Introduction

Accessibility can be defined as the easiness with which a person can obtain needed healthcare, from the practitioner of choice and within a timeframe appropriate to the urgency of the problem.¹

Accessibility to the general practitioner (GP) is a defining characteristic of family medicine/general practice, but in Portugal, it has been poorly studied and measured focusing on face-to-face consultations, which is reductive. A study evaluating the strengths of primary health care in European countries identified barriers to telephone and e-mail access to healthcare. ⁽²

Taking into account the epidemiological transition (aging population and multimorbidity), the Organization for Economic Co-operation and Development (OECD) recommends the diversification of communication channels with GPs. ⁽³ For OECD, telemedicine (including telephone and e-mail contacts) enables the partial transfer of healthcare tasks to patients and their caregivers, empowering them and keeping them active, and in their own homes.

Accessing the GP by telephone is a current practice in Portugal and is recommended to potentiate accessibility. ^{(4)- (5} Telephone consultations are contemplated in the recommendations of the Legal Medical Council, ⁽⁶ in the accreditation process of primary care centers, ⁽⁷ and in the evaluation of patient satisfaction. ⁽⁸ The EUROPEP questionnaire evaluates patient satisfaction with telephone access to GPs and to family practices, as part of the dimension of organizational quality of the questionnaire. ⁽⁸ In the last EUROPEP survey, in 2015, family practices in Matosinhos achieved an overall satisfaction score of 79.5%, but telephone access reached only 48.1%.⁹ In a similar way, at the national level, an overall satisfaction score of 77.8% was achieved, while satisfaction with telephone access reached 60.7%.¹⁰

In a multicentre study in Portugal, most (85%) GPs reported having telephone calls with their patients, spending an average of 6.3 minutes per day doing so. ⁽¹¹ Time spent on patient calls accounted for 4% of the more than two hours that GPs spent daily on tasks other than face-to-face consultations. ⁽¹¹

Troubles with telephone accessibility are inherent in synchronous communication because it is difficult to synchronize patient calls and the availability of busy GPs. ⁽¹² Other contributing factors include telephone calls not being accounted for in performance evaluations, and the absence of allocated time slots. Another obstacle is the impossibility to register the patient contact in real time⁶ because the software used in Portugal for electronic health records requires the intervention of non-medical staff prior to the entry of any data. Other causes are obsolete telephone switchboards and the shortage of staff to operate telephones in many family practices.

E-mail access to GPs has been recommended by OECD and by the Institute of Medicine, ⁽¹³ it is a current practice in Canada, ⁽¹⁴ mandatory in Denmark since 2009, ⁽¹⁵ and strongly recommended in England. ⁽¹⁶ E-mail access is very variable across countries, practices, and GPs. ⁽¹⁷

E-mail access to GPs is feasible in Portugal, where 74.1% of households have internet access¹⁸ and reports on its use between GPs and their patients showed satisfaction of GPs and good patient adherence, without increased work overload. ^{(19), (20), (21} A multicentre study in Portugal found that 19% of GPs used e-mail with their patients, spending an average of 48 seconds per day on this task. ⁽¹¹

In other countries, reported results are also positive. ^{(16), (22),(23), (24} Studies confirm that e-mail can act as a vehicle for emotional support and to strengthen therapeutic relationships. ^{(22), (25} Several studies point out the advantages of written communication for some patients to address sensitive issues. ⁽¹⁷ One study mentioned that writing allows patients to organize their problems, which is often impaired by the spontaneity of the face-to-face consultation. ⁽¹⁷

Obstacles to the use of e-mail between physicians and patients have been identified, including: una-ccounted or unpaid work; the possibility of overuse and overload of work; eventual depersonalization of the doctor-patient relationship; issues of confidentiality and security. ^{(26)- (28}

E-mail access to the GP is not evaluated by any validated instrument, nor tracked by any performance indicator in Portugal. We did not identify any Portuguese study exploring the perceptions and attitudes of GPs and/or patients concerning the use of doctor-patient e-mail.

Matosinhos Local Health Unit provides health care services to approximately 175,000 inhabitants and it includes 14 family practices of one of three organizational types. ‘Model B’ units are on a mixed salaried, capitation and pay for performance scheme; ‘Model A’ units are on a salaried scheme only but are applying to ‘Model B’; and ‘UCSP’, units on a salaried scheme and not applying for Models A or B. In 2017, there were 101 GPs working in the 14 family practices in Matosinhos, all provided with work mobile phones and work e-mail addresses. In these family practices, most telephone switchboards are obsolete and only a few centers have a nominated telephone operator.

The aim of this study is to determine how GPs working in Matosinhos family practices use telephone and e-mail to communicate with their patients and their attitudes towards this use.

Methods

Study design: Descriptive cross-sectional study.

Selection of study subjects: Census to GPs working in Matosinhos family practices (n=101). The principals of the 14 family practices were approached with the invitation to participate, and the principals themselves advertised the study among the GPs in each unit, delivering them the questionnaire forms and securing a closed ballot box for the anonymous return of filled questionnaires. Later, on a predefined date, the researchers collected the closed boxes.

Measurements: Paper, self-administered, structured anonymous questionnaire, applied between January 9 and February 21, 2017. The questionnaire (Annex 1), non-validated, was developed by the researchers based on similar studies and included 23 Likert scale multiple choice questions and four multiple choice questions for demographic and professional characterization purposes. A pilot study was carried out and no need for corrections was detected.

Statistical analysis: Proportions and 95% confidence intervals (95% CI) were determined.

To ensure anonymity, no informed consent was requested from participants. No personal data were collected from participants or patients.

Results

Ninety questionnaires were delivered in 13 units, including 6 Model B, five Model A, and two UCSP. The principal of one family practice (UCSP type), with two GPs, did not respond to the researcher’s contact and so no questionnaires were delivered there. Nine GPs, from 6 of the 13 participating units, were on leave at the time of the study.

Eighty-one completed questionnaires were received, accounting for a 90.0% response rate and 80.2% of the target population. Most participants (79.0%) were female and the prevailing age group was 31-40 years (43.2%). Most GPs (50.6%) worked in a Model B unit and 54.3% had patient lists sized between 1751 and 1900 patients.

The distribution by age, gender, and type of family practice of participating GPs overlapped the overall distribution of the target population. Compared to the population of GPs in Portugal, the study sample had a lower representation of males, was younger, and more often worked in Model B units (Table 1).

Discussion

To our knowledge, this is the first study in Portugal focusing on the telephone and e-mail access to GPs. The census of all GPs in a Local Health Unit and the high response rate are strengths of this study, but we cannot generalize the results to GPs working in other locations in Portugal. The study has limitations. First, a non-validated questionnaire was used. Nonetheless, it was built upon a literature search, a pilot study was done, and most questions got a balanced distribution of answers among the available options. Although answering all the questions of the questionnaire was not mandatory, only six missing answers were identified (<0.3%). A significant proportion of answers «not agree nor disagree» were identified in questions assessing GPs’ attitudes like concerns about overuse and risk/benefit ratio. This may highlight a suboptimal formulation of these questions. Second, in survey-based studies, information bias must be considered. Besides recall bias, under-reporting may arise in questions addressing practices that, even under anonymity, may contribute to an undesirable collective picture.

The higher use of telephone between GPs and patients, when compared to e-mail, was also found in a Portuguese study in which 85% of the GPs reported using the telephone and only 19% reported using e-mail to communicate with patients. ⁽¹¹ This is in keeping with the findings that GPs in Portugal seem to use the internet less than their European counterparts. ⁽²⁹ A study in Israel found that GPs preferred to give patients their telephone number rather than their e-mail address. ⁽³⁰ In Switzerland, a similar proportion of GPs used the telephone (74%) and e-mail (72%).³¹

Previous research on GPs’ attitudes towards the use of telephone with patients has found the same concerns found in this study: unfavorable risk/benefit ratio, work overload, non-inclusion in performance evaluation, and overuse by patients. ^{(29), (32)- (33} As for the advantages in the management of the patient list seen by most GPs, they were also seen in previous research. ⁽³¹ Of note, however, is the fact that different studies have found opposite effects of telephone contacts on the overall number of consultations. ⁽³⁴ As for e-mail, previous research has also found similar concerns to those found in the current study: unaccounted and/or unpaid work, overuse, overload, and clinical risk. ^{(17), (27)- (28), (35} The benefit of the use of e-mail with patients on the management of the patient list and appointments seen by participating GPs had also been described before, ⁽²⁶ but a Cochrane review found studies pointing out an associated increase in the number of consultations. ⁽¹⁷

Participating GPs reporting higher use of e-mail with patients showed more positive attitudes. The same association was found in a study with physicians with very frequent use of e-mail, who reported e-mail as an enabler for better care and improved relationships with patients. ⁽²⁴ This may mean that e-mail has advantages that infrequent users are still unaware of.

Although not statistically significant, GPs who reported more frequent use of the telephone with their patients were those who revealed more negative attitudes. Given that, overall, there are more favorable attitudes regarding telephone use compared to e-mail, the more negative attitudes towards the telephone reported by the more frequent users may reveal some saturation of the GPs’ ability to manage telephone calls, but this hypothesis needs to be confirmed in studies designed for this purpose.

In the future, the questionnaire applied could be reviewed, eliminating redundant questions about frequency of use, standardizing the options for better comparisons between telephone and e-mail, and it could be applied to a national sample.

The motivation potential of GPs that more often use e-mail with their patients and exhibit more positive attitudes could be explored on interventions to encourage and guide less experienced GPs with less positive attitudes towards using e-mail with patients.

Finally, in view of the potential advantages to GPs and patients, it is essential to ensure that the use of telephone and e-mail does not overburden GPs who are already working to the limits of their capacity. For this, these tasks must be part of performance evaluation and be considered in the planning of appointments. Moreover, family practices must secure appropriate human and physical resources for remote access and include the possibility of real-time data entry in patients’ electronic health records.

Conclusion

The use of telephone between GPs and their patients is generalized amongst GPs working in Matosinhos Local Health Unit, but the same is not observed regarding e-mail use. The attitudes most often expressed by GPs were overload, lack of time, better management of the patient list, and the perception that these types of contacts would be used more often if the real-time entry of clinical notes into the patient’s health record was possible and if they were accounted for in performance evaluation. GPs who most often use e-mail are those who have more positive attitudes towards this type of contact. GPs with larger lists use the telephone with their patients more often, while those working in Model B units use the e-mail significantly more.

More research is needed to support with evidence the use and development of telephone and e-mail modalities of remote access to GPs. The experience of more experienced users should also be explored to further development on the ground. Organizational policies should consider remote access.

Author contributions

Conceptualization, CP, and MG; methodology, CP, and MG; validation, CP, and MG; formal analysis, CP, GL, and MG; investigation, CP, and MG; resources, CP, and MG; data curation, MG; writing the original draft, CP, and MG; writing, review and editing, CP, GL, and MG; visualization, CP, and MG; supervision, CP, and MG; project administration, CP, and MG.

Conflicts of interest

Os autores afirmam não ter quaisquer conflitos de interesse.