There’s been a recent barrage of med-blog posts on the unhappy relationship between doctors and electronic communications. The first, a mainly reasonable rant by Dr. Wes* dated August 7, When The Doctor’s Always In, considers email in the context of unbounded pressure on physicians to avail themselves to their patients 24⁄7. That piece triggered at least two prompt reactions: Distractible Dr. Rob’s** essay on Why I Don’t Accept eMail From Patients and 33 Charts’ Dr. V on The Boundaries of Physicians Availability.
Perhaps the most astonishing aspect of these three guys’ essays is that, in 2010, there’s still a question about whether doctors should use email to communicate with patients. It’s hard for me to imagine physicians – including bloggers — so disconnected. But many are.
Last year, I had the opportunity to speak with Professor Nathan Ensmenger, a historian of technology at the University of Pennsylvania who’s studied physicians’ use of the Internet and email. Physicians aren’t luddites,” he told me. “On the whole, they’re a computer-savvy group, among the first to use the Internet in research and for professional development.”
Ensmenger contrasted doctors’ hesitation to take on email with patients with their early espousal of the telephone, which facilitated their practices and care in the early 20th Century. Doctors might want to work on-line, he suggests, even out of self-interest: the asynchronous nature of email, by contrast to telephone calls, affords more flexibility and workload control. Published studies, including an early 2004 report in the British Medical Journal, cite evidence that an overwhelming majority of patients would welcome the chance to communicate with doctors by email. Nonetheless, many medical providers refuse to email patients.
Here’s a partial list of reasons why some doctors are reluctant to get on board with this (1990s) program:
1. Physicians don’t get compensated for time spent emailing patients.
2. Any written communication with a patient, or about a patient, is a potential liability that might be used in a malpractice suit against them.
3. There might be a breach of patient’s privacy if the email is not sufficiently secure, encrypted, or is accidentally sent to the wrong person.
4. Email is a time sink, dragging physicians further down the slippery slope of doing more, undervalued work.
Each of these points has some merit, I admit. I am most persuaded by Dr. Wes:
…This is not a new trend. We saw a similar situation years ago with the advent of the digital beeper. Even the most basic of private bodily functions in the bathroom could be interrupted at a moment’s notice. The expectation that phone calls should be returned instantly grew from this — personal context be damned. Doctors were accepting of these intrusions, however; the feeling of being omni-present, omni-available, and omni-beneficent fit nicely with the Marcus Welby, MD psyche of the time…
So the problem is that doctors are human, i.e. we have limits. Which of course isn’t a problem, but a good thing. I don’t particularly care for robotic physicians.
I’m not sure how to resolve this, but here are my thoughts:
1. About the compensation issue – I think physicians should be salaried rather than paid per unit of work. Communication is an essential part of what physicians do, and so this type of task should be included in their designated workload – whether that’s part-time or full-time.
2. About liability – we need medical malpractice reform, sufficient such that physicians aren’t afraid to write messages to people who are their patients.
3. About privacy – this seems a relatively bogus excuse. Compared to faxing, email is far superior in regard to privacy. And, as many others considering this issue have pointed out, we’ve learned to trust internet-based communications for other critical matters such as bank accounts, credit cards, etc.
4. About physicians’ time – this is a critical issue that hits close to home. Unless the health care system evolves so that mature doctors can carry out expert, interesting and careful work with reasonable hours, few bright young people will choose careers in medicine, and more seasoned physicians will have to stop practicing to protect their own health and well-being. And then we’ll all lose out.
So I don’t think that physicians shouldn’t use email – they should. But the system needs adapt to the 21st Century.
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*Westby G. Fisher, M.D. is a cardiologist who blogs as Dr. Wes;
**Robert Lamberts, M.D. is a primary care physician who blogs on Musings of a Distractible Mind;
***Bryan Vartabedian, M.D. is a pediatric gastroenterologist who supplies 33 Charts.
Elaine–
Great post. I too have noted these recent discussions and have been thinking a lot about the issue. It’s complicated.
As a physician who accepts email, I’ve learned that like all new technology, it needs to be tamed, and that no matter what method of communication we open up with our patients, some will abuse it.
I do think I am getting less phone calls now that I accept emails from patients. Most emails are actually appropriate and can be dealt with quickly — either by forwarding to my secretary or doing the task it triggers — refill, question answered, etc. But some patients do expect medical decisions and management to happen via email — A typical such patient writes to report her medication isn’t working/is causing side effects/costs too much — and wants a change in dose or formulations. This is rel medical care, and often results in back and forth email conversations. And all for free. The thing is, a lot of what I do could happen via email but I don’t have the free time to do it for free.
Making docs salaried does not solve the issue of unreimbursed care. The word “salaried” is deceiving — because most salaried docs are given volume targets by the suits who run their practice or system. No administrator ever asked me how many emails I returned yesterday, or how much free care i gave — their jobs are dependent on making the budget which means I make my volume targets.
Your bottom line is correct — the system needs to adapt to the available technology. We need to find a way to compensate docs for the time they spend online with patients. It’s real time, real care, and if it is to continue, needs to be paid for in real dollars.
Thanks for continuing this important discussion!
Peggy
This is an important issue, Elaine, and a well written post. I recently wrote about this topic myself for the L.A. Times and was quite interested to learn about some of the statistics regarding current physician use of email and the extremely important reimbursement issues. Here’s a link to the story: http://www.latimes.com/news/health/la-he-doctor-emails-20100607,0,5447555.story.
Insurers are slowly starting to recognize that they will have to pay physicians for the time they spend online and I would think that trend is going to have to grow — consumers are hungry for digital access and I believe it’s going to ultimately be tough for doctors to avoid this type of contact. Personally, as a Kaiser Permanente member, I can tell you that the ability to communicate with my doctor, see my test results, book appointments and gain access to information online is an incredible convenience and one I would be loathe to give up (I realize this starts to veer off into EMRs, but still).
I hope we’re able to find ways to help doctors get online and gain fair compensation for the time they spend communicating with patients via this medium. It seems it’s happening anyway and that those who don’t get on board are likely to be left behind…
Stopping over from Grand Rounds, I enjoyed a lot of your post, but one part gave me pause: the line about email privacy. While the security of email itself is about as secure as you would expect from a phone conversation, email has the trick of being “permanent,” in the sense that it can immediately be forwarded to as many people as anyone on either end of the conversation wishes. That’s a security issue, perhaps one people will learn to live with, but it’s there. Then there’s the issue of email ownership and use; my work email is technically owned by my work’s server, my Yahoo! service is technically owned by that server, etc. Nearly all “free” email services scan information contained inside mail to target ads: will there be an issue that comes from that sort of medical communication and advertising? Also, will information sent in emails also be included a patient’s EHR? What will happen if that email account is hijacked for spam and/or malware (as happens)?
It’s not that I think these concerns are deal-breakers, but I think the topic is a little more complicated than might first appear.
It really comes down to being paid.