Use of alternative consultation forms in Danish general practice in the initial phase of the COVID-19 pandemic – a qualitative study

Abstract

Background Attempts to manage the COVID-19 pandemic have led to radical reorganisations of health care systems worldwide. General practitioners (GPs) provide the vast majority of patient care, and knowledge of their experiences with providing care for regular health issues during a pandemic is scarce. Hence, in a Danish context we explored how GPs experienced reorganising their work in an attempt to uphold sufficient patient care while contributing to minimizing the spread of COVID-19. Further, in relation to this, we examined what guided GPs’ choices between telephone, video and face-to-face consultations. Methods This study consisted of qualitative interviews with 13 GPs. They were interviewed twice, approximately three months apart in the initial phase of the pandemic, and they took daily notes for 20 days. All interviews were audio recorded, transcribed, and inductively analysed. Results The GPs re-organised their clinical work profoundly. Most consultations were converted to video or telephone, postponed or cancelled. The use of video first rose, but soon declined, once again replaced by an increased use of face-to-face consultations. When choosing between consultation forms, the GPs took into account the need to minimise the risk of COVID-19, the central guidelines, and their own preference for face-to-face consultations. There were variations over time and between the GPs regarding which health issues were dealt with by using video and/or the telephone. For some health issues, the GPs generally deemed it acceptable to use video or telephone, postpone or cancel appointments for a short term, and in a crisis situation. They experienced relational and technical limitations with video consultation, while diagnostic uncertainty was not regarded as a prominent issue Conclusion This study demonstrates how the GPs experienced telephone and video consultations as being useful in a pandemic situation when face-to-face consultations had to be severely restricted. The GPs did, however, identify several limitations similar to those known in non-pandemic times. The weighing of pros and cons and their willingness to use these alternatives shifted and generally diminished when face-to-face consultations were once again deemed viable. In case of future pandemics, such alternatives seem valuable, at least for a short term.

What has the COVID-19 pandemic taught us about the use of virtual consultations in primary care?

“…10 While some PCPs expressed a preference for video consultations, others reported that video consultations and telephone consultations were equivalent, and they only used video consultations if they needed to see something (eg the face of a patient with depression, or a rash). In studies conducted from April to August 2020, 13 and May to July 2020, 9 some Danish and UK GPs preferred to combine telephone consultations and photographs, 13 particularly for 'static problems' that required visual assessment (eg rash). 9 UK GPs also found it challenging to know how or when to switch from telephone to video, with concerns related to missing physical signs of disease.…”

What are patients’ first-time experiences with video consulting? A qualitative interview study in Danish general practice in times of COVID-19

“… 2 Compared with telephone consultations, the visual aspect in VC adds gestures and body language to the GP-patient interaction and enables the patient to offer their body for visual examination. 3 …”

“…Literature relating to VC user experiences in primary care both before and during the pandemic present mixed and highly context-dependent results. 3–6 Generally, quantitative and qualitative studies, reporting on patient satisfaction of VC in primary care, point towards high satisfaction (compared with physical or telephone consultations) and high interest in future use, especially among patients with non-critical conditions, mental illness and chronic conditions, who report increased convenience in terms of time saved (avoiding travel-time and waiting time) and of consulting with the practitioner from a place of one’s own choosing (mostly the home). 4 6–9 While some patients have reported VC to be their preferred consultation type for selected health conditions, indicating that needs for patient-centred care and rapport-building have been satisfactorily met through a VC, others have reported to prefer physical consultations due to technical challenges, privacy issues and loss of the ‘personal’ feel of a physical encounter.…”

“… 4 10 Although many GPs find VCs to be appropriate for selected consultations, GP-experiences with VCs have given rise to concerns about quality and health outcomes: that VC will increase the risk of missing out on patients’ symptoms, weaken relational rapport-building due to a limited use of one’s senses and ‘gut feeling’ and widening health inequalities among groups of disadvantaged patients. 3 11 In a cross-sectional study among GPs in Norway, 51% of GPs evaluated VC to have similar or better suitability compared with physical consultations. However, the GPs perceived suitability to vary across health problems and reasons for consulting.…”

“…VC is a remote, synchronous consultation type which facilitates audiovisual two-way communication between general practitioner (GP) and patient 2. Compared with telephone consultations, the visual aspect in VC adds gestures and body language to the GP-patient interaction and enables the patient to offer their body for visual examination 3…”