This study adopted a qualitative approach, employing focus group discussions. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure comprehensive reporting of the research processes and outcomes [14].

Participants included patients and GPs with experience of being involved in primary care consultations, both face-to-face and remote interactions within the United Kingdom. Adult patients aged 18 years or older who could communicate in English and had lived experience of virtual consultations (video or audio) with GPs were targeted to facilitate meaningful engagement and interaction during the discussions. Patients were recruited through Valuing Our Intellectual Capital and Experience, an online platform for community engagement and involvement in research [15].

GPs were recruited through a combination of convenience and purposive sampling via the research team’s networks, followed by snowball sampling to ensure diversity among participants [16]. GP participants were required to have professional experience conducting virtual consultations (video or audio) in primary care within the UK National Health Service to ensure shared familiarity with the primary care context, including relevant policies and regulations.

All participants received, via email, a detailed participant information leaflet describing the study background, proposed methodology, and objectives. Participants were encouraged to ask questions for clarification before providing informed consent and participating in the focus groups.

Four online focus groups were conducted via Microsoft Teams between June and August 2024: 2 with GPs and 2 with patients. Each group participated independently to capture distinct perspectives. The focus groups were conducted as part of a larger study aimed at identifying the safety implications of virtual consultations in primary care. A researcher (TL) with a clinical background, PhD qualification, and expertise in patient safety and digital health in primary care moderated all 4 focus groups. A senior researcher (ALN) comoderated the first GP focus group to ensure alignment of the discussions with the study’s objectives.

A semistructured topic guide was developed to facilitate interactive discussions during the focus groups, covering key aspects of communication challenges and potential solutions. The guide was piloted within the research team to ensure clarity and a logical flow. The questions in the topic guide aimed at exploring communications issues and strategies are presented in Textbox 1.

Microsoft Teams’ transcription feature was used to generate automatic transcripts of the discussions, which were later reviewed against the audio recordings by the focus group moderator to ensure accuracy before finalization and analysis. An interpretivist approach was adopted for this qualitative research [17], considering that participants construct meaning through their experiences and regular involvement in consultation dynamics. The analytical focus was therefore on understanding how participants interpreted and made sense of communication within virtual consultations. Transcripts were not returned to participants for further review; instead, the transcripts were directly analyzed by the research team to identify recurring themes and insights into participants’ experiences and perspectives.

A deductive-inductive approach was employed for data analysis to ensure a comprehensive assessment while allowing for new themes to emerge [18]. The deductive analysis was guided by the components of the extended SWCM model [6], which were set as proposed themes for communication challenges and gaps. The extended SWCM originally included 9 components, which were reviewed and refined by the research team into 7 key components (Table 1), representing the major deductive themes for this analysis. For the analysis of suggested mitigation strategies, the COM-B model was adopted as the framework for deductive themes, as illustrated in Figure 1.

The initial analysis was conducted by a researcher (AA) with expertise in qualitative data analysis and the study topic. Analyses of the patients’ and GPs’ focus group datasets were first conducted independently, followed by triangulation across both sources to support a comprehensive and coherent interpretation of the findings [19,20]. This process combined a deductive approach, using the predetermined models, with an inductive approach to identify any newly emerging themes. NVivo software was used to facilitate the analysis [21].

Data adequacy was supported by the concept of information power [22], given the focused discussions, the relevance of participants recruited through purposive sampling, and the strong alignment between the data and the study objectives. During analysis, the research team observed thematic stability across the focus groups, indicating that additional data collection was unlikely to generate new insights and suggesting a level of data saturation appropriate for the study aims [23]. Preliminary themes were further refined through iterative analysis and discussions among all members of the research team to reach a consensus on the final themes.

Ethics approval for this study was obtained from the Imperial College Research Ethics Committee (ICREC 6833567) before commencing the recruitment and study processes. All participants provided informed consent prior to taking part in the focus group discussions. This consent was obtained after participants had reviewed comprehensive participant information leaflets detailing the study’s aims and procedures, and after they had the opportunity to ask questions and receive clarification on any aspect of the study. To protect privacy and confidentiality, data were pseudoanonymized; identifiable details were removed after verification of transcription accuracy, and only deidentified qualitative data were used in the analysis. Participants received a £30 (US $40.36) voucher as a token of appreciation for their time and contribution.

A total of 21 participants (12 patients and 9 GPs) were involved in 4 focus group discussions; 2 patient groups, each with 6 participants, and 2 GP groups with 5 and 6 participants, respectively. None of the invited participants refused to take part. Each online focus group lasted for an average duration of 90 minutes. All participating GPs (n=9) were based in England, along with the majority of patients (10/12). The participating GPs had a mean of 5.33 (SD 4.06) years of National Health Service experience, with a range spanning from 2 to 16 years. Table 2 provides an overview of the participants’ characteristics.

The proposed mitigation strategies targeted the identified challenges and gaps, which were categorized into 3 deductive themes (capability, opportunity, and motivation) based on the COM-B model [13]. Table 4 outlines these major themes and the associated subthemes based on the data analysis.

This study adopted a qualitative approach using focus groups with GPs and patients to identify communication challenges in primary care virtual consultations compared to traditional face-to-face appointments, as well as exploring mitigation strategies. Four online focus groups were conducted, 2 with GPs (n=9) and 2 with patients (n=12).

Six major themes emerged regarding the challenges and gaps in virtual consultations, 5 of which align with the SWCM model: sender-encoder, message, channel, receiver-decoder-feedback, and context with modality appropriateness. An additional theme, patient autonomy and inclusivity, was identified inductively. For GPs as sender-encoders, misinterpretations and missed clinically significant cues were major concerns. The “message” was often compromised by limited clarity in dialog and difficulties in communicating diagnostic information virtually. Technical issues, poor connectivity, and accessibility barriers complicated the remote “channels” of communication. Patients, as receiver-decoders, reported a lack of trust in discussing complex medical needs remotely and perceived reduced empathy and emotional engagement from GPs in virtual consultations. Social norms and cultural factors, especially among elderly patients, shaped preferences and communication styles, highlighting the importance of “context and modality appropriateness.” Furthermore, patient autonomy and inclusivity in choosing virtual consultations influenced their engagement and willingness to communicate effectively during virtual primary care appointments.

Proposed mitigation strategies were mapped to the COM-B model: capability (training and resource provision), opportunity (triage systems and supplementary communication tools), and motivation (patient engagement and system adaptability). Participants highlighted the need for tailored capacity building through virtual-communication-focused training and skills development, supported by resource provision and standardized approaches. Recommendations to enhance the opportunity for better communication in virtual consultations included implementing triage and risk mitigation strategies, using supplementary materials to support remote interactions, and continuously identifying and addressing communication barriers. To strengthen motivation among both GPs and patients, participants emphasized the importance of respecting individual preferences for consultation modality, offering preparatory guidance and materials to support patient engagement, and ensuring flexibility and adaptability in care models.

Consistent with our findings, previous studies have identified common challenges in virtual consultations. Patients often struggle to articulate complex symptoms over the phone, while GPs face difficulties ensuring patient understanding of medical information and management plans [24]. These challenges are particularly pronounced in sensitive discussions, cases involving complex health needs, conditions requiring physical examination [25], and with new patients unfamiliar to the GP [26,27]. Some conditions, such as mental health concerns, raise questions about the appropriateness of virtual consultations on some occasions [28]. Our participants described a perceived lack of empathy in virtual appointments, contributing to dissatisfaction in mental health care. However, previous studies reported contrasting evidence, suggesting that offering timely virtual appointments may enhance mental health care by enhancing accessibility to medical advice whenever needed [3,28,29]. This inconsistency in evidence for some medical conditions highlights the importance of contextualizing and adapting care and communication models, including the choice of consultation modality, to align with individual patient needs and clinical circumstances [11]. It is also important to note that patient preferences for communicating remotely versus face-to-face are influenced not only by their health needs but also by personal characteristics [30]. Evidence shows that younger individuals, those with busy schedules, and highly educated patients tend to favor virtual appointments for convenience and accessibility [3,31].

Existing literature has tended to identify similar communication challenges in primary care consultations, but these are often presented in a fragmented manner [26,29,32]. Our study synthesizes these challenges within a structured, theoretically informed framework [6], with particular emphasis on virtual consultations as an emerging norm in primary care [3]. By framing communication issues as a shared responsibility between patients and GPs [33], we offer a more nuanced interpretation that supports practical approaches to mitigation. Through the application of the adapted SWCM framework [6], we further highlight how patient, clinician, technological, and contextual factors intersect, enabling us to propose targeted interventions that may lead to meaningful and sustained improvements in communication practices.

Importantly, communication challenges in virtual consultations extend beyond the consultation itself, involving both pre- and post-encounter interactions [32,34,35]. A qualitative study conducted in Australia highlighted pre-consultation patient-related factors that influence GP-patient communication, particularly health literacy and familiarity with digital platforms [26]. Many patients struggle with completing pre-consultation forms required for describing their symptoms and concerns for booking virtual appointments, especially when selecting appropriate terms to describe their symptoms [32]. From a GP’s perspective, familiarity with the patient, as well as access to and time for reviewing medical records, plays a crucial role in shaping communication style and ensuring a high-quality virtual consultation [27,36]. Existing tools also provide structured checklists and guidance to support high-quality virtual consultations, with communication highlighted as a central component [37]. For example, the Telehealth Etiquette Competency Checklist (TECC) emphasizes communication alongside technological, environmental, and confidentiality considerations [37].

Effective communication remains essential even after the consultation itself, particularly in follow-up messaging, referrals, and sharing components of the agreed-upon management plan [34]. The widespread adoption of virtual consultations has raised concerns regarding continuity of care, as it may challenge the foundation of building a strong professional relationship between GPs and their patients, which is an essential factor in enhancing the consultation experience and overall quality of care [38]. Ensuring clarity in follow-up plans after virtual consultations is crucial, particularly in guiding patients on how to seek further care if their concerns persist or if the initial virtual visit does not fully address their health needs [8,35]. Clear and efficient remote communication can help reduce unnecessary follow-up visits, whether in primary care or to hospital and ambulatory care [3].

To mitigate the identified communication barriers and enhance interactions during virtual consultations, GPs often use verbal affirmations, such as “yes” and “I see,” to prove active listening [33]. They may also verbally narrate any concurrent tasks, such as reviewing investigation results or previous reports, to maintain transparency with patients for reassurance. Such capacity-building requirements for these supporting skills have been proposed by the participants in our study to improve communication.

Evidence suggests that, when feasible, video consultations may be preferable for initial appointments to establish rapport, for assessments requiring observation of physical signs [25], and for counseling appointments. Existing literature also offers evidence-based guidelines, emphasizing aspects regarding the knowledge, skills, attitudes, and teaching strategies required for high-quality videoconferencing, which primary care teams can adapt to their local context [39]. However, no clear advantage or superiority of video consultations over face-to-face interactions has been established [40]. The collective evidence from broader literature indicates that both GPs and patients generally prefer communication through face-to-face consultations, followed by video calls when feasible, with phone consultations being the least preferred [41]. However, this hierarchy may vary depending on the context; for instance, when the consultation is for routine medication renewal, or patients live far away from their GP surgeries, phone or video consultations could be more practical [42].

This study focuses on the core aspect of virtual consultation -communication- as a critical determinant of both satisfaction and patient preference in clinical practice [5]. Focus groups were employed due to their ability to foster an in-depth dialog among participants and to identify shared concerns effectively [43,44]. However, focus groups could potentially allow vocal participants to dominate the discussion and the possibility that some individuals may share less in-depth reflections in a group setting [45]. To mitigate these risks, the moderator had substantial experience in conducting similar research, ensuring balanced participation and providing sufficient time for individuals to share their views [45]. Additionally, in terms of methodology, future research using direct observation or other objective methods could reveal communication nuances that focus group discussions may miss [46]. This would enable a clearer assessment of communication aspects in different consultation modalities.

The analysis was strengthened by the use of 2 theoretical frameworks to structure the data analysis and guide its interpretation: the SWCM framework [6], which addresses the challenges and gaps, and the COM-B model [13], which informs the development of mitigation strategies. Our analysis integrated insights from both GP and patient transcripts, emphasizing that effective communication is inherently reciprocal and requires active engagement from both parties.

While we aimed to recruit a diverse patient population, further research is needed to explore communication challenges among particular groups with potential distinct needs, such as patients requiring interpreters or those with mental health conditions and complex chronic illnesses like cancer. Additionally, all participating GPs were based in England, with an average of 5.4 years of experience. Future studies should include GPs at varying career stages and across different practice settings to identify role-specific communication challenges and potential training needs. Moreover, our study categorized both video and telephone consultations under the broad term of virtual consultations; however, each modality presents unique communication dynamics that warrant further investigation.

Virtual consultations have become an integral part of the “norm” in primary care, whether in the UK or globally. Therefore, it is essential to optimize remote communication to uphold patient safety and care quality [3]. The communication challenges and mitigation strategies identified in this study, structured using theoretical frameworks, provide actionable themes to be considered by policymakers and practitioners for improvement plans. For example, targeted communication training for GPs, ensuring that GP practices are equipped with stable and reliable technology for virtual consultations, and implementing guidelines to allocate virtual appointments to patients who are both medically and personally suited for them are all key areas for intervention.

Further research should focus specifically on GP-patient communication during virtual consultations, examining its impact on patient satisfaction and clinical outcomes, including safety. Policy efforts should extend beyond the provision of technology and infrastructure to include structured training programs that equip GPs and other clinicians with the skills necessary for effective remote communication. The training efforts should target not only qualified GPs but also undergraduate medical students and other healthcare professionals who are involved in patient care provision, potentially through virtual appointments [12]. In practice, the allocation of virtual consultations should consider both the GP’s level of experience in remote communication and the patient’s health condition and background. Communication in healthcare should be viewed holistically, not merely as spoken language, but as the means through which care is delivered, tailored to the needs of each patient.

This study highlights the pivotal role of communication in virtual consultations, highlighting existing gaps and potential strategies for improvement in primary care. Through focus groups with GPs and patients, we identified key communication challenges and potential mitigation strategies. While virtual consultations offer convenience, their use should be tailored to individual patient needs and clinical contexts. Future research should explore the distinct communication dynamics of different virtual modalities in primary care, informing policymakers and practitioners with avenues for improvement to ensure equitable, high-quality, and patient-centered primary care delivery.