Eleven RFPs were recruited via email across Canada (east, central, west). The participants consisted of five males and six females ranging in age from 35 to 65 years old with 5 to 35 years of experience in rural practice. The study uncovers five categories: 1- Virtual care as a backslide or forward progress; 2- Increasing accessibility or damaging care 3- Shortage of health care providers and supporting staff; 4-Ongoing coping with the pandemic guidelines; 5-Covid combat fatigue.
1- Virtual care as a backslide or forward progress
Given that rural/remote areas have always suffered from the unavailability of healthcare services, virtual care is considered a miracle. Despite the promises and advantages of virtual health care, the downsides are equally outstanding. Besides making clinical decisions and detecting diagnoses over the phone, physicians are constantly struggling with their patients' health literacy. Vague symptoms such as dizziness or skin rashes and the lack of visual cues (e.g., body language and facial expressions) amplify this difficulty. Some patients cannot describe their symptoms or pronounce their medications over the phone.
"They are trying to tell me like what medications they are taking, and they cannot pronounce the names of the medications."
Although virtual care employs different communication services (e.g., virtual care video calls, phone calls, and chatting), phone calls are the most available and accessible. However, this can be ineffective for communities challenged with inadequate technological devices and literacy, unreliable Internet and cell-service connectivity, and limited calling plans. Due to poor connectivity or calling plans, physicians have been frustrated by frequently disrupted phone call appointments.
"I think the other thing is that many people added their Internet or phone connection. Their cell service is just not good where they live. So, we are asking them to do that, but then at the same time, they do not have the resources, or some financially do not have- like, they run out of minutes on their phone or things like that."
2- Increasing accessibility or damaging care
Rural and remote communities have been struggling with various difficulties associated with accessing healthcare. These difficulties include limited access to public transportation; the time and cost of travelling long geographical distances; out-of-pocket expenses; time away from work; and mobility impairments. One of the most predominant advantages of virtual healthcare during the pandemic has been the ability to provide rural residents with accessible and convenient healthcare services.
"I think, for many in the rural area…, it is nice to save a whole ton of time travelling and some of them work in a different community than my office might be in, which has been a good thing. I think for me too… because sometimes virtual care is faster… So, instead of having a 3-4 week wait time to come in, I can see people within a few days usually when they want an appointment"
However, physicians have expressed concerns regarding the consequences of cancelling lab tests such as pap smears and mammograms as a part of the regular and routine screening procedures that occur every 6 to 12 months. Also, patients with critical medical conditions (e.g., cancer) have dramatically suffered from decreased hospitalization opportunities, delays, and rescheduling of surgical appointments. Additionally, cancelling in-person visits, a lack of information about virtual care, the fear of being infected in emergency departments, and the lack of guidance on the importance of receiving medical care have been expressed to have irreversible consequences for patients with chronic diseases.
"At the beginning of the pandemic, there was a perception among patients that it was not safe for them to go to the emergency department… that their family doctors were not seeing patients or did not know where to go. So, they ended up getting much sicker- people with chronic diseases get much sicker before they went to the hospital and a lot more people were admitted to the hospital; it would not have been… I mean- I think if there had been better communication to people with chronic diseases about the importance of getting stuff checked out… that it was better to get it checked out rather than waiting until you were so… so- so sick."
Furthermore, due to cancelling in-person visits, patients who intended to have face-to-face visits were suggested to go to the emergency department. However, RFPs in emergency departments did not possess access to the patients' medical history. Due to the lack of access, patients were not subject to timely care. Therefore, family physicians operating in emergency rooms (ERs) follow up with patients to avoid any consequences of delayed follow-ups. However, this is not part of the clinical goals and objectives of ERs.
"FP [Family physician] not seeing patients in person - telling them to 'go to the ER' if they wanted the face-to-face care. we do not even know them, their medical history, previous investigations, etc., because ER departments do not have access to their FP charts, etc. No one to follow up with investigations or a follow-up appointment due to reduced accessibility or just no family doctor… delayed follow-up and ER physician access to FP via phone/internet, etc. Not knowing whether the patient will get follow-up at all… Then, who is responsible for the test results, ensuring that the patient is seen expediently, etc.? Places big stress on ER doctors who fear these patients will fall through the cracks. The choice then is only to bring them back to the ER ( overloading it) for follow-up - which is not the purpose of the ER department but seemed the only assurance for follow-up/timely care."
3-Shortage of health care providers and supporting staff
A shortage of physicians and administrative/support staff during the pandemic established many complaints about the workload of RFPs. The shortage of physicians in rural communities only intensified due to the pandemic. COVID-19 restrictions and guidelines (e.g., travel restrictions and quarantine guidelines) dramatically decreased the number of locum physicians. Also, early retirement and resignations due to heavy workloads, excessive stress, and burnout were among the most common reasons for staff shortages. Additionally, many physicians with particular health issues (e.g., autoimmune conditions) have been on leave during the pandemic.
"Well, we have got a very fragile system here. So, we do not have enough physicians to start with… very fragile and it has worsened. People, I think, have just become burned out. So, we have had a few in the last month… we have had – somebody is leaving; somebody is retiring; somebody else just retired. So, we lost three physicians in a month. So, that is a huge challenge…"
"Many of the groups that work here are between 4 and 7 physicians in smaller rural environments. You lose one physician out of a group that size and it is tough to absorb that."
As a result of instituted restrictions, many patients receiving long-term care in hospitals did not have a caregiver and community and familial support systems. The lack of support enhanced the burden on nurses and physicians. Furthermore, devoting increased attention to patients who require long-term care (e.g., dementia) restricts focusing care on acutely ill patients who require constant monitoring.
"I think for me, in the practice that I was doing because, as I say- a number of the people in our hospital are waiting for long-term care. Number one: visitors being unable to come into the hospital… for patients with dementia, to lose that contact with families was devastating. Two: for the nursing staff to lose those caregivers as support was devastating… and because of the loss of those family members and caregivers. Being able to be with those in the hospital meant that nursing staff time was taken away from acute care patients. There were times when I had a patient who was acutely ill [who] needed more close monitoring and [I] was scrambling to try and get the nursing staff to be able to do the things that I needed. However, they were trying to trace down a patient with dementia who… was trying to leave the hospital or something."
Due to the shortage of physicians and administrative staff, RFPs working in clinics are overwhelmed by various clinical and administrative responsibilities (e.g., requesting and completing medical records, sending consult notes, setting up consultant appointments, patient contacts, charting, and answering phones). They not only have to shoulder the burden of excessive responsibilities but also must handle the significant pressure and stress of not infecting their family members.
"I went into the clinic and there was hardly any support stuff… it kind of like- it all cleared out… like there was nobody there… It was just like the streets were empty. So, my clinic was empty of support staff, so I needed to answer phones and fax papers- You know, send consult notes or set up appointments with consultants; that kind of stuff and it was a little- It was thin on the ground and that surprised me and I was in essence, working by myself. They did not even turn the lights on. The hallways were dark! It was really- it was very lonely actually. I often worked there by myself till 7:00 P.M. because of some of the things the support staff would do. I had to find an alternative pathway to writing letters; making sure that the messages I was sending were followed-up; those kinds of things because I was uncertain about having support..."
4-Ongoing coping process with the pandemic guidelines
Frequently changing healthcare policies and regulations occurred during the early stages of the pandemic. According to the interlocutors, these changes confused physicians and patients who had to adjust frequently.
"So, most people were screened pretty well, but early on, I mean most people did not know what was happening. There was a lot of confusion about who needed to be tested [and] who did not need to be tested… in a small community- in a small hospital communication, confusion about policies early on was challenging"
The circumstance was complicated due to most COVID policies and regulations catering to urban areas. Thus, rural healthcare clinics adjusted the policies or developed more contextualized alternatives.
"The protected code blue guideline policy- whatever it is called. It was built or developed for urban centers because I think the minimum number of people it called for was something like 5- where… overnight, there are two staff members in the building and then if they need to call the doctor, the doctor comes in. So, for policy, by default, that minimum required 5 humans when we only have a max of three. It made us very sad on one side that they have not thought about the rural aspect."
This situation becomes more complex with physicians and patients who have not adopted pandemic guidelines regarding personal health safety (e.g., wearing masks or getting vaccinated). Physicians have difficulties with patients who are skeptical of news about the pandemic and refuse to get vaccinated regardless of their advice. A participant shared a story of a patient who refused to get vaccinated. After a couple of days, the COVID infection hospitalized the patient and her husband, leaving their highly stressed children home alone. The patient survived but still faces challenges in adjusting to life post-treatment. The daily process of advising and convincing patients to follow health safety guidelines and protocols is challenging. Furthermore, most participants experienced conflict with at least one colleague who resisted adopting the safety guidelines. Usually, these conflicts are resolved after a couple of months.
"Although, I have to say some of the colleagues I was working with never really shift to virtual care; they saw all their patients face-to-face… continued to do that and I think- almost ignored guidelines because it was outside their sense of how to adjust. They were not that adaptable; they just did not adapt!"
5- Covid combat fatigue
Reorganizing the clinic, modifying the clinical approach, and performing patient screening upon arrival at the clinics have increased workloads and emphasized adverse effects on the well-being of physicians. Following COVID-19 protocols, such as constantly donning and doffing personal protective equipment (PPE), delayed clinical practices and medical examinations have resulted in increasing work fatigue. The adverse effects maximize, in addition to the broadened professional obligations discussed earlier.
"There is more workplace fatigue with having to work full days in PPE instead of only putting on PPE on a case by case basis and that is the key… from just having the mask and the gloves and goggles on all day. Being a bit more tired with being cautious and not touching your face and other stuff, but also fatigue… when trying to help a patient but knowing that you have delayed starting certain things because of the COVID protocols. For example, making sure that every person gets into full PPE before we start bagging a patient. Well, in a small rural community when you only have so many people, that takes much time. So, you are delaying starting that procedure on a patient by potentially 5-10 minutes until you have enough to be able to do it."
Participants frequently discussed their anxiety and stress due to the high risk of contracting the virus at their workplace and transmitting it to their friends and family members. They often described experiencing loneliness stemming from geographical isolation and not having regular support and contact with their colleagues. Resistance to vaccinating or following safety protocols (wearing masks) among patients and colleagues were sources of significant frustration and distress. As illustrated by a participant, physicians feel "defeated" and "helpless" every day since they increasingly witness terrible circumstances in intensive care units.
"I have never worked harder than in July and I have never been sadder at work. There is a family right now and it is interesting because they… do not believe in the vaccine; like it is a Unicorn or a leprechaun- like it needs your belief to exist and so, they do not believe in it. The wife came in; we had to put her on a ventilator. She had to be ventilated and shipped to the ICU [Intensive care unit] and you know, we brought in the hospital iPad… so her kids could wish her good luck, but you know- potentially saying goodbye to her kids on the iPad, because the kids could not be in the room. All the kids have got COVID. The husband now- he is still in ICU."
Physicians often discuss that the pandemic intensified burnout and work fatigue, which led to a loss of clinical empathy. The physical and emotional exhaustion of physicians not only harms patient care but also communication with their colleagues. One of the interlocutors expressed that their communications with colleagues have gone "downhill." Participants believe they are too burnt out and overwhelmed by their workload to provide empathetic care for patients or interact with colleagues effectively.
"We just work harder which is a short-term solution that eventually impacts patient care because we get tired and we get less empathetic, less compassionate and over time. I think our patient care deteriorates because we are just not there for the patients. It also deteriorates. After all, our communication with coworkers goes downhill because we are just tired and not as empathetic…"
Member Checking
Following our analysis, we conducted member checking with the participants, which resulted in receiving positive feedback from several participants who not only supported the extracted categories but also suggested some complementary information.
"In my opinion, this pandemic has been beyond challenging and has had innumerable negative consequences that will continue well into the future. You have identified them in your interviews. Some aspects of working in a rural area made those challenges and negative consequences even greater."