Learning to Listen Again Preserving Clinical Presence in a Digital World

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.