Physicians’ experiences delivering provincial real-time virtual support services: A qualitative interview study

Abstract

Rural, remote, and Indigenous communities in British Columbia (BC) tend to have lower access to healthcare providers and poorer health outcomes—an inequality that the COVID-19 pandemic has exacerbated. In response, Real-Time Virtual Support (RTVS) pathways were developed to advance equitable access to care for patients and provide peer support to physicians working in underserved communities. This study aimed to describe the perspectives of Virtual Physicians (VPs) who delivered the RTVS services. Forty-five RTVS VPs engaged in 30-minute semi-structured interviews about their experiences and perspectives delivering RTVS. Three themes emerged: (1) RTVS’s contributions to VPs’ personal and professional development; (2) impacts on communities; and (3) considerations for the availability and expansion. VPs identified incremental expansion and attaining funding stability as critical next steps for virtual healthcare in BC. This evidence informed RTVS program evaluation and may provide learnings relevant to other jurisdictions.

Introduction

Disproportionately fewer physicians practice in rural areas and residents of rural and Indigenous communities have poorer health and less access to services than their non-rural counterparts.^1-4 This poses a challenge, as gaps in healthcare for rural, remote, and Indigenous patients exist across Canada.^5,6 Particularly, Indigenous patients need culturally safe, tailored, and accessible care that addresses historical injustices outlined by the Truth and Reconciliation Commission. The Review of Family Medicine Within Rural and Remote Canada notes that more than 15 years ago “the First Ministers of Health set a target that by 2011 at least 50% of Canadians should have access to an appropriate primary care provider 24/7 regardless of where they live.” However, patients in rural, remote, and Indigenous communities still face challenges obtaining equitable access to healthcare in Canada, partly due to there still being disproportionately fewer physicians practicing in those areas.

The COVID-19 pandemic created new challenges and exacerbated existing ones for the healthcare system, such as disruption and closure of local services in First Nations communities and overwhelming nurses in the public health telephone service in British Columbia (BC).^7,8 In response to existing healthcare system gaps and exacerbations brought on by the COVID-19 pandemic, the Real-Time Virtual Support (RTVS) virtual care pathways were formally deployed in April 2020. The RTVS pathways include patient-facing and peer-to-peer virtual physician services focused on to improving health equity in rural, remote, and Indigenous communities in BC. ⁹ Pre-existing relationships between founding organizations facilitated the rapid implementation of RTVS and its flexibility to adapt to the changing health challenges. ¹⁰ Several prior on-demand, virtual initiatives also paved the way for RTVS, including CODI ¹¹ (Critical Outreach and Diagnostic Intervention) and the Robson Valley Virtual Care pilot project, and the Virtual Health and Wellness Collaborative for Rural and First Nations BC was established in 2019.^12,13

Several studies to date have examined physicians’ perspectives and experiences delivering care during the pandemic.^14-18 One of these include a community-based participatory study of 13 rural family physicians across Canada that highlighted several challenges for physicians, including staffing shortages and pandemic fatigue.^14,15 There is a significant lack of evidence in the literature that aligns with our work; thus, this type of study may contribute valuable evidence to understand how to better support physicians delivering healthcare virtually. With the ongoing widespread deployment of virtual care and its apparent entrenchment even as the pandemic wanes, we sought to describe the perspectives of over 150 physicians staffing the RTVS pathways through qualitative inquiry.

Methods

Study design and participants

In this evaluation, we aimed to describe the experiences and perspectives of Virtual Physicians (VPs) who delivered various RTVS pathway call-lines using qualitative interviews as part of an overall mixed-method evaluation of RTVS. ⁹ A participatory approach was used in which partners including program leads collaborated through an evaluation advisory table where processes and were co-developed and findings were iteratively shared for verification and to inform ongoing quality improvement. The COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used to ensure comprehensive reporting of our qualitative methodologies and findings. ¹⁶ Purposive convenience sampling was used to recruit participants for this study. Participants met the following criteria: (1) were VPs staffing at least one of the RTVS pathway lines offered between December 2020 and February 2021; (2) had access to a telephone or electronic device to call or join a Zoom meeting for the interview; and (3) provided full verbal consent. All 150+ VPs from each RTVS pathway were invited to participate in the study through e-mail invitations. Demographic information such as age, gender, community of residence, and years in practice were not collected in order to minimize VP identification risk, since they are supporting small, marginalized communities. Recruitment, data collection, and data analysis occurred concurrently until the research team determined that data sufficiency had been reached and the evaluation period ended. ¹⁶ All participants provided verbal consent prior to commencement of their scheduled interview.

Data collection

After participants provided verbal consent, one-on-one, 30-minute interviews were conducted with each participant by RTVS evaluation team members. All interviewers either had previous experience conducting open-ended semi-structured interviews or were trained by a fellow colleague in preparations of data collection. None of the interviewers had personal relationships with the participants.

Interviews were conducted over telephone or Zoom videoconferencing using an open-ended semi-structured interview guide developed by the evaluation team. The interview guide consisted of questions aimed at capturing the experiences and perspectives of VPs who helped deliver RTVS during the COVID-19 pandemic (see Textbox 1). The interview guide was further refined throughout the data collection process to include any emerging topics. Interviews were audio-recorded using Zoom, and supplementary field notes were written throughout the interview process.

Textbox 1.

Interview guide.

1. Tell me a bit about why you got involved in RTVS? What makes you stay?

2. From your experience, what qualities are important for a virtual physician in [pathway] to have?

3. Can you tell me more about the types/range of calls that you support during a shift?

4. Can you share a memorable case from your time as a RTVS provider? What stood out about this case and made it significant? What do you think would have happened without RTVS?

5. Have you collaborated with PTN (Patient Transport Network) in RTVS?

6. Do you see any enduring inequities faced by patients in rural, remote, or Indigenous communities? Do you know of particular challenges faced by specific communities? Has RTVS or [pathway] helped address these inequities?

7. From your experience, has RTVS impacted access to healthcare for patients in rural, remote, Indigenous communities? Please describe/provide examples from your experience or that you’ve observed.

8. In what ways do you think RTVS or [pathway] supports healthcare providers working in rural, remote, and Indigenous communities? What examples can you describe?

9. What is your perspective of the availability of RTVS across BC? Is it equitably available? Please elaborate. Are there certain communities or areas that are not accessing RTVS?

10. From your perspective, what are the successes or strengths of RTVS or [pathway]? What are the challenges? What areas of improvement would you suggest?

11. What is needed for RTVS to be sustainable for the long-term?

12. Is there anything else that you would like to share before ending the interview?

Analysis

Content analysis using a constant comparative approach was done to compare similarities and differences between the data. Analysis began with research assistants transcribing the data verbatim after each interview session. Transcripts were read multiple times in detail to increase validity as the data was being transcribed, and theoretical and reflective thoughts were documented on the side for data immersion. ¹⁸ The same two research assistants and two other research assistants identified, categorized, and sorted important sections of text into codes using NVivo 12. Coding began with each team member independently coding the same transcript to recognize and identify key elements. They met to discuss their coding and note similarities and divergences, and through discussion agreed upon an initial coding guide. The remaining transcripts were then divided among the four research team members for coding. The four research assistants held regular meetings to continue discussion of findings throughout the analysis process. During the coding process, a coding guide was further developed to include new codes. Once all data had been collected and initially coded, codes were extracted from NVivo 12 to be reviewed and summarized. Through the summarizing process, themes were identified and discussed. Themes brought “meaning and identity to a recurrent experience” ¹⁹ and captured something important about the overall research question. It is important to note that saturation was reached approximately two-thirds into the process, with no new themes emerging from the data at that point. All records of raw data, field notes, and transcripts were kept for researchers to clearly systemize, relate, and cross-reference data. ²⁰

Findings

Forty-five RTVS VPs (n = 45) engaged in 30-minute semi-structured interviews via Zoom videoconferencing or telephone call. Table 1 summarizes the pathways that VPs were assigned under at the time of their interviews. Among the sample, nineteen VPs (42.2%) had experience delivering one of the patient-facing pathways. The Virtual Physicians’ backgrounds varied depending on the pathway they work within. FNvDOD and RUDi VPs have more extensive experience working with remote, Indigenous communities. The length of time practicing varies from a few years out of residency, to comprehensive experience across the healthcare landscape. Pathways are described by Novak Lauscher and colleagues in an article summarizing RTVS Year 1 evaluation findings. ⁹ Three themes were derived from the analysis and are explained in further detail below.

Table 1.

Sample (n = 45): Virtual physicians by RTVS pathway.

RTVS pathway	Type	Count (n = 45)
First Nations Virtual Doctor of the Day (FNvDOD)	Patient-facing	11
HealthLink Emergency iDoctor in-assistance (HEiDi)	Patient-facing	8
Rural Urgent Doctor in-aid (RUDi)	Peer-to-peer	9
Child Health Advice in Realtime Electronically (CHARLiE)	Peer-to-peer	3
Maternity and Babies Advice Line (MaBAL)	Peer-to-peer	4
Quick Reply Pathways (related to various medical specialities)	Peer-to-peer	4
Supported multiple (>1) pathways	Varied	6
Total		45

RTVS contributes to personal and professional development of virtual physicians

VPs shared a range of reasons for getting involved with RTVS. In general, most of VP’s reason for getting involved and staying involved in RTVS was because of its contribution to their personal and professional development. Areas of learning that were often described could be broken into the following two subthemes: “understanding communities being supported” and “learning to use RTVS and balance it with other healthcare work.”

Understanding communities being supported

VPs spoke often on the importance in understanding the inequities in rural, remote, and Indigenous communities to provide better support. These include: low-resource environments (e.g., access to lab and X-ray); low specialist availability; fewer allied health resources (counselling, social work, dietitian, and home care nursing); less palliative care available; and transportation for accessing care. A physician shared:

Being able to talk to a RUDi doc is so vastly different from talking to an emergency doc down in say Vancouver, where there’s just a real mismatch in understanding about resources and capacity, especially around nursing resources...even access to certain medications or ability to provide like one-on-one care...that...being able to talk it over with someone who gets it is completely priceless. (FNvDOD VP #1)

Particularly, geographic limitations and barriers to access to care (plane cannot land in dark, extreme weather) were cited.

“I spent a lot of time google mapping… you have two critically ill COVID patients in [a rural town], and they need to be where, tell me where they need to go across this province because I’ve never actually been to [that rural town], so, yeah, it’s opened my eyes” (FNvDOD VP #2).

VPs also spoke to the need to understand the local dynamics of healthcare provider burn out to acknowledge the wellbeing of the providers in rural, remote, and Indigenous communities.

Learning to use RTVS and balance it with other healthcare work

VPs spoke of their own learning, both technical and soft skills, and how it impacts their practice. For instance, using multimedia (phone, pictures, teleconferences, and Zoom) and every piece of technology available helped VPs understand the available resources, know the status of the patient, and collaborate effectively with the local healthcare provider. In addition, VPs shared learning new methods of communication between a RUDi doctor and local doctor to balance best practices to support patients (e.g., lots of encouragement to reduce feelings of isolation for local doctors). One VP identified pathway connections to create a supportive network for patients:

I had a sick kid in a small island community off of Prince Rupert, and they suffered a burn and had a hard time figuring out what to do by myself and set up transfer for the patient to go to the city, but needed some extra help, and brought in the CHARLiE doctor...to help manage the case over Zoom, and then I got off the phone and called PTN, and set up the transfer, and then I had another call come in about a maternity case. I heard about that and I brought in the maternity, the MaBAL doctor, and they took over that case while I did the other transfer. So, I think cases like that where you can really bring in all of your friends from the patient transport network to MaBAL to CHARLiE, and when we're all sort of firing on all cylinders is probably more satisfying, I'd say. (RUDi VP #1)

One challenge is that VPs usually don’t receive any follow-up about what happens to the patients/providers that they were helping. For this reason, they do not know if they are doing their job correctly, or if there are ways that they need to improve their delivery of virtual care. Because of the nature of RTVS, most often VPs do not connect with the same patients again after the first call, and thus they do not always know the outcome of patients after a call ends.

Other VPs also commented on their experience of balancing their virtual health shifts with RTVS and other work. Balancing children and family life with flexibility in work shifts, providing remote care to reduce relocation needs, and availability to continuously support smaller communities are of great appeal to some VPs, along with the appeal of 12-hour shifts to allow for normal daily activities. When successfully balanced, this brings forth a sense of reward and potential for the RTVS site and can address physician burnout. However, RTVS work does expand the scope of practice, which can be challenging:

It’s a juggle to get fit this into a full-service family physician role with providing local community obstetrics or many others that we play. The one thing that we’ve decided as a group is that our current volume of calls that we handle…is manageable within our practice by doing about two shifts a month, when we start to get more than that, it’s quite hard to juggle that volume. (MaBAL VP #1).

Areas that need attention that were mentioned by VPs regarding balancing RTVS with other healthcare work included having a sufficient workforce, a clear definition on the scope of RTVS, making RTVS financially viable, and ensuring adequate workflow.

Impacting communities on a system level

Alongside professional development, VPs also reflected on the inequities in the various Indigenous, rural, and remote communities that RTVS aimed to support (i.e., how to address health inequities faced by patients/providers in their respective communities). These also led into VPs discussing about how RTVS could help enhance care options and shift healthcare on cultural levels in these communities.

Understanding health inequities faced by patients/providers in their respective communities

In the context of geographic barriers, the landscape of BC presents inherent inequities for individuals residing in rural, remote, Indigenous communities due to the vast geographic distances (4-12-hour drive) between rural communities and larger medical centres. Navigating geographical features in BC (dangerous roads, mountain ranges, water bodies, and poor weather conditions) presents increased risk of adverse health outcomes during patient transport out of community. Patients often cannot afford out-of-pocket expenses (gas/other transportation costs and childcare) and loss of income (taking time off work) to receive in-person healthcare service outside their community.

A lack of physical infrastructure, transportation, and medical education resources exacerbates inequities in healthcare and health outcomes in rural, remote, and Indigenous communities. Limited healthcare centres (walk-in clinics, emergency departments, and tertiary care centres) and associated personnel/providers contribute to poor health outcomes. Specifically, nurses in rural nursing stations are often presented with medical problems outside their scope of practice and are only able to stabilize a patient in emergencies, resulting in a delay of care that targets the root issue. The COVID-19 pandemic has amplified barriers and limitations in accessing transportation services from rural areas to specialists/healthcare centres in urban settings (e.g., restricted public transportation, basic ambulance, roadside/airside lifts, and lower likelihood of carpooling). A lack of continuous medical educational experiences for providers within their respective communities, compared to urban areas of BC, limits faculty/educational development. Through delivering RTVS, VPs could better acknowledge these geographical inequities in healthcare access and recognize the impact that RTVS has had to better support people in these communities:

The inequities are largely geographical, access to urgent care or emergent care because the geography of British Columbia and that is where I think a platform like HEiDi or RTVS in general is so valuable in that sometimes we are able to you know give advice to somebody in a remote location that will help them get over the next 24 hours, so they can get transportation to the care, to the definitive care that they need. (HEiDi VP #1)

Factors such as intergenerational trauma, colonial attitudes entrenched in the healthcare system, and systemic racism and discrimination from non-Indigenous healthcare providers have fed into mistrust between Indigenous patients and the healthcare system. Combined with the limited infrastructure (only 1 or 2 providers/centres in a community), this leads to delays in seeking care for urgent medical needs, ultimately worsening health outcomes. Discomfort may stem from lack of culturally safe care received from a rural provider or not wanting to run into their healthcare provider in the community (outside of healthcare appointments).

Enhancing care options and shifting healthcare on cultural levels

Most VPs believe RTVS services were making a positive impact on rural healthcare, both for patients and providers. Some RTVS providers have reported being surprised by their ability to form meaningful connections virtually as well as by the pleasant interactions they have had with colleagues and patients through RTVS. On the other hand, some providers were initially hesitant about the benefits of telehealth/virtual services due to their personal preferences in providing in-person care. Working with the RTVS service has led to shifts in perception, with providers reporting this as some of their most fulfilling and satisfying work.

RTVS expands care options for patients in rural and remote communities in a range of ways. For patients who feel uncomfortable disclosing health issues with a community or family doctor (e.g., stigmatized topics on sexual health, addictions, and mental illness), RTVS has been a safe alternative option for accessing and receiving healthcare from a virtual provider. RTVS gives patients virtual access to multiple pathway streams (e.g., pediatrics and maternity) and specialist expertise (e.g., dermatology and rheumatology) that typically require out of community transportation and/or long-wait times to access in-person. RTVS options also enable patients to access online healthcare services remotely with minimal disruption to their daily schedule. For many patients who do not have a family doctor, RTVS is an alternative to accessing culturally safe care in a timely manner rather than travelling to the closest walk-in clinic. As one of the physicians working in the First Nations primary care service noted:

I think a lot of communities, maybe do have access to one or two physicians, but perhaps like people in those communities don’t necessarily want to see the one physician that they have access to, in person…for whatever reason. And so RTVS I think it’s a nice way for people to have a little bit more option in terms of the care that they receive, and…who they receive it from. (FNVDoD VP #4)

Considering the availability and expansion of RTVS

Lastly, VPs discussed about ways that RTVS could continue to expand its availability to various rural, remote, and Indigenous communities in BC. Much of these comments contributed back to finding ways to improve the delivery of RTVS overall. Most of the comments revolved around technology use, as well as expanding accessibility, willingness, and awareness of RTVS throughout the province.

Technology use

Overall, video capability has helped decrease inequities in terms of physician access. The RTVS IT support team has been very reliable and available. Zoom allows providers to see what is going on in the room and helps communicate with patients and providers; this functionality cannot be replaced by a phone. However, VPs also commented running into IT challenges trying to configure the platform, resulting in time being taken just to get the video going. The patient’s entire clinical information and history may not be available, and providers must go through multiple logins to receive clinical history from different health authorities. The Patient Transport Network cannot be integrated into Zoom calls which make it more difficult to provide seamless communication. As a result, providers frequently rely on cell phones to start another call with PTN. Providers have suggested to find ways to integrate the PTN calls into their Zoom calls:

It would be more seamless if we could integrate PTN into the zoom calls, rather than having to make a phone call separately. So if there is a way to invite PTN into a zoom call and have that as part of their pathway as well, I know that's sort of a bigger discussion than just RTVS but that would that would make it more seamless. (CHARLiE VP #1)

Improving the positioning of the camera during video meetings to integrate more people into the call and serve as host to multiple providers is also recommended.

Accessibility, willingness, and awareness

Some VPs noticed that there are locations that they regularly receive calls from and other locations that they have never received a call from, but they did not know the cause of the discrepancy: “I think it’s about getting that messaging out and having communities know about” (RUDi VP). Possible reasons that some locations may not be accessing RTVS include a lack of reliable internet or phone signals, not being aware of the program, or they are aware of RTVS but either do not know how to use it or are not confident in their abilities to use the service. Raising awareness of RTVS services is needed to extend the program into communities that will benefit from virtual care options, and to gain support from providers that may not be aware of the program. The more people try RTVS and get used to using it, the more willing they will be to continue using it and tell others about it.

Discussion

In this qualitative study, we describe the perspectives of VPs for quality improvement reporting of the RTVS pathway services. Our findings highlight areas of benefit to VPs delivering the various RTVS services, as well as areas to consider for long-term service sustainability. Overall, delivering RTVS has, in return, contributed to VPs’ personal and professional development (i.e., “Contributing to personal and professional development of virtual physicians”) and supported rural, remote, and Indigenous communities (i.e., “Impacting communities on a system level”). Furthermore, interviews gave VPs the opportunity to voice their thoughts and ideas regarding long-term sustainability of RTVS (i.e., “Considering the expansion and availability of RTVS”).

Previous literature has reflected on how shifting to virtual health delivery has influenced healthcare providers and their practice. Overall, providers have previously reported positive feedback for virtual visits. ²¹ However, with this shift in healthcare delivery, providers also need to be able to adapt their clinical and examination skills for virtual care. ²² Because of the nature of video and telephone appointments, providers need to enhance skills in empathy, trust, observation, and good communication to build good rapport with patients. ²² Through our findings, RTVS VPs highlight similar points, but further add the importance in understanding the general context of rural, remote, and Indigenous communities. Many RTVS VPs understood the geographical barriers, lack of certain resources, and cultural considerations of these communities and learned to communicate with patients and end-user providers located within these communities to come up with solutions that utilize what is available for them. Thus, our findings add further importance to virtual health delivery in the context of delivering to rural, remote, and Indigenous communities, as VPs also needed to adapt their clinical and examination skills according to what is accessible in these communities. As such, for RTVS, the number of virtual providers who completed cultural safety training went up from 40% in 2021-2022 to a 100% of the virtual providers in 2023-2024.

One underlying challenge, however, that is highlighted in our findings and in the literature is overcoming the barriers that come with using technology to deliver healthcare. While our sample seemed to contain providers who were able to quickly learn and adjust to using the technology for RTVS, VPs still highlighted minor information technology, organizational, and communicational challenges that emerged when delivering their health services virtually. Similarly, previous literature further reflects on these challenges, especially with providers who are not as familiar with using technology. ²³ Providers who were not as familiar with technology tended to have more uncertainty and apprehension when having to shift to virtual care during COVID-19. ²³ Additionally, while RTVS was successfully able to reach and support various rural, remote, and Indigenous communities across the province, VPs reflected on how there were locations that they never received calls from. VPs speculated that these locations may not have reliable internet access, or other such barriers that rural, remote, and Indigenous communities may experience more than urban communities. ²⁴ Future quality improvement endeavours should consider figuring out ways to create easily adaptable and smooth experiences for VPs of all technological experience levels, while also finding ways to further bridge the gap between communities that may not have as easy access to technology, internet, or phone signals compared to others.

Limitations

There are several limitations to the study. While there were some critiques of RTVS being shared during the interviews, findings suggested that the sample group focused mainly on sharing positive feedback on RTVS. Thus, the voices of those VPs who may have experiences greater challenges or had more criticisms to share about RTVS may not have been captured in this study. Social desirability bias is also possible due to the interviewer’s presence and the participants knowing that their responses were being audio-recorded. Finally, as sampling was done via purposive convenience sampling within a limited time frame, there was unequal representation of VPs from each RTVS pathway. Specifically, there was a lack of volunteers coming from pathways such as CHARLiE. Nonetheless, all VPs at the time were given the opportunity to participate, and the themes were applicable to RTVS as a whole.

Conclusion

Our findings show the overall positive impact that RTVS had on the personal and professional development of VPs delivering the service pathways. VPs identified areas that need attention to long-term sustainability leading to measured, collaborative expansion and stability of funding as critical next steps for virtual healthcare in BC. Our team is currently also investigating the health system cost savings from RTVS as well as the patient travel cost savings. Overall, our evaluation highlighted the importance of including qualitative perspectives to describe the depth and breadth of VP experiences for RTVS quality improvement. The thoughtful and safe support of client-patients and providers and the “authentic, trusting relationships that prioritize equity and cultural safety to enhance access to high-quality care and professional support” is truly what makes RTVS unique. ¹⁰ This is foundational in RTVS being able to prevent emergency department closures, provide high-priority patients access to COVID treatments, and provide equitable healthcare to patients. ²⁵ These findings can be leveraged by program stakeholders to evolve the RTVS services and establish a foundation for future, iterative quality improvement work in virtual care.