Dear Colleagues,

Our offices are increasingly busy and the upcoming viral illness season looms. With the DFCM at UofT, we had our biggest COVID Community of Practice session on August 21, discussing these practicalities, and we will re-visit this topic and more on Sept. 18. Watch for the registration link coming soon.

Today I want to address a few key things:

• Patient request for “off work” notes or workplace accommodations;
• Mask exemptions;
• Cancer Care Ontario screening restart;
• A toolkit from CEP for planning for fall and winter;
• Our submission to the OMA Negotiations Task Force; and
• A brief mentoring update.

A patient is asking for a work accommodation. What do I do? Details are below, and also available here.

Information from government sources is very general in terms of who’s high risk for severe illness from COVID, so we have tried to pull together advice from various specialty groups to help you. As a family doctor, you will use your clinical judgement and knowledge of your patient in the advice you give as it relates to any potential requirements for that individual to be exempt from being at work in person, or to work remotely.

**Please note** It is not up to you as a family doctor to determine the necessary accommodation. It is up to the employer based on the Human Rights Code to make the accommodation for their employee.

The recommendations that follow are unavoidably based on expert opinion and extrapolation from the morbidity and mortality data we have thus far from the COVID epidemic.

In general, writing doctor’s notes:

As referenced above, your role in these circumstances is to provide information in support of a third-party process (e.g., work accommodation form), not to determine the outcome of the process (CPSO). In short, accommodation is the responsibility of the employer.

There are conditions with high enough risk of severe COVID to warrant workplace accommodation, beyond routine precautions (mask wearing, physical distancing, hand washing).

Summary statements from various medical societies which have reviewed the evidence are noted below.

Pregnancy: Patients with complications of pregnancy such as diabetes, preeclampsia, anemia, advanced maternal age, and obesity require work from home (Society of Obstetricians and Gynaecologists of Canada). Of note: "Current data do not suggest an increased risk of severe disease from COVID-19 in healthy pregnant women compared to non-pregnant reproductive-aged women."

Asthma: “Patients with mild-moderate asthma should work from home if feasible. Patients with severe asthma should also work from home if feasible and, if not feasible, should remain off work for medical reasons until such time as the WHO or local public health authorities declare that physical distancing is no longer necessary” (Canadian Thoracic Society, “Physician Distancing for Asthma Patients” section). This will be an ongoing clinical issue to monitor.

COPD: "Patients should stay at home as much as possible, including working from home if feasible" (Canadian Thoracic Society).

Diabetes: There is no specific guidance on workplace accommodation from Diabetes Canada – but expert opinion suggests taking into consideration other risks such as age >40 and other co-morbidities as work accommodation is considered.

Cardiovascular disease: There is no specific guidance on workplace accommodation from Heart and Stroke, although that organization suggests people who have a heart condition or vascular disease, or who have had a stroke, should stay at home as much as possible to minimize risk of exposure.

Cancer: There is no specific guidance on workplace accommodation from the Canadian Cancer Society – but expert opinion suggests those in active treatment (chemo, radiation, immunotherapy, recovering from surgery) stay home as much as possible to minimize the risk of exposure, and practise physical distancing when needing to go out. This would likely preclude in-person work.

Inflammatory Bowel Disease: The guidance is to work from home or to school at home if new diagnosis, severe active inflammation, malnutrition, prednisone >20 mg per day (Crohn’s and Colitis Canada). See this letter for the workplace.

Patients on immunosuppressants: For all transplant recipients taking immunosuppressants, as well as patients on chronic prednisone >20 mg per day, it is likely best that they avoid a workplace setting. 

• BC Transplant has provided the following guidance: “As a transplant recipient who is immunocompromised, you may be at higher risk of significant complications from COVID-19. As per public health orders, employers are expected to have policies in place to support physical distancing and prevent the spread of this virus. We strongly recommend discussing with your employer options for teleworking, flexible hours, staggered start times and use of email/ teleconferencing or, where these options are not possible, potentially a leave from work.”
• Consider contacting your patient's transplant team about appropriate work accommodations for their particular situation.
• Note: DMARDS do NOT appear to be associated with increased risk of serious COVID-19 related disease (Crohn’s and Colitis Canada).

School boards requesting "clearance" notes

We understand that some school boards are asking for a doctor’s note to clear students who may have been off sick before they can return to school. These requests are not consistent with Ministry of Health guidance, which notes: “Medical notes or proof of negative tests should not be required for staff or students to return to school.”

We are working with the OMA on ways to promptly address these issues.

Mask exemptions

As noted in my last blast, there are very few conditions that justify an exemption from wearing a face mask for reasons of prevention. In Ontario, these are:

• Children under the age of 2;
• Anyone who has trouble breathing; and
• Anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

We have no new updates on the above – except to say that we are seeking clarification on the recommendation for those with breathing difficulties on the basis of the Canadian Thoracic Society recommendation: “There is no evidence that wearing a face mask will exacerbate (cause a 'flare up’ of) an underlying lung condition."

Patients with asthma and COPD or other conditions requesting a mask exemption should strongly be encouraged to avoid public settings if they cannot wear a mask. Some patients may feel anxious about wearing masks or may have PTSD about a mask due to personal experiences. Please consider the reason for mask anxiousness. For some, this video on overcoming mask anxiety might be helpful.

Screening

As of August 25, Ontario Health (Cancer Care Ontario) updated its guidance:

Primary care providers can resume sending FIT requisitions to LifeLabs for targeted cancer screening. Ontario Health (CCO) will communicate when routine colorectal cancer screening can resume. Primary care providers should gradually resume cervical and breast cancer screening, initially considering targeted cancer screening for those at the highest risk of cancer and based on local factors gradually expand to routine screening.

New resource from the CEP

The Centre for Effective Practice (CEP), in collaboration with various stakeholders, has developed content to support family physicians and other primary care providers in preparing for fall and winter.

Please complete this two-minute survey so that the COVID-19 Resource Centre can continue to develop resources and supports that meet your needs.

OCFP submission to the OMA Negotiations Task Force

An OCFP committee – with two Fee for Service, one community FHO/FHT and one academic family doctor – made this submission to the OMA Negotiations Task Force based on the questions posed to us.

This long document has appendices that refer to the evidence that underlies our recommendations. Among our key points:

• Ensure family physician access to funded team-based resourcesand payment supports to enable care for complex patients;
• Open access to blended capitation modelsfor all family physicians, and address inequities resulting from COVID-19 on FFS and FHG practice models;
• Sustain and optimize virtual carefor primary care, anchored by the FP as the MRP;
• Support clinical leadership and organizing primary care; and
• Develop a central referral processthat maintains choice for FPs and their patients.

OCFP mentoring update

We are pleased to welcome Dr. Javed Alloo and Dr. Melissa Holowaty to the leadership team of the OCFP’s mentoring program for mental health, addictions and chronic pain. If you would like to get involved in the design and delivery of the program, we are seeking a co-chair and three members for the Mentoring Implementation Group.

To be considered, submit your letter of interest and Declaration and Disclosure of Conflict of Interest to Susan Taylor at [email protected] by September 18, 2020. Please watch our website for more details as we begin to recruit mentors and prepare to launch the program in the fall of 2020!

New resource to support newcomers to Canada

Check out this terrific Newcomer Guide developed by the Mississauga Halton LHIN. So often, the lack of services isn’t the main issue. Indeed, often there ARE services available, and we need to identify them and share them so more people can benefit. Many of the resources in this document are applicable across regions, and hopefully this Guide inspires something similar in your region. Thanks to OCFP Board Director, Dr. Sundeep Banwatt, who thought of this great idea in his former role as a sub-region clinical lead.

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Enjoy the last days of summer, and know that the OCFP is doing its best to serve you – providing resources and education that inform your day-to-day decisions, advocating for policies that support the essential work you do, and being part of the primary care leadership that will make our healthcare system what it should be.

Be well, be safe, and keep running this marathon of ever-changing realities. We are in it with you.

Jennifer