A candid COVID conversation with Dr. Ruby Alvi

In studio today, we have Dr. Ruby Alvi, the undergraduate site director at Trillium Health Partners - Mississauga site, and the University of Toronto Department of Family and Community Medicine's pre-clerkship director. Today, we're having a candid COVID conversation.

Recorded April 1, 2020.

Transcript

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Dr. Rezmovitz 0:00

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. Today we're having a candid COVID conversation with Dr. Ruby Alvi. I hope you enjoy the show. And again, we're doing this through Zoom. Ruby, why don't you tell us some of the roles that you play in the department.

Dr. Alvi 0:26

All right - thanks Jeremy for having me here today. I am an undergraduate site director at the Trillium Health Partners Mississauga site. And I'm also the DFCM's pre-clerkship director.

Dr. Rezmovitz 0:40

And which site do you work at? Like where is your office?

Dr. Alvi 0:43

The Mississauga. So it's one of the expansion sites - Trillium Health Partners - the Mississauga Hospital, specifically, at the teaching unit.

Dr. Rezmovitz 0:50

And so , being in Mississauga, I assume that none of this COVID-19 has impacted you yet?

Dr. Alvi 0:56

No, not at all. I don't think COVID-19 is a Toronto problem. It's - I don't know if you heard, but it's kind of a provincial, national, international. It's a pandemic.

Dr. Rezmovitz 1:09

Oh, okay, good. Thanks for updating me on that. Yeah. So how are you coping?

Dr. Alvi 1:15

Coping? It's - you know what - almost - I hate to say this, but almost overnight our world has changed hasn't it. I would say March 18th was the magic day for me when everything changed. I was supposed to be off for March break, but obviously like everybody else, travel plans had to be reassessed and changed, so I stayed home. My son didn't - my son went on a trip to Peru with a bunch of classmates from medical school and that kept us quite busy on March 17th, as borders [inaudible] international [inaudible] the b orders were closing down and people were scrambling to get home. But we stayed home. We were supposed to go to Dubai and Cairo just ahead of the cases in Cairo. So when big changes had to happen at our clinics, I was at home and I was able to actually take that time to do some of the work that was needed to shift our practice to really a virtual practice. L ike, I can't even imagine how the people who were seeing patients at the same time w ere able to make that adjustment on the fly. There were some of us who weren't scheduled to see patients [inaudible] that we're really able to investigate - do what they n eeded to do to help the people that were already working, get our offices ready for the big changes that came the week after.

Dr. Rezmovitz 2:46

So how were you able to shift your practice? Like in what sense? What did you do?

Dr. Alvi 2:50

Well, I mean, luckily many of us had capabilities [inaudible] to use OTN to see patients. But really just getting our office prepped, doing phone visits - we have a large teaching unit, we have about 20 residents at our site - figuring out how we were going to shift our care to see the patients who really need it to be seen, bring in staff that needed to be there and really provide our patients with as much service as we could virtually by phones mostly, video if needed. So we were fairly well-equipped in terms of the technology to do that. And we're grateful for that.

Dr. Rezmovitz 3:37

And so did you guys redeploy any of the residents?

Dr. Alvi 3:41

No. We did not at that - and we still have not yet. What we've done is we - our residents are coming in - the first - I mean everything's changing on a day by day basis, right? So the first week everybody was coming in. The second week - and I'm going back to just before March 18th, everybody was there. We had a full cohort of people and we were benefiting from the experience other people have had, not just across the city but also really across the world. I think social media has, in some ways it's - we've learned so many lessons from people and the advice we were getting was usually like two or three steps ahead of where we were at, which was kind of a nice opportunity for us to prepare. So we knew that we would have to make big changes. We developed protocols and systems for not having everybody physically on site. The big challenges were things like phones - all the admin staff. We have a large unit. How are we going to answer the phones? How are we going to call patients back? Are all our staff equipped to do this at home? And you learn a lot about people's circumstances, I think, what their home situation is like when you make people work from home. Kinda like us, right? We're hiding in a room, in a corner of our house doing the Zoom call because every other the room is being occupied by people doing really important things or kids making a racket. So it was an opportunity for us, I think, to learn about our staff and to offer support to them and to figure out - it's time for problem solving, isn't it? Like I [inaudible] That has been probably the neatest thing about this is that we have been given an opportunity where we have a problem that we're confronted with, we don't know all the answers we've had to work together with usual partners and sometimes the unusual partners to come up with solutions. We've made some really great alliances during this time.

Dr. Rezmovitz 5:55

Can you expand on of the solutions that you've come up with or you've partnered with?

Dr. Alvi 6:02

In what areas specifically?

Dr. Rezmovitz 6:05

Well, so we spoke on the weekend. I mean it's a small world. It's the way things go. Specifically let's talk about personal protective equipment and supporting family doctors - community family doctors specifically right now , if you're not part of a hospital , and how we are going to continue to see our patients. So tell me about what you guys started.

Dr. Alvi 6:33

Okay. So let me just give you a little bit of the background. I'm sure that you and every other physician and non-physician right now is on probably 10 WhatsApp groups - either community groups, professional groups, friend groups, whatever - about the current situation and how it's evolving and what needs to be done. Most of the groups that I was on were really focused on people who worked in the hospital. So the front line workers: the emerge docs, the ICU docs, the anaesthetists. And so I'm reading some of the stories coming out from here, and it kind of made [inaudible] I mean, I'm sure every family doctor, every primary care provider, doctor on the community was wondering the same thing. Like what about us? So we started looking into our supplies. Most community doctors, I don't think, have the resources or just didn't have the plans in place to order a large supply of things like masks. We don't use them on a regular basis, right? So when we took inventory of our own supply, we realized that if we were going to use our masks, the way people in the hospital were using masks, they weren't going to last very long. And we didn't really - we weren't able to order more. So we called our usual suppliers - Medical Mart, others, and they were delivering so far out and actually they weren't even giving us delivery dates, right? So that's kind of where the urgency came in. And I started calling my friends at other fits other people in the community and I'm like, "what are you guys doing about this?" And they were all in the same position. So some of them were going to Home Depot and picking up like masks that construction workers use to avoid inhaling dust, and people were coming up with all kinds of - there were problems solving. Like how are we going to protect ourselves in a time when we can't find what we're supposed to be using? And you know, the conversation became one of - the focus is, and it should be, it should be on those people that are really right in front of the patients that are very, very sick. So nobody disputes that, but we kind of felt that there was a bit of a gap and we didn't really hear anything from anybody really. Like I can't say I felt like any organization was really addressing. So what about the doctors out in the community? What about our doctors that we use to teach FMLE? What about our doctors who - our partners out in the community? So that's where, that's where my involvement with sort of - actually no , that's not where my involvement came with COVID-19. My involvement came with conqurecovid19, which is what I think you're talking about. It came from a personal connection. So many people know that, that my kids are all o n the no fly list. They're all on Canada's no fly list, which is the funniest thing. The list is huge - they're probably like 100,000 people on the list. People with common names. It doesn't matter what ethnicity the name is, common names often e nd up on this list. So we've been advocating for a redress system for the past four years. And quite successfully, we were able to lobby the federal government and then the senators to approve funding for a redress system and then approve - and then pa ss t he bill that was required for the operationalization of the funding to create the redress system. So along that journey, we met some really cool people. We m et some amazing people who were in the same situation as us. And then we met some really awesome Canadians who had nothing to do with the no fly list, but just saw that this wasn't fair. Like it made no sense - it was an inequity. And they helped us out a lot. They advised us, they supported us, they made connections for us, and one of those people was the president of the auto parts manufacturing association. Like who would think, right? That's how this guy became a real great ad visor a nd advocate for us. So it was actually him that was on the news one day. He was on CB C s peaking about how his auto parts manufacturing groups were looking to retool and rejig their operations to provide ventilators - to make ventilators. And so we're listening to this and we're like, "you know what? Wow, that guy is awesome." He has like - he has an interest in helping in so many different areas, right? So one of the parents that actually th e s tarted the, no fly list kids sent out a tweet. And we kind of la ugh b ecause no fly list ki ds s tarted with a tweet. This guy sends out a tweet at the airport that his kid is flagged and his kid has the same name as mine. So, you know, I tweet back and I'm like, "Oh my God, we must be on the list too, because that's my son's name." And from there ballooned into this beautiful organization that spans the country, spans different age groups and demographic groups. And that's kind of what happened with this, that same little bird that Twitter helped to b ring a bunch of really cool people together. So this guy sends out a tweet and says, "Hey, there's anybody interested. I'm going to hope" - he puts a Twitter out and then also sends a LinkedIn message. He's hosting a Zoom session to teach people how to use LinkedIn to make connections. And all kinds of great people joined, right? People from industry, people from the ph arma w orld, lawyers, two people who work for the WHO in crisis - not pa ndemic, but crisis relief - all kinds of really, really cool people, people who are just interested in helping. And that's ki nd o f h ow the group started. And along the way we've picked up some other amazing people like yourself.

Dr. Rezmovitz 13:14

Yeah . So let's talk about conquercovid19.ca. We had a conversation on the weekend where it seemed like we were all duplicating efforts. And I think hopefully we can get a message out today through this podcast is how to not duplicate efforts - how to collaborate, how to bring people together and solve problems. And it seems that community family physicians have one common problem. How do we keep seeing patients in the face of an infectious disease that can severely limit our abilities to care for patients? And so with conquercovid19 , we've been working tirelessly over the last four days - I can't believe it's been four days. There's so much back and forth , building the website , getting collaborators. Last night I got an email from - who is it ? It's the - I think the director of patient safety at Ontario Health, asking me if I could get face shields for somebody for a walk in clinic. And I said, "okay, here's what you do. Go to conquercovid19.ca, type in your need." And then I also texted your son and said, "Hey, watch for this." I think within 15 minutes , your son said, "okay, we're on it." And he reached out to a group that's manufacturing face shields through 3D printers right now - an architectural group. And hopefully by the end of this week, he will have five face shields. And I know it's not the answer - it's not the end all answer for every single group that's out there because we really do need ministry support, but we need to figure out how we can leverage our size. We need to really come together as a group and hopefully people will rally behind what you and and the partners have started, which is conquercovid19.ca.

Dr. Alvi 15:29

Yeah. You know, what this is really highlighted is that family medicine is such a huge discipline -we know that. But there are a lot of people that work in silos. I mean, family docs often work in silos unless you're part of a hospital system or you're part of a large family health team - which I would say is not the majority of family doctors - there's a real problem with communication, right? And especially during a time like this. I mean, I work in a family health team, I have a few levels and layers of administration above me whose job it is to look after this kind of stuff. Like, do you have enough equipment? Are you - they have direct connections with the ministry so they know what's happening at that command table, right? But our colleagues out in the community really don't know, and as a matter of fact, we were talking on the weekend about the survey that went out. I don't know what the percentage of family docs is who've stopped working right now because -

Dr. Rezmovitz 16:30

Well I can tell you.

Dr. Alvi 16:30

Tell me.

Dr. Rezmovitz 16:31

5% have stopped working completely. And according to the survey, out of like 400 plus respondents , around 30% are planning to stop working in two weeks.

Dr. Alvi 16:43

That's huge.

Dr. Rezmovitz 16:43

Huge.

Dr. Alvi 16:44

That's huge. And we didn't have that data in my community, right? So when you told me about the numbers you had, I went back to our group and I said "this is the number I heard from Toronto." The reason we're seeing about 8 to 10 newborns a day in our clinic that aren't our patients is because we've colleagues out in the community that can't work for whatever reason, right? And that number is only going to grow. So as much as it's really critical to support those people that are in the hospital - I think a lot of work is being done in that area and it needs to continue to be done, but we need to stop for a minute and think about how we're going to keep our community healthy and our doctors in the community safe and people enter the hospital so those folks in the hospital can do the work that they really need to do right now.

Dr. Rezmovitz 17:40

Yeah. So it turns out - I was just reading this online last night - there are other diseases other than COVID-19.

Dr. Alvi 17:47

Right?

Dr. Rezmovitz 17:47

Who knew? So I thank God I was reading that last night and I found that out and I was like, "Oh, I should probably still work." I am working. And it was interesting when you said earlier about, all the WhatsApp groups that you're on and all the chats that you're on - I'm a solo practitioner right now. I'm not in as many groups that you're in. And it's interesting because we don't - we talk in the hallways in the medical building that I'm in, but everybody runs a solo practice. There are a few group practices, but for the most part it's a lot of solo practices. And it's like, well, who's looking out for the solo practitioners who aren't affiliated with the Department of Family and Community Medicine , who aren't affiliated with a hospital, [inaudible] for those people who have probably very large practices - the guy across the hall from me, he and his partner - so it's a two person practice - have like 5,000 patients, I think. It's a lot of people. And so if they get sick - and they had a positive case of COVID-19, so they shut down the office. That's another reason why people aren't practicing right now. If you have a positive case of COVID-19, you have to get your office cleaned and you need to get PPE so that you can keep doing this.

Dr. Alvi 19:10

You know, I think that this whole experience - I hope people are taking lots of notes and journaling for so many different reasons, right? Because it's a time in history. I think that we're not going to forget, but also there are so many lessons to be learned from this time, right? And one of them that really sticks out for me is - again, like I'm a family doctor and I'm in leadership and in my community in family medicine and at the university - what role do we have? What role do we have in bringing at least our communities together and especially those solo practitioners, the physicians who work in smaller practices, so that they feel like they're part of a community? Because that's who we are, aren't we? We're like family and community medicine. These guys are our partners and when they can't work, we have to step up. There's an obligation. So I think it's really highlighted to me the importance of really fostering those networks and reaching out to people. There are people.

Dr. Rezmovitz 20:17

Yeah, I find it really interesting though. This little tiny virus - I can't remember how big it is, but it's not very large. I mean for viruses, I think it is pretty large but, but you know, compared relatively to scope to other things, it's not very large. And so my point is, is that - who's that your husband?

Dr. Alvi 20:38

Yep.

Dr. Alvi's husband 20:38

Hey, what's up?

Dr. Rezmovitz 20:40

Not much, you?

Dr. Alvi's husband 20:40

Oh, you know, living the dream. We haven't got a divorce yet, so everything is fine.

Dr. Alvi 20:47

This is a podcast!

Dr. Alvi's husband 20:47

Oh sorry. [ inaudible]

Dr. Rezmovitz 20:50

I think it'd be great for the podcast.

Dr. Alvi's husband 20:52

More love.

Dr. Rezmovitz 20:54

Okay. Well let me know when you guys get a divorce. Ruby's awesome, okay?

Dr. Alvi's husband 20:59

I heard you're awesome man. I heard you're awesome.

Dr. Rezmovitz 21:01

Yeah, we'll meet. I promise.

Dr. Alvi's husband 21:03

I hope so.

Dr. Rezmovitz 21:04

Yeah. One day if this ever lets up, okay?

Dr. Alvi's husband 21:07

Well alright man. Keep up the great work. Peace guys.

Dr. Rezmovitz 21:12

So what this virus has done is expose our vulnerabilities in the system - that we aren't connected as much as we are family and community medicine, we aren't connected. We don't have a system that connects all of us so that when a pandemic is laid upon us, that we can hit the button and say, okay, the system is now enacted. We have this emergency system, we have a distribution list of people, information. We can change - we don't have that. And it turns out this isn't the first infectious disease to hit our world in the last - ooh, how old is our world? So it's not the first, and it won't be the last, and the question is, are we going to learn these lessons or be condemned to repeat them?

Dr. Alvi 22:04

Totally. You know, just going back to conquercovid19 for a second - I'm just looking down here at a note that I made. We had a meeting last night and as you know, everyone has their day jobs, right? Like so everyone that's involved in this has a full time day where they're taking care of their kids, so most of our meetings are late at night and go well into the early hours of the morning. But one of the things we were talking about yesterday was just like vision and mission and like the short term goals and long term goals, that sort of thing. And I was amazed, I was making a list of the people that were on the call last night and I actually stopped for a minute and I said, "you know what? Let's just stop and find out - like do a bit of a [ inaudible]" or what's it called? "The timeline. How did you guys get involved? What made you get involved?" Right? And the answer was so - it was so great to see because I feel like nobody here had like a financial interest in doing any of the work that they're doing. They all had either an expertise that they could offer, they had a personal interest in terms of they were concerned about health care workers and their ability to do their job, they were citizens who had - some of them had family members who were unwell and they were concerned about different populations. There's a gentleman who does work with the homeless population and people - there were engineers - engineers who know other amazing engineers who can think differently than we can think, right? So just like that whole idea of blowing up problems when you and I sit together to solve a problem, you bring your perspective, I bring mine and some of them overlap because of our shared interests, right? When you bring a bunch of people like people from the World Health Organization, engineers , industry lawyers, people who do work in strategy and logistics - they have the coolest perspectives. And I kind of thought, "man like I wonder if the people at the command table have these kinds of people with that can look at problems through these lenses on a regular basis," right? And that was what was really cool because people from this group actually are speaking with the government and they are speaking with hospitals. So that kind of made me think like, is this an opportunity for even provincially and nationally to start thinking about like who wants to be partners or who wants to be involved? Who can we recruit to just help solve problems? Maybe not the usual people. Let's think outside the box.

Dr. Rezmovitz 25:06

[inaudible] I mean, that's what innovation is, right? Innovation is taking an idea to solve a problem in an area that hasn't used that idea before. Right? So Zoom has been around for awhile , right? Video - Skype. I mean, we started Skyping how many years ago? And yet it was not adopted into medical practices until around - I don't know , March 18th? I mean, we've done OTN across the province and specialists and stuff like that. I've been using it for about eight years, but I haven't been using it as much as I've been using it now. And so that's what innovation is, right? And so you get - if you want to talk about the theory of innovation, there's a curve. I don't know if you've ever heard of Rogers' diffusion curve of innovation where you've got the innovators and then you have the natural safety risk monitors there . They - in his curve, he calls them laggards. There's - but it's for everything. You know, like I'm a cocaine laggard - I still haven't tried it, but maybe one day, I'll be innovative enough and shift my position along that spectrum. But the same is true for family doctors when we're talking about video conferencing and getting your office up and running to the point where you can support your patients. It's about innovation. It's about trying something new. It's about taking a risk. And I would hope that the command table right now has input from people who are resourceful and have the ability to think outside the box, because right now we are not using - I believe the expression that I heard also last night is we are not in Kansas anymore. This just isn't the same. And so people that are still applying that same thought process to this current situation are going to be left behind. For instance, I had a patient who was interested in screening and I tried explaining that "you're not going to get the screening right now." And the response from the patient was, "no, I don't think you understand. I'm getting it. I just need to know when the - what's the upper limit that I can wait before the screening happens so that I don't miss out and jeopardize my life." And I said, "no, you're not getting it. I don't think - like you're not getting the screening right now until we resume that life." So you can't apply that screening for colorectal cancer, breast cancer, cervical cancer right now to the current situation. All those things have been suspended. They're not testing for those things right now. And the unfortunate thing is we're totally going to miss things because of it.

Dr. Alvi 27:59

Totally. I mean, I think everyone has been forced to confront the reality in whatever way they live, right? And going back to your point about people being laggers and those that jump at challenges - it has been - there are things that we should have been doing a long time ago and for so many different reasons - whether we couldn't get the funding to do it, we couldn't get the institutional support -

Dr. Rezmovitz 28:25

Like what? Like what? What should we - I hate that word "should."

Dr. Alvi 28:29

Good. So you know what? Like really phone visits, virtual visits - our patients have been coming into our offices. The model that we have to practice medicine - in so many ways - I think we've debunked that it makes 100% sense. I've been using - I've been calling patients for the last two weeks and people are so happy to not have to miss - I mean right now they're not working, but to not have to miss work to get to stay at home, attend to their usual responsibilities and take 10 minutes out, not worry about driving across the city, paying for parking, to address their medical concerns. And you know what? We can do a pretty good job. I am satisfied. The patients are satisfied and hopefully, you know, the powers that be will see that maybe this is something that should continue beyond this pandemic. So that's one example. The other is leveraging video, right? So we all have EMRs pretty much now - how are we going to even document things in our EMR with pictures and video so that we have objective details that actually mean a whole lot more than my notes, right? So I think that that's one area. The other area is learning. Learning is huge. I mean do we need to go - I see that the shift has been going towards more e-learning but not using videos. And Zoom - I think Zoom is one technology, but I'm guessing that in the next year or so - maybe sooner people are probably already working on it - but there is going to be all kinds of amazing technology that's going to allow us to learn great things with people that work with us and people who don't work with us, right? So I think that the push that people needed to try these different mediums - we've kinda just been thrown into it. And it's amazing, even for myself - I'm not the most tech savvy person, but gosh, I learned so much about Zoom and WhatsApp and Slack - I'm still not an awesome Tweeter, but I've been forced to learn some things and I think that a lot of other people have as well. So I don't think we're going to go back to what we're [ inaudible] nor should we.

Dr. Rezmovitz 30:56

That's interesting. So I agree with you, but again - one of my positions is the lead for a CPD and innovation in this department. And so I had a conversation with some individuals who direct the CPD in this country, and it turns out the Royal College and the CFPC have suspended credits - submitting credits so you don't have to submit the credits for your CPD activities this year. And I said, "why would you do that?" And so there's two thoughts here - two mind spaces - headspaces , if you will. One is focusing on learning. And so if you are focused on learning and you value learning and and problem solving, then this crisis that we're in - because it's a crisis, it's really challenging our systems - will force people to learn how to do other things. It'll say, "wait a minute. You know what? Large in-person conferences that are canceled or not a way for me to get my credits right now. Maybe I need to look at webinars. Maybe I need to look at linking learning practices. Maybe I need to look at reflection, journal reading. Maybe I need to look online modules." Maybe. Right? And instead, what we've been told now is don't worry about it. And it's like, you know, really? Like you just - you would have forced innovation in a whole group of laggards. Like take that curve and say "sink or swim. I'm sorry, it's time for you to swim." And you could've also said, "you know what? We'll relax some of the rules. "But you do it on a case by case basis without people knowing full well that you're relaxing some of the rules. But it would have forced a whole lot of different ways for people be innovative and try new stuff. And instead what we're doing is saying "it's okay, we realize you're busy." You know what? It turns out people are - we're busy. I've been - now that I've taken on certain roles since since the weekend I've been even busier and still seeing my patients or videoing my patients and phone calling my patients, but you know what? For the most part, there's still time in the evening that you could probably do a webinar. They're really -

Dr. Alvi 33:09

Yeah, and I agree with you. I actually think that people are looking up things more or now because there's so much they don't know that they could use that for continuing education and the method of delivery of the information we're getting right now about COVID, about managing things as outpatients during this time. I mean, that could totally be used for CPD, right? -And I think that the messaging, it's about labeling. Like you're doing it anyways. You're reading anyways. You are linking what you're reading to your practice anyways. So it would've been - I totally agree with you - would've been a great opportunity for the colleges to say, "Hey, you guys know how to do this. You are afraid to do it, but you actually do know how to do it and you're doing it. And here we'll give you the credits for it. And now you can do it again once this is all over."

Dr. Rezmovitz 34:03

That's right. I really would've liked to have seen that. It would have been a real step in the right direction towards innovation, supporting people. Like why not get - instead of relaxing everything, just say, "you know what, we're going to support you through this process." You know, the same thing we do for medical students, the same thing we do for our residents. So the thing is, is that when you're an early learner for whatever technology, vehicle, device, platform - whatever you're learning, you need support. You can't do this without support. You can't do this job without support. And this brings us back to the original point, is that family doctors can't do this job without support. We need support from our patients and buy in to say, "you know what, we're going to do phone phone calls, we're gonna do video calls." We need support from the ministry of health to say, "you know what? You're still doing the work. Thank God there are codes now that that remunerate you for the work that you're doing also." We need support in the supplies. We need actual supplies to help us continue to do our job. We don't need wellness initiatives right now that say, "okay, we're going to have a yoga Zoom session on Thursday. Everyone can -" No, I need supplies. Let me do my job. I think that's the biggest thing right now. We can improve mood , anxiety, depression, if we could just give people the tools that they need to do their job. Because the biggest thing that we get with a crisis is anxiety from not knowing, from uncertainty. That frustration. And if we could just give people the tools to do their jobs, it turns out doctors will do their job .

Dr. Alvi 35:48

Yeah. The yoga lessons aren't a bad idea. The meditation is not a bad idea either for some people, but I do you agree with you. We talked about -

Dr. Rezmovitz 36:00

It's Maslow's hierarchy of needs. I need PPE before I go to Zoom Wednesday yoga.

Dr. Alvi 36:04

Point taken. And that - we talked this weekend also about how this has impacted - you and I both work with learners and other faculty and faculty development. What's been really, really cool, Jeremy, is to see how students have stepped up, right? So we have medical students who's - for a couple of weeks school was suspended and clerkship kind of put on hold and we had a bunch of students who all of a sudden weren't in clinics anymore looking for something to do. And that's - I mean, that's k ind o f how you s ort o f got involved. Partly because he's my son and I roped him in, but he w ould've done it anyways, right? But these students w ere doing pretty awesome things around, PPE drives because they're seeing - especially the students w ho've done things like the family medicine longitudinal experience - their preceptors are calling them saying, "sorry, you know what? I'm shutting my clinic down." So these students have gone together and they are organizing these amazing PPE drives and I feel like - I don't think we could have taught them advocacy any better, could w e?

Dr. Rezmovitz 37:14

That's right. [ inaudible] innovation.

Dr. Alvi 37:19

Innovation. And the other really cool thing I just want to put out there is we had a resident two years ago, graduated in 2018, went on to do a year of emerge and he started mask a hero. He's a BC right now - he's practicing BC started mask a hero, which is basically a drive to people identify that they need PPE and there are those who have extra, it's an opportunity for people to share PPE, mostly focused around hospital work. But I connected with them and I said, "you know, Sonny -" [inaudible] "How do we get family doctors to do this?" He said, "you know, I'm really shocked that family docs aren't coming forward and saying we need supplies." And you know what the issue there , going back to feeling isolated? They don't know who to go to. They don't even know who they need to filter these concerns up to like do I tell the ministry, do I tell my MP? Do I tell like - if you're a solo practitioner, who are you going to escalate to? So there's a beautiful platform that's been created to share PPE and none the family docs are coming forward and saying "help, I need help" and we know that they're closing down. So that's kind of what we're doing now, right? We're going to focus our energies on - there's a gap. there's a gap in people's awareness of how they need to access resources or identify what their needs are. And there's a gap in what we know is being done. I'm sure lots is being done behind the scenes that we don't know about. So I'm not even - I'm not disputing that that work is being done. I'm sure it is , and it's great work, but we don't know about it. And [inaudible].

Dr. Rezmovitz 39:09

And that causes anxiety.

Dr. Alvi 39:11

Which is why you need the yoga. And the meditation. So -

Dr. Rezmovitz 39:16

That's why we need assurances from the ministry that we can continue to work because the equipment is coming.

Dr. Alvi 39:23

Yes, agreed.

Dr. Rezmovitz 39:25

That's what we need. I need an assurance that says, "you know what? We haven't forgot about you. We will support you to continue practicing medicine because we know that if the family doctors go down, that hospitals will surge."

Dr. Alvi 39:37

Totally. And the family doctors will never ever be able to compete to purchase anything right now with all the big institutions and hospitals and governments across the world buying millions and millions of items right now. Like none of us would ever be able to compete with that. So you're right - we need assurances from - I'm not exactly sure who. So I'd love to be able to sort of label who those assurances should be coming from to say, listen, we got you. And when you need stuff, don't go to your regular supplier that's marking it up five times what it's worth. We're going to order 10 million. You can let us know what you need and we'll get it. We'll get it to you.

Dr. Rezmovitz 40:25

That's right. The other message that really needs to get out is how to conserve PPE. How to get a pair of goggles and wash them at the end of the day. How to get a gown and reuse it. You know, get a couple of gowns - reusable gowns and wear it all day or half the day, and then wash it. How to structure your office so that you're bringing people in together and bunching them in. Don't bring them in the morning and then later in the - try to bring everybody in at one time so you restructure your office , so that you can support conserving PPE because you can wear a mask for more than one patient. You know, change your gloves - definitely change your gloves, but you can wear the same mask for more than one patient. How do we get masks to our patients because we're going to run out of supplies. So maybe it's important to wear cloth masks - have cloth masks in the office so that you can wash those. And so one of the comments I got from someone was, "you know, family doctors aren't gonna do that. They're not going to wash their own stuff." Guess what? System's changed. Times have changed. Step up. Take care of your patients, find new ways, be resourceful. What are you telling me? So you have nothing. You'd rather let your patients sit there and suffer than you finding cloth mask? I mean, something right now is better than nothing. And I know there are PPE levels of - what's the term? Certification, I guess, of PPE. And it comes down to what do we use every day? And I've been using level one P PE, which is a shirt and pants. I've been going doing house calls for a long time - going into p atients' houses. Now you do your best - you wear a m ask, you wear gloves, you wear goggles if you have t hem, a gown, if you can. But if you don't, you need to come up with better - you need to figure it out, or else we're at risk of closing - sorry, closing. We really need to figure out how to conserve our PPE because this is not ending tomorrow. You know, I would love to say that. You know, I told my kids this morning, I said, "it's over. You're going back to school." And they said, "really?" "No, no, you're not. April fools." This is mother nature battling back and saying, "by the way, we couldn't get all the governments to work together on a single issue. So I sent something in that all of you could work on." You know, I've heard that water is becoming cleaner in certain areas of the world now. We've reduced our carbon emissions and so it's only a matter of time before we go and do the exact same thing. So hopefully we can learn some lessons from all of this and really protect the world and ourselves and of course our patients.

Dr. Alvi 43:14

That's the hope, man. That's the hope.

Dr. Rezmovitz 43:16

That is the hope. Ruby, I'm going to say thank you very much for this candid COVID conversation and I'll see you on the front lines.

Dr. Alvi 43:28

You got it. Thank you so much.

Dr. Rezmovitz 43:29

Take care.

Dr. Alvi 43:30

Bye.

Dr. Rezmovitz 43:34

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.