There were 773 registered clinicians eligible for inclusion. Two hundred and seventy-nine completed the survey, resulting in a 36.1% response rate. Basic information on participating clinicians and their clinical practices can be found in Table 1. The majority of participants (207, 74.5%) worked in a private clinic setting. Most had been in practice for 21 to 30 years (77, 27.8%) and were located in “District 1—Toronto (100, 36.0%) or “District 5—Central East” (78, 28.1%). These jurisdictions contain municipalities with the largest populations in the province. Participants were closely split between those who worked in a single practice or institution (156, 56.5%), versus those with a secondary practice (120, 43.5%).

Survey participants described the impact of the COVID-19 pandemic on foot care services in a variety of ways. In particular, they experienced a decrease in patient volume (189, 68.0%), an increase in the cost of running their practices (163, 58.6%), reduced access to podiatric equipment and supplies (150, 54.0%), and increased wait times for patients (147, 52.9%) (Table 2). The biggest barriers, according to respondents, were scheduling of patients to allow for physical distancing (110, 39.6%), additional time to provide care (92, 33.1%), increased operating costs (92, 33.1%), and what clinicians perceived as patient anxiety or reluctance to return to care (172, 61.9%) (Table 2). During the first wave of the pandemic (March to August 2020), the provincial government declared a shortage of personal protective equipment (PPE) from medical distribution channels and COCOO notified members of a known shortage of accessible PPE. However, by April 2021, 41.0% (n = 114) reported access to PPE as a barrier, with access to disposable surgical or procedure masks (55, 19.8%), disposable gloves (53, 19.1%), and N95 masks (49, 17.6%) representing the PPEs most difficult to obtain (Table 2).

Participants’ responses indicated a consistent decline in patient volume as compared to pre-pandemic patient capacity levels (Table 2). Specifically, 36.1% of respondents reported seeing over 76 patients per week prior to the pandemic, while only 18.8% have reported seeing high patient volume during the pandemic (up to April 2021). The greatest changes were observed for clinicians seeing less than 25 patients per week and over 100 patients per week pre-pandemic. Conversely, only 30.5% of respondents saw fewer than 50 patients per week pre-pandemic, which increased to 61.7% during the pandemic. By April 2021, 36.2% of respondents reported no change in the number of patients compared to their pre-pandemic patient volume (Table 3). In terms of the financial impact of COVID-19 on clinicians’ practices, the majority of respondents reported a moderate to great impact (46.5% versus 38.7%), while only 14.8% of clinicians (n = 32) reported minimal to no impact.

Following the cessation of care which lasted from March 19, 2020 to May 26, 2020, the CMOHO encouraged all health care providers “to implement a system for virtual and/or telephone consultations when and where possible” [3]. Initial consultations conducted by virtual or telephone consultation would determine whether an in-person appointment was necessary. This would also support physical distancing efforts and limit contact of individuals who may potentially have had COVID-19 with others in healthcare settings. One hundred and twenty participants (55.3%) reported incorporating telehealth and/or virtual care into their practices. Specifically, 80 (36.9%) used telephone only, 2 (0.9%) used video (i.e. virtual care) only, and 38 (17.5%) used both. Ninety-seven (44.7%) did not change their practice to include telehealth or virtual care. Participants commented on a reluctance to implement virtual care as they felt the need to provide direct hands-on interventions in order to provide effective, appropriate and safe foot care. As the pandemic wore on, many moved to some form of virtual care while some participants reported that virtual care was not possible due to barriers faced by patients not having a phone, equipment, or sufficient internet access.

The CMOH also encouraged health care providers to introduce precautionary measures and modifying the delivery of services [4]. Study participants reported a variety of modifications which they introduced in their clinical practices (Table 2). There was broad uptake of these safety precautions, which notably included: pre-screening of patients (i.e. travel history, any contact with a COVID-19 positive individual, presence of any COVID-19 symptoms) (215, 77.3%), increasing sanitizing practices in the clinic environment (210, 75.5%), providing PPE to clinicians and other healthcare setting staff (204, 73.4%), rescheduling patients who reported being COVID-19 positive or reported potential COVID-19 symptoms (190, 68.3%), increasing wait times between patients (180, 64.7)%, and installation of physical structures (e.g. sinks, ventilation, glass or plexiglass, etc.) (172, 61.9%).

Despite the increase in costs associated with many of the modifications to service delivery and the reduction in patient capacity, only 67 (24.1%) of respondents reported increasing fees to patients (Table 2). In the open-ended comments, numerous respondents communicated their intention to continue with the precautionary measures and augmented infection control practices in their clinical practices post-pandemic.

Due to the halt of all non-emergent surgeries and non-urgent health care services (from March through May 2020), participants found it necessary to prioritize in-person care for urgent foot health problems after restarting non-essential services in June 2020. In April 2021, 197 (83.8%) respondents reported that they had been contacted by patients or seen patients regarding an urgent foot health problem since the start of the pandemic. Furthermore, 131 (55.5%) respondents reported seeing an increase in the number of patients with foot health problems between November 2020 and April 2021. The type and number of urgent foot health problems varied greatly by respondent. One hundred and sixty-nine clinicians saw patients for pain-limiting mobility (60.6%), 183 for infection (65.6%), 176 for wounds (63.1%), 150 for diabetic foot changes (53.8%), and 164 for self-inflicted injuries sustained while trying to provide their own foot-care (58.8%) (Table 4). Respondents also reported treating foot health issues, such as ingrown toenails, tendonitis, foreign body, trauma, and gangrene. Fifty-six clinicians (23.8%) described at least one patient with a non-traumatic or diabetes-related lower extremity amputation during the pandemic.

Survey respondents expressed that the COVID-19 pandemic had affected their mental health and emotional well-being in a variety of ways: stress (162, 58.3%), fatigue (139, 50.0%), anxiety (128, 46.0%), burnout (90, 43.4%), fear (54, 19.4%), and depression (53, 19.1%). Only 15 individuals (5.4%) reported no impact. Sixty-two respondents (28.6%) sought support or accessed other resources to improve their mental health and physical wellness in the time encompassed by this survey (up to April 2021).

In April 2021, 149 respondents (68.3%) reported feeling prepared for subsequent COVID-19 waves, 186 (86.1%) felt prepared for future pandemics, and 181 (83.4%) thought that vaccines would return their practices to their pre-pandemic state. Respondents also indicated that vaccines, stable supplies of PPE, public health crisis guidelines, and clear provincial and federal responses are important factors that contribute to their feeling prepared for future pandemics.