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ORIGINAL ARTICLE

Resilience among family physicians during the COVID-19 pandemic in Canada

Anne Snowdon, PhD1 ; Cindy Ly, MA1 ; and Alexandra Wright, PhD1

Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/08404704241302717 journals.sagepub.com/home/hmf

Abstract The purpose of this study was to investigate how the COVID-19 pandemic’s inaugural wave impacted the professional autonomy of family physicians in Canada. This study highlights how family physician’s resilience enabled them to overcome the many challenges they faced to provide health services to patients and has enabled them to rebuild their sense of purpose and duty of care. Four themes were found to summarize physician experiences: (1) loss of clinical autonomy and control; (2) abandonment and neglect by the health system; (3) a fear of patients “falling through the cracks” and moral injury; and (4) building resilience to support duty of care in family practice. These results highlight the emergence of resilience among family physicians to restore professional autonomy in family practice, overcoming moral injury in order to fulﬁl their “duty of care” to their patients. Physicians believe the health system’s crisis preparedness efforts need to be dedicated to protecting the autonomy of practicing physicians to maintain the continuity of quality patient care in future health crises.

Introduction The COVID-19 pandemic’s onset in January 2020 was accompanied by deep uncertainty within the healthcare system, coupled with rapid spread of infection among the population and the health workforce. The Canadian Institute for Health Information reported the country exceeded 1.4 M COVID-19 cases, with approximately 7% of them being among healthcare workers.1 The Canadian workforce was not just affected by the rate of infection, but the pandemic profoundly affected psychosocial and emotional outcomes for the health workforce.2-4 Now over 4 years since the onset of the global pandemic, there are significant workforce shortages across health systems with a projected global shortage of 18 million health workers by 2030.5 There is emerging evidence of the short and long-term impacts of the pandemic on the health workforce, who have been at the frontlines relentlessly delivering care since the virus first emerged.6,7 One sector within the health workforce that provided a critical access to care for the majority of Canadians were family physicians. Family physicians are part of the medical sector who provide primary care to a broad range of patients of all ages, sex, ethnic cultures, and conditions.8 They are known as the “generalist” in medicine and are typically the first point of contact for patients receiving care, making them one of the primary points of access to the healthcare system.9 During the pandemic, family physicians were reported to have experienced countless challenges in providing care to patients.10-13 In an effort to mitigate the spread of the virus, physical distancing regulations were enforced across the country, decreasing patient volumes by approximately 30% and impacting financial reimbursements associated with feefor-service models.14,15 The most notable challenge reported by

the physician workforce was the reduced ﬁnancial resources needed to adequately deliver patient care.16-18 Available panCanadian data reported family practices experienced ﬁnancial losses up to 78% reduction in billing which challenged the viability of physician practices.19,20 Family physicians rely on a fee-for-service compensation model, with approximately 66% of family physicians receiving 50%–90% of their clinical payments through this model, resulting in income being highly dependent upon patient volumes.21,22 The purpose of this paper is to examine the impact the COVID-19 pandemic had on physicians in family practice, to inform health leaders on how they could build a resilient workforce that is sustainable with the capacity to meet the health needs of Canadians during health crises.

Methods During the early waves of the pandemic, the College of Family Physicians of Canada (CFPC) undertook a national research study to capture the immediate impact of COVID-19 on the professional autonomy of their family practice physician members. The College of Family Physicians of Canada’s COVID-19 On-line Survey was developed to elicit the perspectives of family physicians during the ﬁrst wave of the COVID-19 pandemic to better understand the impact of the pandemic on this workforce. Data collection was collected under a COVID-19 Rapid Research Funding Opportunity 1

University of Windsor, Windsor, Ontario, Canada.

Corresponding author: Anne Snowdon, PhD, University of Windsor, Windsor, Ontario, Canada. E-mail: anne.snowdon@uwindsor.ca

Healthcare Management Forum

grant and received ethics clearance from the University of Windsor. The survey was circulated by the CFPC to its 33,243 members between April 28, 2020, and May 13, 2020. Responses from 4,308 family physicians were obtained (a response rate of 13%), with most of the participants practicing in Ontario, British Columbia, Alberta, or Québec. The survey was a mixed-methods survey comprised of closed-ended and open-ended questions. Three open-ended questions were included in the survey and were the focus of the analysis in this study: (1) Overall, how is COVID-19 affecting your practice and how are you responding? (2) What does your practice need most urgently to deal with COVID-19 in the coming weeks? (3) What do you think family physicians should do to prepare for the post-pandemic future? The quantitative results for the survey were previously reported by the CFPC.23 A reﬂexive thematic analysis was used to analyze the survey responses to the 3 questions in the survey to identify patterns that had a shared meaning within the dataset.24 Patterns in physician responses that consistently emerged throughout the dataset were identiﬁed as themes and formed into an overarching narrative that succinctly captured how the pandemic’s inaugural wave impacted family practitioners.

Results Four themes emerged that illustrated the experiences of family physicians during the pandemic: (1) loss of clinical autonomy and control, (2) abandonment and neglect by the health system; (3) a fear of patients “falling through the cracks” and moral injury; and (4) building resilience and refusing to abandon duty of care.

Theme 1: Loss of clinical autonomy and control During the ﬁrst wave of the COVID-19 pandemic, public health protocols focused on reducing the spread of COVID-19 (e.g., physical distancing and wearing personal protective equipment [PPE]) which required family physicians to abandon their care delivery practices and establish new workﬂows to meet public health directives. Family physicians were limited to virtual care with few options to assess patients in person, described by one physician: “Virtual care is not the same as in-person, proper clinical care and assessment. There is no substitute for a good physical examination. This will degrade medicine.”

Reduced patient volumes resulted in profound limitations in financial reimbursement to sustain their practices and deliver quality care, particularly for physicians who operated on the feefor-service compensation model: “My bookings are significantly decreased, and I cannot participate in in-patient care currently…... I am losing money without being able to bill procedures (PAP smears, IUD, excisions, etc.) or bill for complete physicals for older patients. … I am worried for myself financially and do not know how I will sustain this for any length of

time in the current fee-for-service system. I was already struggling with the increasing costs of overhead [fees] and low remunerations in my province ...”

Professional constraints linked to public health directives and resulting ﬁnancial constraints eroded physicians’ sense of control over their ability to provide quality care and sustain their practice, forcing some to consider closing their practices altogether. The loss of autonomy highlights the deep connection between a physician’s professional identity and their ability to deliver care, and the loss of control over their practice which placed limitations on their professional obligations to their patients.

Theme 2: Abandonment and neglect by the health system Constant changes and lack of clarity in pandemic protocols had a signiﬁcant impact on care delivery which contributed further to challenges experienced by physicians in primary care settings: “[We need] guidelines on how to see patients, whom to see, and exactly what PPE we should all be wearing. I am most frustrated with the PPE guidelines not being concise and across the board or with community spread.”

In many jurisdictions, provincial health system did not support primary care delivery as mass shortages of health supplies were being reported around the globe. “The community [of] family physicians seem to have been forgotten in all the talk of maintaining supply chains of PPE. No one has contacted us about supplying us with masks, gowns, gloves, [and] hand sanitizer that we are having [a] hard time getting through usual suppliers and [the] costs have gone up” “We were actually told to work without the PPE. This caused low morale and feelings of abandonment by our own government and Public Health. The work intensity and factors of danger [has] multiplied, leading to tiredness and some ill health. ... We seem to be disposable.”

As the pandemic progressed, family physicians felt unsupported and betrayed by the health system, feeling like they were left to “fend for themselves”: “I am the only physician in my ofﬁce. I am a GP [general practitioner] and expected to continue to provide the same level of care, availability and responsibility to my patient[s], staff, and practice. I am expected to provide all my own supplies and PPE despite shortages, increased costs, and reduced income. I am expected to provide virtual care to patients who do not know how to use technology and when the internet connections and systems, at large, do not adequately support the demand and technology. I have also become my receptionist when I need to contact the next patient, the IT support for my older patients to get on or reconnect to OTN [Ontario Telemedicine Network] … I am bombarded daily with updates and changes to regulations and screening and closures. I am expected to keep up to date with the research and treatment of COVID-19. … this level [of work] cannot continue without something giving or

Snowdon, Ly and Wright falling apart. Physicians will burn out ... This is not sustainable.”

Feelings of frustration, abandonment, and neglect were a consistent theme among physicians who felt ill-equipped with the necessary guidance and resources to maintain quality care, which further eroded their sense of autonomy to deliver patient care.

Theme 3: A fear of patients “falling through the cracks” and moral injury The transition to virtual care delivery made family physicians feel concerned towards their patients “falling through the cracks” as physicians struggled with adequate assessment of patients remotely with very limited access to laboratory or imaging tests: “My main concern is having to assess most patients through virtual care. I have to try to get as much information that I can, subjectively and objectively, through [the] phone or video and [I] do not have access to all the laboratory or imaging testing [that] I would have otherwise requested in the past.”

Additionally, patients reported refusing to attend in-person appointments (when they were available) in fear of contracting COVID-19, or assumed their ofﬁces were closed because of pandemic restrictions, while others refused to attend virtual appointments because they preferred in-person care or lacked the skills to operate the technology required for virtual appointments: “I am very concerned that many patients are holding back and not calling for appointments because of the pandemic, and I am also concerned because I cannot get regular testing done and people with chronic illnesses may be running into further problems as time goes along.”

Unique patient cohorts were of particular concern to family physicians. The data showed that seniors, patients with chronic conditions, and homeless patients were particularly vulnerable to the required changes in practice: “My patients are all complex elders who require home visiting, as they would not be able to get to a family doctor’s ofﬁce and/or get to an ofﬁce frequently enough to have effective and appropriate medical management. Setting eyes on my patients is a very important part of [the] assessment. Most have cognitive and physical impairment[s] and lack [the] ability for [a] genuine selfassessment.” “Most of my patients are high risk/homeless [patients] with no working phones. [I am] unable to reach them. [I am] doing a bit of work when they are able to contact me through [my] secretary.”

Family physicians felt the healthcare system was ill-prepared for mental healthcare which further increased their fear of more patients “falling through the cracks”: “Mental health delivery to vulnerable population is a major challenge. Not all our patients have internet or phone-reliable service. We cannot reach some very vulnerable patients. I have

3 driven out to call on some [patients] at their residence and did a chat while physically distancing. Mental health support is desperately needed.”

Physicians’ fears of patients falling through the cracks underscores the emotional burden and moral injury experienced by healthcare providers. During COVID-19, family physicians faced situations in which they are unable to provide the standard of care they deem necessary due to external constraints, adding to greater feelings of moral distress and contributing to the emotional toll physicians faced in the pandemic.

Theme 4: Building resilience and “making do” in the primary care system; refusing to abandon duty of care As the pandemic progressed, family physicians adapted to and integrated the pandemic protocols into their workflows in order to deliver care safely to their patients. For example, to manage the shortage of PPE, some physicians reported creating and washing their own PPE, while others reported carrying more administrative tasks to keep their offices operating. Yet, despite these challenges, physicians found a sense of optimism and resilience: “No PPE, [so I am] wearing a wood-working-shop face shield, sort of like a welding helmet! [A] N99 respirator that I usually use to clean the chicken coop [and] old scrubs that I launder at home. Making do. Pretty safe.” “I am a solo family doctor, and my sole assistant decided she did not want to be in the office during the pandemic. That left me doing it all by myself. Some days I spend 8 hours straight on the phone answering the incoming calls. I’ve had little time to call some of my patients just to check on them. But today, I left two hours early and went for a lovely walk with my dog on the waterfront. Life is good again and tomorrow will be better!”

Over time, physicians worked to regain their sense of purpose in care delivery, which helped them reconcile with the moral distress they experienced and empowered them to overcome the challenges created or exacerbated by the pandemic: “I feel conﬁdent that my ofﬁce-setting is safe for the essential patients I am seeing and that they, and myself, are not at [an] increased risk of contracting COVID-19. Myself, and my colleagues, have implemented protocols that are keeping ourselves, our staff, and our patients safe. It is more work and requires diligence and keeping up with the data as it changes. [However,] it is important work and I feel purposeful.”

Practicing family physicians overcame the many challenges and a sense of resilience emerged as physicians continued providing care for their patients while refusing to abandon their “duty of care,” described in the following: “[It is] physically, emotionally, and ﬁnancially draining. But [for] my obligation to the [Hippocratic] Oath, personal patient connection, and for the general well-being of society – I’m putting my head down, grabbing my lunch bucket, and heading to work.”

Discussion These results profile the impact of the pandemic restrictions on physician autonomy to deliver primary care to their patients and emergence of resilience that enabled them to continue advancing their sense of purpose and duty of care. In the early stages of the pandemic, family physicians faced a loss of clinical autonomy as guidelines imposed new workflows, restricting their professional judgement in care delivery. As the pandemic continued, many felt abandoned by the healthcare system, lacking the necessary resources and support to maintain care, which further eroded their sense of agency.25 Family physicians reported experiencing moral injury, as patients were at risk of “falling through the cracks.”26 The findings of this study highlighted the negative impact of pandemic restrictions on physicians’ professional autonomy to practice. However, in order to practice autonomously, clinicians require work environments equipped with necessary resources, such as medical supplies and personnel.27-29 Without them, clinicians may feel limited in their ability to provide optimal care, leading to burnout and decreased well-being.30-33 As the pandemic progressed, family physicians experienced erosion of their professional autonomy, feeling constrained in their ability to deliver appropriate care due to resource limitations.34 Prolonged loss of professional autonomy has been associated with “moral injury,” where clinicians experience ongoing moral distress due to their inability to deliver optimal patient care amid resource shortages and workplace challenges.35-38 This compels clinicians to compromise their moral values, and their “duty of care” to prioritize.36 A scoping review by Riedel et al.39 identified loss of autonomy as a predictor of moral injury, while Ngo et al.40 found that family physicians in residency faced moral injury due to limited autonomy in providing quality care. Additionally, Rushton et al.41 reported a 32.4% prevalence of moral injury among healthcare workers in the United States (US), indicating widespread issues across multiple health sectors during the pandemic.42-44 Despite the many challenges and loss of autonomy, these results also describe the resilience among family physicians who adapted to the many pandemic directives to ensure patient care was restored to ensure patients did not fall through the cracks. Family physicians demonstrated resilience by adapting to new protocols and “making do” with limited resources, such as creating makeshift PPE and taking on multiple administrative roles and duties to make it possible to deliver care to patients. These findings suggest evidence of resilience that allowed family physicians to regain a sense of control and restored their “duty of care” to patients. This resilience enabled physicians to reconcile with the moral distress caused by pandemic challenges, fostering a sense of purpose and confidence in their ability to overcome a challenging situation.

Healthcare Management Forum inform preparedness frameworks and encourage health leaders to strengthen resilience in healthcare systems, as health leaders have the moral duty to build healthy work environments and care for the well-being of the health workforce.45-47 The disorganized communication regarding guidelines for care delivery could be overcome by establishing clear channels of communication for health providers as a key strategy to strengthen preparedness. Establishing clear guidelines and resources for virtual care could strengthen resilience and support physicians to offer patients the choice of virtual care where it is most effective in order to further strengthen agency and autonomy in care delivery.48 A robust and very transparent communication strategy to ensure physicians have the knowledge and guidelines to support clinical best practices could be developed and informed by these results as a preparedness strategy for future health crises.49,50 Communication could be strengthened by building centralized bidirectional communication channels between health leaders and the workforce to transparently share consistent crisis information with regular updates.51,52 Crisis preparedness must also address equitable distribution of PPE which emerged as a crucial factor in protecting family physician safety, given the availability of PPE was vital for maintaining patient care delivery.53-59 This study further highlights the role of supply disruptions and its impact on the capacity to deliver patient care. The lack of PPE during the pandemic resulted in moral injury among physicians due to the many limitations in care delivery options and the increased risk of patients “falling through the cracks.”26,60-62 These ﬁndings highlight the need for health leaders to advance health supply chain resilience as a priority for pandemic preparedness to sustain primary care capacity, protect the autonomy and well-being of family physicians, and ensure every Canadian has access to quality patient care during future health crises.63 Strategies to build a resilient healthcare supply chain while protecting clinician autonomy could include engaging family physicians in healthcare supply chain decisions to ensure workforce safety and supplies meet care delivery demands.64 It is important to note, that the long-term effects of COVID-19 on patients is still unknown and therefore, there continues to be implications on the healthcare system. These health system reforms must be motivated by the moral imperative of a “duty of care” to the health workforce, and this reform must go beyond practicing family physicians because all healthcare workers should have the autonomy and support to deliver the best patient care.65 These reforms could become the fundamental building blocks to redressing the projected health workforce shortage in the post-pandemic future, for the healthcare system is dependent upon the health workforce, much as the primary care system is dependent on family physicians, to deliver patient care.5,66

Future directions

Conclusion

These results inform a number of opportunities for health leaders to advance and strengthen resilience in primary care settings. Resilience strategies evident among family physicians may

Family physicians, as primary care providers from “cradle to grave”, are a critical access point in the healthcare system.9,67 At the onset of the COVID-19 pandemic, they faced signiﬁcant

Snowdon, Ly and Wright challenges in meeting patient needs due to public health restrictions, scarce resources like PPE, and diminished autonomy, which contributed to a sense of moral injury. Despite these obstacles, family physicians adapted quickly, demonstrating resilience and leadership to maintain quality care and uphold their commitment to the “duty of care” for their patients. Declaration of conﬂicting interests The author(s) declared no potential conﬂicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no ﬁnancial support for the research, authorship, and/or publication of this article.

Ethical approval Institutional review board approval was received from the Research Ethics Board at the University of Windsor (REB# 20-137).

ORCID iDs Anne Snowdon  https://orcid.org/0000-0003-4640-6842 Cindy Ly  https://orcid.org/0000-0002-7572-6119

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