* * Anonymous Doc: "Can I have your e-mail address?"

Monday, July 23, 2012

"Can I have your e-mail address?"

I've had a couple of clinic patients ask for my e-mail address.  I gave it to one of them, whose son is a doctor, and who had an e-mail relationship with the previous fellow in the clinic.  I didn't give it to the other one, partly because the day after I gave the e-mail address to the first patient, she sent me three long e-mails, and I found myself concerned about setting up a situation where I'm receiving e-mails that I don't have time to read and answer promptly.

I'm not sure what to do about it, as a general rule.  There doesn't seem to be a policy, at least not one that I can figure out.  The attending I asked said it's up to me.  Some fellows do it, some don't.  The issue that some doctors in practice have with e-mail is (1) it's not compensated, and (2) liability issues, if you don't reply instantly and something needs to be urgently done about the patient's condition.  I think the biggest issue is time.  There aren't enough hours in the day to have an e-mail relationship with every patient.  And the barriers to someone sending an e-mail feel like they're a lot lower than picking up the phone.  There's an expectation that if you call a doctor, they might not get back to you for a few hours, or until the end of the day.  That expectation doesn't hold with e-mail, even if a doctor may not actually be checking e-mail for hours in the middle of the day.

On the other hand, who wants to tell patients they can't contact you via e-mail, if e-mail is their preferred method.  In other professions, no one would tell a customer they can't send an e-mail if they have a quick question.

It's hard to tell tone over e-mail.  It's hard to ask follow-up questions, since you may end up in a days-long back and forth.  It's hard to give any advice more specific than, "you should come in just to be sure," which isn't advice that requires an e-mail relationship.

I don't want to e-mail with patients, if there's a choice.  There are systems in place to speak to a doctor on call 24 hours a day.  There are other ways to ask questions.  And yet that feels like a bad attitude, or at least an attitude that doesn't reflect the reality of how people communicate.  We can use the Internet without question for so many transactions and relationships-- even many that used to be in person-- grocery shopping, etc.  It can't possibly be the case that in the future people won't be e-mailing with doctors.  So why does it feel like such an imposition?  Why does it feel out of bounds, like a form of communication that is too direct, too easy to abuse, too personal?

We're on the hook for so many hours of the day.  To be able to go home and not be on the hook-- yes, there can be phone calls, and messages through the answering service, but it's different, somehow-- doesn't just feel like a relief but like a necessity.  People's health issues are important, usually require full attention, and can't be effectively dealt with in the same way you scroll through Facebook posts.  You can't half-answer a question and hope it turns out OK.  A patient e-mails saying he's feeling x, y, z symptoms and you can't necessarily just flag the message and say you'll deal with it tomorrow.  I don't want the responsibility of having to be fully engaged 24/7 with every patient.  It sounds bad to say that, but I don't know any other way to express it.


  1. Nah, you expressed it right. If you're already working 12 hours or more in a day, are on call an extra few days a month, there's really no call to have to communicate with patients by email during your time off. That's what it would come down to because I'm sure you don't have an hour to waste everyday catching up on your emails.

    And there's not really any value added as a doctor, right? If there's anything wrong, you're not going to rely on emailed symptoms for your diagnosis - they're going to have to come see you in person, or call, or go to the Emergency room.

  2. As a patient, I like the idea of being able to have a seemingly closer access to my physician, but then I think it would be awkward to have email contact on any basis other than something they're expecting. If I, as a patient, initiated the email conversation, I would feel almost invasive because I didn't follow the standard protocol.

    With that being said, there has been only one instance where I have used email with a physician- I was a high risk pregnancy, and she requested that I email her something specific in a certain situation. In that case, I did.

    I think it's too much to ask doctors to keep up with email as a general rule of thumb.

  3. I'm with you on this, Anon. I do not want to email my doctors. I don't check my email often, and it seems like a real pain in the butt to make them check email in addition to having to answer phone calls.

  4. I feel like, if patients understood that you would not get back to them immediately, AND there were a limit to how much they could write per email (like 150-200 words?), it would be ok. But then I vastly prefer doing email to talking on the phone.... EVER.

  5. I used to work as a researcher under a physian scientist who routinely used email to communicate with patients. I believe they were compensated for it, possibly by billing incorrectly (claiming it was a 10 minute phone consult instead of a 10minute email consult). He had an autoreply that went to non-work email addresses that said something about needing 24 hrs to respond to emails and that if their issue was urgent they should call his secretary. Maybe you could set up some sort of auto reply about the time frame on which you can respond and the importance of calling if they need faster turn around?

  6. The practice I use for my PCP and pediatrician has an incredible system. We can log in to the practice website and ask non-urgent questions that will be answered in "24-48 hours" and specify whether the question is for a doctor or a nurse. I do it somewhat frequently, especially with my kids, usually about rashes they have. I never write more than a sentence or two. The nurse calls me back if they have further questions. I definitely use it a lot, but I feel like it's less annoying than actually calling.

  7. My previous doctor's office had a system similar to the one Fizzy described. I used it only because my doctor asked that I stay in touch about a specific health concern. I never expected an immediate reply. I think it's appropriate for non-urgent communications that don't require an extensive dialog.

  8. From the various responses, and from my gut instinct as a patient and a VERY email-happy 30-something, it seems that it's not an effective way to communicate with any ole patient. A system that allows any patient to communicate on non-urgent matters is great, and an ad-hoc system for specific patient concerns about a specific condition is fine as well. That said, it also matters if the individual provider is willing to commit to that kind of system. Personally, I wouldn't do it for many of the reasons already given, but mostly because I wouldn't feel comfortable with a patient's ability, on a regular basis, to accurately describe diagnosable symptoms (disclaimer: I'm not a provider, just pretending to be one for the purpose of this post).

  9. You bring up good points about the problems of e-mail communication with patients. The other issues I struggle with are: is patient information secure on e-mail (I doubt it is, especially if it's going to my personal e-mail account)? How would I "document" e-mail communication - do I print it out and put it in the patient's chart? Can I really give a medical opinion without properly assessing the patient? What if the issue seems benign, but then something bad happens to the patient?
    - A Canadian family doc

  10. Kaiser Hospitals have an email system in place. Only short 150 symbol messages on non-urgent issues. Stated that response time may be 48 hrs, and you get a "away until x date" when doctor will not be in. It is part of the patient's computerized medical file.
    Good for prescription refills or requesting blood tests and other NON-urgent issues. Your personal email address.... nope don't think so.

  11. I think the only docs who do this effectively are ones that aren't answering them personally (common), don't work full time, or are workaholics. I started by doing it and ended up having to stop it. Patients would email long messages, want treatment over the web, and get mad if not responded to daily. Don't start what you can't keep up.

  12. In the IT industry, we do this by having a support desk. You e-mail the common support address, any of the first line support staff picks it up, responds to simple routine questions and possibly escalates to second line if they can't handle it internally.

    Of course, the handling of email is then a paid job, the handling is organized to filter unnecessary communication with higher level support, and the client end up having a relationship with the company rather than the specific support staff. Offering this kind of communication should therefore be a company policy, not an individual policy.

    Either that, or you outsource the filtering to a personal assistant in lower income country.

    That being said, in Norway we have strict policies on personal information. Unless you can ensure encrypted, untappable information flow, e-mail and fax are considered a big no-no. The standard response here is therefore "sorry, we are not allowed to accept e-mail as a channel to communicate personal data, because that channel is unsafe for that purpose."

  13. tag. you're one lovely blog! http://ahyesplans.wordpress.com/2012/07/12/blog-awards/

  14. I'd agree with all the comments above, but as a patient, I've found it useful in a few cases. I currently correspond with two physicians via email on a regular basis. One actually prefers email to phone; the other prefers long phone dialogues, but email is useful to request a phone call.

    I'm a teacher and understand the hassle of dealing with student requests via email. (We tell our students that we will respond to any email within 24 business hours.) If it's not straightforward or requires more than a three sentence answer (or the email is longer than 5 lines), the reply just reads, "You raise some interesting points. Please come see me in office hours (or set up an appointment) to discuss this further." Then email becomes a great way to set an appointment or tell the TA that you missed class because you have pneumonia and will bring a doctor's note with you; otherwise, we don't respond fast enough for us to become an encyclopedia or a walking syllabus, etc.

    With both these physicians, I know that they've each taken a particular interest in me and my case. I try to keep emails short and use bullet points. Usually the content is: 1) I'm taking this and this meeds, 2) I followed up with Dr. X and he suggested x, 3) update on how I'm feeling (10 words or less), 4) preferred method of reply (can we discuss this at my next visit?, can you call me at x time?, let me know what you think, call in a new prescription, can you contact Dr. X?)

    In conclusion, I'd say that email is useful in limited circumstances, particularly with a specific patient, provided that basic expectations are understood. Anything that I need an immediate response to, I know to visit my primary care physician or call a particular office and request to speak to a nurse. In general, it's probably not necessary; that's why there are dedicated means for patients to get medical feedback without direct contact with their physician.


  15. I have a kid with a complicated immune deficiency. Sees a wide range of specialists.

    I communicate with the immunologist by email. He gave me his email address.

    I don't expect instant response, ask questions that are more "clarifications" of lab results, etc. and always offer to schedule an appointment if he'd rather see my son/talk in person. The one time we had an urgent situation, we had the on-call fellow paged.

    For the rest of his doctors (and mine), I just go through the normal nurse/advice lines. Immunologist is special because (a) the questions lend themselves to email responses, (b) his appointments are often scheduled months out, due to limited clinic hours, and (c) he gave me his address.

    I personally wish I could use email for others, but recognize that it's not how they work.

    Personally, I'm in a profession where I am on the hook 24/7. I look at my phone right before bed and immediately upon waking to triage what needs to be answered immediately, and wish I could avoid it, but I can't, so I understand the desire not to do it.


  16. I work for a health system that uses a system similar to what Fizzy described. It's actually not bad, if patients understand the turnaround time and not for urgent matters. On the flip side, i go to a private practice physician who tells me to email him (he has a work email). I also email the MA if i have a question. Don't use it all the time, but it does work and not for urgent issues. personal email...absolutely not.

  17. As a HUC, one of my duties is to tell patients that it is against hospital policy to give out staff's email addresses including all providers :) No one blinks an eye after that :)

  18. I often prefer it, especially for the types of patients that would call nearly every day and talk my ear off, were difficult to reach during normal hours, or would page the on-call doctor after hours for non-urgent needs. Writing the email seemed to satisfy that "I need to talk to a doctor NOW about EVERYTHING" impulse. I can quickly read an email on my own time, and answer in few words vs. lengthy phone conversations about nothing. If complicated & necessary, I call the patient to discuss further or tell them to make an appt. I did "train" my patients by refusing to answer patient emails on weekends/holidays, even though I did check from home (the patient emails went to my general work email including research/admin/other correspondence that I DID need/want to deal with). It was part of work and I dealt with it at work.

  19. I respect the often "informal" nature of email communication. The "urgent" requests sent via email do indeed suggest that an "instant" response is required by the health care provider. But, today I had an experience that strongly suggests that email AND direct personal contact (via phone or office visit) BOTH have their place in the patient/provider scheme of things.

    In anticipation of my upcoming annual physical, I ordered a battery of lab tests online (the tests were CONSIDERABLY lower cost than my physician's "in-house" facility – another story). I called his office to inquire as to whom or where I might email the results so that my doctor might have them prior to my visit for his review. "Oh no", was the response from the receptionist," we don't do that...only fax is available". Really? How many of us have home faxes?? A “generic” administration email address sure would go a long way in paving a better path to enhanced patient/practice communication and time management!