COVID-19: A Qualitative Analysis of Academic Family Physician Leaders’ Crisis Response

The onset of the COVID-19 pandemic threatened all aspects of academic family medicine (FM),¹ constituting a crisis.² It prompted multiple research articles on leadership,^1, 3 FM management,^4,-9 academic pivots,^10,-12 and lessons learned,^13-19 but few have examined how these responses arose.²⁰ Our objective was to gain insight into the context and nature of FM leaders’ discussions to address a crisis.

We used a qualitative descriptive design, which is appropriate to understand a phenomenon within its context.²¹

The Department of Family and Community Medicine (DFCM) at the University of Toronto uses a distributed academic model,²² with over 1,900 faculty at 14 hospital sites and multiple community practices. Monthly executive meetings include the chair, academic programs leaders, hospital site chiefs and senior staff. Meetings are forums for exchanging information, formulating policy, and coordinating action.

From a sampling frame of recordings of monthly executive meetings, we purposively sampled²³ six: three meetings before Ontario declared a state emergency in March 2020 and three afterward (Figure 1). All attendees (median 33, range 30-36) consented and the University of Toronto provided ethics approval.

The coding guide was informed by three dominant attributes of effective leadership: a vision, enabling others to succeed, and excellence in an area. ²⁴ We identified additional attributes from crisis leadership literature. ^25-33

We used the constant comparative method.^34-36 Two researchers who were not members of the executive committee and did not attend meetings independently coded transcripts. They assigned codes to leadership behaviors and compared codes within and across transcripts. Major themes with supporting quotes were then developed and discussed with the team. To reduce the potential for errors in data interpretation, three research team members who were on the executive committee checked the deidentified quotes against the themes.³⁷ We maintained study rigor through a systematic record of codes and memos, using data management software and research team expertise.^37-39 We addressed member checking through a presentation and discussion of our findings with the executive in December 2021.³⁷

Figure 2 presents an overview of the themes and timeline. 

See Appendix Table A for descriptions with exemplar supporting quotes, of the following six major themes.

Building capacity and expertise in academic FM was a focus of all meetings. After pandemic onset, everyone demonstrated eagerness to help through expanded clinical roles and broader responsibilities in response to community needs, despite uncertainty. Table 2 lists examples.

Building leadership capacity in FM was evident in many examples of nurturing and supporting leaders and identifying rising stars. During the crisis, we noted the emergence of new leaders among front-line staff.

Commitment to advancing equity, diversity,and inclusion (EDI) was evident in all meetings. An equity lead was appointed in January 2020 and an EDI retreat was planned. During the pandemic, we noted advocacy for vulnerable populations.

The executive consistently took responsibility for learner safety and well-being. During the crisis, concerns centered on emotional well-being, physical safety, and supporting attainment of competency.

All meetings had examples of striving for and celebrating excellence, including encouragement to apply for awards, grants, and promotion, and a standing agenda item recognizing recipients. As the crisis unfolded, recognition focussed on successes in improving virtual care and education.

A supportive and collegial environment was evident in frequently expressed appreciation for the ideas, contributions and expertise of faculty, residents, and learners, and included respectful voicing of disagreement or concerns.

Situational awareness was a key executive function, through gathering and interpreting pertinent crisis information. Leaders grappled with decision-making in the face of uncertainty and rapid adaptation to changing clinical and educational protocols.

Increasing multidimensional communication beyond existing networks was essential. A web page was published with current information and links. Frequent email and Zoom check-ins kept everyone updated. A “Chief’s COVID-19 Roundtable” facilitated joint problem-solving. Improving communication with isolated community family physicians was highlighted.

The executive demonstrated emotional awareness of the pandemic’s impact, with opportunities to vocalize fears and address concerns. Staying calm and reassuring staff and learners were priorities. Wellness and resilience initiatives were shared. There were expressions of positivity, optimism, and gratitude, despite challenges.

Innovations in education and patient care included rapid pivots to virtual care and education (Table 2). Alternative locations and protocols were launched for in-person care and COVID-19 assessments, mitigating the impact of the closure of some community FP offices.²⁴ A province-wide webinar program was launched to provide resources and support for FPs.

Proactive planning for extended adaptation began shortly after the onset of the pandemic, such as anticipating the needs of incoming learners. Executive members expressed commitment to maintaining core functions.

This research adds to the literature by systematically identifying the context, nature, and culture underpinning actions academic family physicians undertook in response to the COVID-19 pandemic. The specific clinical and academic initiatives are similar to those previously reported. ^1, 4-12

The six ongoing themes formed the foundation for the crisis response. The collegial environment fostered trust, considered essential for crisis management.^40-45 Crises are unexpected, unstructured, characterized by incomplete and conflicting information, and outside typical operational frameworks.^{3, 25, 46 *} The need for new approaches was evident in the emergence of five crisis-specific themes. Situational awareness is essential for developing strategies and making decisions during uncertainty.^25, 28, 29 Along with increased multidirectional communication, this sustains trust in a chaotic and rapidly changing environment.

The ongoing themes of building capacity and expertise, striving for excellence, and developing leadership created an expectation to confront the crisis with authenticity, competence, and credibility.^{13, 25, 41, 44} Enhanced support for the well-being of the health care workforce, including trainees, is an important learning.¹⁶

The pandemic has highlighted the importance of quality primary care for population health^47, 48 and the value of generalism for rapid adaptation to addressing emerging needs.⁴⁹ This research suggests that the skills and culture of FM facilitate an effective crisis response.

A strength of analyzing meeting transcripts is avoiding recall bias by accessing discussions as they occurred, but a limitation is omission of nonverbal interactions. The six selected meetings underrepresent communications and discussions throughout the DFCM and focussed only on the initial onset of a pandemic that continues to generate crises and controversies. We assessed that our analysis achieved informational saturation, but we are cautious due to the limited data set.⁵⁰ This study is exploratory; a richer grounded-theory approach capturing more executive meetings and discussions throughout DFCM’s 14 sites could provide greater insight into the response and its perceived effectiveness.

This exploratory study identifies six themes describing the cultural and organizational approaches that formed the foundation for the pandemic crisis response of academic FM leaders. Five crisis-specific themes reflect skills and attitudes that are essential in clinical family medicine, including adapting to community needs, communication, and emotional awareness.

* These descriptors usefully distinguish the COVID pandemic crisis from medical emergencies, for which there are recognized management protocols.