After 2 days on antibiotics, a patient comes to your ED for a second opinion because her sore throat has not improved. She thinks her virtual care diagnosis may be wrong, and it is. She actually has a large viral ulcer on her soft palate. Another patient is referred in for a physical exam because he reported “dark” stool to the virtual care doctor. Yet another arrives with cough and fever. He looks well, his lungs are clear and he has a viral syndrome, but he demands a chest X-ray because the virtual doctor sent him for one.

As part of the COVID-19 response, the Ontario Ministry of Health funded a virtual urgent care (VUC) pilot program at 14 Ontario emergency departments to divert patients with low acuity problems and reduce the need for face-to-face contact. In this issue, McLeod et al. surveyed patients who used this service [1]. Mean age was 27, 73% were female, 87% had higher than post-secondary education, 90% already had a primary care provider, and 72% fell into CTAS 4 or 5. Two-thirds were discharged; the rest were referred to the ED or another provider, and most were very satisfied with their virtual visit. The study did not evaluate whether VUC reduced ED visits but concluded that VUC should be accessible to underserved populations, and could perhaps be provided more economically by non-emergency physicians.

During COVID, people worked from home and liked it. Post-pandemic, many stayed at home or even refused to return to the office. A recent CMA report acknowledged that many physicians were also reluctant to return to the office [3]. Before COVID, 1.2% of primary care visits were virtual. During the pandemic, this number skyrocketed to 71%. As the pandemic waned, virtual visits settled at 40% overall, but 52% for family physicians [2]. A 2021 Health Infoway survey found that 64% of physicians intend to maintain or increase their current level of virtual visits [4]. This is terrifying.

Some things should be virtual: prescription refills, counseling, and follow-up checks for patients with chronic (already diagnosed) conditions. And virtual care for remote settings may be a step toward healthcare equity [5]. Proponents often claim that telehealth reduces health costs, but there is little evidence to support this contention, except where physicians or patients have substantial travel costs to access or provide care [6]. Virtual care’s greatest selling point is convenience. Patients and physicians like it [6]!

Virtual care also has drawbacks, including overuse and inappropriate use, the cost of virtual infrastructure, limited provider training, inability to perform physical examination, heightened clinical uncertainty, misdiagnosis, diagnostic and treatment delays [6, 7], and the inability to perform basic procedures. Difficulty establishing new therapeutic relationships, interpreting complex mental health issues, and missing important findings or nonverbal cues are also problematic [2]. When a physician decides a physical exam is necessary, it mandates a second (in-person) visit for the same problem or a referral to the ED [7].

The VUC system described by McLeod et al. fits the description of a “virtual walk-in clinic.” It provides episodic care by physicians who have no prior knowledge of the patient and no ongoing accountability for the patient. These models compromise care continuity, promote fragmented lower quality care, and drive up healthcare costs [8]. The growth of virtual walk-in clinics is leading to incorrect diagnoses, unnecessary antibiotic prescriptions and duplication of care [7, 8]. A 2020 position statement from the BC Family Doctors stated that, “Episodic telemedicine services pose risks to patient safety and quality of care.” The BC College of Physicians and Surgeons concluded that it is “almost impossible for virtual care physicians to meet expected care standards for the majority of patients presenting with episodic concerns” [9]. Virtual technology will improve but, currently, if a patient is ill, injured, or needs a correct diagnosis, in-person medicine is unequivocally superior.

Virtual care may also aggravate healthcare inequities. Marginalized patients and the elderly often have poor access to technology and may not be able to advocate for in-person appointments. Several studies show, as this one did, that patients who access virtual care are younger, wealthier, have lower health needs, are usually already connected to family health teams, and consume a disproportionately high number of services [1, 2, 7, 10, 11].

Canada has more doctors per capita than ever [12]. Despite this, Canadians face huge challenges getting a doctor and accessing care. Part of the reason is that primary care is hard. Family physicians have all the stresses and obligations of small-business owners, as well as ethical and personal accountability to their patients, and they are poorly compensated. In a series of policy blunders over the last 2 decades, governments and system planners have created countless opportunities for family physicians to leave primary care and do something easier. They can work in urgent care centres (UCCs) that were ostensibly intended to reduce ED visits and mitigate primary care shortfalls. Sadly, UCCs do not provide quality primary care or reduce ED visits, but they do suck large numbers of patients and physicians out of primary care, exacerbating primary care shortfalls. GPs seeking a better work life can also become hospitalists, work ED shifts in smaller communities, or provide boutique care in an endless variety of clinics ranging from cosmetics to sports medicine to maternity to addictions. These services provide value, but our problem is primary care.

Virtual walk-in medicine provides the greatest opportunity yet for physicians and nurses to escape primary care settings, where they provide high-value care, and move to home offices where they will provide some useful and some inappropriate or substandard care. This huge shift away from in-person care is driven by physician and patient convenience rather than outcomes or cost-effectiveness, and is likely to further exacerbate physician and nursing shortages [10]. As evidenced by the stampede of corporations like Zoom, Babylon, Cisco Systems, Amazon, Telus, and countless others into VUC provision, there is money in virtual care. This is attractive to corporations and to physicians.

I have no major concerns about the study. It is well done and the authors present a balanced and interesting discussion of virtual urgent care, although I need to know about outcomes other than just patient satisfaction. I appreciate the authors’ comment that “they question whether ED physicians and nurses should provide this type of care.” I question whether we should endorse any further shift to a care model that, despite its convenience, is inferior to in-person care for most things, draws physicians and patients away from more complete care interactions, does not save healthcare dollars, and is likely to not meet care standards, according to credible physician organizations. This shift does not bode well for patients who need actual care (the majority) or for physicians still willing to provide it.

Do we really aspire to a system where you can deliver or receive health care without leaving the breakfast table? “Mikey likes it” is a good reason to buy Life brand cereal, but not to fundamentally change healthcare delivery.