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Much has changed at Dr. Javed Alloo's busy family medicine clinic in Toronto because of COVID-19.When possible, appointments are now done by telephone or Skype.Others have been cancelled or deferred. This is especially important, because many of Dr Alloo's patients are older and have compromised immunity due to chronic disease, and so they are at high risk for the virus."The routine of us saying the best thing I can do is to see you back here in two weeks, or two months, suddenly might not be the safest thing to do for them because of COVID," he says.The waiting room at the clinic, which serves about 650 people, has also been shut down.Now if a patient has to come to the clinic, they sit in their car until the doctor is ready to see them and then they are ushered straight into one of the examination rooms.And after every visit, Dr. Alloo disinfects all hard surfaces. He says because of all the new precautions with prep and clean-up, it takes him nearly three times as long to see a patient in person and so there is more pressure on the clinic than ever.But these are the easy changes to make, he says. What's more difficult is how to administer primary care during a pandemic."The reality is nobody knows how to practice this way," he says. "None of us have been trained to work during a pandemic."We have all been trained to work in a stable environment where we know the variables involved."Protecting himself from COVID-19The changes Dr. Alloo has made to his practice are not just to protect his patients — they're to protect him, too.Alloo understands better than anyone the risks of working in a frontline medical clinic. He got his start during the SARS epidemic."The doctor I replaced [at the practice] was a victim then. He died from SARS. He caught it from a patient he was taking care of. So that's the reality," says Alloo.So far during this outbreak, the government has not provided protective equipment for his clinic. The only masks he has are left over from the H1N1 epidemic in 2009."I don't have what I need to do the job safely. It's scary and upsetting," he says."We are willing to put ourselves on the line — being the front-lines — knowing the risk, knowing we have to do more than we are used to doing and to be prepared for that," says Alloo."The general public can afford to stay away. We can't — every day we are back here."'He's passed away'At the time of SARS in 2003, Dr. Alloo was just out of medical school. The Ontario Medical Association asked if he could fill in at a family medicine clinic in Scarborough, Ont., that had been hit hard by the virus. One of the clinic's doctors was quarantined at home with SARS-like symptoms — two others were sick in hospital.Dr. Nestor Yanga was in critical condition."One day the nurse came in crying and saying 'he's passed away,'"" says Dr. Alloo."And so we all knew that the person that we had been working with for so long wasn't going to come back after SARS."Many of Dr. Yanga's patients stayed with Dr. Alloo, and he still cares for them today."It created a strong bond between myself and the patients that I inherited," says Alloo."This is something that has actually brought us together — recognizing the common humanity and the risks we take together getting care when we need it, and giving it when we can."'Not doing the best we can anymore'On this day, Maria Demurrell had to bring her 15-month-old son Ethan to see the doctor to get a vaccine — which the Canadian pediatric society says should not be delayed during COVID-19.Even so, she and her husband debated whether or not to cancel."My husband and I had a conversation about it — he was more terrified than me. His concern was, what are you gonna do if someone there is sick, who does have COVID-19?"That's the risk Dr. Alloo has to balance with providing the regular care his patients need to stay healthy."We are trying to make the best decision between the risk of not coming in, and the risk of coming in," he says."There are some people we will protect this way, and there are some people who are going to get hurt this way. So we are facing the reality that we're not doing the best we can anymore — we are doing the safest we can, given two really bad risks. The risk of managing illness and the risk of COVID."Dr. Alloo explains that some patients will receive inferior care because it will be too risky to see a doctor face to face — or their appointments will be delayed."That means you may be taking some liberties in how you manage their illness," says Alloo. "And perhaps a bad thing will happen and not be caught, because we are not being as vigilant as we normally are. And that's a big concern."'Who won't we save because we are distracted by COVID?'Dr. Allo says his experience during the SARS epidemic helps him today during COVID-19 in several ways. He understands intimately the risks to frontline workers, and that he needs to be mentally prepared for anything."I saw the family of the physician who died of SARS. I saw his kids growing up without their father," he says."And so it wasn't something I could pretend or deny was a reality of this job. It was very lucky that the time to test that reality didn't come again until now."The other lesson he says he reflects on with every patient he sees today is about a near-miss he had during SARS."I remember this one man, this was the first time I met him and this is right at the peak of SARS, and I did his physical checkup — something which we don't want to do right now, we are deferring them during COVID," he says. "And during the examination, I realized that he had cancer. And so there I was wearing full gear — the mask, the gown, the gloves, the most barriered way of two humans talking about something this horrible. And I told him 'hi, we just met — but I think you have cancer.' Then I had to plan for him to get his care."Because of Dr. Alloo's diagnosis, the man had surgery three days later and lived. He is still one of Allo's patients today."I don't know if he realizes every time I see him or his family, I remember what he went through during that time. And right now it actually makes me worried about the people we won't be taking care of because we are so worried about COVID — that we are going to defer their care."Who won't we save because we are so distracted by COVID right now?" he wonders.Still, no matter what happens in the coming weeks, Alloo says he will do whatever he can to care for his patients. "We chose this profession wanting to be of service to people, and it's hard to give that up. That's the bond and the obligation that I have to them," he says."That's the relationship I have with them when I took on the decision to be their family doctor. And that's why I am still here."
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