A total of 26 residents participated in three focus groups between May 2021 and June 2021. Codes identified during transcript analysis were categorized into five themes: 1) history-taking and patient assessment; 2) clinical decision-making and diagnostic uncertainty; 3) patient relationship and communication; 4) preceptorship; and 5) team-based care. Descriptions of subthemes and exemplary quotes are provided below. Additional quotes are provided in Table 1.
Table 1: Exemplary quotes for themes identified during focus group analysis.
Theme
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Exemplary Quotes
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History-taking and patient assessment
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“It just feels like you don’t get a full sense of the picture. Like, you don’t get a full sense of what their issues are, you don’t get a full sense of what they look like, who they are, and it’s harder to make that connection in order to get them to really tell you the full story.”
“I think that I've been able to use video visits to do a lot of things. Even one time I had a patient who was diabetic, kind of high risk for having complications, who said he had an ulcer, but I was able to look at the foot on video, and it was actually just a bruise, which was nice. I think you can do a lot on video if it's used correctly.”
“In certain ways, it makes it kind of easier with some things, you know, when patients have all their pills with them, and you say, ‘Go get the pill bottles. Let's go through what you're actually taking.’ So certain things like, you know, that adherence is a little bit easier to do over telemedicine because they're actually at home.”
“It's usually a little more challenging to kind of ask the more personal questions. So if somebody is sitting in their living room, and they have a bunch of family members in the background, you're not gonna be asking about smoking, drinking, sex, etc. The same way -- I had a patient who decided to take their call while walking around a department store, so you're not gonna go there.”
Generally, there's a direct correlation between how old your patient is and how likely [telemedicine] is to be successful. And I mean I think also you're probably less likely to be able to kind of screen for frailty in these older folks since you're not seeing them, and you're not seeing the change. With that being said, for the younger folks where it's really just ‘I need my referral to this. I need this refilled,’ it is certainly a lot more efficient.
“Probably around 90 percent of my visits have been telephone visits. Most patients don’t really know how to use the video, or… don’t feel comfortable using the technology for video… if they do, they have trouble finding either the link for the VA video or it sort of doesn’t work for them.”
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Clinical decision-making and diagnostic uncertainty
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“Heart failure is one of the ones where it's really hardest or, you know, if you're doing a sick visit and somebody has upper respiratory symptoms and they don't have a pulse ox at home, are they hypoxic? It's a little bit hard to get the objective data.”
“I think it’s really hard for me to get a sense of the symptoms that they’re describing, whether it’s—especially really common ones like just dyspnea and exertion… It’s led to me ordering echoes and PFTs more frequently than I normally would because it’s just like, hard to get any objective data, and it’s like, ‘Okay, are they just deconditioned because they haven’t been exercising or is there something more serious going on?’ So my threshold to order tests is lower and [to] have people come in for in-person visits is also lower.”
“I had a patient a few months ago who had a history of a pretty severe bleed, and then he told me over the phone that he was having symptoms and felt the same as he had the last time, so I just sent him to the ED. And it turned out -- I think he was having a panic attack. But if I had seen him in person and had access to his vital signs, maybe I wouldn't have had to send him to the ED.”
“I think that the physical exam has sort of fallen by the wayside, and that there's not much, to be honest, …that I'm lacking. The only thing is… frailty overall like watching them walk into the office, seeing what they just generally appear like. And then lower extremity swelling. So if somebody's having heart failure, that's really the only thing that I can't assess.”
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Patient relationship and rapport
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“I had a patient that I'd never met before, and he was just assigned to me recently. And I've seen him – I talked to him on the phone three months ago, and then I was following up today, and he was like, after our whole conversation, "Are you my primary care doctor?" Like, he wasn't really clear about what the role was despite me saying like, "I'm Dr. [NAME]. I'm calling from the Manhattan VA." You know, he's not in the office, and he doesn't know where the clinic is. I'm just some random person kind of calling him and saying I'm a doctor.”
“It all depends on having had that preexisting relationship. People that I’ve seen a bunch, especially… in person, … a video visit or a phone call here and there is totally manageable, especially if you have a focus.”
“[For] patients who have limited mobility or can’t afford to get a ride to the VA to come in person, it’s easier for them to at least engage in some form of care… That’s been really nice because now I’m able to at least have visits with patients who I otherwise always miss their in-person appointments.”
“Well, since most of mine are phone calls, I don't have to do the things I normally do like maintain eye contact and show them that I'm listening… So practically, for me, it's a lot faster, but, yeah, I certainly lose that connection with the patient.”
“[After a visit I] give a summary of ‘do this, this, this, and this.’ And if you're telling people that over the phone, I feel like there's less of a chance that they're actually gonna follow through.”
“If you're seeing them in person, you can just say, ‘Okay, our visit's over now. Go down to the lab on the first floor and get all of your blood work done,’ or you can even have them do it before the appointment. But if there's no other reason for them to be physically in the VA, then I think then it becomes a little bit difficult getting them to follow up from that perspective.”
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Preceptorship
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"It is a bit awkward to like, finish the visit and then go precept and then have to call them back about something.”
“[During in-person visits], you’re actually in the middle of a visit which makes you feel like you can kind of bring more things up to the preceptor and maybe change your management a little bit more based on their feedback and then go back to the patient, whereas on a video or phone call you’re like, ending the phone call to go precept. So unless there’s something that I’m really unsure about, that’s kind of it. And anything that I want to change about their management based on my discussion with the preceptor can probably wait until next time.”
“I'm glad [pre-visit precepting] is no longer a thing[…] Oftentimes I would pre-precept, say like what I felt the plan was gonna be based on what I knew about the patient, and then a lot of the times nothing changed. So I didn't really understand the point of the post encounter precepting.”
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Team-based care
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“One of the disadvantages is when you have a very busy clinic schedule, spending time each visit trying to get the technical aspect to work, that can take time away from your 30 minutes that you have… And that can be kind of frustrating sometimes.”
“When the patients are not in person, the other members I just don’t think are as involved naturally because we’re just in a room doing a video visit. Whatever we may need like, support-wise, I just feel like naturally isn’t offered, or it doesn’t feel like as much of a teamwork effort to take care of the patient when the patient is on a video with you and then the video is done and you’re just there, as opposed to like, when I have patients come in person I feel like there’s a little bit more support from them because I feel like they feel maybe that they have more of a role in the patient’s care… They don’t feel ownership of patients who aren’t physically there when I’m on a video.”
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1. Barriers and facilitators to history-taking and assessment
Residents conducted virtual visits via a videoconferencing platform and audio-only phone calls. Residents had a preference for video encounters, which made it possible to visually assess patients when they complained of symptoms. They noted the value of being able to see patients within the context of their homes. In particular, they benefitted from the input of family members who normally would not accompany patients to visits, and from the opportunity to attain clinically useful information about patients’ daily environment and routines.
“I've had some times patients would be like, ‘Actually, let me get my wife here. It might be helpful to hear her perspective.’ And then the wife comes in and is like, "Yeah, this is not normal for him," or something like that. So I actually gain, sometimes more, from that.”
On the other hand, conducting visits with patients outside of the exam room setting occasionally led to concerns about patient privacy, preventing residents from discussing sensitive topics and obtaining a comprehensive history. They noted major challenges in learning about new patients through telemedicine encounters, which was compounded by the inability to conduct a physical exam and make use of skills emphasized in in-person care.
"The very first thing you’re taught in medical school is… to identify patients’ general appearance. I think we spent like, a month just talking [it]... So you’re not getting that… You may not know if they’re obese… Are they… huffing and puffing? There’s… a lot of intangible stuff that you’re not getting.”
Due to technical issues that arose during visits and hesitance among older patients to use videoconference technology, residents carried out the majority of virtual visits by phone. They felt that telemedicine was less appropriate for older patients because it was not possible to assess for frailty or track physical changes.
“My older patients… will immediately shoot this down. ‘I don't understand the technology. I don't want to do this.’ And so they'll just kind of default to doing a phone visit[…] Sound is really hard to deal with on the computers here, and I can't really hear the patient, so I'll have to call them on the phone and then also have them on video.”
2. Clinical decision-making and diagnostic uncertainty
Residents were challenged to provide care to patients without data from a physical exam or up-to-date lab tests. They felt increased uncertainty around making decisions and diagnoses, particularly when presented with nondescript acute symptoms. They acknowledged lowering their threshold for ordering tests when faced with diagnostic uncertainty. They were more likely to escalate to in-person care when symptoms that were difficult to assess over video or phone could have severe and worrisome etiologies.
“I think it’s really hard for me to get a sense of the symptoms that they’re describing… especially really common ones like just dyspnea and exertion… It’s led to me ordering echoes and PFTs more frequently than I normally would because it’s hard to get any objective data..my threshold to order tests is lower and [to] have people come in for in-person visits is also lower.”
Residents had varied views regarding the impact the loss of the physical exam had on their clinical decision-making. While some considered it to be a major limitation of telemedicine, others felt that only a few exam components were truly necessary (e.g. lung auscultations, assessments for heart failure). Difficulty with completing physical exam was therefore only seen as a limitation when a patient’s history warranted one of those necessary exam components.
“In the outpatient setting, I was always doing this full, head-to-toe physical exam, and it wasn’t really changing my management. So I still don’t think [the loss of the physical exam] changed my management that much, but I think the lung exam is one that we do use to make triage decisions.”
3. Patient relationship and communication
For new patient visits, the virtual environment had a notable, and largely negative, effect on the patient-provider relationship. Residents felt awkward meeting patients for the first time over telemedicine and had difficulty establishing a connection with patients they had never seen in person, even after follow-up virtual visits. Audio-only visits seemed to have a greater negative impact on relationship development than video visits as these encounters did not lend themselves to natural opportunities for residents to build patient rapport.
“You're missing that aspect of, like, small talk. ‘Like, oh, come into my office. Oh, is it raining out?’ You know silly little things that kind of like you pick up with a patient.”
For visits with pre-existing patients, residents felt positively about their abilities to maintain relationships. Many residents considered telemedicine an appropriate or preferable method for chronic disease management and an improvement to care for patients who had faced barriers to in-person visits prior to the pandemic. Some residents were able engage patients more effectively by helping them take detailed notes during visits and creating follow-up plans together. Other residents, however, found it difficult to engage patients in their follow-up and treatment plans during virtual encounters, particularly if the plans involved traveling to the hospital for in-person labs and testing.
“In an ideal world, we would have both in-person and video visits, mostly in-person but some video visits, and the video visits would basically just serve as a more frequent touch point with patients…They can be short visits and it’s more efficient for us and easier for the patients.”
4. Preceptorship
With the move to virtual care, residents were asked to complete pre-visit precepting with supervisors to discuss cases in advance, in addition to traditional post-visit precepting. Residents did not find the extra precepting to be helpful and reported eventually stopping pre-visit precepting. Residents perceived there to be less opportunities for real-time learning of clinical skills since they were not conducting physical exams.
“The only thing that's missing that I had a lot of first year was I had a lot of knee pain and shoulder pain come in, and I'm terrible at those exams. And I would have preceptors come into the room and do it for me and show me how to do it. So that part I'm lacking.”
Residents felt awkward navigating the asynchronous workflows for precepting of remote visits. Post-visit precepting involved concluding the visit, calling the preceptor, and then calling the patient back to relay any changes made to the original treatment plan. Residents were reluctant to make “additional” calls because they perceived them to be disruptive to the preceptor – who was conducting their own virtual visits – or patient’s schedule. This led residents to ask fewer questions about a patient’s care and feel less able to make adjustments to a patient’s treatment plan.
5. Team-based care
The switch to telemedicine led to the breakdown of existing clinic workflows for team-based care. New workflows put in place for telemedicine resulted in less interaction between the patient and the medical team and between the resident and the medical team, due to non-physician team members not being involved in telemedicine visits. As a result, residents felt a lack of structure and support during virtual clinics and perceived other team members to be less engaged in patients’ care. Residents assumed responsibility for various tasks that were normally completed by other team members during in-person visits. Due to difficulty accessing technical support during visits, participants felt solely responsible for helping patients troubleshoot any arising issues.
“So I’ve had an issue where like, I’ve had to basically start calling my whole panel upfront before a session just to see if people know about their appointments and if they’re going to be a phone visit or a video visit or whatever. And that’s actually supposed to happen—like, a team member is supposed to do that.”