Small Changes Big Impact
Small Changes Big Impact
Supporting residents and seeing patients in the COVID-19 era with Dr. Allyson Merbaum
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In studio today, we have Allyson Merbaum, community family physician at North York General Hospital, post-grad site director and assistant professor at the University of Toronto and the Department of Family and Community Medicine. Today's episode focuses on addressing challenges in community family medicine, and supporting our residents.
Recorded April 30, 2020.
Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Allyson Merbaum, community family physician at North York General Hospital, post-grad site director and assistant professor at the University of Toronto and the Department of Family and Community Medicine. Today's episode focuses on addressing challenges in community, family medicine, and supporting our residents. I hope you enjoy the show. How are you?
Dr. MerbaumI'm doing okay, thanks.
Dr. RezmovitzThank you so much for agreeing to be on the show today. Tell me about your experience so far. What's been going on in your life and how has COVID impacted it?
Dr. MerbaumWell, certainly the past few weeks have been very, very challenging - both personally and professionally, I would say. I think I had no idea how much would change in such a short time, and trying to balance looking after my patients in this climate, and looking after our 32 residents and the impact that this is having on them has definitely been challenging.
Dr. RezmovitzThat's a lot of children to look after.
Dr. MerbaumThat's what I say. I call them my 32 other children.
Dr. RezmovitzYeah. Holy smokes. So what's come out of that? Has there been any frustrations or changes to their education? I can't imagine anything has changed whatsoever in their education.
Dr. MerbaumYeah, I mean I think there's a lot of uncertainty within their programs, within their curriculum. And I guess I've been trying to keep the communication going and try to provide some sense of normalcy and continuity despite the changing circumstances. So that means continual communication with them both on a group basis and very often on an individual basis and as well with our faculty to make sure we're all kind of on the same page. And I think it's - normally I rave about our preceptor based program where residents are assigned in community practices and each practice works a little bit differently and the resident's role in that office might be a little bit different, and yet they all come out with a similar experience. But again, in the current times, that makes this - I think - even more challenging because the way each office is able to incorporate their residents is a little bit different.
Dr. RezmovitzSo can you expand on that? 32 residents - so first of all, are they working?
Dr. MerbaumAbsolutely. Our residents are all working. They're all engaged.
Dr. RezmovitzI guess engaged only up to the point of whether or not the office is open and working.
Dr. MerbaumYes and no. I would say very quickly as we each converted more to virtual care of our patients - either by phone or through video visits , our residents kind of jumped into that as well. So in some offices where physicians are coming into the office and doing many of those video visits or phone visits in the office, the resident might also be coming in and separating themselves somewhat physically from the preceptor, but both, let's say participating in phone calls and in video visits and seeing whoever is necessary to be seen in the office. But many of our residents are working virtually from home as well, which means connecting with their preceptors through the EMR and doing their own phone visits and documenting and reviewing at the end of the half day kind of thing.
Dr. RezmovitzAnd are they still going on their regular block rotations? I assume - isn't North York on a block rotation?
Dr. MerbaumNorth York has a block program, yeah. Yeah for the most part they're continuing with their usual duties, albeit with less of an ambulatory component. So all of the rotations that had an ambulatory component, most of that is not taking place and they're doing mostly, let's say, inpatient wards and that kind of thing. So that the block itself looks a bit different, but as much as possible, we're trying to preserve that curriculum for them.
Dr. RezmovitzRight. And what have you heard around testing and examinations at the end of May? Because that's when things would happen. So I can only imagine based on the current situation and the fears that already exist in residency, what is actually coming up might be quite frustrating for a site director.
Dr. MerbaumYeah. So both the CFPC exam and the LMCC part two exams have been canceled for this April and postponed to the next sitting, which is likely October. So for our R2s who are graduating in June and will be graduating in June, they still cannot write their licensing exams before October. So the CFPC has committed to allowing them to practice and our Ontario College will be allowing them to practice under a provisional license come July.
Dr. RezmovitzOh, wow. That's interesting.
Dr. MerbaumYeah.
Dr. RezmovitzThat have calmed a lot of fears.
Dr. MerbaumI think that there is still some fear. I think there's still some fear as to getting a practice supervisor to oversee their practice because that is one of their requirements at the CPSO, and how this might affect the locum opportunities that they may be were looking at before this started. And of course still needing to take some time out of whatever practice they're doing in order to study and participate in the exams in October.
Dr. RezmovitzSo we definitely have some challenges ahead of us, obviously. But let's talk about you for a second and the challenges that you've been facing. I guess balancing personal and professional life right now. How are you managing even with your colleagues at work? Talk to me about some of the challenges that you guys are facing as a group , whether it's a home group or a work group and how you're I guess dealing with that.
Dr. MerbaumCertainly within my office, we're five family physicians. We've been practicing together for a long time. We've weathered other challenges and I think really have strong communication and respect for one another. So our ability to kind of navigate what changes we need to make within our practice has been easier because of that sustained relationship. I think we have generally always on the same page with one another. And so the decisions we've made for our practice in terms of how to set up our staff to work remotely , conserving PPE by only one person, seeing patients on a particular day - that sort of things - those challenges, I think, actually had been reasonably straightforward to navigate because we make those decisions together, and I think generally speaking agree with one another.
Dr. RezmovitzSo if you don't mind, can we have a conversation about PPE?
Dr. MerbaumSure.
Dr. RezmovitzWhat do you guys have in the office? I'm just curious.
Dr. MerbaumYeah, so we have the yellow disposable gowns. We ordered a large supply during H1N1 which never got used, and so luckily I think we had a hundred or 150 gowns available to us, of which we still have probably three weeks worth - depending on how often we're seeing patients. We have goggles, we have a small amount of plastic visors for those of us who wear glasses, who aren't able to use the goggles. Certainly we have gloves and then we do have surgical masks as well. We had quite a lot of N95 masks actually - again, probably dating back to H1N1 and made a decision just to keep one box that fits each person that needs one in our office and donate the rest of our N95 masks to the hospital where they're more needed currently.
Dr. RezmovitzYeah. Well, are you doing any procedures that would require N95 right now?
Dr. MerbaumAbsolutely not.
Dr. RezmovitzThank God. So my question really is around what are you going to do in three weeks when it's gone because the supply chain is dwindling. And I asked this as someone who has been working in the background right now trying to secure a supply chain for community family doctors.
Dr. MerbaumIt's a great question. It's really hard to know what things are going to look like in three weeks in terms of who we're going to be seeing in the office. I think we were seeing far more patients three weeks ago and two weeks ago than we're seeing now. I mean, we're really seeing a very small number of patients and maybe if we're seeing patients five half days a week and using five sets of PPE per week - I don't know, maybe next week we're doing it - we're seeing patients three days a week. It's hard to know. I would say for the most part, patients don't want to come in. And again, there's certainly still a need in certain case or for some form of physical examination that requires an inpatient visit.
Dr. RezmovitzYeah, it really challenges the dogma of family medicine - of what we do. This whole pandemic has really challenged my idea of what is really necessary. You know, the art of the physical exam has gone to the side unfortunately. It really can be helpful, but at the same time, we're all trying to protect ourselves and unfortunately I think they're going to be a lot of things that we miss this pandemic, right? We've stopped - the Ministry has stopped screening for colorectal cancer, breast cancer, cervical cancer. We're going to miss stuff. We're gonna miss - if people are scared to come in and they have chest pain, maybe we're going to miss heart attacks - we're gonna miss, I think, a lot of stuff unfortunately. And the question is how do we respond appropriately? And so one of the ways is to have PPE. Unfortunately, I found out on the weekend that the large suppliers are not - have a directive to not supply to community family doctors. So you can't call up Medical Mart, you can't call up Surgo, right? And so we have a real problem because - I don't know if you heard ,this isn't ending in two weeks.
Dr. MerbaumRight.
Dr. RezmovitzSo we've got this issue of PPE, but we also have this bigger issue of staying connected with our patients. Are you - how are you guys connecting with your patients or maintaining that connection still?
Dr. MerbaumYeah, so a lot of this is happening through phone and video. And I guess for the most part, that's being initiated by patients, but I feel like more and more I'm starting to think about, "Oh, but what about that person who's frail and elderly at home and might not think to call in or might not think that we're available?" And so I do think the onus may be on us to start proactively calling who we might identify as our higher risk patients just to say "hi" and to let them know that we're here if they need anything. So that's sort of an idea I got from my colleague Kim Lazare - I'm going to give her lots of credit. When she suggested that for her mental health patients, she was finding she needed to kind of proactively do a check in phone visit. And I'm starting to think about that more for many of my patients that I think would not proactively call in, but do need to know that we're here for them.
Dr. RezmovitzYou know, it's one of the tenets of family medicine, is being a resource to a defined population. I'm going to talk about Ian McWhinney for a second, but we have that connection with patients, right? It's what we do. And so maybe the Ministry for proactive calling for patients in need, maybe they'll put out a special code called the K N. I. C. E. you know, the "knice" code where you do like nice things for people. Crazy, right? So way to go Kim. Way to go, Allyson. We need to get this out. I'm just trying to find ways to message our patients to start doing proactive things for each other, to be nice because we cannot be everywhere. And if we as family doctors go down, then who's going to take care of our patients, right?
Dr. MerbaumFor sure.
Dr. RezmovitzSo what other joyous things have you noticed then as you know, between the five of you in your practice, in the larger group at North York General that maybe you can speak to or just in the world that you've noticed that you've tried to adopt during these times?
Dr. MerbaumI think as a site director at one of the 14 academic sites, we have this connection with our program, with our postgrad program director, Stu Murdoch , and most of that is actually through occasional emails and a once monthly resident program committee meeting , which always would happen in person. And I think it was quickly recognized that the number of issues we're dealing with on a day to day basis in our silos as you said, is exponential and we really need to connect with one another to make sure that whatever I'm doing at my site is similar to what somebody else is doing at their site and everybody's sort of getting the same messages. And so , S tu has elected to set up a Zoom meeting for all t he site directors on Friday mornings as an opportunity for people to ask questions and k inda check in about what they're doing at their site and whether it's working or not. And similarly, a listserv for site directors to share questions and share ideas. And I think that is an idea really to help to keep us connected despite the physical distancing that we're all having to do.
Dr. RezmovitzSo what are some of the things that are coming up regarding like questions and stuff like that that maybe other people that don't have any learners in - that you guys are dealing with?
Dr. MerbaumI think redeployment is a big one. So we have all been asked from our home hospitals to supply a list of residents who could be redeployed to other services if needed, and the ethics of that - there may be pros to that, but there may be cons to that in terms of taking them away from other rotations where that was really needed for further learning in this very short residency program. And how do we help residents understand that this may be necessary and part of how we're all contributing in this difficult time. So redeployment has been something that's been discussed a lot. In some situations residents are being asked to cancel their vacation weeks. And so we've done so much in terms of resident wellness and then the new messages around "you're needed too much. You need to cancel your vacation" - that hasn't happened at our site yet, but there is certainly a question of would that happen? And even like when it comes to financial issues for residents, if they have to cancel their vacation week and they don't get to take that between now and June, do they get paid out for that vacation time as a salaried employee? So all of those kinds of questions are being brought to the table.
Dr. RezmovitzYeah. Holy smokes. They might graduate early - like six weeks early if they don't take their vacation. Just kidding. They're not graduating. Maybe they are. I'm kidding. Totally. Yeah, I know they're graduating. Provisionally. So what kinds of things are you guys still offering from a wellness standpoint? Have there been any Zoom gatherings? Have you heard?
Dr. MerbaumFor sure. So we I mean I did a Zoom Q and A with the residents a couple of weeks ago - I wouldn't call that wellness, I would just call that communication. But we do a a journal club once a month at our site - typically takes place at my home on a Thursday evening and residents who are in family medicine block and their preceptors are invited to participate. And my colleague, Braden O'Neill generally leads the journal clubs . So we've moved that to Zoom and we had good participation a few weeks ago. And again, nice way - it's a little bit social, and again to keep up some normalcy. We do Valant groups within our academic half-day curriculum. So these are small group facilitated sessions where we talk about the emotional aspects of clinical care. And so this Wednesday at our Zoom academic half day , we'll be continuing with our Valant groups and our facilitators have all committed to participating as well, but we're going to dedicate the session to COVID and the emotional impacts - both in terms of patient care and clinical responsibilities as well as impact on their personal lives.
Dr. RezmovitzI don't want to be too forward or step over any lines, but if you're willing to share any emotional frustrations that you've experienced, or emotional highs that you've experienced through this time , I'm sure our listeners would love to hear that. Almost like a mini Valant group right now. You don't have to - it's a challenging question. It's not fair. But you know what, at this time, what I've noticed is supporting one another is probably the greatest thing that we can do to help get through this.
Dr. MerbaumYeah. I would say early on - our residents have a WhatsApp group, and early on I feel like sometimes residents were posting comments or concerns about rotations that they were on or certain encounters for the whole resident group to see. And I think in some ways it was actually causing more panic and more anxiety amongst the group. So there is this sort of situation where if everybody's complaining about things, it actually causes, I think, more distress. And so I did sort of have to ask them to maybe not share that amongst a of 32, that we all need support and we reach out to a few of our close colleagues and discuss these more challenging scenarios, but we want to be a little bit careful about these large forums being a venue for raising concerns where action can't actually happen from that. So I would much rather if there are specific concerns , that they're brought to me directly so that maybe I can help to advocate for residents or navigate for some change rather than just some sort of brewing between the resident group. Does that make sense?
Dr. RezmovitzYeah. I'm trying to - obviously my role is to try and nail down specifics so that we can explore that. I'm just wondering if there's anything that they're frustrated with specifically that we can deal with as a whole, as a community.
Dr. MerbaumI think specifically - let's say in the emergency department - I think things were changing so rapidly that they would get one message one day and the next day, it would be a completely different message and that wasn't always communicated effectively. Or that one preceptor in the emergency department was doing things one way and another was doing it a different way and it was completely contradictory. And I think that caused a lot of frustration, but I think we all have to recognize that for the emerge staff it was changing on a day to day basis. It was almost unavoidable, except for the piece of communication, which is - I think there was perhaps something missing a little bit in the communication to the residents during that time.
Dr. RezmovitzI think it's really hard. If I remember back when I was a resident two or three years ago, that you're expecting a certain message or you're anticipating that people will support you through this. And what you don't realize, I think, is that sometimes nobody's supporting the front line also right? And that's the maturity that you need to develop in medicine, is to realize that you really need to get information , and pause after you have that information and ask yourself, "do I have enough information to make a decision that will protect myself, my patients, my community? And will it be the 'right decision'?" Because I think a lot of inexperienced or young -what's the word I'm looking for? I don't want to just put this into doctors , but, but young stakeholders ? I dunno, young learners? Is that they may react instead of - and so everybody is at that point right now where we don't know what's going on. There's a lot of disharmony. There's a lot of non-systemic pull, if you will. Like, I know as a community family doctor right now, there are multiple offices vying for all the same equipment. If we go back to PPE for a second, it is not synchronous. There is a lot of people do duplicating the same work that is being done. And it's really exposing the difficulties that we have in our system or the inadequacy of our system for distribution of resources information. And so I'm sure as a resident and not realizing that these things happen to people who have been doing this for 20 years - when you're inexperienced like that you feel like nobody is supporting you. So I can only imagine it must be very difficult to be a resident right now with the uncertainty in the air.
Dr. MerbaumYeah.
Dr. RezmovitzSo other than that, how's home life? How are you coping?
Dr. MerbaumWell, it's always interesting. Having three teenagers at home whose worlds have also been really turned upside down because of this and navigating this with them. I certainly can't homeschool in addition to my clinical and administrative duties. So unless they're self motivated to do that that's a significant challenge as well.
Dr. RezmovitzYeah, I bought into a social contract where I go to work and I pay for my kids to go to school. Do you know that social contract where we pay for teachers through a public health system - sorry, a public tax system and they agree to the school, my children so that I can go to work and do other stuff. And so it's really hard when we get faced with tasks that we're not used to like homeschooling.
Dr. MerbaumYes.
Dr. RezmovitzIt's really interesting. Someone asked me the other day, how's it going with your son? He's six years old , and he's got some home - they've been doing Zoom lessons and stuff like that. And it's funny to watch a six year old - the attention span of a six year old - his at the best of times is not very good, but now that he's sitting there watching the teacher try to give a lesson, I can only imagine what he's like in class because at home, he basically - and I did this on the phone with someone yesterday who said, " what's he like?" And I said, "well" - we can impersonate - for all the listeners out there, this is my son in class pretty much every day. So what I want people to do is extend their heads - extend their necks back and look up at the ceiling, and then stick their tongue out, and then just hold that for a good 5, 10 minutes. And that's pretty much my son every day in class at Zoom. No interest whatsoever. So we've been doing a lot of Lego, and puzzles, and playing in the basement of soccer, hockey c atch. We've created some holes, you know. Typical stuff that you do during p andemics.
Dr. MerbaumWe're crafting a lot. We've taken up needle point and knitting and lots of puzzles also. And a lot of cooking and baking. My kitchen has never been used this much.
Dr. RezmovitzYeah. I baked my own bread last week for the first time.
Dr. MerbaumI did that too.
Dr. RezmovitzYeah. And then my wife said, "there's no more flour. You've got to stop." And she proceeded to use the flour to make PlayDoh and then we had an argument over what was more important, bread or PlayDoh.
Dr. MerbaumRight.
Dr. RezmovitzShe's like, "well, you can eat the PlayDoh." I was like, "I'm not eating the PlayDoh." Anyhow . Okay. Anything else you want to talk about today?
Dr. MerbaumThat's a challenging one.
Dr. RezmovitzIt is. Open invitation to share.
Dr. MerbaumI feel like what the new normal is gonna look like after this is very hard to imagine. I'm really interested to see how our response to this affects how we practice medicine in three months or six months , and whether it changes anything.
Dr. RezmovitzSo what are your plans as far as changing the way that you practice? Are you actually going to bring patients in again?
Dr. MerbaumI'm somebody that really does appreciate that face to face contact and sometimes they talk about the therapeutic laying on of hands. I still think that there's so much to our role as family physicians of that personal connection that just isn't the same by phone or by video. And so - I was very resistant to the idea of a virtual visits before this started. And I think what I've come to is maybe I would take a half a day or a day a week of my clinical practice and do it virtually as opposed to in office and keep the bulk of it still in office, but at least for the situations where perhaps it's challenging for patients to get into the office or it's more patient-centered to do it through video for that particular patient, maybe I would take advantage of my - trying out different modalities in terms of video and continue that on afterwards. So I do think that will change.
Dr. RezmovitzYeah. I mean, counseling can happen through video very easily now, right? And it decreases exposure. I mean , I spoke with Ross Upshur last week and he pointed out that this is the 11th infectious disease - I don't want to say pandemic because we haven't had that many pandemics, but we've had outbreaks - let's use the term outbreaks - 11th outbreak in 17 years. It's going to happen again.
Dr. MerbaumYeah.
Dr. RezmovitzAnd being prepared for this, and changing the way we practice medicine is really going to reveal itself, I guess after this settles down. So let's talk about predictions. W hen do you think this is g oing t o settle down?
Dr. MerbaumGreat question. I mean I think again, with three teenagers, the big questions are they going back to school this year and are they going to participate in their usual summer activities? Which for my kids means going to sleep over camp in the summer. So I guess my prediction is I don't think they're going back to school this year and I hope they're going to camp, but it may not be exactly the a time. It may be delayed, I guess is my guess at this point. What about you? What's your guess?
Dr. RezmovitzOh, I think this school year is a write off. I think of a lot of people are going to be repeating the school year next year and I don't think camp is happening. I think we're looking at September or October before things truly settle down. I really hope it's earlier. They're thinking - by the modeling methods that are going out right now - they think Toronto is probably going to peak around April - April 25th, so about - in a month, where we're going to get our peak. But I mean that could change. It all depends on whether or not people do the things that we're recommending -you know, social distancing , physically distancing each other. You know, I can totally say my kids went squirrely yesterday. Like we just had enough. So we put on the table, let's drive to Niagara Falls. And then we thought, why would we want to be in the car with these kids right now while they're squirrely? That's not happening. So we just thought, "you know what water might be calming for these children." And so we took a drive yesterday and I couldn't believe the amount of people that were out.
Dr. MerbaumReally?
Dr. RezmovitzI mean, look, we were one of them. We ended up finding um, a secluded parking spot. We walked down to the boardwalk and then it was uncomfortable. I said, "I just don't like this" to my wife. So we left. We made it onto the beach and we just threw rocks into the Lake because my kids needed that. And thank God - I was trying to protect them and keep them away from people, but at the same time, it was so uncomfortable realizing that all these people are around.
Dr. MerbaumYeah.
Dr. RezmovitzAnd we really are going to have to learn to deal with the boredom of being at home or outside and really stick to our guns with not interacting with people. And you see it - you look at people - I could see people, I'm like, "there's no way these people live in the same house." There is no way that some of these people live in the same house. As far as the rules go right now. And so we hightailed it out of there. I was just like, "we gotta get outta here" and it's really frustrating. And so there are a lot of things that people are not doing and as the weather gets warmer, it's going to get worse. And so if we don't really push to stay at home, to limit our exposures , this thing could keep going because we know how infectious this thing is.
Dr. MerbaumYeah.
Dr. RezmovitzSo that's - it really opened my eyes yesterday that - we all need to do our part. We all need to do our part . And with that I thank you. It was really great talking to you this morning. I hope the residents succeed and are fine that even in a pandemic that the learning opportunities are still there. All of us are getting our experience or our learning right now about how to deal with a pandemic. Hopefully the learners - the ones in the learning program right now will realize that they'll be prepared much better later than all of us who probably are not as prepared and not getting the education right now that they got. And so hopefully they'll realize that the rest of the stuff can be learned just like you and I have learned to deal with all the stuff that we never learned in residency because it turns out you don't learn as much as you need to know in residency as you're going to need for the rest of your life.
Dr. MerbaumI agree. I mean, it's not exactly what they had anticipated they would be learning right now, but it's still excellent learning that will help prepare them for their future career. And so, I think we can be comfortable in knowing that they're still ready to move forward despite the changing curriculum.
Dr. RezmovitzExactly. Thank you. I hope you have a wonderful day. Be safe.
Dr. MerbaumYou as well. Take care.
Dr. RezmovitzYou too. Bye. This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva and the whole podcast committee. Thanks for tuning in. See you next time.