In our sample from Brazil, telemedicine was employed by most physicians and was directed towards professional interactive activities and the discussion of clinical cases. Only a third of physicians used it for teleconsultation and patient guidance services. During the pandemic, telemedicine was used by physicians working in COVID-19-related services, mainly in hospitals, offices, outpatient clinics and private clinics. Male, younger, dual-practicing physicians working in areas of the capital and in São Paulo were the largest users of this technology. More than three-quarters of physicians in public and private hospitals reported using telemedicine, followed by physicians in private offices and clinics. Only a minority of primary care physicians reported using telemedicine.
These results have to be considered taking into account some limitations. First, the study survey aimed to measure the overall impact of COVID-19 on medical work in Brazil, and some questions were related to the use of telemedicine during the pandemic. We therefore did not go into depth on the distinction between the various uses of telemedicine  in each type of service, or the implications of the different technological platforms available . Second, the complexity of the organization and financing of the Brazilian health system did not allow us easily to identify where physicians practice, as many have multiple jobs and concomitant public and private practice . We chose, based on the individual doctors' main places of practice, to divide them between public, private and dual-practice; and between hospital, public primary care/ambulatory, private outpatient and non-assistance services. Finally, the states of São Paulo and Maranhão have very specific development and health system characteristics, which should be taken into account in the eventual comparison with other low- and middle-income states or LMICs . However, we consider our findings and reflections valid and pertinent to other contexts.
The study showed that most physicians in our sample adopted telemedicine to perform a multiplicity of functions, such as clinical collaboration, healthcare team meetings, professional updating and patient care. Only a minority of physicians stated that they performed consultations and guided patients—a practice more commonly known as “teleconsultation”. While this multipurpose application of telemedicine confirms findings from other studies , the results also indicate that the pandemic may have expanded the frequency of telemedicine employment modalities beyond teleconsultation.
Prior to COVID-19, most reviews regarding telemedicine focused on effectiveness, cost-effectiveness, implementation and patient experience . In the future, reviews will probably need to distinguish between the different forms and functions of telemedicine, including a better delimitation of the concepts of telehealth, telemedicine and teleconsultation, which today are usually interchangeable in the literature.
Our study emphasizes how the main use of telemedicine occurred in the shared discussion of clinical cases, both in the care of COVID-19 and to replace services that had been interrupted due to the pandemic. It therefore proved to be a particularly useful tool in cases where there is a need to obtain in-depth knowledge for diagnostic decisions or patient treatment, which require multidisciplinary knowledge or knowledge from more than one medical speciality.
In post-COVID-19 contexts, the use of telemedicine to discuss cases and healthcare team meetings (another use identified in the study) may be useful in several situations: in critical events and in routine situations, both in primary care and in hospitals; in in-service care and teaching; in remote and rural areas with a shortage of professionals; and in services without the presence of certain medical specialists, or even in the shared management of services and in the management of complex health problems that require a multidisciplinary team .
Another frequent use of telemedicine that was identified in the study as promising is in terms of training, knowledge-updating and continuing education. Distance education activities (through courses, classes, lectures, discussion and doubt-clearing forums) are capable of quickly updating professionals regarding emerging health problems and guidelines that are in constant evolution. But telemedicine can also constitute an alternative for the present programmes of on-the-job training of human resources to keep them updated on rapidly evolving health programmes and policies, medical specialities, clinical guidelines and therapeutic consensus. The expectation is that, in the future, telemedicine will allow the maintenance of quality medical training, even during possible health emergencies .
One-third of the physicians in our sample reported having performed teleconsultations at a higher frequency than during pre-pandemic periods. COVID-19 accelerated the regulation of this practice in several countries, and this will require monitoring its eventual expansion. There will be limits to the growth of teleconsultation  because, in certain specialities and for certain health problems, telemedicine is definitely not the most effective form of care. Despite its lower cost and reasonable acceptance among practitioners, some of the barriers to the more expanded use of telemedicine include the low quality of non-face-to-face care; problems with patients’ medical records and notifiable disease reporting; physicians’ compensation; and ethical issues involving the physician–patient relationship and data sharing.
Our data seem to confirm that it is mainly young, private sector physicians from urban areas who have most frequently adopted telemedicine, and that it has mostly been used in São Paulo, the more developed Brazilian state. The more frequent use of telemedicine in urban areas has been identified already in other studies , but other aspects will deserve attention from future research; in segmented health systems in LMICs where private spending predominates over public (as is the case in Brazil), the expansion of telemedicine may be commercially exploited by popular clinics and health plans sold at lower prices, increasing out-of-pocket costs (albeit such forms of care lack the ability to follow up cases until the resolution and lack linkages to other services in the system).
On the other hand, telemedicine may worsen existing inequalities of access to services. As has already been pointed out by other studies , digital inequalities in the diffusion and adoption of new technologies mean the most socially vulnerable patients with greater health needs use telemedicine the least, a phenomenon described in literature as the “Inverse Care Law” .
In the context of caring for COVID-19, telemedicine was used more by physicians in hospitals (public and private) and in private practices and outpatient clinics, and only by a minority of primary care physicians. In Brazil, as in other LMICs, there will be a need to improve the legislation and regulation of the use of telemedicine , as well as a need to review human, structural, political and institutional capabilities for the better use of this technology .
Nationwide public policies for the use of telemedicine should consider the multipurpose potential of the technology for patient care, integration of services, sharing of expertise and the continuing education of professionals. The technologies needed for telemedicine (internet, computers, etc.) and the training of professionals to match the needs of patients should reach public services and municipalities far from capital cities.
In the specific case of LMICs, the COVID-19 pandemic has demonstrated that telemedicine can be an additional and useful tool in services that would be absent if this technology did not exist. Despite its proven limitations, it holds out the prospect of being employed beyond its original objectives, offering new opportunities to support health systems and human capabilities.