PANDEMIC

Community First: COVID-19 response in Nunavut

Community meeting with Elders in Clyde River, Nunavut

Stronger Together: Caring Through Crisis

Traditional responses to health crises often follow top- ensure these external actors could better meet comdown approaches and rigid frameworks, structures that munity needs and priorities. While developing Clyde fail to address the intricacies and interconnectedness River’s COVID-19 emergency plan, our CommunityFirst of dynamic communities. The COVID-19 pandemic has Approach helped ensure a trauma-informed perspective confirmed this and highlighted the importance of com- and supported the rapid development of a culturally munity-led healthcare. appropriate strategy that was still integrated with federal- and territory-level policies. Since 2018, our team has been working to support vulnerable and isolated communities build resilience Recognizing this could be applicable to other Indigenous and autonomy to respond more effectively to health groups in Canada and vulnerabilized groups around the crises in their own communities. We have named this world, we developed a universal, adaptable version of strengths-based, solutions-focused framework the the Clyde River COVID-19 emergency plan and approach: CommunityFirst Approach. the CommunityFirst Roadmap (communityfirstcovid19. org). The Roadmap is online and open access, providing The partnership between Ilisaqsivik, an Inuit-led com- a straightforward and adaptable action plan with verified munity wellness organization; SeeChange Initiative, a resources aligned with WHO guidelines and best-available, Canadian advocacy non-profit organization; and U of evidence-based recommendations. A simplified outT DFCM, started in Clyde River, Nunavut, to help the line and accompanying checklist help develop a health tuberculosis response - a community-defined priority. emergency response plan with the following steps: Get Here, we worked with Elders and community members Ready/Alert, Organize, Prepare, Respond and Sustain. to co-develop a community-based program to address The toolkit also includes real world examples of other historical tuberculosis-related trauma, dispel stigma, COVID-19 emergency plans from different communities. develop culturally adapted tools like Inuktitut health terminology and support prevention, screening and Since the launch of the Roadmap website, it has been treatment. This included a trauma-informed community accessed by almost 5,000 unique users in over 90 counworkshop, using our CommunityFirst Approach model, tries. Due to demand and organic growth, it has been which has values of humanity, solidarity and humility at translated and is accessible in English, Inuktitut, French, its core, and incorporates a cycle of connection, engage- Spanish, Portuguese and Swahili. ment, co-creation and reflection. Looking ahead, the Roadmap could support post-panIn March 2020, as the COVID-19 pandemic emerged in demic planning and future pandemic preparedness, as Canada, Clyde River municipal leadership asked us to well as management of physical and mental health condevelop and activate a COVID-19 emergency plan based ditions, to ensure equitable, community-led responses on our model. A year later, we are sharing this model with to health issues. other Indigenous partners to assist with post-pandemic healthcare recovery and future pandemic preparedness. Dr. Sumeet Sodhi is a family doctor, Clinician Scientist at University Health Network and Our team was interested in developing a local response Academic Lead for the Indigenous Health that prioritized intersectoral collaboration, especially between public health and primary care providers, to Partners Program at U of T DFCM

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RESPONDING TO THE PANDEMIC

Rich culture and resilience: Reflections on Operation Remote Immunity

Operation Remote Immunity has been a critical part of Ontario’s phased vaccination rollout plan. Led by Ornge, Ontario’s air ambulance service, in partnership with the provincial government and Nishnawbe Aski Nation – representing 49 First Nations in Northern Ontario – and a network of dedicated partners, staff and volunteers, the initiative delivered thousands of vaccines to 31 remote, fly-in Indigenous communities and Moosonee in deep winter. After being vaccinated themselves and taking mandatory Indigenous cultural safety training, multiple DFCM volunteers spent a week or more based in Thunder Bay, Sioux Lookout and Timmins, travelling daily to vaccinate in fly-in communities under the guidance of Ornge and Indigenous community leaders.

Vaccinating in fly-in communities as part of Operation Remote Immunity

Operation Remote Immunity was an incredible feat of logistics, planning and execution. We have often seen pandemics disproportionately affect First Nations, Inuit and Métis people in Canada, because reserves were designed as a system of disenfranchisement without basic infrastructure. These communities often do not have access to healthcare services and experience dangerous public health conditions-thus the urgency of vaccination. Before we could even enter these communities, we had to take the San’yas Indigenous Cultural Safety program on culture, stereotyping and the impacts of colonization, as well as mandatory vaccine training. Our preparation included a lot of discussion about how to build vaccine confidence and trust in the healthcare system that for so long neglected and harmed Indigenous people. Indigenous people are valuable, and our knowledge, culture and languages are important. We have to be healthy and protect everyone we can, because Indigenous life is sacred. My participation in the Ornge project was just two weeks, but it was the most incredible experience of my life.

Dr. Suzanne Shoush is a family doctor at St. Michael’s Hospital, Unity Health Toronto, Indigenous Health Faculty Lead and a Lecturer at U of T DFCM

I travelled to Pikangikum, about 300 kilometres northeast of Winnipeg. Pikangikum is a special place to work: Its population is about 3,000, many community members are young and Ojibwe remains the first language for most residents. There are also challenges related to implementing a vaccination program, including a lack of access to transportation and historically low rates of vaccination. In addition, people face ongoing injustices that contribute to ambivalence toward outside health programs. Our group was joined by an Independent First Nations Alliance team and local Canadian Rangers — their involvement was crucial to the initiative’s success. We worked in small interdisciplinary teams, conducting home visits to answer questions and to provide vaccines to people who were homebound. These visits were a wonderful opportunity to get to know the people and the community better. Initially, taking our constructive interactions as a matter of course illustrates my privilege as a non-Indigenous person living in Canada. After all, if one of my Indigenous co-workers presented to a hospital in Ontario, would they have had the same implicit presumptions of fair and unbiased treatment from our healthcare system?

Dr. Kate MacNaughton is a PGY3 family medicine resident at U of T DFCM

One of the first people I met in Pikangikum was Dean, an educator and community leader. He manages the community Facebook group, which almost every adult in Pikangikum follows. We decided to do a live Q&A about the COVID vaccine which helped us virtually interact with the broader community.

While participating in Operation Remote Immunity, I had the opportunity to go up to two Northern First Nation Communities, Bearskin Lake First Nation and Slate Falls First Nation. While there, I was privileged to provide vaccinations while also learning a little about day-to-day life in remote First Nations communities – particularly through home visits to vaccinate residents with mobility issues. I felt honoured to be assisting these two communities with the vaccination effort to protect against a severe and possibly life-threatening disease, and proud to lend a hand in such a rewarding and once-in-a-lifetime endeavour.

Brett Glena is a second year physician assistant student at U of T DFCM

I was a vaccinator at Sandy Lake, a fly-in reserve about 300 kilometres from Sioux Lookout with a total population of around 3,000. Months before any vaccine approval, community leaders had started building vaccine confidence by discussing safety and efficacy over the radio. Once vaccination began, the local team set up the mass vaccination clinic in the elementary school gymnasium with best public health practices in mind. The logistics of mass vaccination are much more complicated given the location, but it all functioned smoothly thanks to the Sandy Lake community and Ornge leadership.

Spending the week in Pikangikum helped me learn more about the resilience of the Indigenous people. This experience has inspired me to go back to indigenous communities in the future as a family doctor.

Dr. Shima Shakory is a PGY1 family medicine resident at U of T DFCM

Dr. Elliot Lass is a PGY3 family medicine resident at U of T DFCM

Adapted from a Temerty Faculty of Medicine news story

Stronger Together: Caring Through Crisis

I built a great relationship with Dean and am in awe of his tireless work. He visited the vaccine site daily and inspired his community to get vaccinated. On our last day, we even did a mask exchange — we gave him a University of Toronto mask and he gave us a Pikangikum mask. It was symbolic of the connection we made on our shared mission.

The Slate Falls Operation Remote Immunity team

RESPONDING TO THE PANDEMIC

Vaccine hesitancy among Black Canadians during COVID-19 “Are you planning on getting the COVID-19 vaccine?”

University of Toronto Family Medicine Report

This is a question I asked one of my patients, a 43-yearold Black woman living with her elderly father. She feared both catching COVID-19 and passing it on to her father, and getting the COVID-19 vaccine. Fear of getting the vaccine is common amongst many of my Black patients, and is multifactorial. Horror stories heard from friends of friends, family members sharing worrisome articles they’ve read online and community members who have shared their negative experiences interacting with the healthcare system are a few reasons. The most overarching reason for vaccine hesitancy, however, is systemic racism. There is palpable mistrust of several societal systems, including the healthcare system, by many Black Canadians. Western medicine was built on the backs of the marginalized, paradoxically without taking their health, safety, or personhood into account. Starting in 1932, a study entitled ‘Tuskegee Study of Untreated Syphilis in the Negro Male’ used Black Americans with syphilis to observe the natural history of the disease. Treatment was intentionally withheld from them, and many men suffered severe health consequences as a result. This study did not end until 1972. In the 19th century, the physician largely deemed the ‘father of modern gynecology’ was known to conduct experimental surgeries on enslaved Black women without anesthesia under the pretext that Black people had much higher pain tolerance, a notion that still persists today. Fast forward to this last decade, where Black maternal death in America occurs at a rate three times higher than in Caucasian women. Today, many of our medical guidelines are based on studies where an overwhelming majority of participants are Caucasian. So, it is unsurprising that so many Black people do not have faith in Western healthcare systems.

In the case of my vaccine-hesitant patient, she eventually made the decision to get the vaccine after a discussion with me, a Black woman who was able to empathize with her concerns. This is not the case for all Black patients. There is currently some advocacy underway to reduce barriers to receiving the COVID-19 vaccine in Black Canadians. Several Black-led organizations have collaborated to produce a position statement, ‘Black Health and the COVID-19 Vaccines,’ asking healthcare systems to prioritize Black communities; the Black Health Vaccine Initiative by the Black Physicians’ Association of Ontario is working to improve COVID-19 vaccine access in Black neighbourhoods; and I am conducting research alongside other physicians to identify and reduce immediate barriers to Black Ontarians receiving the COVID-19 vaccine. However, these initiatives are not enough. Significant systemic-level policy changes are required to prevent the ongoing disproportionately high rates of COVID-19 infection and low rates of vaccine uptake in populations made vulnerable by policy discourse – including Black Canadians – so that lives can be saved during this pandemic and the next.

Dr. Helen Teklemariam is a PGY1 family medicine resident at U of T DFCM and President of the Black Resident Physicians of Ontario

(L to R) Dr. Akwatu Kente, Dr. David Esho, Ms. Adaoma Patterson, Dr. Neil Issac, Rev. Wendell Gibbs and Dr. Dominic Shelton at the Jamaican Canadian Association

Building vaccine confidence in Black communities The COVID-19 pandemic has had a disproportionate impact on Black communities. Black people are over-represented in frontline roles, while historical and contemporary experiences of racism in health care have translated into lower vaccination rates. This has created a perfect storm for infections and hospitalizations. With the help of community partners, the Black Physicians’ Association of Ontario’s Black Health Vaccine Initiative has been bridging the gap between the healthcare system and Black communities.

Dr. David Esho is a family doctor at Toronto Western Family Health Team, University Health Network, and an Assistant Professor at U of T DFCM

Answering the call, together

We’ve been riding the waves of the pandemic for well over a year. In wave In January 2021, York Region Public one, we were treading water in pri- Health put out a call for additional mary care, keeping our patients, our volunteers to vaccinate residents learners and each other afloat. In wave in long-term care and retirement two, COVID-19 vaccine anticipation homes. Within 24 hours, 125 family ebbed and relief flowed when we got doctors and interprofessional care our jabs. In March 2021, our family providers had responded and were practice was handed 234 shots of ready to help. the Pfizer vaccine for patients over 80 years of age. Our team had a few At a time when speed could days to handpick the line-up with quite literally save lives, we overthe aim of ensuring equity. The nurse whelmed them with enthusiasm practitioner office resembled a pit and a willingness to step outside lane as we hustled to get the slots the usual silos and play to each filled in time. After many months in other’s strengths. Within four the undertow, we are finally riding the weeks, all of our eligible residents high of getting shots into the arms had been offered their first dose. of our patients.

Jessica Bawden is a Nurse Practitioner at Women’s College Hospital Family Practice Health Centre and an Adjunct Lecturer at U of T DFCM and Bloomberg School of Nursing

Dr. Allan Grill is a family doctor, Chief of Family Medicine at Markham Stouffville Hospital and an Associate Professor at U of T DFCM

Stronger Together: Caring Through Crisis

At two clinics, held at the Jamaican Canadian Association, we provided more than 4,200 vaccines, with most attendees identifying as Black, African or Caribbean. Not everyone was ready to get vaccinated – some just wanted to talk and ask questions – but we are building trust and understanding and that takes time.

Riding the waves

Scotiabank Arena, Toronto Vaccine Day

One day, 26,000 vaccines

Preparing to conduct COVID-19 swabbing at a long-term care home

Shots of joy and relief

University of Toronto Family Medicine Report

On June 27, 2021, 800+ vaccina- “I can’t wait to see my mother tors and volunteers delivered a in her long-term care home.” record-breaking 26,771 COVID-19 vaccine doses at Scotiabank Arena “It’s my granddaughter’s first birthday; I still haven’t met her.” for Toronto Vaccine Day. Hosted by University Health Network, These were the conversations as Toronto East Health Network, Maple patients stepped off the elevator Leaf Sports & Entertainment and the at Rotary Place, home of the Barrie City of Toronto, the event was con- Family Medicine Teaching Unit (FMTU), ceived and planned in just six days. as the FMTU vaccine rollout team The organization was miraculous. started their day. Resident physicians identified patients at high risk. On the day, we had 25,000 doses pre- Administrative staff set appointbooked, plus room for walk-ins. The ments and established optimal flow. energy was incredible. We had family Meanwhile, nurses, doctors, third year doctors sitting next to nurses, sitting clinical clerks and student volunteers next to rheumatologists and thoracic provided counselling for informed surgeons. Any barriers between spe- consent, ensured infection control cialists melted away. Throughout the and administered vaccines. pandemic, experiences like these have strengthened inter-specialty Together, we delivered 320 vaccines relationships and built an under- in three half-days. With each shot, joy standing and respect for the power and relief filled the room as we helped of family medicine. to slow the spread of the COVID-19.

Dr. Camille Lemieux is a family doctor, Chief of Family Medicine at University Health Network and an Assistant Professor at U of T DFCM

Dr. Alis (Qinyuan) Xu is a PGY1 family medicine resident and PGY1 representative in the Barrie Family Medicine Teaching Unit at U of T DFCM

Joining the fight, one swab at a time In April 2020, severe respiratory illness hit long-term care (LTC) homes hard. University Health Network family doctors were staffing our hospital testing centre, but the patients who most needed testing couldn’t come to us. LTC homes confirmed, reinforcements were needed. While resources were scarce, DFCM leaders advocated tirelessly for PPE and test kits. With laboratory medicine and infection control on board, we donated storage containers from our homes, and our cars became biohazard transport vehicles. And thus, we waded into the front lines to fight, one swab at a time. We responded with the action, adaptability and compassion that marks our specialty. None of us will forget the feeling of returning to our surviving LTC friends nine long months later, this time armed with vaccines.

Dr. Sabrina Akhtar is a family doctor, Physician Lead for the Home-Based Care Program at University Health Network and an Assistant Professor at U of T DFCM

Building vaccine confidence: 19toZero

A haven for youth experiencing homelessness

Collaboration and flexibility

Dr. Nancy Trimble is a family doctor at Royal Victoria Regional Health Centre and an Assistant Professor at U of T DFCM

Dr. Rebecca Stoller is a family doctor and COVID-19 Assessment Centre Co-Lead (Mar 2020 - Aug 2021) at North York General Hospital and an Assistant Professor at U of T DFCM

Decades of research show that recCollaboration and flexibility have been ommendation from a trusted health Youth Haven Barrie is an emergency key at our COVID-19 assessment centre. professional is a key component for shelter with 21 beds for youth expe- When we started in March 2020, it took vaccine uptake. Family doctors are riencing homelessness. Our teaching just a week to get up and running. Then, consistently ranked as a most trusted unit has been involved in the centre as wave two took hold, we doubled our health professional. So, to get to for many years, so as soon as those capacity to 600-to-700 patients/day COVID-19 herd immunity, we needed in congregate settings were eligible over the course of a weekend. to enable all our amazing family doc- for COVID-19 vaccines, we wanted tors to offer evidence-based recom- to be sure the residents had the From set-up to staffing, this would not have been possible without outmendations to their patients in an opportunity to be vaccinated. standing collaboration. The hospital evidence-based way. Transporting youth to a clinic for quality team helped us optimize It meant developing resources like booked appointments was unfeasible. patient flow to cope with demand, and frequently asked questions, webinars, So, Dr. Kaitlyn Bertram and I secured colleagues from across primary care infographics, and more so that we the Moderna vaccine from our health stepped up to staff the assessment ensured family doctors were armed unit and immunized 20 willing youth centre and provide virtual follow-up with consistent messages and able and four staff at Youth Haven in two care for everyone who tested posito provide those messages to their sessions. Most were enthusiastic, tive, while quite literally running to patients in an effective, empathic way. although some complained about provide off-site swabbing to support This became my role in 19toZero - a needles, of course… long-term care homes whenever we 500+ member coalition of multi-disgot a call for help. ciplinary experts working to build We were pleased to bring vaccines confidence in COVID-19 vaccines and to this group of local youth. Plus, it This collaboration has been one of the was fun! get Canadians vaccinated. silver linings of the past year.

Dr. Noah Ivers is a family doctor and researcher at Women’s College Hospital and an Associate Professor at U of T DFCM

Stronger Together: Caring Through Crisis

Jane Smart (RN) Dr. Leslie Beyers, Dr. Liisa Jaakkimainen, Dr. Jordana Boro, Dr. Claire Murphy, Dr. Karen Fleming, Dr. Mira Shuman and Jane Smart RN with staff from Millwood Retirement home in Leaside

University of Toronto Family Medicine Report

Chapter 3

Staying connected

STAYING CONNECTED

Pandemic Pregnancy Guide: The virtual frontline for perinatal support Babies don’t stop for a pandemic, nor does the need to get reliable health information and support to new and expectant parents. This was the driving force behind @PandemicPregnancyGuide (PPG), a virtual resource that provides free, evidence-based perinatal, paediatric and women’s health information at a time when the usual avenues for sharing knowledge, community building and finding support have been difficult to access. Along with a colleague, Dr. Eliane Shore from U of T’s Department of Obstetrics and Gynecology, and a small team of U of T medical students, we launched PPG on Instagram in April 2020. The account was initially expected to support a small group of patients and clients primarily from St. Michael’s Hospital. Just over a year later, we have a following of over 36,000 new and expectant parents and health providers from across Canada and internationally. Our team collaborates with colleagues from various specialties and fields, including, but not limited to, pediatrics, midwifery, social work, pelvic physiotherapy, nutrition and psychiatry to create and share information. We also invite a diverse range of experts to share information, such as financial advisors, fitness and yoga instructors and advocates on women’s rights during parental leave. These collaborations demonstrate the interprofessional nature of the work that we do.

The reliability of medical information on social media is highly variable and the onus is on users to determine which sources are trustworthy. With this in mind, we post a weekly #medicalmonday post where we break down the newest and most relevant research related to the impact of COVID-19 on pregnancy outcomes or

We have also become a tool for advocacy and research by empowering expecting and new parents through knowledge translation and dissemination and by conducting surveys to understand the most common concerns faced by the perinatal community (including attitudes toward the COVID-19 vaccine). This underpinned our advocacy at both the provincial and national levels in promoting the perinatal population's access to the COVID-19 vaccine. PPG has also served as a hub for community building, story sharing and mental health supports during a time when so many, especially new families, have been isolated. As family doctors who provide reproductive and mental health care, we have been particularly well-placed to support the perinatal population during this uniquely challenging time. Our growing community and frequent media engagements reflect our wide reach and impact. As the pandemic evolves, we will continue to grow, expand and provide information as we enter the recovery phase. The perinatal population will take time to recover, because families have been significantly impacted. We will continue to be there alongside them to serve as a trusted, reliable and supportive space.

Dr. Tali Bogler is a family doctor and Chair of Family Medicine Obstetrics at St. Michael’s Hospital, Unity Health Toronto and an Assistant Professor at U of T DFCM Dr. Sheila Wijayasinghe is a family doctor at St. Michael’s Hospital, Unity Health Toronto and a Lecturer at U of T DFCM

Stronger Together: Caring Through Crisis

At PPG, we believe that knowledge is power. Our goal is to support pregnant individuals, women and their families with the knowledge to understand their unique health needs so they can make informed health decisions.

data on the COVID-19 vaccine in the perinatal population. Many of our patients and followers across Canada have told us that PPG is now their “go-to” resource for all things pregnancy and women’s health related during the pandemic.

STAYING CONNECTED

Communicating during COVID-19: Health journalism in the pandemic

Health reporting has never been more challenging, as Canadian media outlets have faced layoffs, closures and furloughs, leaving newsrooms with skeleton staffs and reporters short on time. The loss of science reporters due to shrinking newsrooms has been at the cost of the public’s scientific literacy. The stories I report on lift the veil on how health care decisions are being made and how scientific evidence informs these decisions. By describing how medical experts were deciding which treatments should be used for COVID-19, I hoped to prevent misinformation and debunk sham medical interventions early in the pandemic.

University of Toronto Family Medicine Report

As a clinician journalist, I try to elevate voices less freSince the beginning of the pandemic, I’ve been reporting quently heard by Canadian media outlets. In a CMAJ News on the issues facing frontline providers. I’ve used my story on nursing shortages at the crest of the COVID-19’s perspective as an emergency physician, clinician scien- third wave, experienced nurses described the complex tist and trained health journalist to highlight important hospital environments and policies forcing them to leave issues related to the COVID-19 crisis in regular stories for or retire early. Pandemic burnout alongside unforeseen CMAJ News, Healthy Debate and The Conversation. This changes to pension plans, excessive and unsafe workin-depth coverage has informed public conversations on loads and denied requests for time off contributed to restricted hospital visitor policies, nursing shortages in unanticipated resignations from senior nursing staff. As emergency departments and intensive care units, and a result of this media story, local hospitals reconsidered tough choices parents on the frontline of the pandemic their part-time rehiring policies in order to improve must make. staffing ratios in this unprecedented time in Canadian healthcare history. In April of 2020, I reported from my workplace – Mount Sinai Hospital’s emergency department – for CBC’s Metro In an era of conspiracy theories and vaccine hesitancy, Morning and The National. With permission of the hospi- the public is desperate to know what health care protal, we filmed in the resuscitation bay and described the fessionals are thinking and experiencing. By sharing real steps of a simulated protected code blue, a respiratory frontline experiences from inside Canadian hospitals, or cardiac arrest. The footage shows nurses and doctors using accurate and clear scientific reporting, I hope I donning and doffing personal protective equipment and have helped readers understand the pandemic and make describes in lay terms an aerosol generating procedure, informed decisions and, in turn, helped shape Canada’s such as placing a tube in the airway of a patient strug- pandemic response. gling to breathe, and explains why these procedures put health care providers at risk of acquiring COVID-19. These television and radio segments demonstrated to Dr. Catherine Varner is an emergency medicine Canadians how Toronto hospitals were preparing for the doctor, a clinician scientist and Deputy Director first wave of COVID-19 patients, while also emphasizing of the Schwartz/Reisman Emergency Medicine the importance of adhering to public health guidance Institute and an Assistant Professor at U of T DFCM early on in the pandemic.

Filming a simulated protected code blue at Mount Sinai Hospital

Sharing stories, Long-term care reflections and poetry and emergency: A united front

The COVID-19 pandemic has brought to light systemic digital equity issues that have a real impact on health, particularly for marginalized people. Enter PHONE-CONNECT, a multi-site emergency department (ED) initiative that gives prepaid cell phones to ED patients who lack phone access. It's an innovative solution to a systemic need. Hundreds of phones have been distributed to ED patients at University Health Network, Michael Garron Hospital and St. Michael’s Hospital thus far. We are evaluating the impact of the initiative through short interviews with phone recipients and a chart audit.

Dr. Andrea Somers is an emergency medicine doctor at University Health Network and a Lecturer at U of T DFCM

Stronger Together: Caring Through Crisis

In September 2020, I was overwhelmed by the feelings of isola- At the onset of the pandemic, it tion and loneliness, fueled in large became clear that all sectors of the part by the pandemic. I felt the urge healthcare system needed to collabto do something. It struck me that orate and form a united front against part of what I, and likely others in COVID-19. the medical community, might be lacking was connection. Long-term care (LTC) doctors from our family health team held weekly I knew that sharing stories could help virtual meetings with emergency forge connections and was thrilled to doctors, community LTC doctors find and join forces with nine other and interprofessional health prodoctors – also MD moms – who were viders to improve communication keen to share life stories. between LTC homes and the emergency department (ED). A dedicated Our blog, Findings (findingsblog.com) phone line was established so LTC was born in January 2021, a com- doctors could alert ED doctors about fortable space for heartfelt sharing patients being transferred from LTC stories, reflections and poetry. We homes, to reduce wait times and expehave been posting and connecting, dite investigations for LTC patients. weekly ever since. This has inspired further research on improving communication between the ED and LTC homes as part of a Dr. Michelle Lockyer is a resident research project. family doctor at Toronto East General Hospital and a Lecturer at U of T DFCM Dr. Deepti Pasricha is a family doctor at Markham Family Physicians and a Lecturer at U of T DFCM

PHONE-CONNECT

STAYING CONNECTED

#StrongerTogether: Unifying two clinics with a common goal On March 10, 2021, two St. Michael’s Hospital Academic Family Health Team (SMH AFHT) clinics – Health Centre at 410 and St. James Town Health Centre – each with their own uniqueness and legacies, came together and the new Wellesley-St. James Town Health Centre opened, a proud accomplishment for the team given the ongoing COVID-19 pandemic. Embedded in the vibrant St. James Town community, and near the colourful Church Street village, the planning team never lost sight of the importance of patient-centredness. We desired a space where all patients and staff would feel safe and respected. We also wanted to honour the history of the community’s struggle to access equitable health care for those who use substances and struggle with addiction, people with HIV/AIDS, refugees and new immigrants, those who identify as transgender and gender expansive, and people living with disabilities and mental health diagnoses.

University of Toronto Family Medicine Report

“Both family health team clinics have a rich history within the community. We provide both general and specialized care and it’s important to us, in this new space, to ensure we’re serving the community in similar ways and also improving in other ways,” explained Dr. Charlie Guiang, a doctor at the Health Centre at 410. The name, Wellesley-St. James Town Health Centre, pays homage to the former Wellesley Hospital, the only hospital in Toronto where the 2SLGBTQIA+ community felt safe to find care. In fact, the new clinic is directly across the street from the old site. Some of us recall participating in peaceful demonstrations on the hospital lawn, advocating for access to antiviral medications for patients with HIV/ AIDS and methadone for patients with opioid-use disorders. We also honour the former St. James Town Health Centre, which was uniquely located below a highrise building home to many new immigrants and refugees. Today, the SMH AFHT provides care for over 1,500 patients living with HIV/AIDS and approximately 700 patients who identify as transgender and gender expansive.

In March 2020, with the new site under construction, COVID-19 pulled the rug out from under us. We pivoted to meet construction deadlines and secure move plans. Delays were anticipated, but we remained hopeful that our new home would be ready. Fast forward to March 2021: Our new clinic opens without fanfare, but with masks and balloons. It is blessed with a smudging ceremony. We await the arrival of artwork that reflects the cultural diversity of those who walk the hallways. As these patients and staff arrive, we welcome them with gender neutral washrooms, 2SLGBTQIA+, transgender and non-binary flags, many staff with Indigenous Cultural Safety training, regular support meetings for Black and BIPOC staff and leadership that places an emphasis on staff wellness. On an initial visit one patient reflects: “When I first arrived, it was a bit hard to find the entrance, but once I entered it was very inviting. The nursing room and blood pressure area, not having to move, as a patient, that felt good. On my way out I noticed a piece of rainbow coloured ribbon wrapped around a pillar. At that moment, I knew this was the same safe space and same safe people I had at 410. I felt welcomed.” Ultimately, what stands out as prominently now as it did when the Health Centre at 410 opened in 1995, is the commitment of staff and patients to tirelessly advocate for inclusive and equitable health care. Unifying two clinics towards this common goal has definitely made us “stronger together”!

Dr. Thea Weisdorf is a family doctor at the Wellesley-St. James Town Health Centre, St. Michael’s Hospital, Unity Health Toronto and an Assistant Professor at U of T DFCM Submitted on behalf of the Wellesley-St. James Town Health Centre Planning Team

Students supporting seniors

“Hello, how are you?”

Frontline Connect Canada

Stronger Together: Caring Through Crisis

For socially marginalized patients, When the pandemic and social restric- COVID-19-related social distancing, "No visitor" policies implemented tions hit, many older adults were isolation and a lack of in-person inter- due to COVID-19 isolated patients in faced with a life-threatening virus action with health teams posed an hospitals, long-term care (LTC) facilas well as isolation, loneliness and increased health risk. ities and hospices from their loved worsening health outcomes. ones. We founded Frontline Connect To address this, the St. Michael's Canada to reconnect patients with To provide emotional support for Hospital DFCM Social Determinants of their friends and families by disseniors and develop medical students’ Health-COVID Working Group started tributing data-enabled devices for understanding of elderly care, the a Wellness Check-In (WCI) initiative virtual communication. Student Senior Isolation Prevention to reach out to patients at highest Partnership paired MD students with risk for the negative consequences of Through this physician-led grassroots isolated seniors for informal weekly COVID-19 and its social restrictions. organization, we distributed over 250 check-ins. devices to approximately 100 facilities WCI callers proactively reached out across Ontario. The donated devices This had positive results for both par- to these patients (seniors, under- have allowed vulnerable patients to ties, improving some seniors’ mental housed, those on social assistance, connect by video with families and health and enhancing student atti- with mental health challenges and close friends unable to be at their provider-identified). They connected bedside. Health care teams have also tudes to elder care. with over 2,000 patients in the first been able to hold critical conversafour months, asking them about tions with families about goals of their needs and offering resources, care, treatment plans and updates. This initiative was led by U of T support and solutions to help address MD students Monisha Persaud their concerns. and Geoffrey Sem and evaluated Dr. Humaira Saeed is a by Dr. Gray Moonen, PGY2 at palliative care doctor at William Toronto Western Family Health Osler Health System and a Dr. Noor Ramji, Dr. Deborah Team (TWFHT) and Dr. Noah Lecturer at U of T DFCM Kopansky-Giles, Dr. Gary Bloch Crampton, family doctor at TWFHT, and Dr. Karen Weyman are all University Health Network and Dr. Ilana Greenwald is an family doctors at St. Michael's a Lecturer at U of T DFCM emergency medicine doctor at Hospital Academic Family Health Scarborough Health Network Team and at U of T DFCM and a Lecturer at U of T DFCM

University of Toronto Family Medicine Report

Chapter 4

Family medicine leadership

FAMILY MEDICINE LEADERSHIP

Building the ship as you’re sailing it: How to lead in a pandemic

Imagine being the captain of a large ship with numerous crew members. When the weather is clear and the ship is in good condition, the captain is simply another member of the crew. Sailing is smooth.

the time, I learned that it is important to stay calm and resolute even if you don’t have all the answers. After all, just seeing the captain at the helm helps reassure the rest of the crew.

Now imagine a bad storm. The ocean is rocky, and the ship is taking on water. You are scrambling to keep your crew on the boat alive, and everyone is working at capacity to keep the ship afloat. But no matter how many hands you have, it never seems like you have enough people.

The NYGH ship is a big one: there are over 300 family doctors affiliated with the hospital. Due to its size, we had a primary care leadership team including myself, Dr. Alan Monavvari, Dr. Maria Muraca and Dr. Rebecca Stoller – nicknamed the Fab 4. The Fab 4 represents the voices of family doctors in North York.

This is what it feels like being a family medicine chief during a pandemic. As the Chief of Family and Community Medicine at North York General Hospital (NYGH), I felt that our family doctors in North York were looking for leadership to help get them through a very turbulent time. But pandemic management was a whole new enterprise for which none of us were prepared or trained.

We were all learning pandemic management on the job. At the end of the day, I’m a family doctor just like everyone else at DFCM. None of us had exclusive knowledge about how to deal with COVID-19, but I was confident we could figure it out together. This show of confidence was a lesson I learned from my mentor, Dr. David White. David was the Chief of Family and Community Medicine at NYGH during the SARS outbreak of the early 2000s. Through his leadership at

So, we leveraged my “Weekly Notes” (departmental newsletter), regular email blasts to share updates, webinars, resources and guidelines so our family doctors were well informed and could adapt to this new and ever-changing environment. We family doctors are uniquely skilled at living in a world where the diagnosis is uncertain. Patients come to us with their health concerns and although we may not know immediately what is wrong, we work with them to figure it out. Leading a large department during a pandemic is similar – we’re all learning as we go. It’s okay to openly admit that you are “learning to build the ship as you’re sailing it,” as long as you keep your cool, communicate effectively with those you work with and have a blueprint for the well-being of the rest of the ship.

Dr. David Eisen is a family doctor, Chief of Family and Community Medicine and Program Medical Director at North York General Hospital and an Associate Professor at U of T DFCM

Stronger Together: Caring Through Crisis

At the beginning of the pandemic, we were all in the dark. The way that we practised changed dramatically overnight: We needed new protocols and safety measures to protect ourselves, our patients and our staff from COVID-19. There were so many new things we had never needed to consider before, such as installing Plexiglass in front of our secretary’s desk or reconfiguring reception areas to allow for social distancing.

Together, the Fab 4 wanted to ensure that our family doctors knew what leadership knew.

FAMILY MEDICINE LEADERSHIP

The crucial role of primary care: Distributive leadership in action Family doctors are generalists and apply their skills in a variety of settings as they care for patients from cradle to grave – at home, in hospitals, long-term care homes and shelters. Family doctors lead with creativity and spontaneity, and if well connected, respond effectively to evolving crises. Just before the pandemic hit, a group of family doctors in east Toronto came together to co-design the East Toronto Ontario Health Team (OHT). Incorporating 200 of 270 local family doctors from all funding models, the East Toronto Family Practice Network and OHT proved crucial to our pandemic response. These networks allowed us to reach all our family doctors quickly and efficiently at a time when east Toronto, with its large number of socioeconomically vulnerable neighbourhoods, was disproportionately impacted by COVID-19.

University of Toronto Family Medicine Report

Family doctors are extremely versatile, a characteristic we put into action on all fronts. We leveraged our network to lobby early for fair PPE distribution, N-95 mask fit testing and vaccinations for community primary care providers to ensure safety for all. We created and staffed the first assessment centres and mobile vaccination units in Toronto, vaccinating over 70,000 people through mobile outreach and 20,000 in our own family practice clinics. We also created, and widely shared, an advanced scheduling system to staff the many pop-up assessment centres and vaccination events with our 180 community family doctors. Our network led the way with weekly virtual forums for long-term care and retirement homes, congregate housing, shelters and school principals – to share information, answer questions and provide support where it was needed most. The network supported family doctors in the drastic switch to virtual care and partnered with pediatricians and practices to ensure undisrupted access to immunizations and newborn care.

(L to R) Dr. Denise Wong, Dr. Blaise Clarkson, Prachi Patel, Hiliary Siurna (NP) and Jean Guo (PA) on their way to vaccinate homebound patients in East Toronto

To ensure that no frail or isolated person would be left without access to care, our family practice network partnered with community health centres, family health teams, homecare, Toronto public housing, patient advocates and various community service organizations to create four Response Teams in each area. Since March 2021, these teams have been delivering home vaccinations while a primary care vaccination group works with the hospital to vaccinate across many family practice clinics and proactively call in at-risk patients. Despite being a large network and hive of activity, one of our young family doctors described feeling “well connected and part of a larger community despite locuming.” Our community thrives because of well-established communication; respectful partnerships between hospitals, primary care and community organizations; and the hard work and dedication of family doctors and all primary care clinicians. Linking the majority of community family doctors into a network with organized, local physician leadership and such a diversity of voices has helped accelerate all of our OHT activities and been invaluable during the pandemic. Bringing together previously unaffiliated family doctors in regional networks and creating true bi-directional partnerships between hospitals and primary care has benefits for both physicians and our patients. This approach deserves to be funded at a system level to create network infrastructure, support physician leadership and enable the highest quality patient care.

Dr. Thuy-Nga (Tia) Pham is a family doctor, ViceChair of the East Toronto Family Practice Network and an Associate Professor at U of T DFCM Submitted on behalf of the East Toronto Family Practice Network and its family doctors

FAMILY MEDICINE LEADERSHIP

Emergency medicine leadership during the pandemic

Seven of Toronto’s emergency departments are led by To respond to the constant changes, Dr. Kyle Vojdani, faculty in DFCM’s Division of Emergency Medicine. During an assistant professor in DFCM and Medical Director of the pandemic, their efforts have been remarkable – from Emergency Medicine at Michael Garron Hospital says, redesigning their emergency departments to co-ordinat- “We committed to a rapidly iterative process in our emering the transfer of critically ill patients across Ontario. gency department of constantly shifting to fill gaps and needs in the community.” Dr. Paul Hannam, an assistant professor in DFCM and Director of Emergency Services at North York General Dr. Vojdani says the work was not only caring for patients Hospital, which is one of Canada’s busiest emergency in the emergency department, but caring for the many departments, says his department set up two separate nearby neighbourhoods heavily impacted by the pan‘hot zones’ – one for patients with mild symptoms, the demic. Their emergency department team led early other for those who were sicker. vaccine efforts, created a phone-connect program for at-risk patients, and supported long-term care homes “At the height of the second and third waves, we con- affected by outbreaks. verted our ambulance driveway with a very high roof into a mini-field hospital with eight beds.” After leading these efforts through the pandemic, Dr. Vojdani says, “The work has been rewarding and re-afHe and his team assembled hundreds of 3D-printed, cheap, firmed the critical role of the emergency department disposable stethoscopes – just one of many examples team in supporting our communities.” of how they adjusted to new infection control measures early in the pandemic.

The emergency medicine doctors at Michael Garron Hospital also stepped forward by developing early COVID19 resuscitative guidance for the hospital, ran in-department COVID-19 simulations, built a new resuscitation space to triple their critical care capacity and staffed the COVID-19 assessment clinic and vaccination efforts. Dr. Catherine Varner is an emergency medicine doctor, clinician scientist and Deputy Director of the Schwartz/Reisman Emergency Medicine Institute and an Assistant Professor at U of T DFCM

Stronger Together: Caring Through Crisis

Reflecting on the last eighteen months, Dr. Hannam says, “In emergency medicine we pride ourselves on having an approach to every situation, adapting with whatever resources are available and knowing what it really means to work as a team. We have done our best to remain true to our shared values and stay focused on the next 'new normal' for our community. I am proud to be part of such a talented and resilient team.”

Learning from leaders Three million pieces of PPE

University of Toronto Family Medicine Report

We conducted a qualitative analysis of academic family physician leaders’ At the start of the pandemic, there responses to the COVID-19 pandemic, was a scarcity of PPE for frontwhich impacted our responsibilities line healthcare workers. Through for clinical care, education, research a grassroots initiative called Conquer and well-being. Our results demon- COVID-19, we collaborated with 120 strated that interactions among DFCM volunteers including 10 undergradleaders, both before and after the uate medical students and a medcrisis onset, were characterized by ical advisory team, to raise over a collegial environment; capacity $2.38 million in funding, procure building; leadership in equity, diver- over three million pieces of PPE and sity and inclusion; and celebrating distribute them using an ethical excellence. framework based on values of equity, diversity and inclusion to frontLeadership responses after the crisis line essential health care workers onset were characterized by frequent and Indigenous communities. We situational assessments; obtaining truly were #StrongerTogether and expert advice; recognizing high stress embodied the values of collaboration, throughout DFCM; expanding com- leadership and patient advocacy as munication; increasing idea exchange we tried to Conquer COVID-19. for solutions; emerging leaders and innovations; focusing on learner safety and well-being; and broader Dr. Ruby Alvi is a family doctor responsibilities to meet community at Trillium Health Partners, needs. DFCM leaders’ crisis response Mississauga Hospital and an was strengthened by an existing Assistant Professor at U of T DFCM organizational culture that fosters Dr. Jeremy Rezmovitz is a communication and leadership. community family doctor and an Assistant Professor at U of T DFCM Dr. David White, Dr. Mary Ann O’Brien, Dr. Sylvie Cornacchi, Dr. Risa Freeman and Dr. Eva Grunfeld are family doctors, researchers and faculty at U of T DFCM

Fast and furious: Making sense of COVID-19 data In the race to understand and manage the global pandemic, COVID-19 trials are being conducted and published at a rate never seen before. Interpreting this rapidly evolving information and helping decision makers distinguish between trustworthy and untrustworthy evidence is a critical part of the global COVID-19 response. In collaboration with the World Health Organization (WHO) and British Medical Journal (BMJ), I am working with international colleagues to conduct a living systematic review and network meta-analysis for the management of COVID-19 that is updated as new data emerge. This work directly informs international clinical practice guidelines including the WHO and BMJ Rapid Recommendations on COVID-19 treatments which provide reliable, actionable and ‘live’ guidance to clinicians and patients that is updated soon after new and potentially practice-changing evidence becomes available. This work has garnered astonishing international attention, with our first publication (Drug treatments for COVID-19: Living systematic review and network meta-analysis) at an altmetric impact metric of 4,122.

Dr. Shelley McLeod is a clinical epidemiologist, Research Director of the Schwartz/Reisman Emergency Medicine Institute, Sinai Health and Assistant Professor at U of T DFCM

Stronger Together: Caring Through Crisis

University of Toronto Family Medicine Report

Chapter 5

Teaching that matters, care that makes a difference

Learning as a community during COVID-19

“These sessions are excellent and have become a main source of clear information which I in turn share with the rest of our team. Many thanks for continuing to have these sessions.”

We have all had to change the way we work in response to COVID-19. For family doctors, keeping up with new guidance in a rapidly evolving environment has been a herculean task.

As the pandemic continued into 2021, we eagerly awaited COVID-19 vaccines and wanted to provide family doctors and primary care professionals with the knowledge and skills to support an effective vaccine rollout.

To help family doctors stay informed, share learnings and navigate uncertainty in these trying times, our DFCM team invited the Ontario College of Family Physicians (OCFP) to join us in two initiatives: the COVID-19 community of practice and the COVID-19 vaccination in Canada educational series.

With our OCFP colleagues, we developed the COVID-19 vaccination in Canada educational series (tinyurl.com/ VaccineModules). Designed both as a continuous learning experience and as a resource to refer back to, the modules bring together best available evidence in a rapidly evolving landscape to ensure primary care providers have the information they need to build vaccine confidence and support widespread vaccination quickly and safely.

TEACHING THAT MATTERS, CARE THAT MAKES A DIFFERENCE

In April 2020, we hosted our first COVID-19 community of practice (tinyurl.com/COVIDCoP). Fifteen months and more than 25 sessions later, it has become “the Friday morning educational event” for hundreds of family doctors and primary care professionals across Ontario. The sessions are an opportunity for family doctors to share and learn from each other. For each session we invite panelists, typically family doctors from across Ontario, who describe unique innovations and impart their expertise and wisdom. Attendees are also encouraged to ask questions and share resources and perspectives. Topics have included implementing virtual care, to organizing community collaborations, supporting patients with mental health and addiction, managing chronic conditions and navigating the evolving science of vaccination.

All sessions are recorded and shared alongside tools and resources, while participants provide real-time feedback and inform future topic selection. In addition, since January 2021, sessions have been available as self-learning modules certified by the College of Family Physicians of Canada and the Ontario chapter.

The regularly updated series includes six interactive modules on why we need the vaccine, the safety and efficacy of mRNA and viral vector vaccines, plans for vaccine rollout, building vaccine confidence and emerging issues. To date, more than 2,400 family physicians and primary care professionals have accessed the series.

“This was hands down the most useful, well designed, clinically relevant set of modules I have ever reviewed. On any topic in medicine. In my entire career. Thank you so much for this wonderful resource!” During this exceptionally challenging time, the community of practice and modules have provided a valuable space for clinician colleagues to connect and learn with and from each other.

Dr. Tara Kiran is a family doctor at St. Michael’s Hospital, Unity Health Toronto, Fidani Chair in Improvement & Innovation and Vice-Chair, Quality & Innovation at U of T DFCM Patricia O’Brien is the Manager of the Quality & Innovation Program at U of T DFCM

Stronger Together: Caring Through Crisis

Since the start of the vaccine rollout, we typically have 600-to-900 attendees per session. As of May 25, 2021, we’ve welcomed more than 2,750 unique participants of which 86.8% are family physicians with 65.5% practicing outside a family health team/community health centre model. Over 60% have joined more than one session and 98.5% strongly agree/agree that their experience was positive.

TEACHING THAT MATTERS, CARE THAT MAKES A DIFFERENCE

Crisis and opportunity: The present and future of virtual care and education

University of Toronto Family Medicine Report

Family medicine clinics are designed not only for clinical care, but also for education. The COVID-induced virtual pivot in our clinics significantly changed our core structures for educating learners.

reflected in the objectives, interactive learning activities and assessments within each module. ViCCTR’s goal is to prepare learners to engage with complex and novel clinical situations in a virtual world where they may not have access to ready answers or routine solutions.

Current and incoming residents were faced with a clinical and teaching environment very different from what they While the modules had to address an urgent need for had anticipated. At a crucial stage in their development learners, the ViCCTR team also wanted to create a resource as family doctors, these learners were developing their that would serve as a foundation for post-pandemic clinical reasoning without physical contact with their learning on virtual care and clinical reasoning. We drew patients and, sometimes, without their preceptors. on the expertise of family physicians and their learners Meanwhile, our family medicine teachers were finding – for example those specializing in the care of vulnerable their feet as educators in a completely new environment. populations – to build modules including both the latest evidence and practical examples grounded in real clinical Recognizing the urgent need to address this challenge for experiences. The result is an evidence-informed resource DFCM learners and faculty, Dr. Risa Freeman – Vice-Chair, that will guide learners well after the pandemic. Education and Scholarship – brought together a team to lead the work. The result is the Virtual Care Competency The list of topics is growing. Modules cover primary Training Roadmap or ViCCTR. care patient management during physical distancing, patient-centered virtual care, virtual physical examinaThis novel virtual education tool is a proactive collabo- tion, care for vulnerable populations, virtual supervision rative effort from teachers, postgraduate leaders, resi- of trainees and much more. Each module builds on the dents, technology specialists, education scientists and principles for safe, effective and patient-centered virtual educators across DFCM’s programs and sites. It includes care covered in previous modules. six evidence-informed modules to guide residents, faculty and practising clinicians in the core competencies Since the launch of the ViCCTR in July 2020, the three necessary for provision of virtual care. While e-modules initial modules have been completed by every new are not new, ViCCTR is unique in its approach to design trainee in our program, as well as many practicing family and delivery. doctors. A mixed-methods evaluation of ViCCTR led by the Office of Education Scholarship (OES) and PGY3 ViCCTR was designed using the latest principles from Enhanced Skills Education Resident (now Associate cognitive science on the development and nurturing of Program Director – Admissions, Awards and Recruitment), clinical reasoning in medical trainees. These principles are Dr. Karina Prucnal, has generated rich examples of how

residents have benefited from and applied the lessons from ViCCTR. As one learner says: “I don’t think virtual care is going anywhere … most PGY1s need to be seeing this.” Another added: “ViCCTR is one of the most valuable modules” for training. Emerging findings are confirming that the modules have been well received by most users. ViCCTR’s impact has extended beyond our department. Collaborations with Critical Care Ontario, Cancer 360 at University Health Network and various departments within the Temerty Faculty of Medicine are underway, and other universities have asked to use the modules. The story of ViCCTR is just one example of how the learners, teachers, scholars and leaders in DFCM came together to not just react, but to innovate and lead in the face of the pandemic.

Dr. Kulamakan Kulasegaram is an education scientist, Director of the Office of Education Scholarship and an Associate Professor at U of T DFCM Dr. Nicole Woods is an education scientist, Associate Director of the Wilson Centre and an Associate Professor at U of T DFCM Submitted on behalf of the ViCCTR team

Stronger Together: Caring Through Crisis

Dr. Batya Grundland is a family doctor, Associate Program Director - Curriculum & Remediation and an Assistant Professor at U of T DFCM

Excellence in virtual teaching

Teaching health professional teachers The INTAPT program (Interprofessional Applied Practical Teaching and Learning in the Health Professions) prepares DFCM faculty to develop and teach educational programs. We successfully transitioned this practical and previously in-person course to online delivery. In preparation, we reviewed the key outcomes we wanted to preserve and engaged with field experts and experienced instructors.

University of Toronto Family Medicine Report

With this insight, we adapted and rehearsed successful in-class interactive activities for the online environment. We designed new initiatives to help students build connections with each other and with faculty members and built in extra time for student collaborative sessions. As a result, our learners developed new skills and friendships, and left excited about their future as health professional teachers.

Dr. Abbas Ghavam-Rassoul is a family doctor at St. Michael’s Hospital, Unity Health Toronto, Program Director of the Academic Fellowship and Graduate Studies Program and an Assistant Professor at U of T DFCM

Interprofessional education: Learning with, from and about Students at St. Michael's Hospital DFCM have the opportunity to learn with, from and about each other in interprofessional education modules focused on team-based and patient-centred care. Learners and faculty work together to better understand the roles of health team members and optimize team functioning with a goal of improving the care we deliver. Module evaluations demonstrate that they are highly valued by students and that team teaching has resulted in health team strengthening. Pivoting these modules to virtual delivery during the pandemic has created new ways to communicate while maintaining a quality program from the perspectives of learners.

Dr. Deborah Kopansky-Giles is the HPE Program Lead, Dr. Ann Stewart is a family doctor and Willem McIsaac is a physiotherapist at St. Michael’s Hospital Academic Family Health Team

Bigger and bolder: PA assessments In September 2020, the DFCM’s Physician Assistant (PA) Program looked for solutions to ensure our trainees were meeting the end-of-year competencies expected of a graduate. Despite most national bodies postponing, cancelling or decreasing the examination objectives tested, our program went bigger and bolder. We created our largest objective structured clinical examination (OSCE) ever run for a cohort, with 30 students rotating through 13 virtual stations, from taking a virtual assessment of patients presenting with symptoms to interpreting ECGs and X-rays, documenting encounter notes and presenting cases to a preceptor. The integrated virtual OSCE had some unique features; as in a real clinical day, candidates had the control to move themselves from virtual station to virtual station every 10 minutes. Taking a scholarly approach, this is now being studied to further improve it for an even bigger OSCE next year.

Dr. Peter Tzakas is a family doctor, Physician Assistant Program Director and an Assistant Professor at U of T DFCM

Innovation as the solution

Meeting DFCM’s future residents Residency interviews are one of the largest annual events for DFCM. This year, we transformed the admissions process and were one of the few residency programs to hold live virtual interviews, with great results.

Point-of-view learning Getting creative with procedural skills Pivoting to a completely online curriculum during the pandemic meant U of T Foundations medical students lost their clinical placements, a major part of clinical skills training.

The seamless shift to an entirely virtual process, while encouraging medical students to select family medicine and our program, is as commendable as it was complex. The positive feedback for our admissions team has been remarkable, creating lasting change for our residency program.

Beyond clinical skills, we are investigating wearable POV technology for career exploration and the Family Medicine Longitudinal Experience, to support learning when physical distancing and/or geographical constraints (e.g., rural/remote locations) present barriers to such experiences.

Dr. Vanessa Rambihar is a family doctor at Women’s College Hospital, Associate Program Director Admissions, Awards and Recruitment and an Assistant Professor at U of T DFCM

Dr. Karina Prucnal is a family doctor and Associate Program Director – Admissions, Awards and Recruitment at U of T DFCM

For those feeling less confident with certain procedures, my emergency department colleagues were happy to join in a procedures skills morning. One preceptor created a realistic gelatin mould to practice CV line insertion; it even had a vein and artery, and was able to be cannulated using ultrasound. I used pork ribs to teach chest tube insertion, and chicken legs to practice intraosseous line insertion. Another colleague had a 3D-printed model for practicing cricothyroidotomies. The residents were so appreciative and felt the practice really helped improve their skill set. I am fortunate to have fellow preceptors who ensure our residents get the best experience – even in a pandemic!

Dr. Stephanie Milone is a family doctor, Orangeville Site Director and an Assistant Professor at U of T DFCM

Stronger Together: Caring Through Crisis

More than 350 DFCM faculty members, staff and residents welcomed over 900 medical students in five live sessions for interviews and meetand-greets to showcase our program and diverse training sites.

Our MD student team acted fast to voice their concerns and deliver point-of-view (POV) interactive clinical learning experiences. Tutors wore smartphones using repurposed chest straps to livestream both clinical skills in the classroom and routine patient appointments in the office.

Thanks to the creativity of preceptors in our small Orangeville community, our PGY2 residents have had a great experience, despite the pandemic and its many restrictions.

Teaching that matters, care that makes a difference Building confidence in critical skills

High-quality care and rigorous education

Emergency Medicine Cases

Effective airway management is a core skill for emergency physicians. But, due to the COVID-19 pandemic, DFCM’s emergency medicine residents have had fewer opportunities to learn and practice airway skills during clinical rotations.

The DFCM at Toronto Western Hospital is the home of the PGY3 in Hospital Medicine and the Family Inpatient Service (FIS). During the COVID-19 crisis, we continued to run the FIS, increasing patient numbers to support the surging inpatient census. We compiled resources and evidence as it emerged, shared our expertise with our outpatient Family Health Team counterparts and supported our trainees through several disruptive outbreaks. We also volunteered our own attending physicians to co-attend on the COVID-19 inpatient ward with our internal medicine colleagues at a time when they were in dire need of capable physicians.

Launched 11 years ago, the Emergency Medicine (EM) Cases initiative (emergencymedicinecases.com) is part of the Free, Open Access Medical Education movement, known as FOAMed. We normally produce one podcast every two weeks, but in March/April, at the height of COVID19 preparations across Canada, we published eight, as well as various other online resources. The podcasts included interviews with 12 Canadian emergency, critical care and infectious disease experts, as well as reflections from an emergency medicine doctor who contracted SARS. In two months, EM Cases podcasts were downloaded more than 500,000 times by 100,000 listeners around the world.

To address this, we created a safe, hands-on, one-day bootcamp using rapid review lectures, directed practice and simulations to help residents gain intubation and ventilation experience, including COVID-19 protected intubations.

University of Toronto Family Medicine Report

Our first group of residents reported feeling more comfortable and confident after our bootcamp, which is continuing and being adopted by other programs. Using our expertise in medical education and simulation, we created this successful bootcamp in just four weeks!

Through the crisis, our group remained dedicated to our shared dual vision: high-quality patient care and a rigorous educational experience – all offered from the unique vantage point and through the generalist skill set of family doctors.

Dr. Carly Ng, Dr. Nadia Primiani, Dr. Eileen Cheung and Dr. Katherine Soucie are emergency medicine doctors at University Health Network, Sinai Health System and faculty at U of T DFCM

Dr. Diana Toubassi, Dr. Francesco Leanza, Dr. Carly Schenker, Dr. David Esho and Dr. Benjamin Kaasa are family and hospital medicine doctors at Toronto Western Hospital and faculty at U of T DFCM

Dr. Anton Helman is an emergency medicine doctor at North York General Hospital and an Assistant Professor at U of T DFCM

Committing to social accountability

Breaking down language barriers The Medical Mandarin Education Program (MMEP) is a student-run group for medical trainees to learn and practice Mandarin in a simulated clinical context with the goal of addressing language and cultural barriers experienced by Mandarinspeaking patients. Since September 2020, MMEP has made creative programmatic changes for virtual learning during the pandemic. We developed online sessions on stroke, health promotion and sexual health and invited a panel of Mandarin-speaking physicians to share their experiences working with Chinese-Canadian communities. Participating medical trainees reported increased confidence communicating in Mandarin, as well as a sense of connectedness during this time of physical isolation.

Dr. Joyce Nyhof-Young is an education scientist and a Professor at U of T DFCM

The Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) is an educational partnership between the University of Toronto and Addis Ababa University (AAU), Ethiopia. The cancelled May 2020 teaching trip to AAU was the first missed visit in our 10-year history. However, our community of TAAAC-EM alumni helped us quickly launch a robust virtual teaching program. Since April 2020, 54 teachers and moderators from Canada, USA and Ethiopia have taught 42 virtual sessions. These included didactic clinical EM and COVID-19 specific lectures, as well as creative delivery of continuing professional development sessions, wellness groups, procedural demonstrations and clinical debriefings. We also launched a Master Instructor program to train senior EM residents to become point-of-care ultrasound (POCUS) instructors for their PGY1 colleagues. With teaching trips and associated POCUS training on hold, this harnessed the expertise of previously trained residents and staff at AAU to continue training EM residents.

Dr. Eileen Cheung is an emergency medicine doctor at University Health Network and Michael Garron Hospital, TAAAC-EM Co-Director and an Assistant Professor at U of T DFCM

Acting on healthcare inequities The Equity, Diversity, Advocacy and Cultural Safety (EDACS) curriculum for emergency medicine (EM) residents is designed to empower EM trainees to act on healthcare inequities. The adapted COVID-19 curriculum includes eight hour-long sessions over two years on a variety of topics, as well as safely distanced introductory visits to sites in the downtown core that serve diverse communities, including high proportions of individuals living near or below the poverty line. Primer documents are being developed for all the EDACS topic areas to help residents to provide safe and supportive care for all.

Dr. Jennifer Hulme is an emergency medicine doctor at University Health Network and an Assistant Professor at U of T DFCM

Stronger Together: Caring Through Crisis

Xinran Liu and Yucheng Zhang are undergraduate medical students in Temerty Faculty of Medicine at U of T

International collaborations during COVID-19

University of Toronto Family Medicine Report

Chapter 6

Research to improve care

RESEARCH TO IMPROVE CARE

An INTRePID international research journey In November 2019, I was invited to the University of Melbourne as a visiting professor to present and exchange knowledge and experiences about primary care electronic medical record (EMR) data research. There I met with family medicine colleagues at the University of Melbourne and the National University of Singapore. Both were interested in further developing their EMR databases. Shortly after, we had a Zoom meeting to discuss potential shared projects and landed on doing a cross-country comparison of the primary care management of chronic kidney disease. COVID-19 hit around the time of our third Zoom meeting and it became apparent that things were rapidly changing in all of our countries. At the same time, universities paused all non-COVID-related research and we all shifted into COVID-related clinical work as part of the pandemic response. It was the few minutes of social talk with these international colleagues, sharing what our various countries and clinical settings were doing in response to the pandemic, that triggered my thinking: we need to study this on a global level. Recognizing that countries worldwide were rapidly adapting their public health polices and health care delivery, I emailed acquaintances working in this space about conducting international comparative research in family medicine.

In less than a year, we have established the feasibility of doing international primary care comparative research. INTRePID investigators have been meeting via Zoom every two-to-three weeks since late 2020.

In recognition of this unique international opportunity, INTRePID researchers are highly engaged and committed to this work despite extraordinarily busy schedules balancing regular clinical care, COVID-19-related clinical care, administrative duties and research. Their adaptability and agility in this rapidly and constantly changing pandemic landscape is a particular strength of this consortium. With INTRePID researchers on the ground, actively involved in patient care and vaccination in their respective countries, we have no shortage of research study plans and ideas. Looking at disease prevention and detection, chronic disease management and other issues relevant to primary care, we hope to inform health policy and health system recovery now and for future pandemic preparedness and responses.

Dr. Karen Tu is a family doctor at Toronto Western Hospital, research scientist at North York General Hospital, Professor and Lead of the UTOPIAN Data Safe Haven at U of T DFCM Dr. Ellen Stephenson is a post-doctoral research fellow at U of T DFCM Dr. Jessica Gronsbell is a biostatistician and Assistant Professor at U of T DFCM and the Department of Statistical Sciences Submitted on behalf of INTRePID

Stronger Together: Caring Through Crisis

The response was overwhelmingly positive. In just a few days, I was able to mobilize family medicine big data researchers in nine countries (Australia, Canada, China, Norway, Singapore, South Korea, Sweden, United Kingdom, United States) with access to and analytic expertise in primary care EMR and/or administrative data. Bringing together varied COVID-19 prevalence, policies and experiences, we formed the International Consortium of Primary Care Big Data Researchers – INTRePID – in November 2020 (intrepidprimarycare.org).

Having family medicine researchers with access to local data and the ability to provide appropriate context and interpretation has proven to be instrumental to the feasibility of this international collaboration. We have already identified commonalities between our individual country data and are preparing our first manuscript on visit volume and the uptake of virtual care in primary care since the pandemic began.

University of Toronto Family Medicine Report

RESEARCH TO IMPROVE CARE

Using UTOPIAN data to improve primary care for our patients Family medicine has been dramatically affected by the In the first three months of the pandemic, we found that: pandemic. We’ve seen significant changes in the way family doctors and our teams provide care, but care has → 35% fewer patients visited their family doctor (in-person or virtually) compared continued — a fact borne out by data from the University to the same months of 2019 of Toronto Practice-Based Research Network (UTOPIAN). Relationships often built over decades have helped ease the shift to virtual care. Patients recognize and appre- → 85% of visits were by phone or by video; virtual care was the norm ciate the friendly voice from their family doctor, nurse and primary care team. → Patients who did contact their doctor visited them more often than before the pandemic Despite all the challenges, one big difference between care during COVID-19 and previous pandemics, such as the SARS crisis in 2003, is Electronic Medical Records → There were no observable differences in the change in visits volume between lower(EMRs). During SARS, paper-based records were the norm. and higher-income neighbourhoods We could only access charts when in the office and could not do video visits. Most family doctors did not yet collect patient email addresses and almost no one was By December 2020, people were seeing their family using secure email. Today, following the near universal doctor more often and there were only 18% fewer patients adoption of EMRs in family practice, family doctors can visiting compared to the previous year. safely and securely access electronic records and communicate with both patients and colleagues remotely. When we look at this information, it makes sense that fewer patients visited their family doctor early in the The data contained in family medicine EMRs represent an pandemic given stay-at-home orders and anxiety about incredible resource to track and measure care in family in-person contact. It took time for patients and doctors medicine. Since 2008, UTOPIAN scientists and staff have to get used to virtual care, but nine months into the panbeen securely collecting and analyzing EMR data from demic (Dec 2020) we saw an increase in visits (mostly a growing number of practices in ways that protect pri- virtual). It is also reassuring that once patients contacted vacy. The data are used for research, to support quality their family doctor they were seen more often to help improvement efforts, advance health equity, monitor our manage their health, and that we found similar changes healthcare system and for reports (including the U of T in visit patterns across diverse neighbourhoods. Family Medicine Report you are now reading). These data highlight the breadth and value of family medicine and Not surprisingly, the reasons why patients contacted emphasize that well-functioning primary care is critical their family doctor changed during the pandemic. for better care and better health for the patients we serve. What we learn from these data during the pandemic can help us improve care in the future.

BY DECEMBER 2020 THERE WERE:

10%

more patients seen for anxiety, compared to before COVID-19. After the initial contact, these patients were seen more often than before the pandemic, usually virtually

50%

89%

fewer visits for periodic health exams (annual check-ups)

25%

fewer visits for chronic conditions like high blood pressure or diabetes

fewer visits for the common cold

No change in visits for pregnancy care

78%

91%

of visits for mental health concerns were virtual

59%

77%

of visits for pregnancy care and

of visit for well-baby care were in person

We are very grateful to the family doctors that contribute data to UTOPIAN and welcome more colleagues to join us. To contribute data safely and easily, please see tinyurl.com/EMRdata.

Dr. Michelle Greiver is a family doctor and Gordon F. Cheesbrough Research Chair in Family and Community Medicine at North York General Hospital, Associate Professor and Director of UTOPIAN at U of T DFCM Dr. Ellen Stephenson is a post-doctoral research fellow at U of T DFCM Dr. Karen Tu is a family doctor at Toronto Western Hospital, research scientist at North York General Hospital, Professor and Lead of the UTOPIAN Data Safe Haven at U of T DFCM Dr. Peter Selby is a family doctor and clinician scientist at the Centre for Addiction and Mental Health, Giblon Professor and Interim Vice-Chair, Research at U of T DFCM

Stronger Together: Caring Through Crisis

of visits continued to be virtual (phone/video)

Our EMR data confirm that family doctors continued to provide patient care during the pandemic and can help us plan for the future. Are annual check-ups still valuable? Could we use this time to ‘catch up’ on important care for chronic conditions? Will we see a resurgence of appointments for the common cold as COVID-19 control measures ease? What mix of virtual and in-person care serves patients best? UTOPIAN data can help us study these questions and prepare for pandemic recovery and future health crises.

RESEARCH TO IMPROVE CARE

Emergency medicine research during a global emergency Dr. David Dushenki as research participant in HEROES study In early 2020, with COVID-19 spreading and the demand for critical care rising, emergency departments across Ontario prepared for the worst. Other healthcare systems around the world were overwhelmed with COVID19 patients in need of emergency resuscitation, and Toronto emergency departments braced for the worst possible scenarios. At the Schwartz/Reisman Emergency Medicine Institute (SREMI) based at Mount Sinai and North York General Hospitals, community spread of COVID-19 and increasing clinical demands in the emergency departments brought in-person research to an abrupt halt. But SREMI is a hub of innovative emergency medicine researchers and educators. Determined to turn the tide of COVID-19, the team focused their efforts on knowledge sharing and collaborating with COVID-19 research networks locally, nationally and internationally.

University of Toronto Family Medicine Report

Working with Dr. Megan Landes, a DFCM clinician investigator at University Health Network, Dr. Shelley McLeod, SREMI’s Research Director, and I (Dr. Bjug Borgundvaag) led a blinded, randomized controlled trial to determine if pre-exposure prophylaxis reduces COVID-19 among health care workers in the emergency department. Dr. McLeod also worked with a World Health Organization and British Medical Journal team to conduct a living network meta-analysis for the management of COVID-19 that informs international clinical practice guidelines (see P34). Meanwhile, a team at North York General Hospital enrolled participants in the Canadian COVID-19 Emergency Department Registry Network. This national network of emergency department researchers collects data on COVID-19 patients – including hospitalization, severe outcomes and prolonged symptoms – to understand and inform clinical decision-making as the pandemic evolves.

In such a rapidly changing environment, sharing knowledge is as important as acquiring it. Many SREMI researchers have been helping to accelerate knowledge translation through podcasts such as EM Cases (see P42) and groups including Dr. Don Melady’s Geriatric Emergency Department Collaborative (GEDC). GEDC developed a series of monthly webinars with topics ranging from emergency department approaches to COVID-19 diagnosis and management to nursing home transitions and telehealth solutions (gedcollaborative.com). Undoubtedly, these communications platforms and networks of experts have saved the lives of patients, health professionals and their families. These education efforts speak to the full potential of SREMI. Writing grants and publishing papers in isolation will never be sufficient strategies to deliver optimal health care to patients in a reasonable timeframe. The success of this past year is a direct reflection of the hard work, perseverance and resilience of the SREMI team. While providing clinical emergency department care, the SREMI team continued successful research studies in areas like mental health and addictions, emergency pregnancy care and the care of older adults in the emergency department. With or without COVID-19, SREMI scientists are among the top academic producers in emergency medicine in Canada and are increasingly being recognized as international leaders in the discipline.

Dr. Bjug Borgundvaag is an emergency medicine doctor, Founding Director of SREMI and a Professor at U of T DFCM Dr. Catherine Varner is an emergency medicine doctor, a clinician scientist and Deputy Director of SREMI and an Assistant Professor at U of T DFCM

Data-informed pandemic response Since April 2020, I have been part of the COVID-19 Committee at ICES, which oversees the use of linked COVID-19 testing and vaccination data for analytics to support health system stakeholders in the pandemic response and the production of the COVID-19 dashboard (tinyurl.com/ ICESdata). Our reports and analyses informed the decision to prioritize hotspots for vaccination.

Dr. Jeff Kwong is a family doctor at the Toronto Western Family Health Team and a Professor at U of T DFCM

Meditation, depression and chronic pain

When COVID-19 was declared, our pregnant patients appeared noticeably more anxious and voiced multiple concerns. We looked to the literature for guidance on how to counsel these patients and found limited exploration of pregnant patients’ psychological condition during infectious outbreaks.

Can meditation help ease symptoms of depression for people living with chronic pain? In March 2020, we began recruiting for a randomized control trial studying this. Because of the pandemic we had to pause indefinitely.

Recognizing this need, we designed a mixed-methods study and recruited pregnant patients from our Family Health Team to help inform future care plans. We asked participants about the psychosocial and behavioural impacts of the COVID-19 pandemic on their pregnancy and post-partum experiences, including their perceived risks, behavioural responses and strategies to manage worry and anxiety. Our findings will help health providers mitigate these impacts by providing appropriate supports.

Dr. Sabrina Kolker is a family doctor at the Mount Sinai Academic Family Health Team and a Lecturer at U of T DFCM

With the support of the DFCM clinical trials group, we’ve been able to reboot the trial for virtual delivery and expand to multiple sites, including Sinai Health, Women’s College, St Michael’s, Toronto Rehabilitation Institute and the Rivlin Medical Group. We hope that this will allow us to better address the unmet needs of those living with chronic pain during the pandemic and beyond.

Dr. Abhimanyu Sud is a family doctor at Trillium Health Partners and an Assistant Professor at U of T DFCM

Stronger Together: Caring Through Crisis

I also co-led a study of predictors of COVID-19 testing and infection that was published in CMAJ, and am leading in the Canadian Medical Association Journal to conduct studies on COVID19 vaccine surveillance, including coverage, safety and effectiveness.

Studying anxiety in pandemic pregnancies

RESEARCH TO IMPROVE CARE

Palliative care research through COVID-19 and beyond

“Instead, what started out as adversity ended up being an opportunity.” Malcolm Gladwell, Outliers: The Story of Success The past 18 months have presented unique challenges for researchers working in palliative care. Our research has always aligned itself closely with our clinical activities, and typically involved in-person recruitment, intervention and observation.

University of Toronto Family Medicine Report

The unprecedented demands placed on emergency departments, intensive care units and general internal medical teams during the pandemic, coupled with the immediate need to adjust clinical activities for virtual care, led to an almost complete cessation of patient-facing palliative care research activities across all sites.

DFCM palliative care members have developed online clinical resources and published papers on a variety of COVID-related topics. These include scalable models for delivering inpatient care during the pandemic; the impact on palliative care services, cancer patients and survivors; informational needs of caregivers of patients admitted to palliative care units; and more general opinion pieces around the rise of xenophobia during the pandemic. Our Division Director, Dr. Kirsten Wentlandt, and colleagues have developed a national COVID-19 registry to collect baseline characteristics, palliative care involvement and clinical outcomes of patients with life-limiting illnesses who have COVID-19. More than 300 unique cases have been logged to date, and this data will ultimately be used for quality improvement and research projects, as well as to help prepare for future pandemics.

As we look toward a time beyond COVID-19, the lessons learnt over the past months will inform how we conduct Patients with life-limiting illnesses and their caregiv- palliative care research in the future. The expansion of ers, a particularly vulnerable and high-risk group, were virtual care and ability to recruit and gain consent from frightened. More than ever, they needed comprehensive, patients remotely have opened up possibilities to reach person-centred care provided by teams equipped with study participants previously excluded due to geograthe clinical and communication skills needed to best phy or time constraints. Platforms such as Zoom and support and advocate for them. It was all hands on deck. MS Teams have allowed us to connect with colleagues in different cities, provinces and countries more easily Dedicated research time evaporated. than ever before, opening up exciting avenues for greater But once a researcher, always a researcher. Our division cross-site research mentorship and collaboration. members were quick to identify ways to meaningfully contribute to the literature around the importance of We look forward to the coming months with renewed optimism and confidence that the future of palliative palliative care during the pandemic. care research in DFCM is brighter than ever before!

At each DFCM site, palliative care teams became actively involved in the development of clinical guidelines, communication skills training and rapid upskilling of non-specialist Dr. Breffni Hannon is a palliative care doctor and colleagues to meet the needs of patients and families. Site Lead at the Princess Margaret Cancer Centre, With this work came opportunities to disseminate strat- University Health Network and an Assistant Professor in the Division of Palliative Care at U egies and experiences through publication. of T Department of Medicine and DFCM

Peer support in the ED Virtual urgent care The Peer Support in the Emergency Department (ED) program launched in September 2020 to help meet the urgent needs of marginalized patients during the COVID-19 pandemic. Employed by The Neighbourhood Group, peers bring their knowledge of homelessness, substance use and mental health issues from lived and/or living experience to support patients in the ED, and we believe the program has had a profound impact on addressing health inequities faced by disadvantaged populations that seek care in the ED. Together with our partners, we are evaluating the program to better understand its successes, challenges and the team and partnership dynamics in diversified health care teams.

I am leading the provincial evaluation of this program, including a quantitative and qualitative evaluation of patient and provider experience, patient health care utilization and an economic evaluation comparing virtual urgent care to traditional emergency department visits. Our goal is to help inform provincial policy decisions on how to best structure and support virtual care moving forward in a sustainable manner.

Dr. Shelley McLeod is a clinical epidemiologist, Research Director of the Schwartz/Reisman Emergency Medicine Institute, Sinai Health and an Assistant Professor at U of T DFCM

In a pandemic, how do you fairly allocate scarce resources? How do you justify public health measures? What is the scope and limit of physician obligations when personal risk is factored in? Since the 2003 Toronto SARS outbreak, I have been investigating the ethical issues raised by infectious disease outbreaks. This research has been taken up by the World Health Organization (WHO) and I have contributed to numerous guidance documents. During the SARS-COV-2/ COVID-19 pandemic, I have had the privilege of co-chairing the WHO Ethics and COVID-19 Working Group. While we were not prepared for COVID-19, this global perspective has helped us consider the broader costs and implications of pandemic management.

Dr. Ross Upshur is a family doctor, Head of the Division of Clinical Public Health at the Dalla Lana School of Public Health and a Professor at U of T DFCM

Stronger Together: Caring Through Crisis

Dr. Jennifer Hulme is an emergency medicine doctor at University Health Network and an Assistant Professor at U of T DFCM

Virtual patient care has seen incredible growth since the beginning of the COVID-19 pandemic. In the fall of 2020, the Ministry of Health introduced a virtual urgent care pilot program across the province of Ontario, intended to support emergency department diversion of patients with low acuity issues and reduce the need for face-to-face contact whenever possible.

The ethical dilemmas of pandemic management

LOOKING AHEAD:

Message from the Chair

University of Toronto Family Medicine Report

Throughout the pandemic, our DFCM community learned a lot about the role of primary care in our health system. In some cases, we have seen our discipline rise to the occasion in truly inspiring ways; in others, we have felt the frustration of delays in fully engaging family medicine’s expertise. Throughout, we've seen family doctors and other primary care providers go above and beyond to keep our patients and communities safe, often at huge personal cost. Now, as health systems all over the world seek to rebuild post-pandemic, this is the moment for family medicine. Health systems built on a foundation of high-performing, team-based, community-embedded primary care deliver better outcomes, more equitably and at lower costs. There are many fantastic examples of such care happening across DFCM. The stories in this report provide just a glimpse of the huge volume of important work being led by our faculty, staff and learners.

As we look ahead, we can learn from these examples and use DFCM as a scaffold to share the wealth of expertise across our department and embed ourselves more deeply in the communities we serve. I believe this is the as-yet untapped strength of our department, the C of DFCM – our communities. Working together, with strong and collaborative leadership, passion and urgency, we can help to establish a healthier future for all, using our tools of research, education, partnerships and innovation. Thank you to all those who took the time to share their stories as part of this report and the countless other members of the broad DFCM community who continue to work tirelessly for their patients, colleagues and communities. I look forward to working with you! Dr. Danielle Martin Chair and Associate Professor, U of T DFCM; family doctor, Women’s College Hospital

Stronger Together: Caring Through Crisis

Index 2 Message from the Chairs, Dr. David Tannenbaum and Dr. Danielle Martin 3 DFCM in numbers

Chapter 1 Caring through COVID-19

Chapter 2 Responding to the pandemic: Supporting communities

5 Eyes closed, arms folded: Inside a longterm care rescue operation, Dr. Ann Li

17 Community First: COVID-19 response in Nunavut, Dr. Sumeet Sodhi

6 Understanding care experiences: DFCM COVID-19 patient experience survey, Dr. Payal Agarwal and Dr. Tara Kiran

18 Rich culture and resilience: Reflections on Operation Remote Immunity, Dr. Suzanne Shoush, Dr. Kate MacNaughton, Dr. Elliot Lass, Brett Glena and Dr. Shima Shakory

8 Caring for homebound patients during the COVID-19 pandemic, Dr. Amy Freedman, Dr. Ann Stewart and Lorna McDougall 9 A hybrid health model, Dr. Kevin Lai 10 Shield and protect: Helping shelters support their clients, Dr. Aaron Orkin 11 Balancing psychiatric and COVID-19 care, Dr. Jennifer Nicolle

20 Vaccine hesitancy among Black Canadians during COVID-19, Dr. Helen Teklemariam 21 Building vaccine confidence in Black communities, Dr. David Esho 21 Riding the waves, Jessica Bawden 21 Answering the call, together, Dr. Allan Grill 22 One day, 26,000 vaccines, Dr. Camille Lemieux

11 Pandemic eating disorder care, Dr. David Makary, Dr. Mahdi Memarpour and Sherri Miller 11 HIV testing, FAST, Dr. Megan Landes 12 Sensitive examinations in a virtual world, Dr. Lilian Robinson

University of Toronto Family Medicine Report

12 COVIDCare@Home: Caring for the most at-risk patients, Dr. Payal Agarwal 13 COVIDCare@Home: Supporting resident education, Dr. David Rojas 14 Providing palliative care through COVID-19, Dr. Ramona Mahtani

22 Shots of joy and relief, Dr. Alis (Qinyuan) Xu 22 Joining the fight, one swab at a time, Dr. Sabrina Akhtar 23 Building vaccine confidence: 19toZero, Dr. Noah Ivers 23 A haven for youth experiencing homelessness, Dr. Nancy Trimble 23 Collaboration and flexibility, Dr. Rebecca Stoller

Chapter 3 Staying connected

Chapter 4 Family medicine leadership

25 Pandemic Pregnancy Guide: The virtual frontline for perinatal support, Dr. Tali Bogler and Dr. Sheila Wijayasinghe

31 Building the ship as you’re sailing it: How to lead in a pandemic, Dr. David Eisen

26 Communicating during COVID-19: Health journalism in the pandemic, Dr. Catherine Varner 27 Sharing stories, reflections and poetry, Dr. Michelle Lockyer 27 Long term care and emergency: A united front, Dr. Deepti Pasricha 27 PHONE-CONNECT, Dr. Andrea Somers 28 #StrongerTogether: Unifying two clinics with a common goal, Dr. Thea Weisdorf

32 The crucial role of primary care: Distributive leadership in action, Dr. Thuy-Nga (Tia) Pham 33 Emergency medicine leadership in the pandemic, Dr. Catherine Varner 34 Learning from leaders, Dr. David White, Dr. Mary Ann O’Brien, Dr. Sylvie Cornacchi, Dr. Risa Freeman and Dr. Eva Grunfeld 34 Three million pieces of PPE, Dr. Ruby Alvi and Dr. Jeremy Rezmovitz 34 Fast and furious: Making sense of COVID-19 data, Dr. Shelley McLeod

29 Students supporting seniors, Monisha Persaud, Geoffrey Sem, Dr. Gray Moonen and Dr. Noah Crampton 29 “Hello, how are you?” Dr. Noor Ramji, Dr. Deborah Kopansky-Giles, Dr. Gary Bloch and Dr. Karen Weyman 29 Frontline Connect Canada, Dr. Humaira Saeed and Dr. Ilana Greenwald

Stronger Together: Caring Through Crisis

Chapter 5 Teaching that matters, care that makes a difference

Chapter 6 Research to improve care

37 Learning as a community during COVID-19, Dr. Tara Kiran and Patricia O’Brien

45 An INTRePID international research journey, Dr. Karen Tu, Dr. Ellen Stephenson and Dr. Jessica Gronsbell

38 Crisis and opportunity: The present and future of virtual care and education, Dr. Batya Grundland, Dr. Kulamakan Kulasegaram and Dr. Nicole Woods 40 Teaching health professional teachers, Dr. Abbas Ghavam-Rassoul 40 Interprofessional education: Learning with, from and about, Dr. Deborah Kopansky-Giles, Dr. Ann Stewart and Willem McIsaac

48 Emergency medicine research during a global emergency, Dr. Bjug Borgundvaag and Dr. Catherine Varner 49 Data-informed pandemic response, Dr. Jeff Kwong

40 Bigger and bolder: PA assessments, Dr. Peter Tzakas

49 Studying anxiety in pandemic pregnancies, Dr. Sabrina Kolker

41 Meeting DFCM’s future residents, Dr. Vanessa Rambihar

49 Meditation, depression and chronic pain, Dr. Abhimanyu Sud

41 Point-of-view learning, Dr. Karina Prucnal

50 Palliative care research through COVID-19 and beyond, Dr. Breffni Hannon

41 Getting creative with procedural skills, Dr. Stephanie Milone 42 Building confidence in critical skills, Dr. Carly Ng, Dr. Nadia Primiani, Dr. Eileen Cheung and Dr. Katherine Soucie 42 High-quality care and rigorous education, Dr. Diana Toubassi, Dr. Francesco Leanza, Dr. Carly Schenker, Dr. David Esho and Dr. Benjamin Kaasa 42 Emergency Medicine Cases, Dr. Anton Helman 43 Breaking down language barriers, Xinran Liu, Yucheng Zhang and Dr. Joyce Nyhof-Young 43 International collaborations during COVID-19, Dr. Eileen Cheung University of Toronto Family Medicine Report

46 Using UTOPIAN data to improve primary care for our patients, Dr. Michelle Greiver, Dr. Ellen Stephenson, Dr. Karen Tu and Dr. Peter Selby

43 Acting on healthcare inequities, Dr. Jennifer Hulme

51 Peer support in the ED, Dr. Jennifer Hulme 51 Virtual urgent care, Dr. Shelley McLeod 51 The ethical dilemmas of pandemic management, Dr. Ross Upshur

52 Looking ahead: Message from the Chair

ACKNOWLEDGEMENTS We would like to thank all of the participating family doctors who are contributing data to UTOPIAN and the authors for their contributions, as well as the many University of Toronto Department of Family and Community Medicine members and staff for their assistance in the completion of this report.

EDITORIAL COMMITTEE Faculty Dr. Karen Tu Dr. Catherine Ji Dr. Catherine Varner Dr. Sumeet Sodhi Dr. Michelle Greiver Dr. Peter Selby Dr. Ross Upshur Staff Amy Noise Dr. Ellen Stephenson Alicia Fung Jemisha Apajee Allison Williams Reviewers Elaine Smith

AUTHORS Dr. Ann Li Xinran Liu Dr. Michelle Lockyer Dr. Kate MacNaughton Dr. Ramona Mahtani Dr. David Makary Dr. Danielle Martin Lorna McDougall Willem McIsaac Dr. Shelley McLeod Dr. Mahdi Memarpour Sherri Miller Dr. Stephanie Milone Dr. Gray Moonen Dr. Carly Ng Dr. Jennifer Nicolle Dr. Joyce Nyhof-Young Dr. Mary Ann O'Brien Patricia O'Brien Dr. Aaron Orkin Dr. Deepti Pasricha Monisha Persaud Dr. Thuy-Nga (Tia) Pham Dr. Nadia Primiani Dr. Karina Prucnal Dr. Vanessa Rambihar Dr. Noor Ramji Dr. Jeremy Rezmovitz Dr. Lilian Robinson Dr. David Rojas Dr. Humaira Saeed Dr. Carly Schenker Dr. Peter Selby Geoffrey Sem Dr. Shima Shakory Dr. Suzanne Shoush Dr. Sumeet Sodhi Dr. Andrea Somers Dr. Katherine Soucie Dr. Ellen Stephenson

Dr. Ann Stewart Dr. Rebecca Stoller Dr. Abhimanyu Sud Dr. David Tannenbaum Dr. Helen Teklemariam Dr. Diana Toubassi Dr. Nancy Trimble Dr. Karen Tu Dr. Peter Tzakas Dr. Ross Upshur Dr. Catherine Varner Dr. Thea Weisdorf Dr. Karen Weyman Dr. David White Dr. Sheila Wijayasinghe Dr. Nicole Woods Dr. Alis (Qinyuan) Xu Yucheng Zhang

Stronger Together: Caring Through Crisis

Dr. Payal Agarwal Dr. Sabrina Akhtar Dr. Ruby Alvi Jessica Bawden Dr. Gary Bloch Dr. Tali Bogler Dr. Bjug Borgundvaag Dr. Eileen Cheung Dr. Sylvie Cornacchi Dr. Noah Crampton Dr. David Eisen Dr. David Esho Dr. Amy Freedman Dr. Risa Freeman Dr. Abbas GhavamRassoul Brett Glena Dr. Ilana Greenwald Dr. Michelle Greiver Dr. Allan Grill Dr. Jessica Gronsbell Dr. Batya Grundland Dr. Eva Grunfeld Dr. Breffni Hannon Dr. Anton Helman Dr. Jennifer Hulme Dr. Noah Ivers Dr. Benjamin Kaasa Dr. Tara Kiran Dr. Sabrina Kolker Dr. Deborah KopanskyGiles Dr. Kulamakan Kulasegaram Dr. Jeff Kwong Dr. Kevin Lai Dr. Megan Landes Dr. Elliot Lass Dr. Francesco Leanza Dr. Camille Lemieux

UNIVERSITY OF TORONTO Family Medicine Report Stronger Together: Caring Through Crisis Department of Family & Community Medicine University of Toronto 500 University Avenue, 5th Floor Toronto, Ontario M5G 1V7 T: 416-946-5938 F: 416-978-3912 E: dfcm.communications@utoronto.ca www.dfcm.utoronto.ca

2021