Introduction
As COVID-19 cases began to rise in Ontario, the public health and healthcare sectors began to rapidly prepare. A core component of preparations was to increase surge capacity in hospitals, anticipating a large influx of patients that would require critical care and ventilation. Plans were made for family physicians to be redeployed to work in hospitals if needed. However, as societal physical distancing measures took effect, the rate of transmission fortunately decreased. In most areas in Ontario, mainly outside of the Greater Toronto Area, the expected surge did not impact hospitals to the degree that was feared and expected. Instead, the majority of cases were managed in the community by primary care physicians.
Family medicine, as a specialty, is defined by several characteristics:
community-based;
continuity of care;
first point-of-contact;
comprehensive whole-person care;
coordination of intersectoral and multidisciplinary team.1
While other medical specialties may at times incorporate some of these attributes, none exemplify all of these characteristics in the same way as family medicine. Importantly, there has been extensive research to demonstrate that access to a family physician improves patient satisfaction, hospitalization rates, clinical outcomes and equity.2-4 It is precisely these characteristics that place family physicians in a unique position in pandemic response. In this article, we outline some of the vital functions of primary care during a pandemic, based on studies and experiences of previous pandemics. Working through the course of a pandemic, from onset, peak, recovery and planning for the next pandemic, we demonstrate the need for support for primary care to explore and perform its role in a pandemic, outside of the hospital system.

Educate and Communicate
Many patients will inevitably turn to their family physicians as “trusted and credible sources of information.”5 In fact, family physicians may be considered more reliable by patients than public health organizations. This may be due to the longstanding relationship between a patient and their family physician, but also due to mistrust amongst some groups of governmental organizations, including public health organizations.5 Therefore, family physicians have a duty to remain up-to-date with the best evidence as the pandemic progresses, and public health organizations must maintain open lines of communication with primary care.6 Family physicians have the opportunity to provide patients with advice on individual preventative measures, self-management of symptoms and to correct sometimes detrimental misinformation.7
Another opportunity for family physicians that may be overlooked and under-utilized is to emphasize with patients with COVID-19 the importance of isolation. Case-contact tracing and reinforcing self-isolation is one of the core responsibilities of public health. Nevertheless, when a patient is diagnosed, there is an opening for their family physician to contact them and reinforce public health measures.8,9 Similarly, if a patient were to identify themselves to their physician as a contact to a case, the role of quarantine can be emphasized. In this way, family physicians help to slow the spread of COVID-19.

Surveillance
Primary care physicians are a key component of surveillance systems, with the responsibility to report to public health when they identify communicable diseases of significance. For example, as a patient’s first point-of-contact, primary care tends to identify a spike in seasonal influenza earlier than emergency departments, and can serve as a reliable indicator of underlying trends in community transmission.5,10 This function will become increasingly important in post-peak surveillance, when primary care physicians will be the ones to whom patients are most likely to first present, and may therefore be the first to identify resurgence of COVID-19.

Triage and Treatment of Pandemic Illness in the Community
While a small subset of patients with COVID-19 will inevitably require hospitalization, the majority will be seen first and solely by primary care because the majority of infected individuals experience only mild to moderate symptoms. In Ontario, as of August 28, 2020, 11.6% of cases had ever been hospitalized, meaning that almost 90% of cases were managed in the community.11 Treating as many patients in the community as possible also removes strain from the hospital system, reducing the risk of overwhelming hospital capacity.12 Furthermore, reflecting on their experiences of COVID-19 in Italy, a group of intensive care physicians wrote, “We are learning that hospitals might be the main COVID-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. . .This disaster could be averted only by massive deployment of outreach services. Pandemic solutions are required for the entire population, not only for hospitals.”13 Similarly, a model based on pandemic influenza and SARS found that a higher concentration of hospitals is linked with greater spread and mortality, while a higher concentration of community-based primary care clinics to triage, diagnose and treat the pandemic illness was associated with reduced transmission and mortality.14 Hence, primary care of COVID-19 in the community is critical to keep as many patients out of hospital as possible to reserve constrained hospital resources and prevent institutional outbreaks.

Prevention of Spread Amongst Vulnerable Populations
Certain populations will be at a higher risk of contracting communicable diseases, such as those who are unstably housed or living in congregate settings. Still others are more vulnerable to worse outcomes from a respiratory illness, such as those who are immunocompromised or have multiple comorbidities. Public health organizations will often attempt to broadly identify, inform, and provide support for these populations. Yet, primary care physicians are in a unique position of being able to individually pinpoint who in their practice is most vulnerable.10 By proactively reaching out to these patients, family physicians are able to provide education and support to prevent spread to these individuals. No one else in the healthcare sector is able to perform this function in the way that family physicians can.
Moreover, in most communities, family physicians form the backbone of outreach services to the most vulnerable and to congregate living settings. In these settings, family physicians may be expected to set the standards for infection prevention and control measures, as well as help coordinate response to outbreaks within the facility.15,16

Home and Community Care of Higher Acuity Non-Pandemic Illness
During a pandemic, primary care physicians will need to provide care in the community to an increasing number and higher acuity of patients. Patients that may have typically been admitted to hospitals for short stays may need to be treated as an outpatient during a pandemic. This is primarily to divert patients away from hospitals that are already stretched in terms of resources.12 Further, this prevents vulnerable patients from risking exposure in the hospital setting. There are multiple potential avenues to provide this increased care, including continued adapted clinic-based care, strengthened multidisciplinary home care, tele-monitoring and virtual visits.17

Vaccination
If and when this becomes available for COVID-19, primary care physicians are going to play an important role in delivering population-wide vaccination. While this process will likely be coordinated by public health, primary care offers a built-in infrastructure for rapid distribution of vaccines. Moreover, in a survey on influenza vaccination in 2009, about a third of people were found to be reluctant to receive the vaccination even after public health messaging.18 Yet, due to longer-standing rapport, patients may be more likely to receive the vaccine after discussion with their family physician.9

Post-Pandemic Recovery
Considering the stringency of societal physical distancing measures, during which many lost jobs and social contact decreased, there will be a lot of rebuilding that must take place following COVID-19. Some patients will have increased health needs due to the long period of physical distancing, and the impact that has had on their physical and mental health.19 Others will have avoided acute or delayed routine medical care due to fears over exposure to COVID-19.20 In the post-peak period, family physicians will have a large role in caring for these needs. Following the relaxation of physical distancing measures, there will likely be an increase in demand of counselling and mental health services, higher volume of preventive care, and a higher acuity of medical complaints.9

Pandemic Planning
Finally, a core component of pandemic recovery is to assess lessons learned and begin to prepare and plan for another pandemic. This needs to take place within each organization and across organizations in the public health and healthcare sectors.16 Traditionally, primary care specific planning has been limited.21 However, COVID-19 highlights the importance of having primary care representatives in the creation of pandemic preparedness plans.