- I Bristow, M Fitzpatrick & A Borthwick
The use of telemedicine for patients during the COVID-19 Pandemic an online survey of UK podiatrists
The onset in early 2020 of the COVID-19 pandemic presented a significant challenge to healthcare practice with national restrictions limiting traditional face-to-face consultations. Consequently, alternative means of safely providing healthcare were sought by practitioners. Telemedicine is the use of a range of telecommunication technologies to provide healthcare remotely. Uptake by health professionals has often been seen as slow and fragmented, but as the pandemic has evolved there has been a rapid implementation of technologies into many aspects of healthcare [1, 2]. Within podiatry, despite a lack of previous use of teleconsultations prior to the COVID-19 pandemic, practitioners have started to use technology to undertake patient consultations. As this is a rapid and recent change in UK podiatry practice, little is known about the extent of its use by podiatrists.
An online survey was devised and distributed to podiatrists within the UK. The 20-item questionnaire was adapted (with permission) from a previously used survey tool developed for a similar purpose in exploring the use of telemedicine during the COVID-19 pandemic within dermatology . Invitations were distributed via social media channels and closed fora used by the members of the profession, websites, and via the College of Podiatry member e-mail which is regularly sent to thousands of members of the College of Podiatry. The questionnaire collected basic demographic data about podiatry practitioners, their use and views of telemedicine and its utility, limitations and benefits for practice using a range of closed and open questions. The analysis was undertaken using a web-based platform using frequency counts and basic descriptive statistics.
A total of 209 responses were received from podiatrists across the United Kingdom. The majority of responding practitioners were aged 40 years or older (75%; n=155) and had been qualified for 11 years or more (85%; n=174), with just 7% (n=15) qualified less than five years. When asked about their employment the figures suggested some worked in more than one sector - 128 (62%) were employed within the NHS, 105 (51%) in private practice and 14 (7%) in academia. Respondents stated their practice was primarily based in a city (38%; n=78), town (52%; n=107) or rural setting (10%; n=21).
Prior to the COVID-19 pandemic, 83% (n=171) of podiatrists reported they had never undertaken any telemedicine consultations, and subsequently, 74% (n=151) undertook them during this period. The majority made their own decision to undertake them (61%; n=90) or jointly with their patients (36%; n=53). The majority of podiatrists offered this service to all their patients (61%; n=90) with others choosing to select patients (28%; n=42), 7% (n=10) to existing patients only or new patients only (4%; n=6).
The 26% (n=53) of podiatrists who did not undertake teleconsultations during that period were asked to rank the main reasons for not using it. The most common reason was personal concern about how to conduct an assessment, followed by a perceived lack of IT equipment or skills. A similar number of respondents felt unsure of the legal aspects of its use or felt it would not help their patients. Within this group, 31% (n=14) said they would consider using it if training were available. Some, 44% (n=20) remained unsure whilst 24% (n=11) would still not want to use it.
Practitioners indicating they used the technology were asked which areas of practice were most and least effective when using this approach to their consultations. The question divided opinion between respondents, with musculoskeletal, general podiatry, and tissue viability being rated the most useful areas for teleconsultations by some, whilst general podiatry, tissue viability and elderly care ranked least useful by other practitioners. These findings are summarised in figures 1 & 2. The most common platforms used for remote consultations were telephone calls (76%; n=109), e-mail (44%; n=63) and other (50%; n=71) with many respondents using multiple methods. Less popular methods included Zoom (22%; n=32), WhatsApp (14%; n =20) and Skype (6%; n=8) (figure 3).
Podiatrists were asked to compare traditional face-to-face consultations with teleconsultations. Five aspects were questioned – time, difficulty, effectiveness, podiatrist convenience and patient convenience. Respondents were asked to rank each aspect on a five-point scale ranging from “more” to “less”. The results are summarised in figure 4 below:
Respondents were asked if they would charge patients for consultations in addition to their normal fees. As 62% of practitioners (n=90) were in the NHS therefore no charge was made to patients for the service. The majority of remaining podiatrists (in private practice) stated they charged the same fee as a face to face contact (13%; n=19) or less (6%; n=9). 74% of respondents (n=108) stated they will continue to offer teleconsultations after the COVID-19 restrictions are relaxed, 21% (n=30) were not sure, whilst 5% (n=7) were not planning to continue with them. However, 63% (n=91) would welcome further training and guidance on how to apply it in podiatric practice.
Despite previously published surveys of healthcare professionals’ views [4-6], to the best of the authors’ knowledge, this has been the first survey investigating the opinions and use of teleconsultations by podiatrists in the UK. From the results, it would appear that during the pandemic, podiatrists have largely embraced the technology with 83% reporting they had never used it before the pandemic. Moreover, a significant number (74%) would continue to use it beyond this period. This figure aligns well with other medical disciplines where similar patterns have been observed – a low usage before the pandemic increasing dramatically during the height of the pandemic . Research has suggested that, in the past, the principle obstacle to more widespread adoption has been the unwillingness of the practitioner to do so . Based on the uptake in this survey, it no longer appears to be an issue. The age demographic within this survey probably is representative of the UK podiatry profession as a whole, but it also highlights the willing adoption of the technology by practitioners who would have qualified at a time when little IT was available. It may also reflect the growing use of technology in general day to day communication(s) that has evolved during the COVID-19 pandemic – a 2020 survey during this period of adults reported a 14% rise in the number of healthcare video or phone calls .
There was a significant division amongst practitioners over which areas of practice the technology was considered most and least useful. The dichotomy may arise as podiatry practice often entails a diagnosis, a practical “hands-on” element alongside patient advice. The technology may be perceived by some practitioners to be an inadequate substitute for the practical elements, such as routine care of the skin or wound care. The BBC calculated that podiatry, compared to many other jobs, has a minimal 1% chance of being automated or substituted by technology , reflecting the view that its practical aspects cannot be performed any way other than face-to-face by a human.
Others may have felt advice for the patient may offer a solution to specific problems remotely using this technology. In the majority of cases, remote consultations were considered less suitable for elderly care. This possibly reflected lower levels of engagement with newer technologies in this age group compared to younger age groups more familiar and comfortable with it .
When questioned about the benefit of using the technology over face-to-face consultations, in terms of time, difficulty effectiveness, as well as podiatrist and patient convenience, opinions tended to suggest there was little difference, indicating it was similar to traditional consultations in these aspects.
For teleconsultation to be more widely adopted and successful in healthcare it is accepted that individuals cannot be solely expected to facilitate change, and where policy adaptations are required  this should include upscaling of available technology platforms, training and support for practitioners. The survey highlights around a quarter of respondents did not undertake teleconsultations with the most common concern being lack of clarity on how to conduct an assessment remotely, as well as a lack of the appropriate skills or equipment. Despite this, the majority of the participating podiatrists were looking to receive further training and advice on the use of teleconsultations. Comments from some reflected the anxieties surrounding the legal aspects of the technique as well as the “correct” procedure that should be followed to ensure maximum benefit and safety for the patient and practitioner alike - a view shared by other healthcare practitioners also faced with the sudden adoption of new ways of conducting consultations during the pandemic .
The limitations of this survey must be acknowledged. The sample of 209 respondents, whilst sizeable, by its content may only attract respondents with positive views of teleconsultation, thus exaggerating the general opinion amongst podiatrists in the UK. Further work is required to fully explore opinion on teleconsultations and their utility in podiatry practice in the future.
This survey of 209 podiatrists has shown a rapid adoption of telemedicine amongst many who had previously not used it before. The general experience was positively received with practitioner perceived benefits in a range of clinical specialities. A significant number of respondents plan to continue using this technology beyond the current pandemic. Most felt there is a need for further advice and guidance on how it may be used most effectively and safely.
Conflict of interest: None declared.
Sources of funding: None.
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