Updated March 5, 2021
(* indicates a newly added question)
Physicians are working hard to support each other and the public through this public health emergency. To help inform this work, we’re keeping an updated list of frequently asked questions and answers. Our goal is to provide clear information to help guide your decision-making, the unique challenges posed by COVID-19 you are asked to continue using your professional judgement. If your question is not addressed here or if you need further support beyond the information provided below, please don't hesitate to contact us.
Critical Care Triage
If we reach a point where Ontario’s critical care capacity can no longer meet the surge in demand, what are physicians’ obligations with respect to the withholding or withdrawal of potentially life-saving or life-sustaining care?
The College appreciates how challenging the pandemic has and continues to be for physicians working in critical care capacities. If the pandemic worsens and intensive care admissions increase, physicians may be faced with very difficult decisions regarding the allocation of scarce resources. It is essential that physicians be supported in making the extraordinary decisions they may be faced with and that the public trust how those decisions are being made.
The College notes that the provincial government has enabled a centralized authority, its command tables, to manage, oversee and co-ordinate the implementation of appropriate critical care triage tools should this become necessary. While only the provincial government can take the steps necessary to enable physicians to withdraw life-sustaining treatment without consent in order to re-allocate those resources to another patient, the College recognizes that issues concerning withholding potentially life-saving or life-sustaining treatments may also arise.
Given the imperative of allocating critical care resources in a manner that aims to save as many lives as possible, the College acknowledges that physicians may, in following direction and guidance from the command tables, need to withhold potentially life-saving or life-sustaining treatments in a manner that departs from the expectations set out in our Planning for and Providing Quality End-of-Life Care policy. To the degree that compliance with triage frameworks, once initiated by the provincial command tables, results in departures from these expectations, the College is supportive of physicians acting in accordance with the command tables’ triage protocols. Transparent and sensitive communication with patients’ families will continue to be of paramount importance in these situations.
Where can I find information about the vaccines? And how will the vaccines be rolled out?
All levels of government are working together to develop plans for the efficient, effective and equitable rollout of COVID vaccines. This includes prioritizing certain populations as vaccine doses become available. The Ministry of Health has more information online regarding the rollout plan and where and how the vaccines will be made available.
What do health-care workers need to know about getting the vaccines?
Health-care workers have been identified as a priority population for vaccination to help protect them as they play a vital role in the health-care system and may face additional personal risk as a result of their roles. The vaccines will help prevent the spread of COVID-19 and protect these front-line workers.
As with all vaccines, there are contraindications and side effects. More information about the vaccines is available from Health Canada and locations where the vaccine are provided may have more information from the Ministry of Health, as well.
What do heath-care workers need to know about administering the vaccines to others?
As with all vaccines, there are contraindications, side effects and adverse events that may occur following vaccination that health-care workers need to be aware of. Locations where the vaccines are administered are likely to have information from the Ministry of Health available to provide health care providers administering the vaccines and more information is available from Health Canada. All staff who administer the vaccines must take appropriate infection prevention and control measures, including donning the appropriate personal protective equipment (PPE).
*Can residents administer COVID-19 vaccines outside their program?
Yes. As highly trained front-line professionals, residents can also play an important role in assisting with the province wide vaccine roll-out that is set to unfold over the coming months.
In keeping with the principles and expectations of CPSO’s Public Health Emergencies policy, it would be permissible for residents to participate in the administration of COVID-19 vaccines outside the context of their program, provided they are delegated the authority to do so, and to be remunerated for this work in the form of a fixed or set salary.
This exceptional approach is limited in application to only the circumstances of the COVID-19 public health emergency and the public health initiative needed to support the vaccine roll-out.
CPSO appreciates the unprecedented efforts residents have made and continue to make in supporting the health system response to the pandemic.
*How can medical students or retired physicians help administer COVID-19 vaccines?
Medical students and retired physicians may be able to play a valuable role in assisting the province wide vaccine roll-out. While they are not able to administer vaccines directly, they may do so if they are delegated the authority to do so.
Recently retired physicians may also be eligible to re-enter practice or re-apply for licensure (see below for more information) if they are interested in taking on a more substantive role in supporting the vaccine roll-out.
What are the current rules for determining what care physicians can or cannot provide?
The provincial rules governing the services that can be provided within each ‘zone’ designation have identified the services of regulated health professionals as being essential services that can be provided. Unless otherwise restricted (see below for more information), this means physicians can provide both medically necessary and elective care using a mix of virtual and in-person modalities.
The Chief Medical Officer of Health’s Directive #2 and the province’s COVID-19 Operational Requirements: Health Sector Restart are clear that the rules do not permit a return to a pre-pandemic practice environment, but that a flexible and safe approach to delivering care within the context of a pandemic needs to be adopted. At the same time, the system is no longer in a state of “restarting” and physicians need to now adjust to practising in this new normal in a manner that support patients’ best interests.
What’s the right balance between providing in-person and virtual care?
Every practice is unique and so the right balance will require judgment on the part of physicians to determine how to best serve their patients’ needs safely and appropriately.
However, we know that in-person care is essential for many conditions, that there are limits to what can be done virtually, and that not all patients will be able to get the care they need virtually. As a result, most physicians should now be practising in a manner that includes a mix of both in-person and virtual care.
For example, primary care physicians may find that a range of the care they provide can be done or supported by virtual modalities, recognizing there are limits on what can be done without a physical examination. The nature of inpatient care in hospitals, however, is generally better suited for primarily in-person management.
We know that many physicians are striking the right balance, but unfortunately we’re increasingly hearing about physicians’ offices that are not providing in-person care, emergency departments that are seeing patients who would be better managed in other settings, an increase in later-stage cancer diagnoses, and referrals to specialists being made without appropriate physical examinations that would have altered the need for a referral if they were done.
While virtual care will continue to be a helpful tool to support access to care during the pandemic, the pressures that existed early in the pandemic that required pushing the limits of virtual care have now diminished (e.g., lack of personal protective equipment) and, in most instances, in-person care can now be provided safely and appropriately.
Where physical contact is necessary to provide care (e.g., newborn care, prenatal care) or where physical assessments are necessary to make an appropriate diagnosis or treatment decision (e.g., infections conditions, post-operative care, chronic disease management), patients need to be seen in person.
CPSO expects physicians providing care virtually to meet the same standard of practice as would apply in-person and to consider the appropriateness of providing care virtually in each instance. In addition to our policy, helpful resources regarding the limits and appropriateness of using virtual care have been developed by the Canadian Medical Association, Ontario Medical Association, OntarioMD, and the Quality Division of Ontario Health and Ontario Telemedicine Network.
My patients want to be seen in person, but it’s appropriate to provide care virtually – what should I do?
Not all patients are able or willing to receive care virtually. As always, you will need to consider what is in your patients’ best interests. You can sensitively explain how virtual care will work in the circumstances, but ultimately your patients’ best interests may be served by providing care in person with the right safety precautions in place.
Do the restrictions on the types of services (e.g., personal care services) that can be provided in different ‘zones’ (e.g., red, grey, etc.) impact the services physicians can provide?
Physicians operating or providing services in a setting where non-medical aesthetic services are provided may be impacted by the restrictions set out in the ‘zone’ designations.
While physicians are permitted to provide both medically necessary and elective care, there are restrictions on the provision of “personal care services” such as facials or hair removal, particularly in the red and grey zone designations, which may impact some physicians or clinics they operate.
If a physician provides or operates a clinic providing non-medical aesthetic services, they must comply with any restrictions set out by the provincial zone designations. This restriction does not impact the provision of any medical services a physician might provide. For example, where the direct involvement of a physician or their delegate is required in order to provide the service (e.g., where a controlled act is being performed) or the service is medically necessary.
Physicians will have to carefully consider the rules for each zone designation to determine whether any of the services they provide or that are provided as part of their practice setting need to be temporarily restricted in accordance with the provincial direction.
Are hospitals restricting access to some elective procedures?
Hospitals need to retain capacity for a potential surge in demand among patients with COVID-19 which has resulted in direction to limit or defer elective surgeries. As the strain on hospitals changes, this direction and the need to adjust may continue to evolve as well.
What safety precautions do I need to take when providing in-person care?
The Ministry of Health’s COVID-19 Operational Requirements document sets out safety precautions that must be met as part of providing in-person care. It’s important that you follow guidance provided by the province or public health officials in order to implement safety precautions that are designed to protect everyone.
Physical (Social) Distancing: Set up your physical workspace and manage your practice in a way that enables staff and patients to observe physical (social) distancing (e.g., barriers at screening points, limited/separated seating in waiting rooms, assigning in/out routes with signs and/or visual markings, limiting the use of some examination rooms, having patients wait in their cars or outside the office (if possible/appropriate), reducing appointment availability, staggering shifts within group practices, etc.).
Hygiene: Have systems in place to support hand hygiene among staff (e.g., before/after every patient) and make hand sanitizing stations available to patients.
Screening: Screen all patients in advance (when possible, through video, telephone , or using web-based/online technologies), and at the point of care. If you are unable to safely isolate and/or provide care to patients with a positive screening result, redirect them to appropriate access points (e.g., emergency room if care is urgently needed). Also know where to direct patients who require testing and know when to report cases of COVID-19 to your local public health unit.
PPE: Follow public health guidelines regarding the appropriate PPE to use for the care being provided and avoid using more or higher levels of PPE than are required for the care being provided (e.g., airborne precautions if droplet precautions are recommended). The government has published guidelines to help physicians optimize their supply of PPE, access alternate sources through the PPE Supplier Directory when experiencing shortages through established supply channels, and request PPE from the provincial stockpile in emergency situations and when all other efforts have been exhausted.
Patient Safety: Tell patients in advance (e.g., at appointment booking) about the safety precautions you’ve put in place and ask them to bring and wear their own mask for their own safety and the safety of others, especially in instances where physical (social) distancing cannot be maintained. If patients do not have a mask, provide them with one or keep them isolated from other patients, and/or reschedule their appointment if necessary. Remember that some patients may have health conditions that make it difficult or unsafe to wear a mask.
Infection Prevention and Control: Infection prevention and control is more important than ever. Follow Public Health Ontario’s Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings and the sector specific guidance provided by the Ministry of Health. Public Health Ontario also has online learning resources available to help build or refresh core competencies in this area. The College has also worked with Public Health to develop a resource specifically for the Independent Health Facilities (IHF) and Out of Hospital Premises (OHP) environment.
Pandemic-Related Practice Issues
How do I treat essential workers that regularly travel across the US-Canada border and who will screen positive as a result?
You may have some patients who are essential workers that are required to regularly travel across the US-Canada border as a part of their job. As a result, they will always screen positive when using the Ministry of Health's screening tool simply because of the nature of their work. Recognizing that these individuals have been deemed essential workers and exempted from the quarantine and isolation rules set out by the federal government, the College is supportive of physicians exercising their clinical judgment regarding how to best care for these patients when they screen positive solely because of work-related travel. An immediate deferral of in-person care or redirection to another facility is not necessary in these instances, provided appropriate safety precautions can be met. If there is no opportunity to see a patient following a 14-day window without travel across the border or a negative COVID-19 test, physicians can arrange to see the patient for any in-person care if they can satisfy the recommended precautions to do so safely (i.e., immediately isolating the individual upon arrival, use of appropriate PPE, etc.).
Patients are asking me to write notes or complete forms for COVID-related exemptions or clearances — what do I need to know?
Patients may ask you to write notes or complete forms exempting them from the requirement to wear a mask or return to work in-person or clearing them to return to work or school.
The College’s Third Party Reports policy sets out the general obligations that apply in these scenarios. Central among the policy expectations is the requirement that physicians be comprehensive, accurate, and objective when completing any notes or forms.
In these circumstances, your role is to provide and attest to information about the patient’s health-care status or needs and identify risks to their health, if relevant. Your role, however, is not to determine the outcome of the process, as it is the role of the third party (e.g., employer) to determine the outcome (e.g., whether the patient will be accommodated, etc.).
For example, this may include identifying the specific risks associated with wearing a mask or returning to work for your patient, or providing accurate information regarding your patient’s symptoms, such as whether they are the result of a pre-existing condition or are new.
The Ministry of Health and some public health units have set out guidance on the limited circumstances where an individual would not be able to wear a mask.
Some medical associations or specialty groups have also developed recommendations regarding mask exemptions and guidance regarding specific conditions that may make it high risk for an individual to return to work in-person.
Finally, the Ministry of Health and Public Health Ontario have also set out criteria on when to discharge someone with probable or confirmed COVID-19 from isolation and considered them ‘resolved’.
Can I charge patients for any masks I provide or a fee to help cover the additional costs associated with additional safety precautions I need to take?
The College recognizes and appreciates the additional investments you are making to help serve your patients. These investments will help you provide care in the short- and long-term progression of the virus. The Ministry of Health has confirmed that infection prevention and control products or practices, including masks provided to patients, are constituent elements of the insured services physicians provide and so cannot be charged for.
What if a patient refuses to wear a mask?
If you encounter a situation where a patient declines to wear a mask, sensitively explain the expectation that they wear a mask and the importance of protecting public health by following the recommendations of public health organizations. Depending on your patient’s needs, your ability to safely isolate them from other patients, and your ability to safely provide care, you may need to defer or reschedule their appointment or redirect them to a setting that can safely provide care. Be aware that some patients have health conditions that make it difficult or uncomfortable to wear a mask, so plan ahead to help accommodate their needs and find ways to help them access care safely (e.g., providing as much care virtually, scheduling appointments during specific times, etc.).
Should I be reminding my patients that I’m available to them in-person and/or virtually?
It’s essential that patients continue to seek out the care they need. Whether it’s an unexpected issue, a chronic condition that requires ongoing care, or providing general support during these times, it’s important for your patients to look after their health. An ongoing relationship with your patients means you know them well and can help them remain healthy and avoid negative outcomes that come from delaying care.
Consider letting your patients know you are available through your outgoing office voicemail, on your website, or through email.
If I order a COVID-19 test for a patient, am I required to follow-up with patients on all test results, or can I rely on patients to access their results through Ontario Health’s online portal or other similar self-directed mechanisms?
Given the significance of a positive result and the imperative that patients isolate themselves, positive results must be communicated directly and promptly to all patients (in practice, this may often be done by public health). For positive results, it is not appropriate to rely on patients accessing their results via the online portal or any other mechanism that requires patients to confirm their test result on their own accord.
However, given the widespread and extensive testing that is underway, a “no news is good news” approach can be relied upon for negative results provided that:
- Patients are informed that they will only be contacted regarding a positive result;
- Patients are informed about how to access their results on their own accord, typically through the online portal; and
- It is confirmed that the patient is reasonably able to access their results on their own accord.
With respect to being able to access the online portal, this means the patient has a valid (green) Ontario health card, has internet access, and is able to understand and navigate a website in English. Other mechanisms for patients to access their results may vary across the province or by assessment center, and so what is needed to access these mechanisms will be specific to the circumstances.
For patients not reasonably able to access their results on their own, negative test results will need to be communicated to them directly.
What do I do if a patient has an expired health card or a red and white health card?
Due to COVID-19, the Ministry of Health has extended recently expired health cards (on or after March 1, 2020) and red and white health cards so that they remain valid. You should still be accepting these health cards from Ontario residents at this time. If a patient does not have a valid Ontario health card, you should not turn them away. You can use the billing codes identified by the Ministry of Health for those without OHIP or another provincial health plan.
Supporting the System Response
I have capacity to help, but don’t know where or how to get involved – is someone coordinating a system response?
Yes. Both the Ministry of Health and the Ontario Medical Association are working to get providers where they are needed the most. The Ministry of Health has launched a website to collect information from health-care providers with capacity and institutions needing additional staffing and the Ontario Medical Association is using an app called BookJane (available for Apple or Android devices) where physicians can register with their OMA access code and create a profile to support redeployment within the system.
I have capacity to help, but doing so would mean practising outside my scope of practice – what do I need to know?
The College’s Public Health Emergencies policy enables physicians to practice outside their scopes of practice during a public health emergency where urgent medical care is needed, another physician is not available to provide the care, and patients are not put at greater risk. For example, a paediatrician might help cover a colleague by seeing adult patients, or a hospital might temporarily grant privileges to a family physician to provide emergency department support. Physicians must always be mindful of the limits of their training and experience and use their professional judgment and work with colleagues to help determine how they can safely support patients.
I am worried about my safety and I’m not currently able to see patients who require care. What should I do?
Provided that the right safety precautions are put in place, most physicians will be able to provide care in-person when it is needed. Additionally, given the broad roll-out of virtual care in the province, most physicians will be able to use virtual tools to help provide care when doing so in-person is not possible for them.
Every physician’s situation is unique and if you or your family are in a high-risk population you will have to consider the best way to manage your practice given your unique situation, the advice of public health officials, and the best evidence available at the time. In extenuating circumstances where you are unable to provide care to your patients there are steps you can take to support them in accessing the care they need:
- Use virtual care to provide what you can or help triage and re-direct patients as needed;
- Coordinate with colleagues to help provide coverage for in-person care;
- Engage with local pharmacists who may be able to assist with some types of care, like extending or renewing a prescription;
- As much as possible, avoid simply directing patients to the emergency department when these resources aren’t required, and instead do your best to help patients navigate the system to find the resources best suited for their care needs.
I’m self-isolating — what are my responsibilities?
If you are self-isolating due to, for example, unprotected exposure, a positive screening result, or returning from out-of-country it’s essential that you self-isolate. Follow the guidance above to help your patients as best you can while you complete your self-isolation.
I don’t have the necessary personal protective equipment (PPE) to provide care safely — what do I do?
At this point in the pandemic, there should not be concerns regarding a shortage of PPE. It is essential that you obtain and use appropriate PPE in line with public health advice.
In the rare instance that you cannot access the PPE necessary to safely provide care, it will be important to protect your health and the health of your patients. You’ll need to exercise your judgment in each instance, considering:
- The need to support not just the patient before you, but future patients;
- The potential for harm, both to yourself and the patients you care for; and
- Whether the patient is known to have COVID-19 or not, and the likelihood of exposure should you provide care.
In instances where potentially life-saving or life-sustaining treatment is needed, additional precautions are needed as this will typically involve performing high-risk aerosol-generating procedures. In these instances, consider:
- Whether the patient’s COVID-19 status is known, suspected, or unknown;
- The risk of exposure based on the specific procedures you would perform and the specific PPE that is currently not available to you; and
- The risk of harm to the patient of not performing the procedures and the likelihood that the intervention would be successful.
The College recognizes how difficult these decisions will be for physicians who are not normally in a position where they have to consider their own protection when serving patients, but it is important for physicians to strike the right balance that considers not just the patient before them, but their commitment to future patients as well.
I’ve read about some drugs that might prove beneficial in treating COVID-19: Should I be prescribing these drugs as a precautionary measure? Can I prescribe them for myself or family?
No. Many of these drugs have an intended use and prescribing them as a precautionary measure has or may contribute to drug shortages, compromising care for others. Should these or other drugs prove useful in combating COVID-19, their use will need to be carefully managed to support those who need them the most.
At a time where resources may be scarce, actions like those mentioned above dramatically depart from the core values of medical professionalism, undermine the public trust in the profession at a time where the public is most vulnerable, and may contravene the College’s Physician Treatment of Self, Family Members, or Others Close to Them policy.
How can I support patients who are isolating access medication?
Do not send patients who should be isolating to the pharmacy to access medication. Instead, tell patients to stay home, send the prescription to the patient’s pharmacy of choice, and explain the situation to the pharmacist. Physicians are permitted to share information about the patient’s COVID-19 status with the pharmacist as they are a member of the circle of care, and the information being shared is directly pertinent to the provision of care. The pharmacist and patient can then coordinate for the delivery or pick-up of the medication by someone other than themselves.
I prescribe opioids for chronic pain/provide addictions treatment — how do I support appropriate access to care for patients who would normally be seen in-person?
The pandemic has created unique challenges for physicians working in these contexts. It is essential that all decisions be made in the best interests of the patient, and the pandemic requires a unique balancing of the risks inherent in opioid prescribing with those presented by the pandemic for each patient encounter.
The system has quickly adapted to help you navigate these difficult decisions:
- Virtual care may be a great tool to assist you in terms of counselling, assessing, or generally treating patients.
- Health Canada has made temporary changes to the Controlled Drugs and Substances Act that enable pharmacists to extend or transfer prescriptions, prescribers to issue verbal orders, and pharmacy employees to deliver controlled substances (see the Ontario College of Pharmacists and Health Canada for more information).
- The Centre for Addiction and Mental Health (CAMH) has also developed guidelines to help with the management of opioid agonist therapy in a time where prescribers may need to depart from normal practices to help protect all patients.
Professionalism and Complaints
What is the standard of care during a pandemic? How will the College respond to complaints that arise during this time?
The standard of care is always evaluated in context and the realities of providing care during a pandemic have the potential to alter how we understand the standard of care and that understanding will evolve with the nature of the pandemic.
Working within an evolving environment such as this can be challenging. It will be important for physicians to be mindful of and practice in accordance with any direction from the Chief Medical Officer of Health and hospital policies or procedures that are developed to address managing the pandemic.
While complaints may result during and as a consequence of the pandemic, we can reassure physicians that the College will address these complaints with consideration of the circumstances.
What should I be thinking about as I engage on social media about issues relating to the pandemic?
Physicians are reminded to be aware of how their actions on social media or other forms of communication could be viewed by others, especially during a pandemic. Your comments or actions can lead to patient/public harm if you are providing an opinion that does not align with information coming from public health or government. It is essential that the public receive a clear and consistent message. The College’s statement on Social Media – Appropriate Use by Physicians outlines general recommendations for physicians including acting in a manner that upholds their reputation, the reputation of the profession, and maintains public trust.
Registration and Licensure
*What does the recently approved MCCQE Part 2 Pandemic Exemption mean for residents?
In March 2021 CPSO Council approved a new registration policy permitting the Registration Committee to issue a certificate of registration authorizing independent practice to applicants who have not completed the MCCQE2 where:
- The applicant was eligible to challenge the exam at the May 2020, October 2020, and/or February 2021 sittings;
- The applicant is presently registered in Ontario or was registered at the time of the above sittings;
- The applicant was within 24 months from completion of their postgraduate training at the time they were eligible to challenge the exam at the above sitting; and
- The applicant otherwise meets the prescribed requirements for independent practice including the non-exemptible standards set out in the regulation.
All applications will require review and approval by the Registration Committee and interested applicants will need to use CPSO’s online application portal.
CPSO may also extend the policy to apply to future scheduled sittings of the MCCQE2 as may be required during the pandemic.
More information and examples to help residents understand whether they are eligible for this exemption can be found by reviewing the policy or companion frequently asked questions. Any questions can be directed to [email protected].
I’m a recently retired physician/out of province physician/International Medical Graduate – what are my options to support the system response?
As demands on our health-care system grow, the CPSO is doing everything we can to support those who want to get involved and contribute to the system’s response to the pandemic. The options available to you will depend on your circumstances. Through our Short Duration certificate and expedited processes, we have streamlined the process to ensure physicians who meet the necessary criteria can gain licensure as quickly as possible. We know that many physicians are eager to be involved and support the vaccination roll-out. This may include retired physicians, who may be well positioned to provide any needed assistance as a result of their experience providing direct care to patients. In order to identify an opportunity to provide care, candidates should visit the Government of Ontario’s Workforce Matching Portal.
Retired Physicians: If you’ve maintained your license, there’s no need to re-apply but be sure to check with CMPA about your coverage. If you have been out of clinical practice for more than 3 years, contact us to confirm your plan to re-enter practice in order to support the pandemic response. Physicians who’ve not maintained their license will need to re-apply for licensure.
Out-of-province physicians: You can provide care virtually in line with our Telemedicine policy or, provided a state of emergency is still in effect, you can apply for a Short Duration certificate for 30 days with confirmation of employment from an approved facility, usually a hospital, and an identified supervisor.
International Medical Graduates: Provided that a state of emergency is still in effect and certain conditions are met, you may be eligible for a Short Duration certificate for 30 days. If you have not yet completed your residency, you must: have completed a medical degree of an accredited medical school; have practiced medicine full-time within the previous two years (including medical school); and have confirmation of employment from an approved facility, usually a hospital, and have an identified supervisor. Please note that we are only accepting applications for Short Duration certificates from those with confirmation of employment from public hospitals or other approved categories of facilities as set out in the Medicine Act and with an identified supervisor. While the term of these certificates is only 30 days, they can be renewed. Please also note that future application for any other type of certification or registration will be considered in the usual course and independent of whether any Short Duration certificates were granted. Eligible applicants for the Short Duration certificates may not have the qualifications needed for any other type of certification.
If you have any questions please contact us at [email protected]