Attitudes and Barriers Towards Video Visits in Surgical Care: Insights from a Nationwide Survey Among Surgeons

Abstract

Background:

Surgeons rapidly adopted video visits during the COVID-19 pandemic. However, video visit use among surgeons has significantly declined, pointing to the need to better understand current attitudes and barriers to their use in surgical care.

Methods:

From August 2022 to March 2023, a nationwide survey was conducted among practicing surgeons in six specialties. The survey included multiple-choice and free response questions based on an implementation determinants framework, covering demographics, provider, patient, and organizational factors.

Results:

A total of 170 surgeons responded (24% response rate). Overall, 67% of surgeons believed their practice lacked motivation for video visit implementation. Additionally, 69% disagreed with using video visits as the sole means for pre-operative surgical consultation, even with relevant medical history, labs, and imaging. Nearly 43% cited the need for a physical exam while 58% of surgeons believed video visits carried a greater malpractice risk than in-person visits. Other barriers included technological, billing, and care quality concerns. Nevertheless, 41% agreed that video visits could improve outcomes for some patients and 60% expressed openness to using video visits exclusively for post-operative consultations in uncomplicated surgeries.

Conclusion:

Surgeons recognize the potential benefits of video visits for certain patients. However, perceived barriers include the need for a physical exam, technological limitations, care quality concerns, and malpractice risks.

INTRODUCTION

The COVID-19 pandemic drove a surge in telehealth adoption. Telehealth use increased 83-fold between 2019 and 2020, continuing to increase post lockdown.^1–2 Surgeons also embraced video visits for patient care during the pandemic, accounting for 35% of new patient encounters.³ However, as in-person care resurged, video visits declined across all specialties, including in surgery. Between March 2021 and August 2021, just 3% of new patient surgical visits occurred via video.³

While video visits increased since the pandemic, they still face challenges in surgical care. Surgeons may find it hard to build rapport via video visits, and a perceived lack of privacy could decrease trust. Geriatric and low-income patients may lack technological access or literacy. Both surgeons and patients may favor in-person care for its depth and perceived ability to better sustain the patient-physician relationship. Considering the broad nature of these potential issues, identifying barriers is crucial for video visits’ success in surgery.

Previous studies found 95% of patients were satisfied with video visits and 75% expressed a perceived equivalence in quality to in-person visits.⁴ Meanwhile, over 76% of surgeons were satisfied with video visits and 85% were confident in retrieving patient health history (85%) through video visits.⁵ We expanded on these promising findings by better defining individual barriers across five surgical specialties: Cardiothoracic/Thoracic Surgery, General Surgery, Orthopedic Surgery, Otolaryngology, and Urology. This study highlights both the benefits and challenges of video visits, a first step towards improving surgical video visits for both surgeons and patients.

METHODS

Data Collection

From August 2022 to March 2023, we surveyed surgeons across five fields. To ensure geographic diversity, we used a random list from the AMA physician master file. These included cardiothoracic surgery, general surgery, orthopedic surgery, otolaryngology, and urology. Based on significant findings in prior literature ^6–8, we also stratified responses by practice type: solo practice, single specialty practice, multi-specialty practice, and hospital-employed. Our outreach included a mailed letter and survey link/QR code,⁹ with cash advance incentives of $20, later reduced to $10.^9,10 Using the Dillman approach, we contacted 158 surgeons in August 2022, 200 in October, 280 in December, and 80 in February 2023, minimizing time between outreach to reduce confounding variables.¹¹ The Institutional Review Board deemed our study exempt.

Study Design

Surgeons completed a 19-item Qualtrics survey using multiple choice, case-based, and open-ended questions, grounded in the Tailored Implementation for Chronic Disease (TICD) framework covering demographics, provider/patient factors, organizational change capacity,¹² and socio-political/legal elements. We chose TICD framework for its rigorous development, inclusion of provider and organization-level barriers, broad usage, and ability to guide implementation strategy selection.^13–19 The fifteen multiple choice questions included true/false, multiple-choice, multiple response, case-based scenarios, and the five-point Likert scale to reliably gauge opinions.²⁰ Four free response questions were included for further insight.

Surgeon Demographics

Our survey began with two questions assessing surgical specialty and practice type.

Surgeon Attitudes to Video Visits

Next, we evaluated surgeon attitudes on video visit implementation, querying their personal motivations and perceived impact on patient outcomes. We also collected data on their current video visit engagement rate to quantify surgical video visit usage.

Role in Surgical Care Process

We integrated case-based questions in our survey to gauge surgeons’ stance on video visits in surgical care. We asked about the appropriateness of pre-operative video visits given complete labs/imaging and medical history, and post-operative visits for the same surgery given no adverse events during the procedure. We tailored surgery types to each respondent’s specialty, highlighting the most common or widely known surgeries in each field: coronary bypass (cardiothoracic surgery),²¹ tonsillectomy (otolaryngology),²² hernia repair (general surgery),²³ ACL reconstruction (orthopedic surgery),²⁴ and prostatectomy (urology).²⁵ We inquired about complications necessitating an in-person consultation over a video visit.

Surgeon’s Perceptions of Patient Attitudes

We surveyed surgeons on their perception of patient opinions towards video visit quality. Using two Likert scale questions, we evaluated if video visits aligned with patient-centered care and matched in-person care quality.

Finances and Malpractice

To address the financial benefits of video visits in surgery, we included questions about surgeons’ beliefs regarding video visit reimbursement compared to implementation costs. We asked case-based multiple-choice questions about compensation rates for video visits, including situations where technical challenges prompt telephone consultations. To explore if legal concerns hinder video visits expansion, we inquired about perceived malpractice risk associated with video visits compared to in-person visits.

Leadership and Organizational Change

We asked three questions about organizational attitudes towards video visits. Using a Likert scale, we gauged leadership’s motivation for their use. We identified which team members were most hesitant through a multiple-answer question and two free-response questions about changes and concerns regarding video visits over the next year.

Additional Comments

Our survey closed with an open-ended question letting surgeons voice additional concerns or insights not previously covered.

Statistical Analysis

Our methods varied based on the nature of our questions. Each of the Likert scale responses were assigned a number ie. 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree. Descriptive analysis was reported by categorizing “Strongly Disagree/Disagree” as “Disagree” and “Strongly Agree/Agree” as “Agree.” Parametric analysis was reported by comparing mean values between specialties and practice types using Welch’s Two Sample T-tests with a 95% confidence interval to assess significance, a method validated for Likert data previously.²⁶ As detailed in the Central Limit Theorem,²⁷ we assumed a normal distribution for samples with n > 30. As a result, we did not include “cardiothoracic” and “other” surgical specialties in any specialty-specific analysis or “solo practice” in practice-specific analysis as these three groups all had n < 30. Findings were visualized using bar graphs and/or pie charts. All case-based questions were multiple choice and thus we used the same methods.

Our four free response questions were analyzed using a formal categorical analysis. This consisted of grouping responses into barrier categories and detailing the top three or four most frequently cited examples, a method justified previously as a formal means of qualitative data analysis.^28–29 Our approach was motivated by prior telehealth research which often described potential barriers following categorical themes such as financial, technological, and accessibility.³⁰ Some findings were also visualized using a bar graph.

RESULTS

Surgeon Demographics

Of the 718 surgeons mailed cover letters with cash incentives, 170 completed the survey, yielding a 23% response rate for those receiving a $20 incentive and 24% for those receiving $10. This suggests that incentive value didn’t significantly impact the response rate (p = 0.93).

The participants spanned six surgical specialties: Orthopedic Surgery (n = 46, 27%), General Surgery (n = 43, 25%), Urology (n = 36, 21%), Otolaryngology (n = 31, 18%), Cardiothoracic Surgery (n = 7, 4%), and Other (n = 7, 4%) (Figure 1).

Figure 1.

Survey respondents hail from a variety of specialties and practice types

They were affiliated with various practice types, with Hospital Employed (n = 69, 41%) being the most common, followed by Single Specialty Practice (n = 53, 31%), Multi-Specialty Practice (n = 31, 18%), Solo Practice (n = 14, 8%), and Other (n = 4, 2%).

Surgeon Attitudes Toward Video Visits

Most respondents had limited video visit experience. In total, 38% of surgeons reported no use of video visits with any patients, while only 17% employed them with at least 5% of patients. Adoption rates were lowest among otolaryngologists (10%), general surgeons (12%), cardiothoracic surgeons (14%), and orthopedic surgeons (19%). Urologists stood out with significantly higher utilization (p < 0.01), with 88% using video visits and over 38% employing them with at least 5% of patients (Figure 2).

Figure 2.

Surgeons stress patient, organization, and legal barriers to video visit adoption

In terms of motivation for video visits, 56% of surgeons disagreed that their practices were driven to use them. Among otolaryngologists, orthopedic and general surgeons, consensus existed about lacking practice motivation for video visits (mean 2.8). Urologists exhibited significantly higher motivation (mean 3.7) compared to orthopedic surgeons (mean 2.6, p < 0.01), general surgeons (mean 2.9, p < 0.01), and otolaryngologists (mean 2.9, p < 0.01). Practice type also influenced motivation: surgeons in multi-specialty practices reported higher motivation (mean 3.3) than those in hospital-based (mean 2.8, p < 0.01) or single-specialty practices (mean 2.9, p < 0.02) (Figure 2). Overall, motivation for video visit implementation remained low throughout except for urologists and those in multi-specialty practices.

Across all fields, 41% of surgeons agreed video visits could enhance outcomes for some patients. Response did not significantly differ between specialties and practice types (Figure 2).

Role in Surgical Care Process

Surgeons were cautious about using video visits for pre-operative consultation. Overall, 69% disagreed with performing surgery on a patient they’ve only seen through video, even with all necessary information. Specifically, 83% of general surgeons, 78% of orthopedic surgeons, 58% of otolaryngologists, and 56% of urologists disagreed. No differences were found based on practice type. Across specialties, surgeons were uncomfortable with operating based on pre-operative video visit consultation alone (Figure 3).

Figure 3.

Surgeons express skepticism about video visits as sole means for Pre-Op consultation

Surgeons were more receptive to using video visits for post-operative consultations without complications. Unlike pre-operative consultations, 49% agreed video visits were suitable for postoperative consultations following a successful surgery. Specifically, 77% of otolaryngologists, 55% of general surgeons, and 56% of urologists agreed. Orthopedic surgeons deviated from this trend, with only 20% agreeing. Orthopedic surgeons (mean 2.3) were significantly less comfortable than otolaryngologists (mean 3.8, p < 0.01), urologists (mean 3.35, p < 0.01), and general surgeons (mean 3.1, p < 0.01). Practice type did not impact this trend (Figure 4).

Figure 4.

Surgeons are more comfortable with video visits for Post-Op consultation

Comparing each specialty’s preferences for pre and post-operative consultations, general surgeons (p < 0.01) and otolaryngologists (p < 0.01) found post-operative video visits significantly more comfortable than pre-operative assessments.

In a free response question about conditions that would prompt surgeons to see patients in-person instead of via video, 59% mentioned wound, hemorrhage, or infection concerns (fever, chills, nausea/vomiting). In addition, 23% cited patient complication, 20% mentioned pain not responding to conservative treatment, and 6% referred to medical comorbidities. However, one surgeon stated “if a patient calls with a postoperative complication, I can generally see them much quicker over a quick video visit. It would actually delay care to see the patient in person.” Despite this, most surgeons still favored in-person visits for potential complications.

Surgeon’s Perceptions of Patient Attitudes

Collectively, 53% of surgeons disagreed patients saw video visits as equal to in-person visits (mean 2.5), including 71% of otolaryngologists, 57% of orthopedic surgeons, and 42% of general surgeons. Conversely, 42% of urologists (mean 3.2) agreed with this, significantly more than general surgeons (mean 2.6, p < 0.01), otolaryngologists (mean 2.6, p < 0.01), and orthopedic surgeons (mean 2.3, p < 0.01). Practice type had no significant impact.

Additionally, 47% of surgeons agreed video visits align with providing patient-centered care (mean 3.3). Unlike other surgeons, over 75% of urologists (mean 4.0) agreed, significantly more than orthopedic surgeons (mean 3.0, p < 0.01), of whom only 36% agreed video visits align with providing patient-centered care. Practice type once again did not yield significant differences in response.

In conclusion, surgeons believed patients viewed video visits as lesser quality compared to in-person visits but still agreed that they constituted patient-centered care.

Finances and Malpractice

Across all specialties, 58% of surgeons were neutral (mean 3.0) on whether reimbursement from video visits outweighed its costs, implying a perceived consensus on cost neutrality.

When asked about payment for video visits compared to in-person visits of equal time and complexity, 79% preferred “same compensation,” while 17% opted for “less compensation,” and 4% chose “more compensation.” Similarly, for telephone consultations, 78% preferred “same compensation,” with 20% opting for “less compensation.” Surgeons advocated for time-based compensation rather than communication methods (audio, video, in-person).

Concerning malpractice, 58% agreed video visits carried higher malpractice risk (mean 3.6). General surgeons (mean 3.9) were significantly more concerned (p < 0.01) than urologists (mean 3.1), while practice types didn’t yield significant differences. Malpractice concerns remained a substantial barrier across specialties and practice types.

Leadership and Organizational Change

Across all specialties, surgeons concurred on practice leadership/administration being supportive of video visit adoption (mean 3.7, mode 4); only 7% disagreed. Practice type influenced perceptions, but overall, practice leadership encouraged video visits.

When asked a “choose all that apply” question on the most hesitant practice members regarding video visit expansion, 48% of surgeons indicated peer surgeons. Nurses/PAs concerned 13%. Administrators and legal teams each garnered 13% and 11% respectively. The consensus remained clear: peer physicians were listed as nearly four times more hesitant than the next most cited team members, a significant finding (Figure 5).

Figure 5.

Surgeons believed their peer physicians were most likely to be hesitant to expand video visit use

Surgeons highlighted several organizational changes needed to expand video visits. The foremost was technology, with 37% expressing the need to improve video platforms, enhance access to rural communities, educate geriatric populations, and ensure patient privacy. One surgeon responded, “we need a subscription to a video service facilitating secure visits. It is difficult at times due to a lack of a standard platform (apple, android, etc).” Workflow concerns, like in-person scheduling preferences, were raised by 16%. For instance, one surgeon conveyed that if they were to implement video visits into their practice, the visits would “have to be properly scheduled within the clinic flow, such as the beginning of the day or at least 30 minutes after the last patient visit of the day.” Legal issues, including cross-state coverage and malpractice, were noted by 10%. One surgeon expressed, “if there is a problem that you can’t recognize because it is a video exam, how much legal trouble are you in?” While 28% saw no need for adjustments, most agreed on the importance of enhancements, especially technologically.

When asked about the top three practice concerns for using video visits in the next 12 months, 43% of surgeons cited the necessity of physical exams, 35% expressed care quality concerns, and 27% highlighted potential billing issues. Surgeons stressed the importance of physical exams, lab tests, and imaging studies. One stated “the concept of physical exam is extremely important in surgical patients and cannot be achieved via video visits. Video visits may have a role in post-operative visits” while another said “a surgical consultation without a physical exam is not a surgical consultation.” Worries about compromised care quality were underlined, with one surgeon highlighting the lack of empathy conveyed through video and the absence of touch in patient-physician relationships. Billing concerns centered on facility fee loss and lackluster reimbursement. Overall, surgeons’ primary organizational concerns included physical assessments, care quality, and billing.

Additional Comments

Some surgeons provided noteworthy feedback. One surgeon said “patient’s tech and medical literacy is typically the biggest barrier. If they can’t navigate the steps for video visits, I resort to phone calls.” Regarding illegal intra-state telehealth another surgeon stated “we are limited to seeing patients in states we’re licensed in. Patients far away would benefit from video visits, but can’t use them as a result.” Despite apprehension about technology, physical exams, and legal or billing difficulties, one surgeon emphasized ”‘if we are being patient-centered, video visits are the future.”

DISCUSSION

This study was the first to comprehensively survey surgeons on their perception of barriers to video visit use in the surgical care process. These barriers can be divided into four categories based on our TICD framework: provider factors, patient factors, malpractice and reimbursement, and administration and leadership. In Table 1, we define the primary barriers from our survey, label them into the four existing TICD categories, and provide potential solutions that were identified upon review of the existing literature.

Table 1.

TICD framework, proposed solutions to identified barriers for video visits in surgical care

Determinants	Identified barrier	Proposed solution
Provider factors	Surgeons require an in-person physical exam for surgical practice.	Video visits can play a supplementary role to in-person visits in order to assess patient symptoms and the need for a potential in-person follow-up rather than a primary role.
Provider factors	Surgeons remain wary of using video visits as the sole means of preoperative consultation.	Establishing the need for an in-person preoperative consultation prior to surgery while defining the role of video visits for postoperative consultation for uncomplicated surgeries.
Provider factors	Surgeons have low motivation for video visit implementation.	Motivation may increase by adequately defining an appropriate role for video visits in the surgical care process to obtain a physical exam and appropriately addressing all defined barriers.
Patient factors	Patients are perceived to view video visits as a lower standard of care.	Previous studies,31,32 including one with 3,486 in-person and video visits for nephrology encounters at Mayo Clinic, show no significant difference in patient perceived access to care, provider satisfaction, or care quality.
Patient factors	Some patients have low technological literacy or lack access to necessary technology.22	Practices can continue to take advantage of improved technological literacy after the pandemic33 and also develop support mechanisms like a “help desk” for patients
Malpractice and reimbursement	Surgeons believe video visits pose a greater malpractice risk.	Implementing patient consent forms before starting video visits will reduce the risk of surgeon malpractice. Professional societies should consider publishing guidelines for video visit use so that it is perceived to be within normal standards of care.
Malpractice and reimbursement	Concern for patient privacy remains prevalent among surgeons.	Requiring video visit platform vendors to follow HIPAA compliance and take responsibility for potential breaches in confidential patient information34 will ease surgeon privacy concerns.
Malpractice and reimbursement	Surgeons believe they should be reimbursed adequately for video or audio visits.	Surgeons should be made aware that there is strong bipartisan support for continued video visit coverage. Additionally, they can work with their professional societies to ensure payment parity for video visits.
Administration and leadership	Surgeons believe peer physicians are hesitant to expand video visit use.	Further research explaining the high rates of video visit use among urology and multispecialty practices may better uncover solutions for practice-level adoption.

Provider factors include the need for physical exams, pre-operative video visits concerns, and low motivation. Half of surgeons saw the absence of a physical exam as a major hindrance to video visits, echoing findings from Breton et al. identifying this as a significant barrier in primary care as well.³¹ Even with comprehensive labs, imaging, and medical history, most surgeons remained skeptical of pre-operative video consultation. However, a retrospective urology review found 95% of video visit surgical plans remaining unchanged following in-person examination.³² Further studies are required to identify specialties where virtual video visits are most feasible, with urology appearing promising.

In contrast, surgeons favor post-operative video visits for uncomplicated cases, consistent with studies indicating no link between video visits and increased readmissions within the first 90 days of surgery.^33,34 Additionally, randomized control trials in lung cancer and arthroscopic surgeries showed similar patient outcomes for in-person and video consultations.^35,36 Video visits appear appropriate for uncomplicated post-operative patients. However, orthopedics, general surgery, and otolaryngology practices expressed low motivation for video visits. Table 1 offers solutions to address these barriers, which may potentially boost enthusiasm.

Patient factors involve quality of care and low technological literacy concerns. A survey from 1,600 patients found 75% cited lack of a physical exam as their biggest concern for video visit use.³⁷ While physical exams are valued by patients and physicians alike, a study at the Mayo Clinic showed no significant difference in care quality between in-person and video visits.³⁸

Patients of low socioeconomic status (SES) or technology literacy face challenges with video visits. Kalicki et al. found 83% of homebound patients needed assistance with them.³⁹ Age and economic burdens decrease video visit completion,⁴⁰ seen in fields such as psychiatry.⁴¹ Thus, video visits can benefit some but should supplement in-person visits for the elderly or patients of low SES. Addressing this requires increased technological training and outreach to rural areas. Table 1 presents potential solutions and provides a basis for future research.

Malpractice worries revolve around misdiagnosis and breaches in patient privacy. Surgeons unanimously worry about misdiagnosis, which accounts for 68% of video visit malpractice claims compared to 46% for in person visits.^42,43 Yet, a 2019 review found no video visit-related malpractice claims heard in court, indicating most are settled outside court.⁴⁴ To prevent lawsuits, it is crucial to define the circumstances for combining video visits with in person visits. Additionally, using patient consent forms and ensuring HIPAA-compliant video platforms can further mitigate unease.

Reimbursement concerns arise from insufficient billing, a key physician concern.⁴⁵ The average payment for video visits is 10% lower than for in-person visits.⁴⁶ Although Congress extended Medicare telehealth coverage parity until December 2024, ongoing uncertainty around video visit reimbursement necessitates policy solutions. To address reimbursement worries, Congress should focus on patient interaction time, irrespective of communication mode (in-person, video, or audio), in upcoming legislation. Nevertheless, it is important to note that while billing concerns remain prevalent in both our survey and prior literature, 73% of surgeons did not list it as a top three issue, labeling other matters described above as more pressing.

Administrative and leadership dynamics reveal surgeons report peer physicians as nearly four times higher than the next most reluctant team member to adopt video visits. Two primary theories could explain this trend. First, surgeons may be likely to change their behaviors to conform with that of the group.⁴⁷ This trend is seen frequently in medicine: a recent study found that presenting physicians with peer prescribing patterns can determine whether they themselves prescribe antibiotics for conditions which do not demand them, such as influenza.⁴⁸ Second, surgeons and their peers may simply be unmotivated to implement video visits and have stronger opinions relating to this as the care provider. Prior literature documenting U.S. surgeon preferences is lacking, though our survey does cite an overall lack of motivation. Nonetheless, the cause for perceived surgeon hesitation remains unclear and presents an opportunity for future research.

These barriers notwithstanding, 41% of surgeons believed video visits could enhance outcomes for certain patients. In complex cases, concerns centered on wounds, hemorrhage, and infection drove preference for in-person consultations. Yet, initial video visits can offer timely care and prevent treatment delays for these cases enhanced post-operative monitoring. Notably, post-operative telehealth has already improved the acute care patient experience through improved communication, reduced wait times, and swift treatment for acute care or postoperative issues.^49–51

Despite our findings, our study did have limitations. Our response rate stood at 24%, which means that non-response bias could affect our findings. While newer research does dispute this assumption,⁵² a lower response rate increases the likelihood of non-response bias. Our study did our best to combat this by including advanced incentives and providing anonymity to survey respondents, proven methods to increase response rates.^53–55 That said, our second limitation stemmed from anonymity, as we were unable to gather information on the age and gender of our respondent population. As detailed by the CDC, video visit use is highest among women and, perhaps surprisingly, highest among the elderly.⁵⁶ Therefore, the demographics of our surgeon population could affect our findings. Lastly, while our study remains broad, we were able to survey only five out of the 14 specialties recognized by the American College of Surgeons. Further research is needed to best determine the feasibility of video visits for other specialties such as plastic or vascular surgery. Nonetheless, our study included a broad surgeon population representing specialties that accounted for 79% of the total surgeon population, according to the AAMC.

CONCLUSION

Surgeons recognize the benefits of video visits, such as cost reduction, improved efficiency, and better access to care for specific patients. However, perceived barriers hinder widespread adoption in surgical practice. Concerns about physical exams, technological limitations, care quality, and malpractice risks make surgeons cautious about relying on video visits as the primary mode of patient care. Addressing these barriers and emphasizing post-operative video visits can lead to more effective implementation of video visits in surgery.