Telemedicine Could Reduce the Role of Family Physicians to Case Managers

Dear Editor,

The short reflection by Kannai and Rice, “Telemedicine Could Reduce the Role of Family Physicians to Case Managers” (1) is an apt reminder that technology re-shapes professional roles even when its immediate aim is to widen access. As a family physician researchers, we find ourselves welcoming digital tools while noticing how easily they displace the clinical habits that once anchored our discipline. This letter, the second of three (2–4) we intend to submit on the article, turns to themes the authors only touched on: the potential of artificial-intelligence (AI) support during video consultations, the place of group therapy delivered virtually, and the safeguards required for privacy and emotional safety in remote care. Our comments draw on evidence that has accumulated since the first pandemic wave and on daily experience inside the Spanish public system, where each autonomous community now pursues its own blend of incentives for digital innovation.

Artificial-intelligence systems already participate, sometimes silently, in video visits across Europe. Most remain research prototypes, yet their relevance to family medicine is clear when one examines the literature on speech and facial-gesture analytics for early neurocognitive disorders. Automated language models can discriminate between healthy ageing and mild cognitive impairment with accuracies that rival traditional screening tools, provided that recordings are long enough and background noise is controlled (5). Huang et al. recently showed that linguistic features alone, extracted from a short free-speech task, classified cognitive decline with an area-under-the-curve of 0.84, and that the classifier could operate on data captured by an ordinary laptop microphone (6,7). Similar results have been reported with smartphone-based speech analysis in multicentre datasets collated by industry–academic consortia such as Aural Analytics, again pointing to a future in which the physician may receive a silent probability score while listening to the patient’s narrative (8). We see opportunities for carefully designed pilots in the Basque Country and Catalonia, where electronic records have pioneered some embed machine-learning modules for prescription safety alerts in research-related studies. The goal should not be to replace memory tests, but to prompt an earlier face-to-face assessment when a conversational cue suggests deterioration that neither the clinician nor the patient had recognised.

Once AI enters the consultation room, even a virtual one, familiar questions about validity, bias, and interpretability follow. That conversation is no longer hypothetical: algorithms trained on video frames can flag micro-expressions that correlate with depressive states; language-model analysis of vocal prosody can estimate Parkinsonian dysarthria; and wearable sensor streams are being parsed to infer psychomotor slowing. A JMIR Mental Health study that combined lexical, acoustic, and webcam-derived facial features reported 83 % sensitivity for major depression in cancer survivors using a model that ran in real time during short coaching sessions (9). These advances justify exploration but also require boundaries. The World Health Organization’s 2021 guidance on AI ethics underscores the need for transparency, local validation, and explicit lines of accountability before algorithmic advice is allowed to influence clinical decisions (10). Spanish legislation already demands human oversight for automated decision-making in health records, yet regional procurement contracts still vary in how they specify audit trails. We suggest that any deployment begin as an opt-in decision support tool, with performance tracked prospectively against hard outcomes such as diagnostic delay and avoidable referrals (11). Only by pairing innovation with a rigorous post-market evaluation framework can we ensure that statistical gains translate into meaningful clinical benefit and do not widen disparities for patients whose dialect, accent, or camera quality differs from the data on which the model was trained.

Technology also creates room for therapeutic formats that were previously impractical. Group videoconference interventions have moved from being an emergency substitute during lockdown to a viable adjunct for primary-care mental-health work (12). A 2021 systematic meta-analysis that pooled thirty-one trials of videoconference-delivered cognitive-behavioural therapy (VCBT) found an effect size for depression that was non-inferior to face-to-face CBT (Hedges g = 0.45) and reported retention rates above 80% across modalities (13). Acceptance-and-commitment therapy and behavioural-activation protocols delivered synchronously to small groups produced similar symptom reductions in a randomised trial of adults with chronic pain and comorbid depression, with incremental cost–utility ratios that fell below common willingness-to-pay thresholds (14). These results matter for Spain’s publicly funded system, whose prevalence of affective disorders far outstrips the capacity of on-site psychology services. Andalucían and Galician primary-care districts, where community-based group CBT was already part of the mental-health offer, could expand reach through video while preserving one in-person intake session to establish rapport. The same hybrid logic applies to eating-disorder services: Couturier et al. described how family-based treatment for adolescent anorexia shifted online during the pandemic; families appreciated the convenience yet endorsed a mix of virtual and clinic visits to secure physical monitoring and weigh-ins (15). Integrating those lessons, our proposal is that regional planners couple any remote group programme with scheduled on-site reviews whose frequency depends on clinical stability, thereby guarding against the drift towards purely transactional care that Kannai and Rice warn against.

While group screens can democratise therapy, remote communication can also obscure signals of distress that patients feel unsafe to voice (16). Intimate-partner violence (IPV) is a salient example. Simon’s clinical update in JAMA (17) outlined practical steps for recognising IPV during telehealth encounters, explicitly recommending pre-visit electronic questionnaires and the use of coded yes/no questions if privacy seems compromised. A systematic review of ICT-based interventions for IPV (18) confirms that digital tools can facilitate disclosure and safety planning, but only when confidentiality is assured and the patient controls the timing and channel of contact. Building on these principles, several Spanish health centres have asked to modify their corporate patient portals with an unobtrusive “exit” button that hides the browser instantly and insert a silent alert icon within the video interface that the patient can click to request offline help. These design features should be complemented by professional training. Garber and colleagues’ telehealth-etiquette framework (19) emphasises simple but effective manoeuvres, confirming who else is in the room, lowering one’s voice when posing sensitive questions, and offering follow-up by a secure text channel for topics the patient could not address aloud. We recommend that such protocols become mandatory content in continuing-education credits tied to the performance-based incentives many autonomous communities now employ.

Confidentiality is not limited to safety from violence; it also guards the emotional candour on which therapeutic relationships depend. Clinicians notice that discussions of grief, sexuality, or existential doubt often pause when the patient senses the virtual space might be recorded or overheard. One solution, adopted in several Catalan primary-care teams, is to let the patient select the channel—telephone, video, or in-person—at each step of an episode of care and to make switching frictionless. Another is to establish “camera-off minutes,” during which either party can turn off video to restore a sense of privacy while still sharing voice. Early qualitative feedback suggests that these small concessions reduce screen fatigue and encourage spontaneous disclosure, though formal evaluation is pending. The point is consistent with Kannai and Rice’s insistence on maintaining relational depth: technology should expand the palette of communication, not restrict it to the default configuration chosen by the clinic’s scheduling software.

The introduction of AI, expanded group therapy, and new privacy practices will require a recalibration of professional training. Spanish medical schools and residency programs still devote limited curricular time to telehealth. The post-graduate family-medicine curriculum, updated in 2024, now lists “digital clinical competence” as a transversal skill, but implementation varies by teaching unit. Part of the highlighted ideas in this eLetter could be taught online, yet simulated patient sessions remain valuable for practising the non-verbal calibration that escapes algorithmic capture. By foregrounding these concrete skills, training programmes may help new physicians work “through” technology rather than merely “with” it, preserving the clinician’s role as an active decision-maker, even as the screen becomes the main space for care delivery.

In our opinion, Kannai and Rice remind us that making care easier to access is not the same as making it better. Artificial-intelligence augmentation, virtual group therapy, and enhanced confidentiality tools show promise, but they amplify, rather than solve, the ethical and professional questions raised in the original article. Their safe adoption hinges on maintaining the relational orientation that distinguishes family medicine. Our subsequent letter (4) will examine in more detail the organisational incentives that influence technology use and the research agenda needed to evaluate long-term outcomes. For now, we thank the authors for stimulating a dialogue that is as relevant in Spain as it is in Israel.

REFERENCES:

1. Kannai R, Rice (Alon) A. Telemedicine Could Reduce the Role of Family Physicians to Case Managers. Ann Fam Med. 2024 Jan 1;22(1):63–4.

2. Tenajas R, Miraut D. Learning to Listen Again Preserving Clinical Presence in a Digital World. Ann Fam Med. 2025 May 4;22(1):eLetter.

3. Tenajas R, Miraut D. Clinical Strategies for Creating Safe Online Spaces to Protect Vulnerable Patients. Ann Fam Med. 2025 May 4;22(1):eLetter.

4. Tenajas R, Miraut D. From Flat Screens to Deep Care, Designing Telemedicine for Human Connection. Ann Fam Med. 2025 May 4;22(1):eLetter.

5. Tenajas R, Miraut D. Enhancing Conversations on Cognitive Decline Through Patient-Centered Tools. Ann Fam Med. 2025 Apr 18;23(2):eLetter.

6. Huang L, Yang H, Che Y, Yang J. Automatic speech analysis for detecting cognitive decline of older adults. Front Public Health [Internet]. 2024 Aug 8 [cited 2025 May 4];12. Available from: https://www.frontiersin.orghttps://www.frontiersin.org/journals/public-h...

7. Tenajas R, Miraut D. The Role of Voice Analysis in Early Detection of Mental and Neurodegenerative Disorders. Ann Fam Med. 2025 Feb 28;23(1):eLetter.

8. Li R, Huang G, Wang X, Lawler K, Goldberg LR, Roccati E, et al. Smartphone automated motor and speech analysis for early detection of Alzheimer’s disease and Parkinson’s disease: Validation of TapTalk across 20 different devices. Alzheimers Dement Diagn Assess Dis Monit. 2024;16(4):e70025.

9. Smrke U, Mlakar I, Lin S, Musil B, Plohl N. Language, Speech, and Facial Expression Features for Artificial Intelligence–Based Detection of Cancer Survivors’ Depression: Scoping Meta-Review. JMIR Ment Health. 2021 Dec 6;8(12):e30439.

10. World Health Organization. Ethics and governance of artificial intelligence for health: large multi-modal models. WHO guidance [Internet]. World Health Organization; 2024. Available from: https://www.who.int/publications/i/item/9789240029200

11. Tenajas R, Miraut D. The 24 Big Challenges of Artificial Inteligence Adoption in Healthcare: Review Article. Acta Medica Ruha. 2023 Sep 20;1(3):432–67.

12. Tenajas R, Miraut D. The strength of connection: The virtual adaptation of Twelve-Step programs’ meetings. Front Health Inform. 2023;2023(12):1–3.

13. Matsumoto K, Hamatani S, Shimizu E. Effectiveness of Videoconference-Delivered Cognitive Behavioral Therapy for Adults With Psychiatric Disorders: Systematic and Meta-Analytic Review. J Med Internet Res. 2021 Dec 13;23(12):e31293.

14. Kysely A, Bishop B, Kane RT, McDevitt M, De Palma M, Rooney R. Couples Therapy Delivered Through Videoconferencing: Effects on Relationship Outcomes, Mental Health and the Therapeutic Alliance. Front Psychol [Internet]. 2022 Feb 4 [cited 2025 May 4];12. Available from: https://www.frontiersin.orghttps://www.frontiersin.org/journals/psycholo...

15. Couturier J, Pellegrini D, Grennan L, Nicula M, Miller C, Agar P, et al. A qualitative evaluation of team and family perceptions of family-based treatment delivered by videoconferencing (FBT-V) for adolescent Anorexia Nervosa during the COVID-19 pandemic. J Eat Disord. 2022 Jul 26;10(1):111.

16. Tenajas R, Miraut D. From Stigma to Support: Improving Alcohol Use Screening in Family Medicine. Ann Fam Med. 2025 Mar 7;23(1):eLetter.

17. Simon MA. Responding to Intimate Partner Violence During Telehealth Clinical Encounters. JAMA. 2021 Jun 8;325(22):2307–8.

18. El Morr C, Layal M. Effectiveness of ICT-based intimate partner violence interventions: a systematic review. BMC Public Health. 2020 Sep 7;20(1):1372.

19. Kelli Garber D, Tina Gustin D. Put PEP into telehealth: an etiquette framework for successful encounters. Online J Issues Nurs. 2023;28(2):1–10.

Dear Editor,

The brief but thought-provoking narrative by Kannai and Rice (1) on the unintended effects of telemedicine in family practice invites reflection from health-care environments beyond Israel. As family physician researchers, we have witnessed the same tension the authors describe between the promise of digital access and the erosion of the clinical encounter. This letter, first in a series of three (2–4), addresses three themes the article triggers in our context: (a) the risk that the physician’s role drifts from clinician to gatekeeper, (b) the need for deliberately structured hybrid consultations, and (c) the danger that new generations of doctors under-develop essential bedside skills. While the Spanish National Health System differs from Israel’s model, the parallels are striking and, we believe, informative for an international readership.

During the first pandemic wave, telephone and web consultations became the default entry point to primary care in Spain; in some regions they still account for close to 60% of daily contacts. Mixed-methods work from the United Kingdom documents how a rapid “remote-first” transition shifted clinical time toward administrative triage and follow-up, often at the expense of relationship-based care (5). Comparable patterns have emerged in Catalonia, Madrid and Valencia, where targets built into pay-for-performance schemes usually reward throughput more than diagnostic depth. Although a “gatekeeping” function is an intrinsic feature of Beveridge-type systems, the balance is tilting: virtual agendas fragment continuity, and written requests for prescriptions or referrals can be processed faster than they can be clinically appraised. The recent Spanish study “Teleconsulta: encontrando su lugar en Atención Primaria” (6) illustrates how professionals perceive this drift and links it to lower patient satisfaction when problems are complex or sensitive. Our concern echoes that of Kannai and Rice: if managerial metrics overshadow clinical reasoning, the family physician’s core contribution, longitudinal knowledge of the person, becomes invisible.

One practical response is to design hybrid workflows that protect a space for face-to-face assessment whenever uncertainty or psychosocial nuance is likely. The VOCAL mixed-methods study led by Greenhalgh and colleagues showed that outcomes and satisfaction improve when video or e-consultations are embedded in a protocol that includes rapid conversion to in-person review when red-flag criteria are met (7). Drawing on this and other evidences, several Spanish regions (Navarra, Aragón, and the Basque Country) now pilot agendas with guaranteed same-day physical slots reserved for cases escalated from teleconsultations; early internal audits suggest fewer repeat contacts and a modest reduction in emergency-department visits. Aligning incentives with such quality markers rather than raw activity counts would help consolidate the model. For example, Catalonia’s Institut Català de la Salut already links a portion of its annual quality bonus to continuity-of-care indicators; expanding that basket to include “appropriately resolved hybrid episodes” could counterbalance the pressure to process high volumes of asynchronous requests.

The second consequence of an unchecked virtual shift is the gradual loss of practical diagnostic skills among trainees. A national survey of American clerkships found that only one-third formally teach telemedicine competencies and even fewer integrate them with physical-examination training (8). Spanish residency programmes face the inverse problem: residents now spend many clinic sessions on phone duty, with limited opportunity to perform examinations under supervision. Commentary in Diagnosis has highlighted how the physical examination, already declining before COVID-19, risks becoming vestigial unless educators create protected settings to practise it deliberately (9).

While during the height of the COVID-19 pandemic many in-person visits were reduced or reorganized, it is important to clarify that, unlike in some other systems, Spanish primary care centers remained physically open. Residents and attending physicians continued to provide care on-site, albeit often under challenging conditions with shifting safety protocols and increased workloads. However, a significant proportion of their activity, especially in urban centers with high infection rates, moved to telephone consultations, with video-based care still being relatively underused. This transition, though necessary at the time, meant that direct contact with patients was partially replaced by remote triage, with fewer opportunities for systematic, supervised physical examinations or longitudinal follow-up of complex cases.

This change has had implications for how young physicians learn to interpret clinical signs, build diagnostic hypotheses, and develop the intuitive reasoning that emerges from repeated exposure to nuanced, in-person encounters. As Kannai and Rice highlight in their article (1), physical presence enables the clinician to "see through" a patient's words, sometimes literally, and detect cues that often go unspoken. Developing this clinical sensitivity requires time, repetition, and mentorship within real-world clinical settings. When digital interfaces mediate most interactions, the risk is not only that young professionals will under-practice essential examination techniques, but also that they may lose confidence in their ability to explore emotional or psychosocial issues, which typically arise organically in the physical consultation space.

Given this reality, we believe that training programmes must adapt not only by reclaiming protected clinical time for in-person encounters where possible (10), but also by equipping residents with the ability to break through the limitations of virtual formats in creative and clinically meaningful ways. This does not imply returning to a purely analogue model, but rather enhancing the digital encounter through intentional interaction. As the authors of the article suggest in their case of Shira, the physician’s decision to pause, question an assumption, and shift from a written request to a video call with a photographic image led to a significant diagnostic intervention. These micro-decisions (like deciding to ask for a photo, requesting a close-up video, observing lighting and background conditions, or guiding a patient to palpate and describe an area with precision) can become part of a new diagnostic toolkit. Teaching these micro-skills might be as essential as teaching the cranial nerve exam or joint line palpation.

There is increasing literature describing how to integrate such skills into medical training. For example, a study by Tschandl et al. (11) demonstrated that dermatological image recognition by primary care physicians improved significantly when they were trained to evaluate images systematically using a structured schema, even when the image quality was variable; suggesting that with deliberate guidance, image-based diagnosis can be a valuable extension of physical examination. These findings underscore the need for deliberate, evidence-based approaches to clinical reasoning in remote contexts, rather than assuming that virtual care is inherently superficial or less reliable.

In Spain, however, the widespread implementation of such strategies remains limited. While some regional training units have begun offering telemedicine communication workshops, many still lack formal curricula addressing the unique demands of digital care. There is an opportunity here to systematize the teaching of virtual diagnostic facilitation techniques (how to ask for a useful photograph of a skin lesion, how to guide a parent in assessing respiratory effort in a child, or how to interpret ambient noise or breathing patterns through audio…). These are not skills typically taught in undergraduate or postgraduate programmes, but they are increasingly necessary. At the same time, educators must continue to emphasize that these tools are not replacements for physical presence, but rather complementary supports that can maintain diagnostic accuracy and relational depth when used judiciously.

Logically, this pedagogical shift must also be accompanied by institutional support. Time pressure and overloaded digital agendas often prevent residents, and even senior physicians, from taking the extra minutes needed to ask a clarifying question, propose a video connection, or request an image. If performance indicators and administrative expectations reward only volume, these subtle but critical clinical decisions are easily overlooked. Therefore, training alone is insufficient. The organizational environment must encourage and recognize these efforts, valuing not just the number of consultations completed, but also the quality and safety of the clinical reasoning applied—especially in digital interactions where the risks of over-treatment and under-diagnosis coexist.

While the present letter concentrates on the professional identity of family physicians, on consultation architecture, and on postgraduate training, one cannot ignore the technological horizon. Decision-support systems that operate in the background of video visits are beginning to flag cognitive impairment, speech changes, or affective cues that escape the busy doctor’s eye (12). A 2023 scoping review mapped how such tools are being integrated into multimorbidity care and cautioned that validation in real-world primary-care workflows remains limited (13). Although no formal programmes have yet been widely deployed across Spain, the potential for AI-assisted tools such as speech analysis to support early detection of cognitive decline has been highlighted in international literature (14). Pilot initiatives exploring these technologies and their current limitations (15) may offer future pathways to complement clinical observation, especially in resource-limited settings. We will return to the promises and pitfalls of these systems in the second letter of this series.

In our opinion, Kannai and Rice remind us that telemedicine is neither neutral nor transient; how we deploy it shapes the essence of family medicine. Spanish experience suggests that hybrid models can restore equilibrium between access and depth if organisational incentives value continuity and clinical judgement. Equally, residency programmes must preserve ample in-person practice so that the next generation can blend digital proficiency with the craft of examination and conversation. These reflections aim to broaden the dialogue the authors have initiated and to set the stage for further discussion on technological adjuncts and on group-based virtual interventions, which we will address in subsequent correspondence (2–4).

REFERENCES:

1. Kannai R, Rice (Alon) A. Telemedicine Could Reduce the Role of Family Physicians to Case Managers. Ann Fam Med. 2024 Jan 1;22(1):63–4.

2. Tenajas R, Miraut D. Learning to Listen Again Preserving Clinical Presence in a Digital World. Ann Fam Med. 2025 May 4;22(1):eLetter.

3. Tenajas R, Miraut D. Clinical Strategies for Creating Safe Online Spaces to Protect Vulnerable Patients. Ann Fam Med. 2025 May 4;22(1):eLetter.

4. Tenajas R, Miraut D. From Flat Screens to Deep Care, Designing Telemedicine for Human Connection. Ann Fam Med. 2025 May 4;22(1):eLetter.

5. Murphy M, Scott LJ, Salisbury C, Turner A, Scott A, Denholm R, et al. Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study. Br J Gen Pract. 2021 Mar 1;71(704):e166–77.

6. Acezat Oliva J, Alarcón Belmonte I, Paredes Costa EJ, Albiol Perarnau M, Goussens A, Vidal-Alaball J. Teleconsulta: encontrando su lugar en Atención Primaria. Aten Primaria. 2024 Jun 1;56(6):102927.

7. Greenhalgh T, Vijayaraghavan S, Wherton J, Shaw S, Byrne E, Campbell-Richards D, et al. Virtual online consultations: advantages and limitations (VOCAL) study. BMJ Open. 2016 Jan 1;6(1):e009388.

8. Bajra R, Lin S, Theobald M, Antoun J. Telemedicine Competencies in Family Medicine Clerkships: A CERA Study. Fam Med. 2023;55(6):405–10.

9. Restrepo JA, Henriquez R, Torre D, Graber ML. The physical exam and telehealth: between past and future. Diagnosis. 2024 Feb 1;11(1):1–3.

10. Tenajas R, Miraut D. Unhurried Conversations in a Hurried System: Lessons from Spanish Primary Care. Ann Fam Med. 2025 Jan 19;23(1):eLetter.

11. Tschandl P, Rinner C, Apalla Z, Argenziano G, Codella N, Halpern A, et al. Human–computer collaboration for skin cancer recognition. Nat Med. 2020;26(8):1229–34.

12. Tenajas R, Miraut D. Enhancing Conversations on Cognitive Decline Through Patient-Centered Tools. Ann Fam Med. 2025 Apr 18;23(2):eLetter.

13. Wiwatkunupakarn N, Aramrat C, Pliannuom S, Buawangpong N, Pinyopornpanish K, Nantsupawat N, et al. The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review. J Med Internet Res. 2023 Jun 28;25(1):e45944.

14. Tenajas R, Miraut D. The Role of Voice Analysis in Early Detection of Mental and Neurodegenerative Disorders. Ann Fam Med. 2025 Feb 28;23(1):eLetter.

15. Tenajas R, Miraut D. The 24 Big Challenges of Artificial Inteligence Adoption in Healthcare: Review Article. Acta Medica Ruha. 2023 Sep 20;1(3):432–67.