The aim of this study was to investigate primary care physicians’ perceived work demands, control over working processes, and social support when providing digital consultation to primary care patients. We found that physicians working with digital consultation experienced several advantages with this type of work. The physicians perceived that the job demands were reasonable because the medical cases handled in digital consultation were generally not too complicated. Moreover, the physicians experienced a high level of autonomy and perceived control over their work, which they considered to be very valuable. The physicians also felt they received a great deal of social support from patients, which they found very satisfying. Overall, the participants saw numerous benefits, not only with regard to their own job situation but also for patients and the health care system in general, even though they identified some shortcomings and risks with digital care.
Concerning job control, the participants seemed to value the flexibility and autonomy of digital consultation very highly. The ability to choose where and when to work was a considerable advantage with digital consultation over traditional primary care work. Participants felt they had more time to spend with family when they could work from home. These findings are consistent with earlier research concerning remote working, which has shown that flexible working hours and schedules have a positive effect on productivity and outcomes, such as increased job satisfaction, lower turnover intentions, and reduced role stress (i.e., combining professional role with family role) [15, 37].
The freedom of being able to choose when and where to work was highly appreciated by the participants. They do not have this sort of autonomy in the traditional primary care setting, which largely lacks opportunities for employees to have a flexible working schedule . One way of increasing flexibility for primary care employees could be to integrate digital consultation into the schedule of the daily work in traditional primary care, as well as employers offering the opportunity for physicians to work elsewhere (i.e., at home or other out-of-office arrangement). This would give physicians more decisional latitude on how and when to meet their patients.
The participants identified the technical equipment used for digital consultation as an occasional source of problems. The participants could not control these aspects of the consultation, but it occasionally caused them problems; patients were “lost” and could not be reached again after internet connection issues. Similar technical issues have been reported as a shortcoming and a source of stress in other studies concerning digital consultations [8, 39, 40]. Technical issues and problems were more common and pronounced among participants employed by publicly funded health care compared with participants employed by private companies, who perceived the technical equipment as well developed and highly user friendly.
The participants raised some concerns regarding the potential misuse of health care because the digital route to medical advice is very convenient for patients. This, in turn, generated thoughts about who is entitled to health care and to what extent health care is available for everyone. Similar questions and opinions have been raised by both clinicians and researchers and caused a lively debate in newspapers and medical papers in Sweden as well as in the United Kingdom and in the United States [22, 41, 42]. On the other hand, participants discussed potential unloading of traditional care when patients with minor health problems turned to digital consultations instead of seeking physical care in a traditional way. The participants emphasized that this could possibly lead to more time available for other patients with multiple, chronic diseases and for the elderly. This potential unloading has not been realized in practice; instead there is an increase in the number of patients seeking medical advice digitally [22, 41].
Regarding social support when working with digital consultation, the participants expressed a feeling of satisfaction in that the patients were very rewarding. Some of the participants felt somewhat socially isolated and lonely from time to time. However, others thought the interaction with colleagues improved compared with traditional primary care consultation in that they could get in touch with colleagues through various electronic channels and chat forums. This interaction provided an opportunity to learn from other physicians who were also engaged in digital consultation. Digital consultation enabled the physicians to work from home, i.e., remote working. Earlier research on this type of work has shown that remote working does not have to impede employees’ social contacts with co-workers . However, the findings are inconclusive regarding social support and its effects on psychologic well-being and job satisfaction for employees who engage in remote working in general [12, 43, 44]. Vander Elst et al.  showed that remote workers experienced lower social support from colleagues the more extensively they worked from home and that this was related to higher levels of adverse psychologic symptoms, such as cognitive stress and emotional exhaustion. This finding is congruent with the results in our study because several of the participants expressed that remote working was something they did on a part time basis. The participants employed by private companies experienced slightly more support from co-workers than publicly employed participants. This could possibly be explained by the well-established digital chat forums available for the employees as well as the opportunity to work from the common office rather than from home whenever they chose.
There were some differences in perceived support from supervisors between the physicians in our study who were employed by publicly funded health care and those who were employed by private companies. These differences entailed, among other things, a decline in support from supervisors in private companies compared with the situation at the start. The participants in publicly funded health care received sufficient support from supervisors although there were some differences in supervisors’ enthusiasm for digital consultation, which could affect employers’ experience of support in a negative way. Digital working is a change in the physicians’ way of working and seeing patients, therefore it is important to have supervisors’ support because earlier research has shown that this can mitigate change-related stressors, such as exhaustion and cynicism among employees .
Another notable finding in our study was the satisfaction most of the participants expressed with patients who conveyed their appreciation and gratefulness to the physicians with the consultation. This sort of recognition was highly rewarding and somewhat of a new experience for the participants, who were not used with this type of direct and positive feedback from patients. Research on the patient-doctor relationship in the digital era suggests the need for physicians to acquire new skills in the consultation to be able to diagnose patients without a physical examination as well as interact through digital channels with patients they may not have met before . Furthermore, Mesko and Győrffy  propose a change in the patient-doctor relationship to more of a partnership The findings in our study are also in line with earlier research concerning communication and the relationship between caregiver and patient; patients may experience the digital way less intimidating and find it easier to say what is on their mind than in traditional consultations .
Our findings suggest that digital consultation entails lower job demands than traditional work as a physician in primary care. The participants observed that they predominantly handled easier medical cases in digital consultations. The combination of high levels of control and low demands is well established in low-strain jobs, according to Karasek and Theorell . This type of job yields few, if any, challenges for employees, but in return stress levels are low and the risk of experiencing adverse strain is generally very low, which makes this kind of job highly desirable. Earlier research has shown that being a physician is an occupation with high demands and medium-to-high control, which leads to the development of competence and increased learning and motivation (e.g., active job), which the low-strain job does not . This lack of development and learning was also a concern raised by several of the participants in our study. There seemed to be consensus among the participants that they did not want to work exclusively with digital consultation; they wanted to continue with traditional primary care work as well to maintain and develop their competence. In the short term, digital consultation seemed to provide some relief for stressed physicians, but in the long term they believed this work could disqualify them from working in regular health care.
This study has a few limitations that should be noted when interpreting the findings. We chose a qualitative approach because little is known about primary care physicians’ views on digital consultation. For this reason, we conducted interviews with physicians to gain a deeper understanding of the topic. Participation was voluntary; the interviewees were included in the study after they actively expressed their interest in participation. This means that the participants may have been particularly interested in the topic and/or early adopters with a curious and positive mindset. The findings of the study cannot be directly transferred to international settings. The transferability of our results is limited to primary care settings in Sweden, although participants were recruited from different types of employers and forms of employment. Despite this, the results in our study may be applicable to other settings because the sample is considered variable and adequate . Instead of statistical generalization, we sought analytical (theoretical) generalization by comparing findings with comparable research to the extent it was possible due to the limited amount of research on physicians’ digital consultation in primary care.
The study also has considerable strengths. The multidisciplinary research team enhanced the credibility of the study, because it allowed different perspectives on the issue under study . The team consisted of the following professions: physician (HF), behavioral economist (PN), political scientist (IS), public health researcher (JS), behavioral scientist (CE). Another strength was the relatively high number of interviews (n = 28), although Malterud et al.  have emphasized that the strength of the information received (information power) is more important than the size of the sample. Regardless, this enabled us to use quotations from many different participants, adding transparency and trustworthiness to the findings. It was also a strength that the participants came from different geographic regions of Sweden and from both public and private organizations. Another strength was that the participants included men and women of different ages and with different experiences from previous primary care work.
Implications for further research in the area are important because the work with digital consultation differs greatly from the traditional consultation approach that is part of physicians’ education. Digital consultation is developing rapidly and further research on how it affects physicians in primary care and other settings is important. According to the findings in our study, digital consultation could be one way to increase physicians’ perceived autonomy and reduce stress levels to some extent if it is incorporated in the daily or weekly work. This could possibly lead to increased job satisfaction and reduced burnout among physicians, which is an important issue. It is also important that digital consultations are combined with traditional consultation so that competence is maintained and developed.