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Family physician's perception towards virtual care during COVID-19 pandemic: A cross-sectional study

Background: The COVID-19 pandemic has ingendered a significant transition in medical practice towards an online model of care. Although virtual methods of service have been liberally used these past months, the precise level of satisfaction of physicians is important to understand the barriers that the service faced and the future of maintaining these models of patient care. This quantitative study aimed at measuring the satisfaction of family medicine physicians with virtual services while practising in Saudi Arabia during COVID-19 pandemic. Design and Setting: A questionnaire was distributed to participating physicians working in Saudi Arabia. Demographic, satisfaction, and thoughts on future applicability of online care was evaluated. Results: A total of 118 physicians responded to the questionnaire. Demographic values were mostly evenly distributed whereas mean satisfaction level during the pandemic was 77.53% ± 15.04. The only variable impacting levels of satisfaction was overall burden of work in number of different sites worked for on a weekly basis. Conclusion: The family medicine physicians who worked during the pandemic using virtual services were generally satisfied with the services. Future studies should evaluate the applicability of using these tools after the end of the pandemic.


Introduction
The spread of COVID-19 has created an adverse impact on healthcare systems around the world, causing a burden overload on staff, facilities, and equipment. [1] This in turn has presented difficulties in service access by patients due to the risk of infection and the increasing unavailability of protective tools required, which are crucial to maintain self-protective measures in place. [2] Consequently, several hospitals worldwide have to turn to novel technological solutions and operational platforms to retain their ability to provide healthcare services to patients. [3] One such technology has been the application of virtual platforms on healthcare practices, the practice being globally termed as "Telemedicine," [4] By making use of these digital technologies and tools, the spread of COVID-19 has to some degree been temporarily lessened, protecting healthcare practitioners from infection as a result of reduced in-situ care. [5] Using Telemedicine as a system for communication and diagnosis has therefore been instrumental in increasing patient morale and enabling the physicians to maintain some semblance of care. [4] However, despite the acceptance of these tools on the basis of need and cost-effectiveness, satisfaction of the status-quo is not universal. An increasing number of individuals express a preference for the traditional presential style of medical care, [6] with patients reporting a lack of proper training in the use of these tools, [7] and healthcare providers being forced to provide service without remuneration, and at increased workloads. [4,8,9] This last has triggered a rise in psychological conditions and anxieties, all of which impact the satisfaction of the physicians in the use of virtual tools. In this study, we aim to evaluate the possibility of a shift in Saudi physicians' perceptions and acceptance of Telemedicine as a viable form of medical practice during the present pandemic.

Methodology
This cross-sectional study was conducted in Saudi Arabia. The targeted population were Saudi Arabian physicians of 26 or above years of age.
The tool used for data gathering was a self-assessment questionnaire with questions regarding personal experience, opinion, and perception of virtual care techniques, and suggestions or recommendations on the methods to improve these services, both during and following the COVID-19 pandemic.

Ethical considerations
Confidentiality was assured to all participants, with sensitive and confidential information being assured by limiting unauthorized access to all data. The research was approved from PSMMC, Riyadh, Saudi Arabia.

Physician demographics
One hundred and eighteen family medicine physicians were surveyed during the study period. Regarding these, gender distribution was mostly even for males and females, and the majority (59.8%) were included in the 31-40-year-old age group participants. Regarding professional levels and years of practice, 48.3% were consultants and 53.4% had over 10 years of medical practice expertise [ Table 1].

Degree of participation during the pandemic
Physicians were asked about their working condition during the COVID-19 pandemic. About 72.9% of respondents were working on high-traffic sites, with enrolment inbetween four and 10 separate clinics per week [ Figure 1].

Satisfaction of physicians during the pandemic with virtual services
Physicians were asked a group of questions to assess their satisfaction towards virtual services during the pandemic. The physicians were asked to choose a standard 5-Likert scale starting from "strongly agree" through to "strongly disagree." Results showed that more than one-third of the physicians agreed that virtual services are good for patients and physicians and can save time. Additionally, 54.2% of the participating physicians were generally satisfied with the service [ Table 2].

Comparison of means for satisfaction in relation to demographic variables
A total score for satisfaction was calculated for each responder, such that responses with "strongly agree" had five points, whereas "strongly disagree" were given one point. Total scores were then calculated and the mean ± SD taken, both separately and total. M tot = 77.53 ± 15.04, with individual means ranging between M = 21 and M = 105.
The average scores were then compared over different demographic variables using one-way ANOVA test at level of significance P value < 0.05. It was shown that physicians with intermediate years of experience (6-10 years) and those who worked on low-producing sites (1-3 clinics/w) were significantly more satisfied as compared to the remaining ones [ Table 3].

Discussion
COVID-19 pandemic has significantly changed the conventional ways of providing medical care to patients. [10] Due to the pandemic situation, face-to-face communication and physical contact has been greatly reduced to protect both clinicians and their patients. Accordingly, most of the services that can be delivered Low-producing sites (1-3) High-producing sites (4-10) electronically were transferred to online modes. [11] Although online delivery would seem to be cheaper and time saving, it also has some limitations. Hence, measuring the satisfaction of physicians and patients towards virtual services is essential. [12] The present study examined the satisfaction of family physicians towards using virtual care during the COVID-19 pandemic.
The study illustrated that the vast majority of the responders who used virtual services were females and aging between 31 and 40 years. Furthermore, most of the physicians were consultants, with above 10 years of experience. The physicians showed acceptable level of satisfaction with the provided service, which was demonstrated by an above-average total satisfaction score (77.53 ± 15.04 out of 105 points). Furthermore, intermediate years of experience (P value = 0.036) and working on low-producing sites (P value = 0.037) had more satisfaction rates compared to their peers.
Satisfaction with online and virtual medical services during COVID-19 has been evaluated in different settings. Tenforde et al. [13] examined the satisfaction of patients towards using telemedicine for virtual visits during the COVID-19 pandemic for rehabilitation services. Of the whole responders, 93.7% of the patients described the service as excellent or very good. Furthermore, Tenforde et al. [13] showed that females were more satisfied compared to males.
Although the present study did not examine the satisfaction levels of patients, family physicians also showed high overall satisfaction about using the virtual services. However, similar to Tenforde et al., [13] most of the responders in the present study were females, which can be correlated to the high satisfaction rate; yet it could not reach the level of statistical significance.  Also, the satisfaction of cancer patients by virtual genetic clinics during COVID-19 pandemic was examined by Norman et al. [14] The patients were very satisfied by the service. Norman et al. [14] showed that cancer patients believed that virtual services would prevent their appointments' cancellation and reduce their waiting time.
In the present study, 47.5% of the physicians agreed that they can monitor their patients' conditions well through virtual services, and 39% strongly agreed that it saves time, whereas 40.7% strongly agreed that virtual care increases patient access to medical care. Also, 35.6% of the physicians thought that virtual care can improve patient's health. Hence, 54.2% of the included physicians in the present study were overall satisfied with the virtual care.
Another study in surgical setting by Sorensen et al. [15] examined the satisfaction of patients with telemedicine surgical consultations during COVID-19 pandemic. Sorensen et al. [15] illustrated that more than half of the patients preferred the telemedicine consultation compared to conventional consultation clinics and found it more convenient and cheaper. Additionally, most of the patients preferred that these virtual clinics resume after the end of the pandemic.
In the present study, there was a general agreement among 55.1% of the physicians who found virtual services a convenient form of healthcare delivery. Also, 40.7% preferred to provide follow-up for their patients by telemedicine rather than face-to face clinics. Moreover, 45.8% of the responders found virtual service a useful addition for the primary care provided.
Nevertheless, it should be realized that the present survey analysis suffered from some barriers and limitations. The sample size of the included physicians is small, and the satisfaction of patients was not examined. These limitations could affect the outcomes of the present study. Additionally, the responses to the questions included in this questionnaire are merely subjective and depends on the opinion of the responding physician, which could be a limitation for the reliability of the findings.

Conclusions
The satisfaction of family medicine physicians who worked during the pandemic in Saudi Arabia using virtual services was generally high and acceptable. Additionally, mid-career physicians and physicians who had low workload were more satisfied compared to their peers. Through these findings, the research team would endorse the applicability of continuing virtual services following the pandemic. Also, future studies are recommended to examine the satisfaction of patients in Saudi Arabia with the use of virtual services for consultations in different specialties during the COVID-19 pandemic or after the end of the pandemic.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.