Why Doctors Don't E-Mail
By KATIE HAFNER
R. ADAM SCHNEIDER, an internist in Austin, Tex., is as computer-adept a doctor as you are likely to find. He uses a Compaq iPaq hand-held for quick access to reference materials and medical records and to navigate the Web. He has three computers at home, and he is the one who configures all the computers for his practice.
Yet Dr. Schneider, 36, draws the line at electronic interaction with his patients. When they ask for his e-mail address, he demurs, telling them he prefers the telephone.
"There are too many variables with e-mail as opposed to a patient picking up the phone," he said. "It's not, in my mind, as effective as the telephone."
As Internet use became commonplace, some experts held up e-mail as a promising new medium for communication between doctors and patients. Many saw it as the potential bridge for a widening gap in communication, accessibility and familiarity.
Indeed, many doctors have added e-mail to their daily rounds. But reality has fallen short of the predictions. Physicians, it turns out, are largely reluctant to exchange e-mail with patients. According to the results of a survey conducted in April by Harris Interactive, while roughly 90 percent of patients want to exchange e-mail with their doctors, a much smaller percentage of doctors ? about 15 percent, by one expert's estimate ? do so.
The doctors' concerns are many. Some are worried about the risks to doctor-patient confidentiality, while others are concerned that an electronic paper trail might increase their exposure to malpractice liability.
Other concerns go to the heart of medical practice in an era of managed care, when doctors find time for patients increasingly scarce and reimbursement rates diminishing. Give patients your e-mail address, some doctors say, and you are inviting trouble: they will overtax your already burdened day, and one sympathetic response could cascade into a flow of demands and questions.
"There's clearly an opportunity for a patient to overwhelm the doctor's time," said Dr. Norman Chenven, 57, medical director of a clinic in Austin. "There's an opportunity for a mismatch between the expectations of the patient and the response of the physician."
Doctors who do exchange e-mail with patients say that while such fears are understandable, they are not borne out by their experience.
Dr. Richard Parker, 45, who practices at Beth-Israel Deaconess Medical Center in Boston, is one such doctor, having traded e-mail with patients for nearly three years. On a typical day, he said, he receives 6 to 10 e-mail messages from patients and spends about two minutes responding to each. That compares with 8 to 10 phone calls a day, averaging three to five minutes apiece, not including the time spent playing phone tag, he said.
"It's definitely a time-saver," Dr. Parker said. "Otherwise I wouldn't do it, and neither would any other doctor."
Many doctors who regularly exchange e-mail with patients say their patients do not abuse it. "One of the misconceptions is that patients will e-mail doctors all the time," said Dr. Daniel Sands, 40, an assistant professor at Harvard Medical School who studies electronic communication between patients and their doctors, a practice in which he estimated that 15 percent of doctors engage. Dr. Sands said he has 600 patients, about 20 percent of whom send him e-mail. He said he gets perhaps one e-mail message a day.
The computer might seem an unlikely way to bring doctors closer to their patients, but physicians who use e-mail say that staying in touch electronically does precisely that.
Dr. Parker said he recently had a patient with pancreatitis. "I told him to e-mail me every day with his symptoms and progress, or lack thereof," Dr. Parker said. "I think the patient felt cared for and attended to. I think he felt relaxed and comfortable about communicating frequently without feeling like he was burdening me."
Part of the hesitation among doctors who are reluctant to use e-mail may be its relative newness as a means of communication. For all its popularity and pervasiveness, e-mail remains a medium in the making. For some it is an invitation to write in shorthand, while for others it is something meant to be mulled over and composed with an eye toward precision and perfection.
Dr. Sands and others say that doctors must be careful to avoid the possibility of misinterpretation or confusion but that that should not deter them from using e-mail as a way to communicate.
"It's important to understand that it can lead to misunderstandings," Dr. Sands said. "So it is incumbent on doctors to read over what they've written a few times before hitting the Send button."
Two years ago, the American Medical Association adopted a set of guidelines for e-mail between doctors and patients. Doctor are advised to tell patients whether anyone else will be reading the message, refrain from sending group e-mail on which other recipients are listed, establish with patients what method of communication they prefer and archive the messages.
The demand among patients for e-mail contact with their doctors is pronounced. According to the recent Harris Interactive survey, 90 percent of patients with access to e-mail said they would like the ability to communicate with their physicians online, and more than a third said they would be willing to pay for it.
Patients want their doctors to spend more time communicating with them, Dr. Sands said. Further, he said, when patients know there is an open line of communication with a physician, the need for constant communication diminishes.
"It's a calming thing," Dr. Sands said. "People get stressed out when they don't have access to their physician."
Such reassurances are not enough to convince Dr. Harold Weinberg, a 50-year-old neurologist in New York.
Dr. Weinberg uses instant messaging throughout the day to keep in touch with family members, but he shuns e-mail with patients.
"All the questions require me to ask them more questions," Dr. Weinberg said. "The doctor-patient interaction is so dynamic that e-mail is like a fossil. It's too slow."
Still, physicians like Dr. Parker say e-mail can occasionally eliminate the need for an office visit.
Two months ago, Carol Butt, a 59-year-old retired nurse who lives in Winchester, Mass., and is a patient of Dr. Parker's, developed a large bruise on her arm. She decided not to drive 30 minutes into Boston to see him. Instead, she had her husband take digital photos of the bruise and send them by e-mail.
"I thought it would be ever so much easier to take a picture of what it was, and I figured he could get a good enough idea of what was going on," Ms. Butt said. Dr. Parker ended up sending her to a dermatologist, a step he would have taken had she driven to his office. "It saved me five or six hours," she said.
Many doctors who are reluctant to send e-mail also point to liability as a major concern. But that is another unfounded fear, e-mail partisans say.
"It's well documented that those who communicate a lot with their physicians are less likely to sue," said Dr. Sands, who also has a private practice in Boston. Dr. Sands said he knew of no malpractice lawsuits that had been filed in which e-mail played a role.
Further, Dr. Sands said, the e-mail trail can be more an asset than a risk. "E-mail is self-documenting," he said. "If you say something stupid, whether it's on the phone or by e-mail, it's not a good thing. And it should be there for review."
Patients who have grudgingly accepted the realities of managed care see little hope for patient-doctor e-mail.
"I would love to e-mail my doctor," said Don Archer, a 47-year-old lawyer who lives in Berkeley, Calif., "but it seems to run against the grain of managed health care, which is to impose barriers to access to doctors."
The Permanente Medical Group ? the clinical group that serves Northern California patients of Kaiser Permanente, the largest nonprofit health plan in the nation ? has long encouraged its doctors to send e-mail to patients according to guidelines it has developed. Some 25 percent of the 4,200 doctors in the group are using e-mail to correspond with patients.
"My sense is that 90 percent of our physicians will embrace this technology," said Dr. Robert Pearl, executive director and chief executive at the Permanente Medical Group.
The major concern among the group's physicians, Dr. Pearl said, is patient-doctor confidentiality. To address that concern, he said, Kaiser Permanente is in the process of putting a Web-based, secure messaging system in place.
Until secure e-mail is established throughout the organization, physicians are being asked to adhere to certain guidelines, Dr. Pearl said.
"They shouldn't be communicating sensitive diagnoses or sensitive pieces of medical information and they shouldn't be communicating any specific details to a patient that would potentially pose a risk if read by other members of the family," Dr. Pearl said.
Dr. Pearl says he believes that the e-mail adoption rate among physicians will accelerate as younger doctors join.
"We've hired a huge number of young physicians ? 500 last year," he said. "And all of these physicians grew up with computers. They believe very strongly that they can not only improve the efficiency of their practice but the lives of their patients. A lot of them are saying, `Bring it out more rapidly.' "
