Thinking creatively — and clinically — about COVID-19

TVO.org speaks with David Kaplan, a doctor and the clinical-quality lead for Ontario Health, about clear communication, virtual solutions, and vulnerable populations
By Mary Baxter - Published on Mar 20, 2020
Many in long-term-care homes eat communally, posing a challenge for self-isolation efforts. (iStock.com/shapecharge)

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During the 2003 SARS outbreak in Toronto, David Kaplan was chief resident in family medicine at North York General Hospital. “I had a six-month-old baby at home,” he says. “I was quarantined twice, each time for 14 days.” Today, he’s the clinical-quality lead for Ontario Health, the province’s new consolidated health agency. He’s also still a family doctor at the hospital, as well as an associate professor at the University of Toronto.

Kaplan is one of the health-care leaders helping to facilitate Ontario’s response to the COVID-19 pandemic. “I wear multiple hats,” he says. For example, he’s leading a group of Greater Toronto Area family physicians working to establish clear messaging for doctors about appropriate care.

The SARS outbreak, he says, taught him how important it is for medical professionals to  communicate clearly both to the public and to one another and that “it is imperative to keep our health-care workers safe so they can look after citizens who fall ill.”

TVO.org spoke with Kaplan about the issues facing family physicians during the coronavirus outbreak and the challenges of providing care for those in the shelter system.

TVO.org: What are among the biggest challenges you’re seeing in terms of managing COVID-19 outbreaks in Toronto?

David Kaplan: One of the things we’re going to have to look at is how we manage patients who live in a congregant setting. Telling somebody who lives in a shelter to self-isolate, it’s going to be really hard because they don’t have any privacy. Same thing as long-term care —a lot of patients in long-term-care homes eat communally. If they’re sick, what does that mean for them?

I think these are challenges not just in Toronto. I think they’re going to be challenges everywhere. We also have lots of patients on reserves, outside of places like Toronto, where we’re going to have similar situations.

TVO.org: What strategies can we use?

Kaplan: [Those working on this challenge] are looking at things like, do we open up old shelters or temporary shelters for [homeless] people who are sick? They’re almost like quarantine shelters. They’re looking at how we can set up new temporary spaces to look after people. We did that with CFB Trenton for the people who came off cruise ships.

We have to think creatively because, obviously, we don’t want — not just to not infect the general public — we don’t want them going home and infecting their own communities. And I think that, in a lot of these congregant settings, it’s pretty ripe for infecting others. We saw it in Washington State, in the long-term-care home there.

One of the other things that people are looking at doing for long-term care, for instance, is how do we get people to see doctors without having to move them? Not people who are sick because we think they have COVID-19, but people who need to seek medical care for other reasons — heart disease, congestive heart failure, or whatever it may be.

We’re starting to look at virtual solutions so that people don’t need to be moved out of a long-term-care home into an emergency department. All that has been happening in the last number of days. It’s all moving quite rapidly and evolving hour to hour, day to day.

TVO.org: Will virtual technology also be part of the long-term solution for the hospital-bed crunch and overcrowded emergency rooms?

Kaplan: I think that’s what’s so interesting. All of a sudden, when there’s a public-health emergency, not only are people able to start thinking creatively, but the policy levers [are being pulled] — for example, the temporary doctor-billing codes for virtual care and telephone medicine that have come online the last couple of days.

TVO.org: Will these measures remain in place after the COVID-19 crisis?

Kaplan: So the virtual-care stuff in medicine had already been announced. [The province recently] broadened what platforms physicians can use and patients can use. They’ve also broadened it to include non-secure platforms, for now.

But if you use a non-secure platform, you’re going to need a patient’s explicit consent —whereas if they used a solution like the [Ontario Telemedicine Network], it’s considered implied consent. Much like when, if you are going to have your blood taken, you don’t sign a consent form: you just open up your arm, and you say, “Take my blood,” and that’s considered implied consent.

I’ve done a number of [virtual] counselling sessions in the last couple of days for patients. It’s really hard to assess someone’s mental state over the phone, but it’s a lot easier to do it when you can see them over high-quality video. Everybody has an HD camera on their smartphone. And, to be honest, sometimes it’s more interesting or more useful to see them in their home because you get other clues that you don’t see in the office.

So it will be very interesting as sort of a social experiment as we use more video-based care, just to see what other sorts of clues we gather. [Family doctors] used to gather these clues by doing home visits, and most of us don’t do that anymore for routine patients. The video is going to start getting us a glimpse back into people’s homes and into their environment.

TVO.org: You’ve said that not everybody needs a COVID-19 test, because most people are going to get better on their own, and a positive result won’t change the approach to clinical management for most people — self-isolation for 14 days. So why are we still testing?

Kaplan: It’s important in certain cases. It’s really important, for instance, if somebody is a health-care provider, that we test them. It’s important if people are in a congregant setting, like what we were just talking about — long-term care, reserves, homeless shelters — because we need to know what to do. Because if we send somebody back to those settings with COVID-19, there’s a real risk that it could spread quite quickly in that community. Every test in medicine [is applied with the same goal]: “What am I going to do with that piece of information, and is it going to change my management of that patient?” I think that’s the lens that we’re looking at testing in right now.

This interview has been condensed and edited for length and clarity.

Ontario Hubs are made possible by the Barry and Laurie Green Family Charitable Trust & Goldie Feldman.

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