Virtual Care: Perspectives From Family Physicians

The COVID-19 pandemic transformed the health care system as the availability of virtual visits expanded and robust online patient portals developed. Virtual care, which includes video or phone visits, has continued as an alternative to in-person appointments. Virtual care may reduce both the burden on the health care system and exposure to communicable disease; however, potential downsides include the invasion of patient privacy, ^{1, 2} safety incidents that can lead to patient harm, ³ poor fit for chief concerns, ⁴ and challenges communicating and building rapport. ^5- 7 Moreover, the benefits are unequal because patients most likely to have cancelled or missed video visits are over age 65, ⁸ historically minoritized races and ethnicities, ^{8, 9} male, ⁸ lower income, ⁹ limited English proficiency, and those with disabilities or multiple comorbidities, ^{8, 9} Single parents, people of lower income, those with disabilities, and work-family conflicts are more likely to experience time poverty and also may have poorer physical and mental health outcomes. ^{9, 10} Research with primary care team members has noted that virtual care resulted in improvements in wait times ¹¹ and an increase in the number of visits related to mental health. ¹² The continued use of virtual care has the potential to change the practice of family medicine and the health care system.

Family physicians care for patients of all ages with a variety of concerns and develop long-standing patient-physician relationships. Family physicians are uniquely positioned to assess the role of virtual care for a wide range of chief complaints as well as for its impact on patient-physician relationships. However, little is known regarding family physicians’ perspectives on optimizing virtual care.

This study explores physician perspectives to improve the quality and effectiveness of virtual care for both patients and physicians. Unlike literature published as a direct result of the pandemic, this study allowed for investigation into a virtual care system that has evolved since the pandemic began. This study adds possible practice implications and provides future directions for ongoing use of virtual care.

We conducted qualitative semistructured interviews with physicians at Michigan Medicine, a large academic medical center. The University of Michigan Institutional Review Board approved the study as exempt (HUM00199739).

We recruited from two sources, inviting 38 respondents in the Department of Family Medicine to a physician survey (31% response rate) ¹³ and 47 additional physicians who practiced in clinics serving diverse populations or providing specialized care. Interview invitations were sent in November 2021, approximately 20 months after the World Health Organization declared COVID-19 a pandemic in March 2020, ¹⁴ and 16 agreed to participate. Recruitment was guided by purposeful sampling based on two criteria; physicians had to provide virtual care as well as specialized care. These specializations ensured that the study applied to the entire scope of family medicine practice and captured vulnerable populations. All saw general primary care patients.

The interview protocol covered domains of access, uptake, adherence, and efficacy of virtual care. Sample questions included (a) How convenient is virtual care for your patients? (b) How did your patients respond to virtual care? (c) How engaged are your patients during virtual visits? and (d) In what ways do virtual visits make it easier or more difficult to see patients?

All interviews were professionally recorded and transcribed verbatim. Analysis followed an inductive thematic analysis approach. ¹⁵ Two researchers (OR and TG) coded two transcripts independently to develop a codebook. Through consensus meetings, they compared codes, revised codes, and refined the codebook for application to the remaining interview transcripts. Next, with the larger research team, they identified themes. We conducted analysis in MAXQDA (VERBI) software.

Sixteen family medicine physicians, including two residents, participated in the interviews. Most (n=11) were female, and areas of specialization included women’s health, deaf health care, Japanese family health, and sports medicine. Four major themes were identified, including (a) chief concerns appropriate for virtual evaluation, (b) physician perceptions of patient benefits, (c) patient-physician communication, and (4) structural support needed for high-quality virtual care.

Physicians identified several chief concerns that were appropriately addressed virtually, as well as other concerns best evaluated in person (Table 1). Chief concerns that do not require a physical exam or that can be followed asynchronously (eg, blood pressure or glucose measurement) were considered well-suited for virtual care. In contrast, some acute concerns (eg, gynecologic or respiratory concerns) are best assessed through physical exam, and thus physicians preferred in-person visits. Despite their discomfort addressing some acute concerns virtually, such as possible ear infections, several physicians believed that virtual care is preferrable to no visit.

Physicians identified convenience as a patient benefit of virtual care (Table 1). Providing virtual care has the potential to decrease barriers that may prevent patients from accessing care. For example, with virtual care, patients can continue with daily tasks instead of sitting in a waiting room and dealing with issues such as transportation, childcare, or work schedule. Additionally, virtual care is more convenient for caregivers, enabling multiple caregivers to attend visits without being physically present.

Physicians noted that virtual care has enabled new means of communication with patients (Table 1). The ability to have visits outside of the office setting provides a window into a patient’s home environment. Physicians also noted that virtual visits are more efficient for providers, because discussions during virtual visits are more focused.

Physicians identified the need for systems and structures, such as workflows and technical support, to be in place for virtual care to provide high-quality care comparable to in-person visits (Table 2 subthemes).

Family medicine physicians believed that virtual care increases appointment efficiency, while also opening doors for patients who may not be able come to the clinic, perhaps because of physical, travel, or time-related challenges. ¹⁰ Increasing visit efficiency and advocating for increased integration of virtual care is especially important in these populations and may contribute to increased health care access.

This study reinforces findings in prior research that seeing patients in their home setting yields contextual insight into a patient’s life and allows providers to see their patient as a whole person and not just a set of symptoms. ^{1, 12} Thereby, physicians may be better equipped to address upstream social determinants of health. Including caregivers in the appointment can broaden the patient’s network of medical and social support and improve health outcomes. ¹⁶

Virtual care has the potential to increase visit efficiency and improve quality of care. ^{12, 17, 18} Physicians in this study identified systems such as triaging, ⁴ portal enrollment, technical support, and postvisit follow-up as imperative to providing equitable and quality care. Next steps include developing systems to ensure proper follow-up care and identifying which chief concerns are appropriately triaged for virtual visits. Training related to virtual rooming, patient portal registration, and troubleshooting will be necessary. Further studies are needed to clarify how to systematically train and support team members. ^{19, 20}

Limitations of this study include its completion in a single department at an academic medical center with mostly urban and suburban settings. Physicians’ perception of patient reaction may differ from actual patient experience; study of patient experiences is needed. Comparison of provider and patient perspectives of virtual care may help to identify mismatches in expectations and goals. Future research is needed in different health care settings such as community health centers, office-based practices, and rural areas.

Dr Veinot’s work on this research was supported, in part, by an unrestricted gift from Google Health. In addition, a University of Michigan, Department of Family Medicine Building Block grant provided funding for this study.