The 28 participants displayed different characteristics (Table 1). Seventeen were employed by publicly funded primary care units in 4 regions and 11 worked in 4 different private companies. Of the 4 private companies, 3 work predominantly with digital consultation although they also offer traditional consultation to a limited extent, and the fourth company offers digital consultation as an option besides their regular primary care. The public regions offered digital consultations as a minor part of their regular primary care. The publicly employed physicians either performed digital consultations as part of their regular employment or as an additional, reimbursed task. Participating regions and companies were located in urban areas in central and southern Sweden. However, the patients could be expected to live in both rural and urban areas since the service is available to patients from the whole of Sweden, i.e. without geographical restrictions. Thirteen of the participants had received their medical training in Sweden, and 15 had undergone medical education abroad. Digital consultation was carried out both during office hours as well as in the evenings and at weekends.
Table 1. Participant characteristics
Characteristic
|
Number (%)
|
Sex
|
|
Male
|
12 (43)
|
Female
|
16 (57)
|
Age
|
|
28–39 years
|
10 (36)
|
40–49 years
|
10 (36)
|
50–63 years
|
8 (28)
|
Level of medical training
|
|
Specialist in primary care medicine
|
18(64)
|
Resident in primary care medicine*
|
8(28)
|
Specialist in other specialty than primary care
|
1(4)
|
Not specialist or resident
|
1(4)
|
Employer
|
|
Publicly funded health care
|
17 (61)
|
Private company
Type of work
Combined digital work with traditional consultation
Digital work exclusively
|
11 (39)
25 (89)
3 (11)
|
|
|
*In Sweden, resident physicians have finished medical school, possess medical license and for five years they both provide healthcare and are learning to become specialist physicians (in this case, specialists in primary care medicine).
The analysis of the data yielded 9 subcategories, which were mapped onto the 3 categories of the JDCS model (Table 2). The results of the analysis for each category and subcategory are presented in the following sections.
Table 2. Categories and subcategories
Control over job situation
|
Demands of job situation
|
Social support in job situation
|
Autonomy
|
Workload
|
Colleagues
|
Competence
|
Patient safety
|
Supervisors
|
Technology
|
Resource use
|
Patients
|
Control over job situation
Control over job situation concerns employees’ ability to organize their work, adopt their own initiatives, and have latitude about decisions. This category consists of 3 subcategories: autonomy, competence, and technology.
Autonomy
Participants experienced a great deal of decisional latitude concerning their work situation. The digital consultation allowed for high levels of flexibility in terms of deciding working hours and choosing where to work, including having the ability to work from home. Several participants saw the opportunity to determine the location of work as very positive. They stated that they had more time to spare and could spend valuable time with their family when they did not have to travel to and from work. However, some shortcomings were also expressed, e.g., not having scheduled coffee breaks and uncertainty about whether they could take breaks as usual or not.
You’re at home. The advantage of this [digital consultation] is that I don’t have to travel to and from work. I start at 8 a.m. and I sit down at my computer at 8 and when I quit at 5 p.m. I’m already at home. It’s an incredible benefit. [#24]
Competence
Concern regarding loss of clinical competence when working exclusively with digital consultation was expressed by participants. They underscored the importance of combining traditional clinical consultation and digital consultation to maintain and develop their medical proficiency. There was agreeance among the participants as regards the concern about the lack of improvement in their medical skills because they experienced that digital consultation consisted mostly of relatively simple medical issues. Lower urinary tract infections in women, upper airway infections, allergies, prescription renewals, and certification of sick leave were common issues.
Digital consultation, that’s something else, it’s an easier approach to work. It’s some sort of symptomatic treatment for, most commonly, one condition, which means you can close the case and the patient is content, and you’re pleased because there’s no more work to do when finishing the case. To work only with digital consultation, I don’t think that’s a solution because I can’t imagine you’re able to maintain your competence if you only work digitally. [#6]
Technology
The technology used in digital consultations caused participants some problems, including recurring issues with the internet connection. This was experienced as particularly worrisome when the connection with the patient was lost in the middle of a consultation and the physician was not able to reach the patient again. Further, participants reported that there were some disadvantages working from home because they lacked technical support when working outside office hours, forcing them to try to solve technical problems by themselves. However, most of the participants experienced very good technical quality, e.g., concerning pictures of skin conditions. Several of the participants saw potential in incorporating the digital consultation system into their own everyday journal system rather than using a different system for digital consultation.
Yes, the technical challenge is that we’re not primarily working in our regular computer system but in another system. For this to be really efficient, it needs to be integrated into our existing journal system. So, there are technical parts that can be improved. [#28]
Demands of job situation
Demands of job situation are the physical, psychological, social, or organizational aspects of jobs that require physical and/or psychological effort. Perceived time pressure and role conflict (incompatible demands related to one’s job or position) are also a part of the demand dimension. Three subcategories were identified in this category.
Workload
Participants experienced that the workload was significantly lower when working with digital consultation. They explained this in terms of non-existing production demands, i.e. number of consultations with patients per hour, in combination with the type of medical cases they handled in digital care. However, participants employed by private companies had seen an increase in demands of production, e.g., the number of patients they were expected to counsel per hour. The privately employed participants described that they had a very reasonable workload from the outset, with no demands that they must administer a certain number of patients per hour, but they noted that this was changing as patient volumes increased, which they perceived to be a shortcoming. The increased demands had led some of the participants to look for other employers who could offer more favorable working conditions.
The workload was quite low, the patient cases were usually very simple to solve in 15 minutes, so there were no large problems. You managed that without any problems. [#3]
Patient safety
The participants believed maintenance of patient safety when working with digital consultation was part of the job demands. They noted that digital consultation had some shortcomings that could have a negative impact on patient safety, e.g., when patients sought medical advice for conditions that were not suitable for digital consultation or when there were technical problems so that the contact with the patient was lost and the patient could not be reached again. Some participants stated that difficulties in mutual understanding between physician and patient was quite common when there were language differences. This communication problem could negatively affect patient safety, according to some participants.
For I think, for example, sometimes when your patients’ Swedish [language] is very poor, I feel, and I actually think many agrees with me, that it is better with a traditional consultation where you really can sort things out and talk, face to face. [#17]
Another concern about patient safety expressed by the participants was the lack of a unified documentation system. It was viewed as risky to prescribe medication without knowing what other medications the patients were prescribed since a majority of patients were unknown to the physicians when working with digital consultations.
Resource use
Digital consultation requires that the participants handle medical cases suitable for digital care. The participants raised concerns about the risk of generating “unnecessary” health care with digital consultation, making them somewhat ambivalent towards the use of their medical competence in the digital consultations. They noted that the digital consultation predominantly reached young, presumably healthy individuals, possibly at the expense of the elderly population with a higher burden of disease. Issues concerning the use of constrained health care resources created concern for some of the participants. The question about who decides what is, and what is not, an important medical condition was also brought up. Participants perceived that some patients used digital consultation as a form of health care advice service, which they considered as unnecessary health care because a free health care advice service already exists in Sweden. In most regions and private companies represented in this study, digital consultation means that patients first get in touch with highest medical level (i.e., a primary care physician) instead of, e.g., discussing their problems with a nurse as a first step. Some participants expressed that they would like to see some sort of selection of patients because a large proportion of patients did not need to see a physician if limited health care resources were to be used most effectively.
In my opinion, health care today is very, very available for quite young, healthy individuals. But for those who are really the most ill, it can be a complicated system and difficult to access. [#15]
Moreover, it [digital consultation] may be a waste of resources, like I told you before, you immediately get the highest level of competence, in a very convenient and available way. And that’s really the greatest risk, that you pay a lot for a small measure from the health care system. [#3]
Social support of the job situation
The social support of the job situation includes helpful interactions with colleagues and supervisors. Social contacts and structures affect basic psychologic mechanisms, which are important for well-being in the long term. Social support can also influence job stressors in a positive direction, acting as a “buffering” mechanism.
Colleagues
Participants conveyed that they could feel somewhat socially isolated when working with digital consultation from home and/or in the workplace outside office hours, which generated uncomfortable feelings of loneliness. This was mostly reported by participants in publicly funded health care who were accustomed to having a regular workplace to go to. Participants employed by private companies did not express the same sense of loneliness or isolation. On the contrary, they had the opportunity to interact with remote colleagues through internal chat forums where they could obtain both medical advice and support from others.
We have this community, it’s a fantastic source of support among colleagues concerning both work environment issues and also practical concerns, but also concerning knowledge about patients. So it’s really… It’s invaluable. It is not possible in regular health care to have that sort of contact with colleagues. Here, we have that possibility and you can also receive a lot of support from your colleagues and the employer too. But this collegial interaction with colleagues is so valuable, so valuable. [#20]
With regard to support from colleagues in health care in general, i.e., not necessarily colleagues in digital consultation, most participants reported non-supportive attitudes overall. This lack of collegial support seemed to generate feelings of shame and guilt among some of the participants, with some even avoiding telling colleagues about their work as a “digital doctor” to avoid being taunted.
You feel ashamed, you know how others react to this “so you’re after the easy money, how bad you are, taking it from taxes”. They mean the cheapest health care goes to traditional primary care and that we (the digital physicians) take the easy patients from traditional primary care, or “unnecessary” patients. Many people think like this, which isn’t true. Most of the patients haven’t been able to get help from traditional primary care. [#18]
Supervisors
Some participants employed by private companies reported an obvious lack of support from supervisors, i.e., health care colleagues in management positions. There had initially been regular staff follow-ups, but they believed that they were no longer able to discuss working conditions with their supervisors. Participants working in publicly funded health care experienced supervisor support differently. In most cases, they perceived satisfactory support from primary care supervisors. However, some of the publicly employed participants expressed that their supervisors were skeptical of digital consultation and did not encourage them to work with this way, which left them feeling unsupported and somewhat alone.
When it comes to work environment, most of it is ok I figure, but a great deal has worsened. For me, I run my cases, but I want my work to be acknowledged as well. From patients I usually get acknowledged but from my employer it has become worse. In my opinion, the employer should be more attentive regarding their employees. This is even more important when employees are doing teleworking and not sitting in a physical office. Initially, the employer was very good in acknowledging my work, but not anymore, so that’s a disadvantage. [#25]
Patients
Participants experienced considerable patient support for the digital consultation. Many patients were very positive and grateful for the fast, readily available care they received, which they often communicated directly to the participants. This response generated feelings of satisfaction among the participants, who felt they could really help patients solve their problems.
I told you before, I’ve never had patients this pleased/content, one after another, everyone’s happy with your work. Ok, it’s not the most complex burden of diseases, but still, the patient’s in need of a solution for a symptom that bothers them. You can solve it easily, readily for all, for you. I think everyone’s very happy with this way of solving the problem. [#6]
However, some of the participants also observed that digital consultation situations could create a more anonymous form of physician-patient communication, making some patients lose their inhibitions so that they were occasionally quite rude and sometimes said inappropriate things they probably would not have done in a face-to-face consultation.