# General practitioners' experience about synchronous teleconsultation in primary care: a mixed-method systematic review

Alphonse Sowanou, Gabin Morillon, Marlène Guillon, Thomas Poder, Maude Laberge

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Alphonse Sowanou, Gabin Morillon, Marlène Guillon, Thomas Poder, Maude Laberge. General practitioners' experience about synchronous teleconsultation in primary care: a mixed-method systematic review. BMC Primary Care, 2025, 26 (1), pp.264. 10.1186/s12875-025-02975-y. hal-05253797

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# General practitioners' experience about synchronous teleconsultation in primary care: a mixed-method systematic review

Alphonse Sowanou¹,²,³,⁴* ID, Gabin F. Morillon⁵,⁶ ID, Marlène Guillon⁵,⁷ ID, Thomas G. Poder⁶,⁸,⁹ ID and Maude Laberge²,³,⁴,⁶,¹⁰* ID

## Abstract

**Background** General practitioners (GPs) extensively used synchronous teleconsultation (STC) during the COVID-19 pandemic. Although this utilization decreased after the state of sanitary emergency was lifted, it remains higher than pre-pandemic levels.

**Methods** The aim is to summarize the scientific evidence on the factors influencing GPs' decision to conduct STC instead of face-to-face consultation. We conducted a systematic review and reported our results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We searched four electronic databases: MEDLINE, Cumulative Index of Nursing Literature and allied health, Web of Science and the Cochrane Central Register of Controlled Trials and conducted the last search on March 23, 2023. Two independent reviewers selected English/French articles reporting on GPs' use, attitude, satisfaction, and experience with STC. We assessed the studies' quality using the Mixed Methods Appraisal Tool, and a narrative approach was performed to synthesize findings.

**Results** The screening of 9,288 references resulted in the inclusion of 34 studies, for a total of 5,563 participants. Results show that GPs' decision to use STC is influenced by six categories of factors: (1) consultation, such as consultation purpose (e.g., follow-up care, administrative requests); (2) information and communication technology, such as quality of equipment and bandwidth (internet connection and the effectiveness of the hardware and software); (3) GP, such as convenience (the flexibility offered by the STC); (4) patient, such as access barriers (ex., physical, geographical, financial); (5) GP-patient relationship, such as ease of diagnosis; and (6) the institution, such as organizational and peer support. Lack of a reliable internet connection, need for physical exams, and limited visual cues were the main barriers to using STC.

**Conclusions** GPs' utilization of STC depends on the interplay of six categories of factors, the most important being the purpose of consultation. Equity in access and a fair payment model are key elements to consider in designing health policies aimed at supporting adoption and appropriate use of STC.

Full list of author information is available at the end of the article

<footnote>*Correspondence:
Alphonse Sowanou
alphonse.sowanou.1@ulaval.ca
Maude Laberge
maude.laberge@fmed.ulaval.ca</footnote>
**Review's Protocol registration** PROSPERO CRD42024505744

**Keywords** Teleconsultation, Telemedicine, Online visit, Teleconsultation's utilization, General practitioners, Video consultation, Phone consultation

**Background**

Synchronous teleconsultation (STC) via video or phone has become a common practice in primary care; the COVID-19 having largely contributed to its rapid adoption [1]. Global use rose from 57 million users in 2019 to over 116 million in 2024 [2]. STC is now commonly used to deliver routine primary care across many countries [3, 4].

STC may improve health system performance by enhancing quality dimensions such as timeliness, patient-centeredness, efficiency, safety, and equity [5]. It has been linked to reduced diagnostic and treatment delays in primary care [6, 7]. It also helps overcome barriers related to geography [8–10], mobility issues [8, 10], and cost [11]. One systematic review reported that STC in primary care reduced the rates of face-to-face consultations and hospitalizations in secondary care, as well as the time spent by patients including travel, wait, and consultation time [5]. Furthermore, it enhances safety during epidemics [12] and supports patient-centered care by aligning with digital preferences [7], and can be considered more convenient [5, 7]. However, its effectiveness may be limited by technological issues (e.g., poor internet connection) [13], lack of in-person contact [14], and providers’ limited digital literacy [7]. Further, a systematic review reported mixed results regarding equity, which varies across studies and depends on socioeconomic status, residence, and ethnicity, which are likely influenced by contextual factors [5]. These challenges highlight the complexity of STC’s adoption.

Although STC's utilization by general practitioners (GPs) declined after the state of sanitary emergency related to COVID-19 was lifted, it remains higher than pre-pandemic levels [15]. For instance, in a study conducted in California, United States of America (USA), STC accounted for 68% of consultations during the peak of the COVID-19 pandemic in 2020 [16]. The pandemic was seen as a “window of opportunity” [17] for long-term adoption of STC. Yet, use among GPs decreased. It dropped from 59% in 2020 to 32% in 2023 in a large USA plan with 12.7 million members that had an integrated care model with a STC option for more than a decade [15]. Similarly, declines were observed in Denmark, from 2.9% in 2020 to 1.2% in 2022 and in the United Kingdom (UK), from 2.6% in 2021 to 2.2% in 2022 [18]. Overall, GPs embraced STC during the pandemic, but usage decreased as COVID-19 related restrictions were lifted in most countries.

One reason for this decline may be the lack of understanding of the factors influencing GPs' use of STC. According to Roger's theory of diffusion of innovation [19], the complexity associated with the adoption of a health innovation is often driven by an interplay of factors such as aspects of the technology, providers' interests, the decision-making process, and the social context factors.

Previous reviews investigated GPs' satisfaction [20], experience [4, 14], and barriers and facilitators to the implementation of STC [13, 21], but few have focused on why GPs choose STC over face-to-face consultation. For instance, Lindenfeld et al. [13] reviewed barriers and facilitators broadly related to telemedicine, without insight on the individual reasons for adoption of STC by GPs.

Therefore, this review aims to summarize the scientific evidence on factors that influence GPs' choice of STC over face-to-face consultation, to document the reasons driving GPs' utilization. The research questions are: what are the determinants of GPs' use, satisfaction, attitude, and experience with STC? What factors influence GPs' preferences for STC modalities over the face-to-face modality?

**Method**

**Design**

We conducted a systematic review since it enables a comprehensive search for studies focusing on a specific and well-defined topic (in our case, GPs' experience of STC modalities) [22], as well as the systematic evaluation of the quality of studies according to precise and pre-established criteria [23]. It is the most suitable review type to synthesize the evidence on current practices [24]. We registered the review protocol in the International Prospective Register of Systematic Reviews (PROSPERO), after validating the search strategy (available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024505744). We adopted the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for reporting the results [25].

**Inclusion and exclusion criteria**

We used the PICOS framework, namely Population, Intervention, Comparator, Outcomes, and Study design as recommended [26–28]. We included studies from any country that are written in either English or French. Table 1 shows the criteria utilized and the rationale behind each of them.
<table><caption>**Table 1** Inclusion and exclusion criteria for the systematic review</caption><thead><tr><th>PICOS components</th><th>Inclusion</th><th>Exclusion</th></tr></thead><tbody><tr><td>Population</td><td>- The population consisted of GPs who conducted STC. We used the term GP to include family physicians, community health physicians, and primary care physicians;<br/>- In cases where studies included various types of primary healthcare providers (e.g., GPs, nurses, physiotherapists), we included them only if distinct analyses were reported for GPs regarding the defined outcomes and if the proportion of GPs was at least 80% of the study population. We established this arbitrary 80% threshold to ensure that the results reported would be representative of the study population.</td><td>- The participants were residents in family medicine or physicians with a specialty other than family medicine (e.g., internists, pediatricians);<br/>- Studies involving GPs working in specialized services other than primary care, such as intensive care units, gynecology or pediatrics.</td></tr><tr><td>Intervention</td><td>- The study focused on STC (e.g., via video or phone).</td><td>- The study focused on asynchronous teleconsultation (e.g., e-mail, text messaging, online medical records accessible to patients at any time);<br/>- The following types of teleconsultations: consultation that consisted of providing a treatment program (e.g., psychological follow-up), as this goes beyond a simple consultation; tele-expertise/e-consult (e.g., consultation between two physicians), remote medical monitoring, and teleassistance.</td></tr><tr><td>Comparison</td><td>- When applicable, the study compared STC to face-to-face consultation.</td><td>- Study comparing video consultation to phone consultation.</td></tr><tr><td>Primary outcomes</td><td>- The study reported on at least one of the defined outcomes (e.g., preferences, experience, satisfaction, use or intention to use and attitude toward STC). In this review, attitude includes acceptance, perception, and views.<br/>- According to Brazier et al. [29], these factors are important determinants for the uptake of healthcare interventions.</td><td></td></tr><tr><td>Study design</td><td>- The study employed a quantitative, qualitative or mixed-methods design [30].</td><td>- The study was a protocol, editorial, guideline, letter, position paper, conference abstract, correspondence, comment or any non-peer-review publication;<br/>- Literature reviews without novel primary data;<br/>- Quantitative study that only reported descriptive results, as it did not allow us to understand the effects of the determinants factors on our outcomes.</td></tr></tbody></table>

## Definitions

We adopted the World Health Organization's definition of STC, which defines it as a remote consultation between a patient and a healthcare provider by using information communication and technology such as telephone (PC) and videocommunication (VC) platforms [31]. We used Olesen et al. [32]'s definition of GP as a front-line physician providing prevention, diagnosis, and follow-up care to the population. Preference is defined as the order in which a person ranks options according to their respective value when seeking for the "optimal choice". Preferences are assessments of values in connection with rationality in practice [33]. GPs' experience can be defined as what happened during the provision of care. The quality of a physician's experience can affect patients' outcomes and their satisfaction [34]. Satisfaction is the feeling (good or bad) related to GPs' condition, including their workload and revenue. GPs' satisfaction is important because it has been associated with the quality of care provided, and with patient satisfaction [35]. Use and intention to use refers to current service/technology utilization and future willingness to use it, offering insights into adoption patterns. GPs' attitudes involve their belief

system, which influences their medical decision-making process [36]. According to Ward et al. [37], GPs' attitude can be a significant factor in the acceptance and efficiency of use of information technology in practice.

## Data sources and search strategy

We designed the search strategy in collaboration with a librarian specialized in health sciences literature reviews. We searched four electronic databases: MEDLINE via PubMed, Cumulative Index of Nursing Literature and allied health (CINAHL) via EBSCO, Web of Science and the Cochrane Central Register of Controlled Trials, from 1990 to March 23, 2023. Relevant keywords and associated truncations used in the searches were linked to the following concepts: teleconsultation, GP, experience, satisfaction, use, preference, and attitude [38]. The Boolean operators "AND" and "OR" were used to refine or extend search parameters, quotations marks ("”) to obtain results with exact expressions, and parentheses to group search terms. One member (GFM) of the research team revised and integrated comments through an iterative process to develop a final version of the search strategy that was
approved by all investigators. The search strategy developed for each database is in Appendix 1.

## Studies selection and data extraction

We used the review management tool Covidence® for each stage of the selection process. Six reviewers (AS, GFM, STM, MG, ML and TGP) conducted each step independently, with each reference being examined by at least two reviewers. To ensure coherence among reviewers, a standardization session was held at each new stage with all the team members. Meetings were organized with the three team leaders (MG, TGP and ML) to resolve conflicts at every selection stage. Two systematic reviews

were planned and conducted together, with separation at the last stage. One review was on GPs' utilization and the other on patients' utilization of STC. The remaining number of references after excluding duplicates was exported into Covidence®. On these references, we conducted the first selection (on title and abstract), which led to identifying references for full text review. We assessed each article on the eligibility criteria to determine its inclusion (or rejection) in the GPs' utilization review [27], (see PRISMA diagram in Fig. 1).

We developed a data extraction grid in an Excel sheet (Appendix 2) following the PRISMA framework [26], that was validated during a team meeting. The extraction

<figure><img src="image_3.png" /><figcaption>**Fig. 1** PRISMA flow diagram with searches completed up to March 23, 2023</figcaption></figure>
grid included the following information: name of the first author, year of publication, country where the study was conducted, target population, theoretical framework used if applicable, study design, type of sampling, number of participants retained/considered for the analyses, STC modality, results, the corresponding defined outcome, the approach used, the type of analyses carried out, the dependent and the explanatory variables (for the quantitative analyses), the guide used for reporting (if applicable), the number of attributes (themes and sub-themes identified). For quantitative results, we extracted the direction of the relationship between the defined outcomes and the determinants of STC, along with the level of statistical significance (*p* < .05). For qualitative results, we extracted relevant quotations describing the relationship between the defined outcomes and the determinants of STC. Two reviewers (AS and GFM) independently extracted the data and double-checked each other's extraction.

## Studies quality assessment

Two reviewers (AS and GFM) independently evaluated the methodological rigor of the included articles, applying the 2018 version of the mixed methods appraisal tool (MMAT) developed by Hong et al. [39], and disagreements between the reviewers were resolved by consensus. This tool was designed for systematic reviews including qualitative, quantitative, and mixed methods studies; thus, allowing the application of a single tool for all included studies [39]. The MMAT tool allow to assess each design of study (qualitative study, randomized controlled trial, nonrandomized study, quantitative descriptive study, mixed-method study) on five criteria [39]. For each criterion, a choice between three options is possible (Yes, No or Can't tell) [39]. The 'Can't tell' response means that the article does not report appropriate information to answer 'Yes' or 'No' [39]. We did not calculate an overall score based on the ratings of each criterion or exclude studies with low methodological quality, as recommended by the authors of the tool [39]. We used this assessment to interpret the data in the synthesis.

## Data analysis and synthesis

Compared to a quantitative synthesis, the qualitative synthesis allowed us to summarize data into themes [40], resulting in the most appropriate output to answer our research question. Textual narrative synthesis has proven useful for summarising evidence from various types of studies, including qualitative, quantitative research, which is relevant to our mixed-study review [41].

Initially, a single reviewer (AS) coded the extracted data using content analysis under the direct supervision of a senior researcher (ML). Quantitative data (e.g., means, percentages, estimates) were first interpreted to derive

their textual meaning, upon which codes were developed, while qualitative content was directly coded. These codes were then organized into relevant themes, according to barriers to and facilitators of STC use by GPs. Several rounds of discussion among co-authors were conducted to validate identified themes and define relevant categories, ensuring both validity and reliability. Finally, we mapped the identified themes onto the predefined categories (Appendix 3). We interpreted and reported only the most relevant themes [27, 40], referred to as factors, to address our initial research question.

## Results

### Study selection

After deletion of duplicates, the initial search yielded 9,288 references. After the selection process against our criteria, 34 articles were included (see the PRISMA flow-chart in Fig. 1).

### Study characteristics

The 34 included articles comprised a total of 5,563 participants (GPs). Sample sizes ranged from 4 GPs [42], to 1,605 GPs [10], who experienced at least VC or PC.

The publication year ranged from 1992 to 2023. Eleven studies (11/34, 32.35%) were conducted before 2019 [3, 6, 43–51]. A total of 19 studies (19/34, 55.88%) were conducted during the COVID-19 period (2020–2021) [8–11, 52–66]. Four studies (4/34, 11.76%) published in 2020 [67], 2021 [42], and 2022 [68, 69] did not report their study period.

Almost one-third (11/34, 32.35%) of the included studies were conducted in the UK [6, 9, 44, 46–50, 52, 53, 58] whereas four (4/34, 11.76%) were conducted in the USA [51, 57, 65, 66]; three (3/34, 9%) were conducted in Norway [42, 60, 63]; two (2/34, 6%) each were conducted in Canada [8, 68], and Denmark [54, 64]. The remaining studies were conducted in European [43, 45, 56, 62, 67, 69], Oceania [3], Asian [59], and Middle Eastern [61] countries. Moreover, there were three (3/34) studies involving GPs from multiple countries [10, 11, 55].

In terms of methodology of the included studies, 19 were of qualitative design [9–11, 43–45, 47, 49, 50, 52–55, 58, 59, 63–65, 68], 8 of mixed-method design [3, 6, 8, 42, 46, 57, 62, 67] and 7 of quantitative design [48, 51, 56, 60, 61, 66, 69]. The main characteristics of the 34 retained articles are provided in Table 2.

## Outcomes measurement

As mentioned in the methods section, four main outcomes were used: experience, satisfaction, use or intention to use, and attitudes. Seven studies used reliable and valid measurement tools to assess the defined outcomes, while the remaining studies did not provide relevant information. Among the eight studies, two used
<table><caption>**Table 2** Studies' main characteristics</caption><thead><tr><td>Citation</td><td>Country</td><td>Objective</td><td>Outcome as reported</td><td>Modality</td><td>Number of observations</td><td>Study design</td><td>Data collection</td></tr></thead><tbody><tr><td>Alsaffar et al. (2021) [43]</td><td>Ireland</td><td>This study focuses on the attitudes of GPs towards the provision of video consultation for their own patients.</td><td>Attitude</td><td>Video</td><td>8 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Atherton et al. (2018) [44]</td><td>UK</td><td>To explore the feasibility and impact of alternatives to face-to-face consultations, from the perspectives of both staff and patients.</td><td>Attitudes</td><td>Video and Phone</td><td>19 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Brant et al. (2016) [6]</td><td>UK</td><td>To identify the frequency and range of ways in which general practice teams in five areas of the UK were providing alternatives to face-to-face consultations, or had plans to do so in the future.</td><td>Attitude</td><td>Video and Phone</td><td>784 GPs</td><td>Mixed-method</td><td>Survey with open-ended questions</td></tr><tr><td>Brat-bbak et al. (2021) [42]</td><td>Norway</td><td>To better understand what influences the (quality of) patients and doctor's experiences with video consultations.</td><td>Experience</td><td>Video</td><td>4 GPs</td><td>Mixed-method</td><td>Semi-structured interviews</td></tr><tr><td>Breton et al. (2021a) [8]</td><td>Canada</td><td>To explore the adoption of telehealth by PHC providers in Canada since the beginning of the pandemic.</td><td>Attitude</td><td>Video and Phone</td><td>405 GPs</td><td>Mixed-method</td><td>Survey with open-ended questions</td></tr><tr><td>Breton et al. (2021b) [11]</td><td>Canada and USA</td><td>To describe the positive and negative implications of using telehealth during the pandemic.</td><td>Attitude</td><td>Video</td><td>42 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Burn et al. (2022) [52]</td><td>UK</td><td>To explore the general practice workforce's experiences of the shifting pandemic and changes to service delivery made in response to the first year of COVID-19.</td><td>Experience</td><td>Video and Phone</td><td>13 GPs</td><td>Qualitative</td><td>Survey with open-ended questions</td></tr><tr><td>Donaghy et al. (2023) [53]</td><td>UK</td><td>1. To evaluate the impact of the Living Well Assessment quality improvement project in primary care from GPs' and patients' perspectives;<br/>2. To determine whether there was a preference in the methods of delivery of LWA (face to face and remote by telephone or video).</td><td>Experience</td><td>Video and Phone</td><td>10 GPs</td><td>Qualitative</td><td>Individual semi-structured face to face, phone, and focus group interviews</td></tr><tr><td>Due et al. (2021) [54]</td><td>Danmark</td><td>Our study asked how Danish GPs experienced reorganising their work in their attempt to uphold adequate patient care while contributing to minimizing the spread of COVID-19. Further, and in relation to this, our study asked what guided GPs' choices between telephone, video, and face-to-face consultations.</td><td>Experience</td><td>Video and Phone</td><td>13 GPs</td><td>Qualitative</td><td>Interviews</td></tr><tr><td>Durupt et al. (2016) [45]</td><td>France</td><td>The aim was to explore their perceptions of telemedicine, and teleconsultation in particular. We sought to identify the perceived advantages and disadvantages of its development.</td><td>Attitude</td><td>Video and Phone</td><td>32 GPs</td><td>Qualitative</td><td>Focus groups</td></tr></tbody></table>
<table><caption>**Table 2 (continued)**</caption><thead><tr><td>Citation</td><td>Country</td><td>Objective</td><td>Outcome as reported</td><td>Modality</td><td>Number of observations</td><td>Study design</td><td>Data collection</td></tr></thead><tbody><tr><td>Fernández Coves et al. (2022) [55]</td><td>Hong-Kong and Netherland</td><td>What features of the different healthcare funding models facilitate and hinder the adoption of teleconsultation in primary care in Hong Kong and the Netherlands.</td><td>Attitude</td><td>Video and Phone</td><td>13 GPs</td><td>Review plus qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Florea et al. (2021) [56]</td><td>Romania</td><td>To explore how family physicians perceived the use of telemedicine, recently recognized as a tool for PC provision and reimbursed for the first time by the Romanian Public Health Insurance House (PHIH). In addition, we analyzed their opinions on the need for its further reimbursement and patients' satisfaction using ICT as perceived by family doctors.</td><td>Attitude</td><td>Video and Phone</td><td>108 GPs</td><td>Quantitative</td><td>Online questionnaire</td></tr><tr><td>Foster et al. (1999) [46]</td><td>UK</td><td>To assess GPs' concerns and levels of confidence in providing telephone consultations to inform the development of a new training course.</td><td>Attitude</td><td>Phone</td><td>Qualitative: 15 GPs<br>Quantitative: 22 GPs</td><td>Mixed-method</td><td>Semi-structured interviews</td></tr><tr><td>Gold et al. (2021) [57]</td><td>USA</td><td>To measure family physician experience with video visits at the start of the COVID-19 pandemic.</td><td>Experiences</td><td>Video</td><td>102 GPs</td><td>Mixed-method</td><td>Survey with open-ended questions</td></tr><tr><td>Greenhalgh et al. (2022) [9]</td><td>UK</td><td>To explain why video consultations are not more widely used in general practice</td><td>Experience</td><td>Video and Phone</td><td>55 GPs</td><td>Qualitative</td><td>Interviews<br>Focus groups</td></tr><tr><td>Grut et al. (2023) [53]</td><td>UK</td><td>To broaden the evidence base in qualitative research, using in-depth interviews to explore the experiences and perspectives of GP and GP trainees during the pandemic.</td><td>Experience</td><td>Phone</td><td>11 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Hallam, (1992) [47]</td><td>UK</td><td>To explore the nature and content of calls, the organization of telephone access and the perceived rewards, frustrations and effect upon workload of extensive telephone contacts with patients.</td><td>Attitude</td><td>Phone</td><td>49 GPs</td><td>Qualitative</td><td>Structured interviews</td></tr><tr><td>Han et al. (2022) [68]</td><td>Canada</td><td>To acquire an in-depth understanding of doctors' previous experiences and their perceptions about video-based appointments.</td><td>Attitude</td><td>Video and Phone</td><td>12 GPs</td><td>Qualitative</td><td>Semi-structured and scenario-based interviews</td></tr><tr><td>Hasani et al. (2020) [59]</td><td>Oman</td><td>To explore the perceptions from physicians with the implementation of TC service in PHC in Muscat, Oman, with respect to<br>- Process of implementing telephone consultation;<br>- Challenges and limitations;<br>- Lessons learned and the way forward.</td><td>Attitude</td><td>Phone</td><td>22 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Jiwa et al. (2013) [3]</td><td>Australia</td><td>To explore Australian general practitioners'attitudes to video consultation with a range of patients who may not be known to them previously.</td><td>Attitudes</td><td>Video</td><td>46 GPs</td><td>Mixed-method</td><td>Questionnaire</td></tr></tbody></table>
<table><caption>**Table 2 (continued)**</caption><thead><tr><td>Citation</td><td>Country</td><td>Objective</td><td>Outcome as reported</td><td>Modality</td><td>Number of observations</td><td>Study design</td><td>Data collection</td></tr></thead><tbody><tr><td>Johnsen et al. (2021) [60]</td><td>Norway</td><td>To explore how GPs in Norway perceived the suitability of VCs compared to ordinary face-to-face consultations during the COVID-19 lockdown. In addition to addressing the suitability of VCs across a wide range of health problems (reasons for contact), we were also interested in knowing whether continuity of care (i.e., prior knowledge of the patient/problem) had an impact on GPs' perceptions of VC suitability.</td><td>Experience</td><td>Video</td><td>855 GPs</td><td>Quantitative</td><td>Online survey</td></tr><tr><td>Kaufman-Shriqui et al. (2022) [61]</td><td>Israel</td><td>To evaluate physician experiences and attitudes to the change in practice paradigm during the COVID-19 pandemic.</td><td>Experience</td><td>Video and Phone</td><td>159 GPs</td><td>Quantitative</td><td>Online Google Survey questionnaire</td></tr><tr><td>Koch et al. (2020) [67]</td><td>Sweden</td><td>To explore how general practitioners (GPs) experience video consultations with patients compared to physical consultations in primary care in Sweden.</td><td>Experience</td><td>Video</td><td>32 GPs</td><td>Mixed-method</td><td>Survey with open-ended questions</td></tr><tr><td>Kursite et al. (2022) [62]</td><td>Latvia</td><td>To describe the dynamics of consultations and the volume of remote consultations and to explore clinicians' experiences of providing remote consultations during the first wave of the COVID-19 pandemic in Latvia.</td><td>Experience</td><td>Phone</td><td>19 GPs</td><td>Mixed-method</td><td>Semi-structured interviews</td></tr><tr><td>Li et al. (2022) [10]</td><td>Multicountries</td><td>To explore GPs' perspectives on the main benefits and challenges of using virtual care tools (e.g., telephone, online consultations tools, messaging platforms), mapping them against the main domains of quality of care whenever possible.</td><td>Experience</td><td>Video and Phone</td><td>1605 GPs</td><td>Qualitative</td><td>Survey with open-ended questions</td></tr><tr><td>McKinstry et al. (2009) [49]</td><td>UK</td><td>To progress understanding about the contexts in which telephone consulting is most appropriately used</td><td>Use</td><td>Phone</td><td>25 GPs</td><td>Qualitative</td><td>Focus groups</td></tr><tr><td>McKinstry et al. (2010) [48]</td><td>UK</td><td>To determine if face-to-face and telephone consultations differ with regard to the number and type of problems presented; the quantity of data gathering and patient counselling that took place; the amount of rapport and partnership building; the degree to which doctors tried to involve patients in decision making; the quality and safety of the consultation; and patient satisfaction and enablement</td><td>Satisfaction (Comparison between face-to-face and STC)</td><td>Phone</td><td>19 GPs</td><td>Quantitative</td><td>Online Google Survey questionnaire</td></tr><tr><td>Norberg et al. (2023) [63]</td><td>Norway</td><td>The aim of this study was to explore regular GPs' experiences of potentials and pitfalls with the use of VCs in Norway during a critical period with rapid uptake.</td><td>Experience</td><td>Video</td><td>657 GPs</td><td>Qualitative</td><td>Survey with open-ended questions</td></tr></tbody></table>
<table><caption>**Table 2 (continued)**</caption><thead><tr><th>Citation</th><th>Country</th><th>Objective</th><th>Outcome as reported</th><th>Modality</th><th>Number of observations</th><th>Study design</th><th>Data collection</th></tr></thead><tbody><tr><td>Nordtug et al. (2022) [64]</td><td>Denmark</td><td>To explore the professional uncertainties that emerged among Danish GPs with the introduction of video consultations</td><td>Experience</td><td>Video</td><td>15 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Price-Haywood et al. (2023) [65]</td><td>USA</td><td>To compare patient and primary care provider (PCP) perceptions of facilitators and barriers to engagement in using patient portals, remote telemonitoring, and/or telemedicine in medically underserved communities; and to recommend strategies for effectively facilitating interactive patient-provider use of these interventions among socioeconomically disadvantaged and medically underserved population.</td><td>Experience</td><td>Video and Phone</td><td>26 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Rand-hawa et al. (2019) [50]</td><td>UK</td><td>To explore the views and attitudes of General Practitioners (GPs) towards video consultation in primary care; specifically, in three broad areas: the benefits of video consultations to patients and healthcare professionals; potential problems with video consultation and its implementation; the cost-effectiveness of video consultation in this setting.</td><td>Views and attitudes</td><td>Video</td><td>12 GPs</td><td>Qualitative</td><td>Semi-structured interviews</td></tr><tr><td>Silver et al. (2021) [66]</td><td>USA</td><td>To identify visit characteristics that are suitable for telemedicine; focusing on patient, appointment, and physician factors.</td><td>Use</td><td>Video and Phone</td><td>22 GPs</td><td>Quantitative</td><td>Questionnaire</td></tr><tr><td>Stahl et al. (2010) [51]</td><td>USA</td><td>To examine the feasibility, effectiveness and acceptability of a face-to-face office visit compared to a videoconference visit.</td><td>Satisfaction</td><td>Video</td><td>4 GPs</td><td>Quantitative</td><td>Evaluation questionnaire</td></tr><tr><td>Walczak et al. (2022) [69]</td><td>Poland</td><td>To analyze GPs' acceptance of the telehealth system in primary care during the COVID-19 pandemic in Poland and to examine possible factors affecting this acceptance.</td><td>Attitude</td><td>Video and Phone</td><td>361 GPs</td><td>Quantitative</td><td>NR</td></tr></tbody></table>

Multicountries (Australia, Brazil, Canada, Chile, Colombia, Croatia, Finland, France, Germany, Ireland, Israel, Italy, Poland, Portugal, Slovenia, Spain, Sweden, Turkey, UK, USA)

TC Teleconsultation, VC Video consultation, NR Not reported

the Technology acceptance model (TAM) to assess GPs' experience [65] and GPs' acceptance of STC [69]. To assess attitudes, Atherton et al. [44] used Weiss' theory-based evaluation approach framework, Fernandes et al. [55] used the Lau et al. (2016) framework and Hasani et al. [59] used the Interpretative phenomenological analysis (IPA). To assess GPs' use or intention to use STC, Jiwa et al. [3] applied the Theory of Planned Behavior framework and Silver et al. [66] the Plan-Do-Study-Act framework.

In total, 44% (15/34) of studies reported on attitude [3, 6, 8, 11, 43–47, 50, 55, 56, 59, 68, 69] and experience [9,

10, 42, 52–54, 57, 58, 60–65, 67], while 6% (2/34) of studies reported on use/intention to use [49, 66] and satisfaction [48, 51].

## Quality assessment of the included studies

In total, we evaluated 26 of the 34 included studies (76.47%) as containing qualitative data and 8 studies (23.53%) as containing quantitative data. Overall, most studies (24/34; 70.59%) met at least 80% of the quality criteria and can be considered of high methodological quality. However, some concerns were noted in the evaluation of 10 studies, raising doubts about the reliability of their
results. The detailed quality assessment of the included studies is provided in Appendix 4.

Among the qualitative studies, 20 out of 26 (77%) met at least four out of five (4/5) evaluation criteria, including the criterion related to coherence between qualitative data sources, data collection, analysis, and interpretation [8–11, 43, 45–47, 49, 50, 52, 54, 55, 58, 59, 62–65, 68]. The remaining six studies lacked such coherence and met only 3/5 [6, 44, 53], 2/5 [57], or 1/5 [67] of the quality criteria, raising concerns about the reliability of their results. Among the quantitative studies, 4 out of 8 (50%) met at least four-fifths of the evaluation criteria, including the criterion concerning the appropriateness of measurement, defined as having a clear origin, known validity, or using a standard instrument [3, 48, 61, 69]. In contrast, the studies by Johnsen et al. [60] and Silver et al. [66] met 3/5 criteria but lacked sample representativeness; the study by Stahl et al. [51], also meeting 3/5 criteria, lacked blinding of the assessor, and the study by Florea et al. [56], which met only 1/5 criteria, lacked appropriate measurement tools among others.

To prevent the key findings from being disproportionately influenced by lower-quality studies, we critically evaluated whether major themes (factors) were predominantly identified in high-quality studies. Our analysis confirmed that the most frequently cited factors were predominantly supported by high-quality studies (see Appendix 3). Nevertheless, the code “ethnicity”, which contributed to the development of the *patient sociodemographic* factor, emerged solely from the study by Atherton et al. [44]. Additionally, the code “lack of staff

training”, part of the *organizational and peer support* factor, emerged from two studies, one of which was Atherton et al.’s study [44].

We did not conduct a methodological quality assessment for mixed-method studies because the identified mixed-method studies, as noted by the original author, lacked a component that integrated both quantitative and qualitative results. These studies reported either qualitative [6, 8, 42, 46, 57, 62, 67] or quantitative [3] results.

## Factors influencing GPs' utilization of synchronous teleconsultation modalities

Twenty factors emerged from the 34 articles, reflecting GPs' perspectives on factors that influence their choice of STC over face-to-face consultation. We grouped these factors into six categories of factors: (1) category of consultation, (2) category of Information and Communication Technology (ICT), (3) category of GP, (4) category of patient, (5) category of GP-patient relationship and (6) category of the institution (the clinic). Figure 2 illustrates the overall relationship between the categories, based on the number of citations from the included studies. The organization of the categories, particularly their order from left to right, reflects the frequency of citation, in terms of the number of studies. The greater the height and width of a category, the more frequently it was mentioned by many studies. A list of the main factors is provided with details in Table 3.

<figure><img src="image_4.png" /><figcaption>**Fig. 2** Factors influencing GPs' utilization of STC over face-to-face consultation</figcaption></figure>
<table><caption>**Table 3** List of mains factors</caption><thead><tr><th>Categories</th><th>Factors</th><th>Explanation</th><th>Count of studies (n = 34)</th></tr></thead><tbody><tr><td rowspan="2">Consultation-related</td><td>Consultation quality</td><td>• Describes how timely and appropriate a medical consultation is for a given medical condition, leading to a better outcome.</td><td>23 (23/34)</td></tr><tr><td>Consultation purpose</td><td>• Refers to the aim of the consultation.</td><td>19 (19/34)</td></tr><tr><td rowspan="2">ICT-related</td><td>STC' risks</td><td>• Pertains to the risks associated with the practice of STC such as privacy and confidentiality issues.</td><td>13 (13/34)</td></tr><tr><td>Quality of equipment and bandwidth</td><td>• Refers to the efficiency of the internet connection and the effectiveness of the hard and soft materials to enable high-quality image, voice, and video transmission, from both GPs and patients' sides.</td><td>12 (12/34)</td></tr><tr><td rowspan="3">GP-related</td><td>Sociodemographic</td><td>• It refers to characteristics related to age, sex, ethnicity, education and income.</td><td>12 (12/34)</td></tr><tr><td>Convenience</td><td>• It describes the flexibility of STC to provide option that fits in well with the needs of GPs in terms of workload management, working date, working time, working place, etc.</td><td>10 (10/34)</td></tr><tr><td>Attitudes toward STC</td><td>• It refers to GPs' personal perceptions and preferences regarding VC and PC.</td><td>08 (8/34)</td></tr><tr><td rowspan="5">Institutional</td><td>Ability</td><td>• GPs' competency to use STC.</td><td>04 (4/34)</td></tr><tr><td>Guidelines</td><td>• It refers to the protocols and regulations regarding the practice of STC.</td><td>10 (10/34)</td></tr><tr><td>Organizational and peer support</td><td>• It refers to professional assistance (e.g., GPs sharing their experience and providing feedback on STC with their colleagues) and institutional assistance (e.g., training provided by the clinic).</td><td>07 (7/34)</td></tr><tr><td>Workload and demand</td><td>• It refers to how the growing demand of care influences STC's adoption.</td><td>06 (6/34)</td></tr><tr><td>Financial support</td><td>• It refers to the funding required to implement STC in clinics.</td><td>06 (6/34)</td></tr><tr><td rowspan="3">GP-patient relationship</td><td>Ease of diagnosis</td><td>• It describes how the familiarity based on the existing relationship between GP and patient enables a GP to make a diagnosis easily.</td><td>10 (10/34)</td></tr><tr><td>Building trust</td><td>• It refers to how STC contributes in maintaining or strengthening the existing relationship.</td><td>06 (6/34)</td></tr><tr><td>Continuity of care</td><td>• It is concerned with the provision of quality care over time.</td><td>04 (4/34)</td></tr><tr><td rowspan="5">Patient-related</td><td>Sociodemographic</td><td>• It refers to characteristics related to age, sex, ethnicity, education and income of patients.</td><td>09 (9/34)</td></tr><tr><td>Ability</td><td>• It refers to patients' competency to use STC.</td><td>09 (9/34)</td></tr><tr><td>Patients' attitudes toward STC</td><td>• It refers to patients' personal perceptions and preferences regarding VC and PC, according to GPs.</td><td>07 (7/34)</td></tr><tr><td>Convenience</td><td>• It describes the flexibility of STC to provide option that fits in well with the needs of patients in terms of place, date, time of appointment, etc., according to GPs.</td><td>06 (6/34)</td></tr><tr><td>Barriers to access</td><td>• This refers to any patients' situation that hinders access to healthcare services, according to GPs.</td><td>04 (4/34)</td></tr></tbody></table>

**Category of consultation-related factors**

We identified two mains factors that support the importance of factors related to consultation in the use of STC.

The first factor is consultation purpose, which is referred to as the aim of the consultation. In total, 19 articles (56%) reported results on the fact that STC's utilization depends on the reasons for consulting, namely a physical or a mental health issue, a known health problem, an administrative request, etc. GPs reported in 11 studies that STC was suitable for conducting follow-up care [8, 11, 42, 43, 49, 50, 54, 59, 60, 63, 65]. In one

cross-sectional study, 855 GPs assessed 1,921 VCs, which were follow-ups of previous problems. VC was viewed as either superior or equivalent to face-to-face consultation, in more than 60% of the visits [60]. GPs also deemed STC suitable for simpler and more straightforward issues, including administrative requests like for a sick leave or a medical certificate, in five studies [9, 10, 42, 62, 63]. For example, a GP reported that “Much sick leave follow-up that does not require a physical examination is much better on video. It saves a lot of time for both doctor and patient” [63]. Moreover, four studies reported
that STC would be best suited for triage, so to deciding
which patient requires face-to-face consultation [10, 47,
63, 67]. Besides, it is mentioned in several studies that VC
was appropriate for dermatological conditions [6, 9, 45,
50, 54] and PC was appropriate for both renewing pre-
scription [8, 10, 43, 59, 62] and discussing or requesting
test results [8, 47, 49, 66].

The second factor, consultation quality, describes how timely and appropriate STC is for a given medical condition, leading to a better outcome. It occurred in 68% (23/34) of the studies. GPs expressed their concerns about the potential risk of misdiagnosis due to their inability to perform a physical exam on patients, in 14 studies [3, 8–11, 42, 43, 46, 49, 50, 53, 55, 57, 68]. They reported that, for some pathologies, it is harder to establish a diagnosis without a physical exam, making STC difficult. For example, new musculoskeletal cases and pregnancy require face-to-face consultation, as do some acute mental health and pain cases, particularly for new patients [11, 49, 57]. Further, a GP stated about VC: “I suppose common day to day, you can’t put a stethoscope down a camera, so if you can’t do that, then that should generally rule out anything that you would generally be using that for” [43]. Five studies reported that GPs were afraid of not detecting signs of a serious illness due to the lack of non-verbal communication (e.g., active listening, checking patient’s presence, picking up signals, etc.), which mostly exist in PC [6, 8, 45, 49, 58]. VC offers some advantages as reported by Mckinstry et al. [49] and Koch et al. [67], GPs pointed out benefits such as “Visual contact”. In addition, six studies [8, 11, 54, 55, 59, 63] noticed the effectiveness of STC to ensure safety and continuity of care in the context of contagious infection and epidemic contexts.

Category of ICT-related factors

We identified two factors within ICT in the use of STC.

The first factor is the quality of equipment and bandwidth, which refers to the efficiency of the internet connection and the effectiveness of the hard and soft materials to enable high-quality image, voice, and video transmission, from both GPs and patients’ sides. It was reported in 35% (12/34) of the studies. Technological issues such as insufficient bandwidth (e.g., lack of good internet connection) were discussed in 11 studies [6, 8, 9, 11, 42–44, 54, 55, 57, 65]. Lack of good internet connection was a serious obstacle to using VC [43, 44]. In this sense, GPs reported practical issues, such as the reliance on appropriate internet provision and broadband reliability [6]. Additionally, five studies discussed the quality of technological devices and the availability of appropriate equipment [8, 11, 42, 44, 68]. As reported by one GP, "*the quality of the video camera and the sharpness of the image, if you want to observe, for example, a rash or

swelling, it requires the patient being able to get the cam-
era angled in the right place and that the light and the
distance to what we want to see is okay (...); It is also pref-
erable to use a Wi-Fi connection. A 3G network pixelates
it and makes it blurry. It also means that some contrasts
and sharpness are lost, and then you cannot really use it"
[54]. Technical issues occurred most of the time with VC
leading GPs to drop to PC. GPs stated that PC is more
intuitive, quicker, and reliable [9].

The second factor, STC's risks, pertains to the risks associated with the practice of STC, which was mentioned in 38% (13/34) of the studies. Studies noted privacy (e.g., patient conducting a STC in inappropriate place such as grocery) and confidentiality issues during the GP-patient' encounters in 12 studies [6, 11, 43, 45, 47, 54, 55, 59, 62, 63, 68]. Listeners (i.e., family members) on the patient's side can disturb or keep an eye on VC with or without making their presence known to the GP. For example, "*other people in the room disturb, want to participate in the conversation, or have their own consultation (referring to family members who also have questions). It can also be challenging regarding confidentiality if patients conduct video from wherever...! (in the) home situation, it can be difficult to tell personal things - for example when a doctor wants to ask about sexual abuse, violence, and previous trauma experiences in relation to issues the patient raises (...). You also cannot know whether the patient's communication with the doctor is monitored by relatives and thus controlled*" [63]. Security was another particular concern in four studies [43, 45, 50, 55], for which GPs expressed the need for General Data Protection Regulation (GDPR) compliance. Thus, a GP stated: "*I think that if there was some platform within our software package that's GDPR compliant where we can view that patient in a clinical setting with good background information and experienced clinicians on the far side*" [43]. Additionally, physicians thought that STC could raise medicolegal issues [6, 9, 55, 64]. Their concern was whether seeing a patient through STC would be acknowledged as "a proper basis for diagnosing and initiating treatment." As commented by a GP, "*You're behind on points. If something goes wrong, then, naturally, there's a big difference in whether you have seen the patient or not seen the patient from a medico-legal point of view*" [64].

Category of GP-related factors

This category discusses four factors that highlight the sig-
nificance of physicians' factors in the use of STC.

The first factor is GPs' sociodemographic, which refers
to characteristics related to age, sex, ethnicity, education
and income. It appeared in 35% (12/34) of the studies.
One study reported on the importance of age, as younger
physicians were more confident with STC and found it
helpful [9]. Another study found that working from home through VC improved the quality of life of older physicians in an epidemic context [11]. Among the reviewed studies, eight identified additional training (complementary knowledge required to be skilled in digital literacy) as an important element for conducting successful STC [9–11, 43–45, 50, 59]. As a GP stated, “There is nothing related to the low quality of care, but as I said, we need staff who are confident to reach to the diagnosis by history and without examination” [50]. Another important sociodemographic characteristic reported in seven studies, is “income”, which refers to the amount of revenue that STC can generate for GPs [10, 11, 42, 45, 55, 56, 67]. In a study, GPs agreed that paying for STC that are comparable to face-to-face consultation is crucial to encouraging higher utilization [10].

The second factor is ability, which should be understood as GPs' competency to use STC. Several studies (4/34) identified GPs' ability to conduct STC, as a prerequisite to overcome uncertainty. In other words, GPs with extensive STC experience and technical skills are more likely to use it [11, 55, 63, 69]. Furthermore, a study demonstrated that the more autonomous GPs feel, the more they feel the need to utilize STC [69].

The third factor is GPs' attitudes toward STC, which is their personal perceptions and preferences regarding VC and PC. Eight studies discussed GPs' attitudes toward STC [9, 11, 48, 50, 53, 54, 63, 67]. In one study, GPs primarily compared VC to PC and stated that VC provided a welcomed opportunity to gain a complete overview of patients' health status including facial expression and level of symptom severity [11, 63]. They also found positive aspects of VC that included patients' comfort as well as GPs' possibility to observe patients' home environments [11]. However, one study found that GPs were highly satisfied with both PC (85%) and face-to-face consultation (87%) [48].

The fourth factor is convenience. It describes the flexibility of STC to provide options that fit in well with the needs of GPs in terms of workload management, working date, working time, working place, etc. It occurred in 29% (10/34) of the studies. Six studies identified flexibility as an important determinant of STC [10, 11, 57, 63, 67, 68]. The major benefits reported were the flexibility to work remotely in a location of GPs' choice, as well as having more control over their schedule. As expressed by a GP: “Video consultation give more flexibility for me as a physician, flexibility to work from home and flexibility regarding working time” [67]. Five studies described STC as a mean to facilitate access to care for patients [47, 50, 52, 55, 58]. A GP said that VC: “not only improves access for patients but also for doctors. I mean, it'd be much easier for me to go to a patient's home via the computer than to physically drive there” [50]. Another study quotes a GP:

“STC (telemedicine) is *far more time-efficient (GP2) than full days of face-to-face appointments.*” [58].

## Category of GP-patient relationship

This category describes the role of the GP-patient relationship in building trust, ensuring continuity of care, as well as facilitating the diagnosis process. It covers three factors.

The first factor is building trust, referring to how STC contributes to maintaining or strengthening the relationship. Four studies mentioned GPs' challenges in establishing trust with new patients, including missing human contact and non-verbal cues that are essential to building a therapeutic relationship, particularly through PC, when compared to face-to-face appointments [47, 49, 63, 68]. VC was perceived as a strength to improve the relationship between GP and patient as they see each other, compared to PC, in three studies [11, 50, 68]. As commented by a GP, “I suppose just being able to see your doctor could go a long way to improving the doctor-patient relationship.” [50]. Overall, VC appears to be superior to PC in terms of communication and relationship building.

The second factor is continuity of care, which is concerned with the provision of quality care over time. It was mentioned in four studies [10, 47, 54, 55], in which GPs recognized the effectiveness of STC to ensure the continuity of care in contagious disease or epidemic contexts.

The third factor is the ease of diagnosis, which demonstrates how familiarity based on the existing relationship between the GPs and patients enables GPs to readily make a diagnosis. It occurred in 29% (10/34) of the studies. Ten studies reported that GPs were able to understand and diagnose patients' issues through STC, even by PC, when it is a known patient with an established relationship [9, 42, 46, 47, 49, 54, 55, 60, 62, 63]. This is supported by the following quote: “Yes, we are risk takers. We rely on the fact that we can pick up the underlying message behind what somebody is saying, often you will be picking up unconsciously different resonances from what the patient is telling you, and of course if you know the patient you are adjusted to that anyway. You do use it, you can tell from somebody's voice if they are depressed” [49]. In one study, when GPs knew their patients through prior established relationships, they deemed VC to have “greater” or “same” suitability compared to face-to-face consultation in 57% of cases; a percentage that dropped to 32% when the patients were “unknown” [60].

## Category of patient-related factors

This category describes and provides important elements to consider when GPs determine which patients are most likely to be suitable for a STC. There are five factors to be considered.
The first factor is patients' sociodemographic, which is related to the social and demographic characteristics; and reported in nine articles. Eight studies reported that STC use was associated with patients' age. According to GPs, conducting STC, particularly PC, with elderly patients leads to suboptimal patient-GP interaction, as it consumes time due to the probability of communication barriers, because they are not familiar with the use of STC [46, 53, 54, 59]. Meanwhile, younger patients seem to be best suited to STC because they react well [42, 55, 58]. Another patients' characteristic mentioned was ethnicity. A study reported that PC was best suited with native English-speaking patients (this to highlight the shared common language, as the study was conducted in the UK) [44]. A GP commented about PC: "I do notice that *generally the patients that are born and raised in the UK, you can process their problems quicker*" [44].

The second factor is barriers to access. This refers to any patients' situation that hinders access to healthcare services. In four studies, GPs associated STC's use with patients facing diverse difficulties to access care [8–11]. GPs highlighted that STC improved equity in access to care for patients who live in remote areas, patients with mobility issues, or patients experiencing financial barriers, who would have faced serious challenges if they were to use face-to-face consultation due to their situations [8–11].

The third factor is ability, understood as patients' competency to use STC; and it occurred in 26% (9/34) of the studies. GPs reported in six studies that patients' ability to communicate through digital devices was a reason to use STC. They felt more confident in conducting VC when the patient was knowledgeable and competent to use technology [44, 46, 50, 63, 68]. Meanwhile, if a patient is unable to use technology and has low digital literacy, GPs prefer a PC [11]. In addition, for issues concerning children, GPs viewed parents' good communication and verbal skills, along with the ability to accurately describe symptoms, as essential for a PC [6, 46, 49].

The fourth factor is patients' attitude toward STC according to GPs, which is referred to as patients' personal perceptions and preferences regarding VC and PC. It appeared in seven studies. Greenhalgh et al. [9] and Hallam et al. [47] reported that, for GPs, some patients were unwilling to try VC simply because they did not wish to appear on video. A GP commented, "I offer it (VC) to most people with mental health conditions, and most of them say, 'I'd rather just do the phone.'" [9]. On the contrary, some patients preferred VC, despite the face-to-face consultation modality (option) [42, 68]. Finally, according to GPs, a group of patients preferred only face-to-face consultations, perceiving STC to be somehow "substandard" to maximize their patient-physician relationship [10, 50, 58].

The fifth factor is convenience and describes the flexibility of STC to provide an option that fits with the needs of patients in terms of place, date, time of appointment, etc., according to GPs. It occurred in six studies. In these six studies, GPs describe the convenience role of STC for patients. In this sense, McKinstry and al. [49] reported that, according to GPs, PC was used by patients to maintain long-distance relationships and receive advice from them (e.g., when patients are working away or on holiday) or to verify whether a visit to their office was necessary. Another advantage perceived by GPs for patients was saving on time and on parking and transit costs, as patients don't need to travel to and from their appointment place or take much time off work [9, 11, 65]. GPs also believe that STC improves timeliness and decreases waiting time in clinic for patients [10]. Furthermore, GPs believe that VC provides comfort to patients because they are in their own environment while talking on the screen [55].

## Category of institutional factors

This category describes four factors to be considered within one clinic to facilitate the adoption of STC, from GPs' perspective.

The first factor is organizational and peer support, which refers to professional assistance (e.g., GPs sharing their experience and providing feedback on STC with their colleagues) and institutional assistance (e.g., training provided by the clinic). In five studies, GPs noted that the adoption of STC requires a supportive organizational culture, a preexisting teleworking culture, and a perceived need for adaptation [9, 10, 54, 55, 59]. Moreover, GPs reported in seven studies that feeling supported and being able to discuss difficult STC with colleagues within the same health center were key elements to using STC [9, 10, 46, 54, 55, 58, 59].

The second factor pertains to guidelines related to the protocols and regulations regarding the practice of STC. Ten studies reported the critical need to establishing protocols and guidelines for STC practice within each clinic, and the lack of guidelines and protocols constitute barrier to STC's adoption [10, 42, 43, 45, 47, 55, 58, 59, 62, 68]. This involves strong organizational commitment, government policies for STC's practice, constant updates, and training activities to keep GPs on track to provide quality care.

The third factor is the workload and demand, related to how the growing demand of care influences STC's adoption. This occurred in six studies. An increase in healthcare demand was the reason for introducing STC in many clinics, as reported in six studies [6, 8, 44, 45, 49, 50]. It is reported that the recognition that reception staff and phone lines were overwhelmed by patients demands and that to manage that demand and improve efficiency, STC
<table><caption>**Table 4** Summary of factors influencing GPs' use of video vs. phone consultations</caption><thead><tr><th>Factors</th><th>Video consultation (VC)</th><th>NS</th><th>NS</th><th>Phone consultation (PC)</th></tr></thead><tbody><tr><td>Consultation quality</td><td>- Need to detect signs of serious illness by visual communication</td><td>06</td><td></td><td></td></tr><tr><td>Consultation purpose</td><td>- Appropriate for dermatological conditions</td><td>05</td><td>08</td><td>- Renewing prescription<br/>- Discussing or requesting test</td></tr><tr><td>Quality of equipment and bandwidth</td><td></td><td>04</td><td></td><td>- If lack of good internet connection<br/>- If technical issues</td></tr><tr><td>GP's attitudes toward STC</td><td>- Need to observe a complete overview of patients' health status, including facial expression and level of symptom severity</td><td>02</td><td></td><td></td></tr><tr><td>Building trust</td><td>- Need for communication and relationship building with new patient</td><td>07</td><td></td><td></td></tr><tr><td>Patient's sociodemographic</td><td>- Need of interaction with older patients</td><td>04</td><td></td><td></td></tr><tr><td>Patient's ability</td><td>- Patient with high digital literacy</td><td>06</td><td>03</td><td>- Patient with good communication and verbal skills</td></tr><tr><td>Patient's attitudes toward STC</td><td></td><td>02</td><td></td><td>- Patient do not wish to appear on video</td></tr></tbody></table>

NS = number of studies that explicitly differentiated VC from PC on the factor; consultation quality and consultation purpose are derived from the category of consultation; quality of equipment and bandwidth is derived from the ICT category; GP's attitudes toward STC is derived from the category of GP; building trust is derived from the category of GP-patient relationship; patient's sociodemographic, patient's ability, and patient's attitudes toward STC are derived from the category of patient

was a good avenue [44]. The decision to adopt STC does not depend only on GPs; it also depends on the organization within one clinic as to whether it perceives STC as an alternative that could offer flexibility to both staff and patients. For GPs, the main motivation for introducing alternatives (STC) to face-to-face consultations was to help them manage their workload, as it helps them decide when and in what order to see a patient [44].

The fourth factor is financial support, meaning the funding required to implement STC in clinics, which was reported in six studies. In these studies, the offer of financial support and the availability of funding for staff training such as, GPs receiving funding from research institutions, facilitated the adoption of STC in several

clinics [6, 10, 43–45, 59]. GPs described barriers to adoption as issues related to finances, including a general lack of investment and, more specifically, lack of funding allocated to human resources and supporting the costs of systems set-up and maintenance [10].

Beyond clinical conditions that were generally suitable for STC (both VC and PC), there were cases where GPs explicitly differentiated VC from PC. These situations involved various influencing factors, which are summarized in Table 4 below.

## Discussion

Using a systematic review, we identified 34 studies from which, we extracted data representing 5,563 GPs' perspectives. Using these data, we analyzed and reported studies' findings, based on the narrative synthesis approach, to answer our research question: what factors influence GPs' choice of STC modalities (VC and PC) over face-to-face consultation. We found that GPs' attitude toward, experience with, satisfaction with, and intention to use STC modalities is influenced by an interplay of multiple factors that we grouped into six categories of factors, including consultation, ICT, GP, patient, GP-patient relationship, and the institution (the clinic). For the sake of simplification, we preferred to employ the term “use of STC”.

## Implications for policy and practice

In this section, we will discuss each of these categories along with their implications.

The first category of factors pertains to consultation. Our review reveals that GPs' decision to use STC is influenced by the purpose of consultation, such as follow-up care or administrative requests, and the ability of STC to meet the quality required for such care. These findings are in alignment with previous reviews on STC's use by GPs [13, 14]. This suggests that primary care settings can easily adopt STC, implying a potential increase in its use in the future. However, a recent study in five Northern European countries found that GPs and staff in these settings use of VC decreased in the post-pandemic era [18]. It suggests that even if GPs become familiar with VC, there may still be some individual, organizational, and cultural or unknown barriers that hinder its widespread use, necessitating further investigations. In this sense, GPs expressed concern about some pathologies for which they were unable to establish a diagnosis due to the lack of a physical exam [11, 49, 57]. The purpose of consultation should be a primary factor in guiding decisions regarding the modalities of consultation when the goal is to deliver quality care in primary healthcare.

The second category of factors pertains to ICT. This review found that to use STC, particularly VC, GPs look for a good internet connection and the effectiveness of
the hard and soft materials to enable high-quality inter-
action between GPs and patients. These findings are
aligned with previous reviews [13, 14]. Apart from con-
fidentiality issues, this review identified barriers to STC's
adoption, such as patient privacy (e.g., a patient con-
ducting a STC in an inappropriate place such as a gro-
cery store), data security, and ethical concerns, which are
similar to those reported by Kruse et al. [70]. This implies
that to use STC, GPs not only need appropriate internet
provision and reliable broadband in their office, but they
also need to ensure the same requirement from patients'
side. GPs must fulfill their responsibility by ensuring
patients' privacy and confidentiality, which they can
achieve by asking questions such as "Where are you?" or
"Are you alone?" at the beginning of the conversation, for
example. To ensure the continued use of STC, health ser-
vices organizations must master the issue of data security
effectively. Additionally, the absence of a reliable connec-
tion can pose a barrier to adoption, prompting consid-
eration of resource availability when implementing new
technologies.

The third category of factors pertains to GPs. Our
review revealed that sociodemographic factors (e.g.,
financial incentive, training), ability (e.g., positive pre-
vious experience, level of digital literacy), attitude, and
perceived convenience related to STC (e.g., flexibility)
influence GPs' use of STC. Ours results align with some
results of previous reviews conducted on the adop-
tion and use of STC in primary care, including conve-
nience and positive previous experience [13, 14, 70], as
well as reimbursement policies [13]. This highlights the
importance of flexibility, digital skills, and the financial
incentive for GPs to use STC. Therefore, to sustain the
utilization of STC in primary care, it is crucial that policy
discussions surrounding reimbursement meet a fair pay-
ment model for STC.

The fourth category of factors concern the GP-patient
relationship, which can significantly influence GPs' deci-
sion to use STC. An established relationship fosters trust
through increased GP-patient communication, ensures
continuity of care, and facilitates diagnosis. Kruse et al.
[70] also reported in their systematic review an increase
in GP-patient communication through VC. Several
studies included in this review mentioned that PC lacks
human contact and non-verbal cues, which are essential
to establish trust with new patients and build therapeu-
tic relationships [47, 49, 63, 68]. This suggests that PC
may be most appropriate for follow-up care with known
patients while VC could be most indicated for both
known and unknown patients in general practice.

The fifth category of factors is concerned with patients.
This review found that GPs' decision to use STC is influ-
enced by patients' sociodemographic factors (e.g., age,
ethnicity), abilities (e.g., level of digital literacy), attitudes,

perceived convenience related to STC (e.g., flexibility),
and access barriers. In four studies, GPs associated STC's
use with patients who live in remote areas, patients with
mobility issues, or patients experiencing financial dif-
ficulties [8–11]. This suggests that GPs are more moti-
vated to use STC when patients encounter more barriers
to accessing clinics. While GPs might perceive STC as a
mean to improve care accessibility for patients living in
remote areas, patients with invalidity, and patients with
financial barriers, it does not benefit those with low lev-
els of digital literacy and those with language barriers
(e.g., not proficient in the GP's language). This indicates
that the suitability of STC varies across patients' groups,
and the increased use of STC might contribute to repro-
ducing certain forms of inequality in health care access.
Therefore, future policies regulating the usage and deliv-
ery of STC should always prioritize equity in access. Fur-
thermore, to ensure the appropriate uptake of STC in
primary care, health care authorities must enhance the
population's capability, such as by providing training for
individual groups in need, to enable them to use it freely
and independently when possible.

The sixth category of factors pertains to the institu-
tion, specifically the clinic. We found that the existence
of organizational and peer support, financial support,
guidelines, and the perceived increase in workload (the
ability of STC to decrease workload) influence the use
of STC by GPs within an institution. In their systematic
review, Hoff et al. [20] and Carrillo de Albornoz et al. [12]
also reported on the role of STC to reduce GPs' work-
load, while Lindenfeld et al. [13] reported on the role of
peer support to facilitate STC adoption. This implies that
even GPs' will to use STC may not be enough for adop-
tion; they should account for the organizational support.
As highlighted by Rogers [19], employees' decision to
adopt an innovation does not depend on them but rather
the organizational managers and policymakers. The
institution plays a critical role in the individual's adop-
tion process by providing financial support, training, and
other resources.

Strengths and limitations

Strengths

One of the strengths of this review is its specific focus on
the perspectives of GPs regarding the factors influenc-
ing their utilization of STC. This approach potentially
enhances the relevance of the findings. Additionally, we
included qualitative, quantitative, and mixed-method
studies in this synthesis to guarantee the inclusion of
all types of findings, thereby reducing the possibility of
missing any evidence. The review's focus on synchro-
nous teleconsultation is a unique aspect, because most
existing reviews on the use and adoption of the ICT in
healthcare have either focused on telemedicine or VC/
PC. Furthermore, the methodological quality assess-
ment showed that most of the included studies were of
high quality (70.59%). However, 23.53% of studies were
considered of low quality due to methodological con-
cerns in several domains, such as consistent analysis and
interpretation of qualitative data, representativeness and
appropriate measurement for quantitative data. While
these studies contributed to identifying some factors,
our analysis revealed that the most often mentioned and
emphasized factors came mostly from high-quality stud-
ies. Although, no formal sensitivity analysis was per-
formed in the conventional statistical sense, we tested the
consistency of our findings by examining the frequency
distribution of studies across factors.

Limitations

Despite these strengths, there are several limitations to
this review.

First, most evidence comes from qualitative studies as we had few quantitative studies. Only three studies [48, 51, 66] performed multivariate analyses to examine the link between explanatory variables and the type of consultation (STC and face-to-face consultation), including two [48, 51] that compared STC to face-to-face consultation. In addition, these two quantitative studies with multivariate analyses had small sample sizes of less than 20 GPs. While qualitative data provided rich contextual insights into GPs' use of STC, the scarcity of robust multivariate analyses limited our ability to assess the effect size of covariables on GPs' decision to use STC when interpreting quantitative associations between determinants and STC use by GPs. Multivariate analyses are essential in health services research because they allow researchers to account for the influence of multiple variables simultaneously, improving the internal validity of findings [71, 72]. Their absence weakens the generalizability and comparability of findings across settings and populations [73]. Consequently, while qualitative findings offer valuable depth, the limited statistical modeling restricts the strength of conclusions that can be drawn about the predictive value or relative weight of identified factors. Future reviews should prioritize the inclusion of rigorous and numerous quantitative studies with multivariate analyses to better inform policy and clinical practice on the utilization of STC by GPs.

Second, a potential limitation of this review is the tem-
poral concentration of the included studies, being con-
ducted during the COVID-19 pandemic (e.g., 2020 and
2021). This review includes 56% of studies (19 out of 34)
that were conducted during the COVID-19 period. This
raises concerns about temporal bias, as the extraordinary
context of the COVID-19 pandemic could have artifi-
cially inflated or distorted GPs' experience, satisfaction,
use, attitude toward, and acceptability of STC, which in

turn could have impacted the identified factors. Dur-
ing the pandemic, STC adoption was often mandated by
health authorities and influenced by emergency funding,
regulatory relaxation, and constrained in-person care
options [74, 75]. As such, the factors that GPs reported
as influencing their decision to use STC during this
period may not reflect typical practice conditions or be
sustained in the long term. This context-dependent usage
of STC suggests that findings may not actually represent
the influencing factors of GPs' utilization of STC for the
integration of STC in post-pandemic primary healthcare.
Fortunately, the review also includes 44% of studies con-
ducted outside the COVID-19 period, whose results were
consistent with those of studies conducted during the
pandemic regarding the twenty factors.

Third, most included studies were conducted in high-
income countries such as the USA, the UK, Canada, Nor-
way, Australia, and Israel. As a result, our findings may
not fully reflect the factors influencing the use of STC
among GPs in low- and middle-income countries, par-
ticularly in regions such as Africa. This limitation high-
lights several underlying issues. One key challenge is the
lack of infrastructure in many African countries, includ-
ing limited access to electricity and reliable internet con-
nectivity [76], both of which are essential for the effective
implementation of digital health technologies. Another
barrier is the limited capacity and expertise required to
produce and use scientific evidence, which contributes to
the scarcity of health data in the region [77]. These dis-
parities contribute to a knowledge gap in the use of STC
by GPs in this region. Therefore, future research should
prioritize STC studies in underserved regions, such as
Africa, to promote a more inclusive and global under-
standing of its adoption and use by GPs.

Finally, although the inclusion of publications only
in English or French was a deliberate methodological
choice, it might have narrowed the scope of the find-
ings, potentially leading to an occidental perspective on
the use of STC by GPs. However, most of the reviewed
publications were written in English, and none were
excluded solely based on the language criterion. Of the
725 articles assessed for inclusion, only 11 were writ-
ten in other languages and were excluded on multiple
reasons (e.g., not GP-specific, not about STC). None-
theless, research should consider adopting multilingual
approaches to gain a more thorough and globally repre-
sentative understanding.

Conclusions

This review summarized the evidence on the factors
influencing GPs' use of STC. The main findings of the
review highlight a multifactorial decision-making pro-
cess, which considers several groups of factors, including
consultation, ICT, GP, patient, GP-patient relationship, and the institution (the clinic).

The results suggest that GPs should first consider consultation-related factors to ensure the appropriate use of STC in primary care. To support the sustained use of STC, policy discussions on reimbursement should promote fair payment models and consistently prioritize equity in access. Future studies could further examine GPs' preferences for various consultation modalities. Such studies could determine which factors prevail over others and to what extent, given that GPs' preferences are crucial to enhancing their experience so as to achieve the Quadruple Aim-enhancing patient experience, improving population health, reducing cost, and improving the work life of health care providers [78], and equity of health systems.

### Abbreviations

* COVID-19 Coronavirus disease 2019

* ICT Information and Communication Technology

* GP General practitioner

* PC Phone consultation

* PRISMA The Preferred Reporting Items for Systematic reviews and Meta-Analyses

* STC Synchronous teleconsultation

* UK United Kingdom

* USA United States of America

* VC Video consultation

### Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12875-025-02975-y.

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

Supplementary Material 4

Supplementary Material 5

Supplementary Material 6

### Acknowledgements

We would like to thank Mr. Saint-Thomas Mbaiamodji for his assistance in the study selection process. We also thank Mrs. Marie-Claude Laferrière for her assistance in obtaining some full-text articles. This work was funded by the Canadian Institute of Health Research (CIHR) (grant numbers 202209PJT-487640-HPM-CFBA-207592) and the Labex Entreprendre, Université de Montpellier. AS received a Ph.D. scholarships from the Centre de recherche du CHU de Québec-Université Laval; the Vitam, Centre de recherche en santé durable-Université Laval; and the Centre de recherche du CISSS de Chaudière-Appalaches et la Fondation Hôtel-Dieu de Lévis. These funding organizations had no involvement in the study design; in the data collection, analysis and interpretation; in the writing of the article; or in the decision to submit it for publication.

### Authors' contributions

CRediT authorship contribution statement AS: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review and editing. GFM: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Writing – review and editing. MG: Conceptualization,

Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review and editing. TGP: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – review and editing. ML: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review and editing.

### Funding

This work was supported by the Canadian Institute of Health Research (CIHR) (grant numbers 202209PJT-487640-HPM-CFBA-207592) and the Labex Entreprendre, Université de Montpellier.

ML is a recipient of a salary award by the Quebec Research Fund in Health (FRQS).

TGP is member of the FRQS-funded Centre de recherche de l'USMM.

AS is supported by doctoral scholarships from: Centre de recherche du CHU de Québec-Université Laval; Vitam, Centre de recherche en santé durable-Université Laval; Centre de recherche du CISSS de Chaudière-Appalaches et la Fondation Hôtel-Dieu de Lévis.

### Data availability

Data will be made available upon reasonable request from the corresponding author.

### Declarations

#### Ethics approval and consent to participate

Not applicable.

#### Consent for publication

Not applicable.

#### Competing interests

The authors declare no competing interests.

### Author details

¹Faculty of nursing sciences, Université Laval, Québec, QC, Canada

²Centre de recherche du CHU de Québec-Université Laval, Axe Santé des populations et pratiques optimales en santé, Québec, QC, Canada

³Vitam, Centre de recherche en santé durable-Université Laval, Québec, QC, Canada

⁴Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada

⁵Montpellier Recherche en Economie, Université de Montpellier, Montpellier, France

⁶Centre interuniversitaire de recherche en analyse des organisations (CIRANO), Montréal, QC, Canada

⁷Fondation pour les Études et Recherches sur le Développement International, Clermont-Ferrand, France

⁸Department of management, evaluation and health policy, School of public health, University of Montreal, Montreal, QC, Canada

⁹Centre de recherche de l'USMM, CIUSSS de l'Est de l'Île de Montréal, Montréal, QC, Canada

¹⁰Department of social and preventive medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada

Received: 28 March 2025 / Accepted: 30 July 2025

Published online: 25 August 2025

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