The clinic patient population consisted of 1,651 patients seen in the year studied from the electronic health record. The mean age of these patients was 18.1 years (SD 3.2 years), and 69.9% identify as female, 28% as male, with the remainder identifying as nonbinary/gender queer, transgender, or chose not to disclose their gender identity (Table 1).
Table 1
Clinic patients who utilized telemedicine compared to patients that were only seen in person March 2020-February 2021.
| Total n = 1651 (%) | Telemedicine Visit n = 825 (%) | Only Office Visit n = 826 (%) | p-value* |
Age in years, mean | 18.1 | (SD 3.2) | 17.7 | (SD 3.2) | 18.5 | (SD 3.2) | < 0.001† |
Legal sex | | | | | | | < 0.001** |
| Female | 1186 | (71.8) | 634 | (76.8) | 552 | (66.8) | |
| Male | 465 | (28.2) | 191 | (23.2) | 274 | (33.2) | |
Gender identity | | | | | | | 0.01** |
| Female | 1154 | (69.9) | 613 | (74.3) | 541 | (65.5) | |
| Male | 462 | (28.0) | 186 | (22.5) | 276 | (33.4) | |
| Nonbinary/Gender Queer | 25 | (1.5) | 20 | (2.4) | 5 | (0.6) | |
| Transgender Female | 2 | (0.1) | 2 | (0.2) | 0 | (0.0) | |
| Transgender Male | 3 | (0.2) | 1 | (0.1) | 2 | (0.2) | |
| Other/Chose not to disclose | 5 | (0.3) | 3 | (0.4) | 2 | (0.2) | |
Race | | | | | | | < 0.001 |
| White or Caucasian | 746 | (45.2) | 396 | (48.0) | 350 | (42.4) | |
| Black/African American | 178 | (10.8) | 58 | (7.0) | 120 | (14.5) | |
| Asian | 255 | (15.4) | 107 | (13.0) | 148 | (17.9) | |
| American Indian/Alaska Native | 13 | (0.8) | 10 | (1.2) | 3 | (0.4) | |
| Hawaiian/Pacific Islander | 9 | (0.5) | 4 | (0.5) | 5 | (0.6) | |
| Other | 370 | (22.4) | 186 | (22.5) | 184 | (22.3) | |
| Unknown/Declined | 80 | (4.8) | 64 | (7.8) | 16 | (1.9) | |
Ethnicity | | | | | | | < 0.001 |
| Hispanic/Latino | 317 | (19.2) | 165 | (20.0) | 152 | (18.4) | |
| non-Hispanic/non-Latino | 1253 | (75.9) | 596 | (72.2) | 657 | (79.5) | |
| Unknown/Declined | 81 | (4.9) | 64 | (7.8) | 17 | (2.1) | |
Insurance type | | | | | | | 0.003 |
| Private | 1157 | (70.1) | 606 | (73.5) | 551 | (66.7) | |
| Public | 494 | (29.9) | 219 | (26.5) | 275 | (33.3) | |
SF county | | | | | | | < 0.001 |
| No | 693 | (42.0) | 438 | (53.1) | 255 | (30.9) | |
| Yes | 958 | (58.0) | 387 | (46.9) | 571 | (69.2) | |
Bay area county | | | | | | | < 0.001 |
| No | 114 | (6.9) | 93 | (11.3) | 21 | (2.5) | |
| Yes | 1537 | (93.1) | 732 | (88.7) | 805 | (97.6) | |
* All p-values calculated using chi-square tests, unless otherwise indicated. |
** P-value calculated using Fisher's exact test. |
† P-value calculated using t-test. |
58% live in San Francisco County, and 93.1% live in counties that make up the Bay Area (San Francisco, Alameda, Contra Costa, Marin, Napa, San Mateo, Santa Clara, Solano, and Sonoma counties) (Table 1). See Table 1 for further details of patient population characteristics.
20 clinic patients ages 13–25 (11 minors, nine young adults) and 10 parents of patients participated in interviews. 23 of the participants identified as female, 13 identified as white, six identified as Hispanic/Latinx (Table 2).
Table 2
Interview participant demographics.
| Parents | Patients |
Total | 10 | 20 |
Age Range | | |
13–17 years | - | 11 |
18 + years | - | 9 |
Gender | | |
Male | 1 | 5 |
Female | 9 | 14 |
Other | 0 | 1 |
Race/Ethnicity | | |
White | 4 | 9 |
Hispanic/Latinx | 3 | 3 |
Asian | 2 | 3 |
Native American | 1 | 1 |
Multiracial | 0 | 4 |
Type Of Visits* | | |
Telemedicine only | 2 | 1 |
In-person only | 3 | 7 |
Both | 5 | 12 |
Home Location | | |
In SF | 5 | 15 |
Outside SF | 5 | 5 |
Language | | |
English | 7 | 20 |
Spanish | 3 | 0 |
* Type of visits utilized by patient with the clinic, as of time of enrollment |
Most of the participants had completed at least one telemedicine visit with our clinic, although 10 of the participants had not utilized telemedicine and had only been seen in the clinic in person (Table 2). 20 of the study participants lived in San Francisco County (Table 2). Most reported English as their preferred language, although three participants (all parents) preferred Spanish and completed the interviews in Spanish (Table 2).
Quantitative results
Among our clinic’s entire patient population, we found differences in patient demographics among those who had accessed telemedicine compared to those who had only accessed in-person care. There were significant associations between telemedicine utilization and each of the patient demographic variables assessed. Higher proportions of female patients (both by legal sex (p < 0.001) and gender identity (p = 0.01)), white patients (p < 0.001), Hispanic/Latinx patients (p < 0.001), privately insured patients (p = 0.003), patients living outside of the county (p < 0.001) and outside of the major metropolitan area (p < 0.001) utilized at least one telemedicine visit (Table 1). Higher proportions of males, black or Asian patients, and publicly insured patients received only in-person care (Table 1).
Qualitative Results
Study participants generally agreed that telemedicine includes more barriers to privacy than in-person visits. For telemedicine visits taking place in the home, it was possible for family to overhear patients' private conversations with their providers. One parent shared that “with video visits, I think the temptation to listen in (on patient’s alone time) is too much, so for that aspect I would prefer in person.” One young adult patient reported choosing to join telemedicine visits from their parked car, as this felt more private to them than being in the home. The concern that their conversations can be overheard can limit what patients disclose to their providers during telemedicine visits:
I think it did kind of limit what I said...which probably impacted how the visit went. I really don't want my parents hearing that. I had some questions, like sexual questions, and yeah, I felt like I kind of had to censor myself a little bit,
- young adult patient.
However, for some patients, telemedicine provided opportunities for privacy and independence that they could not access with in-person appointments. Patients shared that video visits meant that they could attend a medical appointment without being seen by anyone they knew in the waiting room. Patients and parents also acknowledged that telemedicine made it possible for children to access care without their parents knowing.
My mom being there makes me feel less inclined to be honest and open (on intake forms/questionnaires). So sometimes I'll change the facts a little bit, like on the form, ‘cause I would fill out the form…but then my mom would take it and read the form and look it over, to check what I said, and that always made me feel anxious… I feel like on my screen, on my computer, my parents wouldn't look at it,
-young adult patient.
Several parents also commented that telemedicine could help their children practice the transition to seeking care on their own and begin to independently manage their healthcare. A parent of a 14-year-old liked that their child could access a telemedicine visit on their own if needed, even though they were not yet independent enough to navigate the public transportation needed to get to clinic in person. The parent valued that telemedicine would allow their child to avoid the safety risks of arranging transportation and have visits on their own much earlier on in adolescence if needed. Even if they personally preferred in-person appointments, all participants acknowledged that telemedicine can improve access to care. The convenience of telemedicine was particularly attractive to one parent who was relieved they would not need to make a trip to clinic every 3 months for their child’s ADHD medication. Telemedicine required less time, and it spared their child the stress of coming into the clinic environment. Similarly, participants identified that telemedicine requires less logistical planning and can help alleviate geographic and financial barriers to care. As one parent shared,
we are at least six hours away and the trek is not an easy trek…We would not have followed up…[Telemedicine] really saved the day…How I would think about it is always against the backdrop of, we have no (adolescent medicine) care at all, where we are. And, you know, it's always against, you know, (video visits) or no care at all.
Overall, most parents and patients were not concerned about the cyber security of telemedicine visits. However, a few participants did share that they have a general expectation that any information they put on the internet could potentially be accessed by a third party. As one patient shared, “I personally wouldn’t care (about showing physical exam findings on telemedicine) but other people probably would…because people won't shut up about how anything that is recorded it will be there forever. Digital footprint and stuff…” This patient then shared their misunderstanding that all telemedicine visits are recorded.
Patient and parent perceptions of the effect of telemedicine on their relationships with their providers varied, but most felt that they connected better in-person and were able to have more meaningful interactions. One young adult patient shared that, “in person, it’s just easier to talk…it’s just more human, there’s more connections personally…Teenagers, we have a lot of private things to say, and it’s just easier to say it in person.” Another young adult noted, “Sometimes people do just need a pat on the back or something. You can't get that through Zoom.” Patients and parents also noted the value of better nonverbal communication in person compared to telemedicine.
“I need to have that human one-on-one connection and actually be able to see them and hear them and have all of the nonverbal communication as well… that is really important and that's why I feel more comfortable sharing (during in-person visits). So, I prefer all of my visits in-person.”
-young adult patient
In addition to feeling more connected to providers, patients and parents generally feel more engaged in person.
I think probably like virtually it was hard to stay focused. I know for me and, and my mother too, if we're physically there then we're kind of forced to listen.
-adolescent patient
Participants identified more potential distractions on telemedicine, which ranged from noise in the home to distractions on the internet. Some patients disliked that their parents were distracted by other activities or responsibilities during telemedicine visits (joining telemedicine visits remotely from their place of employment, the car, or even the golf course). One young adult patient shared that for telemedicine visits their parents may be, “less involved and maybe not involved at all because, well, I think the reason that they're usually there (in person) is because they need to drive me there.” Additionally, some parents expressed concern that their children did not take telemedicine visits as seriously and that in-person visits were more impactful. This trend of decreased engagement and accountability was particularly noted by patients who disclosed being treated for eating disorders and their parents. One parent said, "Her weight was sliding a little bit. So that's the reason why starting in January, I say, ‘Okay, we need to go in person to have the weight of the doctor's word telling her, you know, she needs to eat.’ We saw (the doctor in person) and I saw a change in her attitude after that.”
Patients and parents also perceived telemedicine visits as having a lower priority or being easier to forget: “Me and my mom we actually did make an appointment… it was on Zoom but we forgot about it. I think also having it on zoom, you can always forget about the times,” one young adult patient shared. AYAs may face additional barriers when joining telemedicine visits on their own. Some participants noted that it can be harder for AYAs to access care without the structured time away from school and parental support required to physically travel to the clinic. As one patient shared: “I have a friend and she had (virtual) therapy every week, and she would just forget. Like, no one would like come and get her to go to therapy so she would literally just forget, and not go…and she didn't do anything about it… I think she quit.”
On the other hand, some participants reported feeling intimidated by the clinic setting and felt it was easier to open up in a telemedicine visit. They reported that the video visit format felt more distant or informal, making it easier to be open about sensitive topics. One adolescent said, “I liked being able to go to my appointments at home, I felt like it was more comfortable…that made it easier to talk with the doctors. I felt like it was kind of easier just because I was in a less anxiety producing environment when I was at home.” For patients who face prejudice and discrimination when accessing medical care, telemedicine could even provide a sense of safety. One transgender patient shared,
I have been discriminated against by doctors in the past, living in Georgia as a transgender kid. I've had not great interactions with doctors where they've just straight up, made me feel bad about my body. Knowing that there's another option to not have to experience that, like there’s not gonna be a physical sense of like, this person in my space is making me feel like my body isn't okay. Which is a matter of safety to a certain extent, especially as a child. So, I think having a virtual platform where you don't have to fear that your body is not being validated in a physical space is really nice for sure.
-young adult patient
Additionally, some patients and parents liked that telemedicine appointments felt less rushed, and they perceived having more time to ask all their questions.
Despite the rapid movement to telemedicine during the pandemic, very few patients or parents reported experiencing technical issues. Those who did experience issues reported that those challenges made it more difficult to connect emotionally with the provider and made appointments longer than they needed to be. As one adolescent patient shared, “It's hard whenever you're trying to have a serious conversation, and it gets broken up by the connection.” One factor that particularly affected the number of technical difficulties patients or their parents experienced was the type of device they used for their appointment. Those who used phones as opposed to computers reported experiencing more technical difficulties. These technical difficulties were compounded by language barriers for Spanish-speaking parents. All the Spanish-speaking parents in our sample only had access to a phone for telemedicine and relied on their children to help them navigate the video software.