The roles of family physicians during a pandemic

Family physicians and other primary care providers play important roles in pandemic response and recovery. They must adapt to new roles and protocols as evidence about the spread, detection, symptoms, sequelae, and treatment of the disease evolves over time.¹ Family physicians may be called upon to provide surge capacity in emergency rooms, hospitals, and long-term care homes that may be overwhelmed by cases^1-4 while continuing to provide essential primary care services.⁵

Public health reports, including those following SARS and H1N1, outline the goals for primary care pandemic response plans (eg, contribute to screening, testing, treating, surge capacity, and vaccination),^1,3,6 but do not explicitly include actionable plans describing family physician roles. The limited number of primary care-oriented pandemic response checklists available prior to COVID-19 were clinic-focused and without mechanisms to consolidate individual family physician roles across work settings, coordinate across different clinics, or integrate with other health sectors or regional organizational structures.^8-10

The purpose of this study was to identify the roles of family physicians during different stages of the COVID-19 pandemic. Roles refer to the specific tasks and/or responsibilities that family physicians are asked or required to fulfill. These roles are expected to be temporary and stop once the pandemic is over and “normal” operations resume. Identifying the various roles performed by family physicians is an integral step to ensuring that required resources and training are incorporated into future pandemic preparedness.

As outlined in a published protocol,¹¹ we conducted a multiple case study of four regions in Canada: the Vancouver Coastal Health region in British Columbia (BC), the Eastern Health region in Newfoundland and Labrador, the province of Nova Scotia, and Ontario Health West. The four regions each include urban and rural communities and cover the continuum of health services.^2,12-14 Each region has had different rates of COVID-19 cases, hospitalizations and deaths, and used primary care providers in different ways during the pandemic. Primary care organizations and policies also vary by region.

In each case, we relied on two sources of data: a document analysis and semi-structured qualitative interviews with family physicians. From March 2020 to April 2022, we identified publicly available policy documents impacting family physician roles in the pandemic. From October 2020 to June 2021, we conducted semi-structured qualitative interviews¹⁵ by phone or Zoom (Zoom Video Communications Inc.) with family physicians in each region. To be included in the study, family physicians must have had an active licence to practice in 2020 in their region. We excluded post-graduate medical residents, physicians on temporary pandemic-related practice licences, and physicians in solely academic, research, or administrative roles.

During the interview, we asked participants to describe the various pandemic-related activities they performed over different stages of the pandemic and the facilitators and barriers they experienced in performing these roles. We also asked about other potential roles that family physicians could have filled.

We used content analysis^16,17 to identify the roles performed by family physicians and the corresponding stage or period during the pandemic in which they were performed in both the collected documents and the transcripts. We presented an initial list of pandemic stages and pandemic roles to our broader study team as well as to family physicians, public health officials, healthcare administrators, and policy makers to confirm the description of these stages and roles.

We obtained approval from the research ethics boards at Simon Fraser University and the University of BC, the Health Research Ethics Board of Newfoundland and Labrador, Nova Scotia Health, and Western University. Participants provided informed consent verbally before interviews were scheduled.

We interviewed 68 family physicians (Table 1). We identified five distinct pandemic stages and the family physician role in each stage: (1) pre-pandemic, (2) phased closure and re-opening, (3) acute care crisis, (4) vaccination, and (5) pandemic recovery (Table 2). There was not always a clear demarcation between these stages, and they did not always occur in a linear sequence. Stages also differed in regards to start dates and duration between regions. The phased closure and re-opening, acute care crisis, and vaccination stages overlap, with family physicians carrying out the roles associated with all three stages at the same time. The following section will define the pandemic stage and describe activities that family physicians perform or are expected to perform.

Through a comprehensive document analysis and interviews with family physicians, we identified five stages of pandemic response and the family physician roles associated with each stage. The World Health Organization (WHO) has identified four phases in pandemic response,¹⁹ which are incorporated into national and provincial/territorial influenza pandemic planning documents in Canada.¹ Table 3 highlights how the pandemic stages in this study correspond to the phases in the WHO pandemic planning document. The stages of the WHO document relate to the detection of new virus mutations, the epidemiology of the spread of an influenza disease, and the coordination of global surveillance and public health measures. The five stages identified in the study provide more granularity about family physician roles during the pandemic at a health system level and can facilitate jurisdiction-specific (eg, national, provincial, and/or regional) planning and coordination of services, as well as material and policy supports.

Our findings draw attention to the importance of family physicians and primary care in a pandemic. Canada’s pandemic response relied heavily on family physicians, highlighting the dependence of public health and acute care on this sector of the health workforce. While family medicine usually includes many public health functions, during a pandemic, family physicians are expected to take on additional public health roles such as staffing assessment and vaccination centres, and communicating and adapting public health directives for their patients and the general population, in addition to continuing to provide routine primary care services to patients. Similarly, acute care facilities rely on family physicians to provide surge capacity by working in emergency departments and/or other units and to reduce demand for hospital-based services by delaying referrals for elective procedures and/or facilitating the discharge of patients who could be cared for in the community. Notably, current pandemic plans do not direct other healthcare sectors to boost primary care capacity,^1,6-8 despite the additional roles that family physicians are required to adopt during a pandemic. Family physicians may also need additional supports to cover patient care responsibilities if they or their clinic staff contract the disease or are required to isolate. Also, primary care funding models may impact family physicians’ ability to take on pandemic roles. Post-pandemic evaluations should examine whether other healthcare providers (eg, registered nurses and specialists) could take on roles such as staffing assessment centres, given that these roles do not require specific family medicine expertise.

Identifying roles of family physicians is also an important step in ensuring that resources needed to fulfill these roles are readily available in a future pandemic. For example, the availability of personal protective equipment from the earliest stages of a pandemic is essential if family physicians are expected to continue to operate their practices and provide services. Also, during the COVID-19 pandemic, the implementation of fee codes was integral to the rapid adoption of telephone and virtual visits.²⁰ Study findings also highlight education and training needs for family physicians. For example, family physicians may need additional training (eg, courses and continuing professional development certifications) to ensure that they have the specific skills needed to provide pandemic leadership²¹ or conduct virtual visits.²²

The primary care sector plays an important role in pandemic response. We identified key roles that family physicians performed during the COVID-19 pandemic over five distinct pandemic stages: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting activities to ensure that primary care services continued to be available, family physicians were responsible for operationalizing public health priorities (such as surveillance and vaccination) and ensuring that acute care facilities can respond to increasing demand for acute care services. Family physicians were also entrusted with responding to the needs of patient populations who are particularly at risk. Pandemic preparedness plans should ensure that the resources needed to enable family physicians to fulfill these roles are available in the event of a future pandemic to allow for an effective and coordinated primary care response.

We thank Aimee Letto from the Newfoundland and Labrador Medical Association for feedback on an earlier draft of this paper.