Thursday, September 24, 2009

Should Patients Email Their Doctors?

This is a less controversial issue than patients ‘friending’ their doctors on Facebook, which I oppose. Although most physicians’ offices are not emailing with patients, perhaps they should. There are several obvious advantages.


  • Decompress phone lines, which are suffocating nearly every medical practice in America.

  • Relieve patients of the cruel and unusual punishment of languishing on ‘hold’ listening to elevator music or dead air.

  • Allow office staff to efficiently respond to patients’ cyber inquiries at scheduled times.

  • Eliminate the need for the ubiquitous phone menu system, a torture chamber that tests the mettle of even the most robust and seasoned patients

  • Facilitate documention of patients’ inquiries, which is not reliably accomplished with phone calls.

  • Permit staff and physicians to access patients’ emails from remote locations.

  • Allow for emails to be forwarded to other staff and physicians with a keystroke.

  • Available 24/7.


Sure, email communications between physicians and patients makes great sense, but it costs doctors dollars. Should this be a free service? The current culture of medical practice in this country is not to charge a fee for patients’ phone calls. Like every doctor, I spend hours each week on the phone with patients. This is free medical care. Patients feel entitled to this pro bono service, as I do when I call my doctor or dentist. But is this fair? If a patient calls me to ask a medical question, then why shouldn’t I be compensated for giving professional advice that requires medical training and experience? Is this free medical care a service that we should provide to our existing patients? What about patients whom we have never seen who call us after hours with a medical issue? Should this be a freebie also? Many phone calls morph into phone office visits, which not only are free, but also may not provide optimal care to the patient.

When I call my lawyer there’s always a ticking sound that I hear in the backround. For lawyers and other professionals, phone calls are fair game. Ironically, while physicians don’t charge for phone calls, we are still legally liable for the medical advice that we offer during these gratis exchanges.

Will emails be the next generation of donated physician time? Emails and phone calls to physicians should be reimbursed. Primarily, because it is fair to pay people for the work that they do. In addition, charging a fee would help reduce many of the unneccessary calls (or future emails) that deluge our office.

I welcome differing opinions on this issue. If I respond back, it will be free of charge.

19 comments:

Steve said...

I've been going to the same doctor for over 25 years. He's given me his email address and I use it sparingly (a couple times a year max) But it sure is a great way to get things done in seconds rather than hours for the right issues.

I would add one more benefit which is implied in what you listed - ending phone tag or having to wait around just in case the doctor's office might call.

Perhaps some sort of charge could be set up after a certain number of emails from a patient per year. And I'm sure a checklist that would help patients decide whether to call or email or come in could also be developed. But if you can't get an appointment for three weeks, an email sure is tempting.

Anonymous said...

I had the occasion to call up my lawn man the other day. He installed some new sod, and I called him up to get some advice about it, the sod root system wasn't taking to the soil as fast as I thought it would. He did not charge me for his time.

I consider him obliged as a courteous service provider to assist the work he did to succeed and stay in place. I paid him for his labor.

The time he spares in the follow up is cost of doing business.

You're entitled to charge for your time. But be prepared for you clients to go elsewhere, to more polite and courteous service providers who are only too happy to spend a couple of minutes on the phone to ensure their work stays in place.

People who work in PIECEMEAL fashions, people like you who do PIECE WORK... have to learn to annualize the money out to cover the cost of living during the times you are not working on the piece. Now in your case, does that include talking to the piece? or when you're working on the pieces body? It's debatable.

One thing for sure is, if you're going to say it is clear cut, you're wrong. You are wrong to arrogantly claim that opening your inbox is 'free medical care' and we should all be paying you the whole time...

When you are stuck in traffic in the morning do you take the view that you're doing us a favor and bedrudge the 'free gas' that you are 'donating' to us, to transport our physician to his office?

Just find a price for your piecemeal work, and make sure it is enough per year for you. That is your right.

Don't bore us with the driving to work, the shaving, the emails, the phone calls, the reading of journals, the buying deodorant... we don't care. Just get it done.

Yeah, we are paying for your head full of rote learning and medical school if this not that and or do this programming... and with a bit of luck one day a human lives in world where a robot can do this shit, because god know's we are sick of your whining.

Oftentimes when you answer an email you do it only after googling something anyway!

drschoor said...

I like email and use it with patients. I find it un-intrusive on my time and easy to add into the EMR/medical record. Most patients do not abuse it and more often than not a few emails end up with an extra visit and some income.
On the balance, I like it.
BTW: I hhave dedicated a chapter to email in my forthcoming book "Sacked: A Physician Guide To Job Loss, Professional Disallusionment, and Reinvention."
I really like your blog.

Anonymous said...

I am a veterinarian and I use e-mail to communicate with some clients. It's much faster than time spent on the telephone and many of my clients (especially Gen Y) really seem to prefer this. I consider it part of customer service.

But if a client has questions unrelated to either an acute or chronic problem for which I've seen the animal, I recommend that the client schedule an appointment - which can also be done via e-mail. Actually, if a client wishes to have a phone conversation about a problem for which I have not seen the animal, I also recommend that the client schedule an appointment. I am not psychic!

As for "free medical advice", that's a plus of e-mail: I can easily link web pages that are reputable sources of information for clients who want to read more about their animal's medical condition. This is helpful to me, as I enjoy educated clients and every so often, I learn something, too. And think about it... many clients are going on the internet, anyhow, so it's far preferable to give a little direction, like the half dozen favorite websites I can hot link in a snap, vs. encountering a client who has been trolling weird bulletin boards and wacko quack medicine cure-all websites.

I hate the telephone. E-mail is much nicer.

Michael Kirsch, M.D. said...

Agree that email offers great convenience. Your triage approach sound great. We have a similar phone approach with our human patients.

Anonymous said...

E-mail offers one other advantage:

(concerned client)

"Doc, Beast has a cut this morning. Do you think it needs stitches?"

or

"Doc, Lumpy has had a strange rash for a few days and it seems to be spreading. What do you think it is?"

(me)

"Can you take a photo of that with your cell phone and e-mail it to me?"

I'm almost certainly going to need to see both Beast and Lumpy - the question is how soon, and how much time should I allow for the appointment? Technology is my friend. It's allowed me to tell concerned clients "I don't think Lumpy has cancer, but I should examine her and maybe biopsy the area just to make sure" while advising laid-back clients "I really don't think we should wait until you're home from work at five for me to re-attach Beast's pectorals to his chest."

(Yes, I've exaggerated. But not much.)

Anonymous said...

I don't have email access to my doctor. I also will not call the doctor (even when she has asked me to call back in a few days to let her know something)
I got very tired of not being allowed to speack to a nurse (unless she called me first and I'm returning her call to get lab results)
and the front office staff messing up my *important* message as something benign (I've got a couple of serious medical issues).

I'm sorry ...but me telling the front office staff that I think I've got a bladder infection and I'm running 102 fever (while on immunosuppressant therapy) is not "P thinks she's got a stomach ache and doesn't feel well"
Calling the doc and giving the message "My cat bit me and it's rather deep" is not "P thinks she got a scratch by her cat"

I gave up with the cat bite that got significantly infected in 24 hours because the doctor thought I'd been scratched not bit.

email ...would be nice. I tend to let things go because I don't want to go in more often than the once every 8 weeks I go in now and I don't trust non medical people to get the message straight.

horsndogluvr said...

I'd love e-mail. No more "translations" of "I have hemorrhaging cystitis again" to "suspected UTI."

My Dr's current nurse is an idiot. I had a blood panel done, and she phoned me to say everything was "normal." I needed a copy for another doc, and when I got it, I saw my A1C was 7.2. And here I'd thought my type 2 was in remission!

Needless to say, my trust level has dropped big time. Any report of "normal" is now an automatic request for a copy of the report.

Just e-mail me the results!

Lisa Gualtieri said...

I liked the points raised about the ease of including links and pictures. I teach Online Consumer Health at Tufts University School of Medicine and I am very interested in physician referral of potentially useful Web sites.

If email is used, does it make sense to offer patients guidelines (doctors too?) in appropriate and effective email use: when to use it, how to craft it effectively, what a reasonable response time is, etc?

Liz Moay said...

I agree phone is too much time consuming and i don't like the fact email is asynchronous so i use an online booking system and almost 40% of my patients already use it so even more time saved for me not to mention the ppointment part which is much easier now.

John Dian said...

I agree with the last comment as use an online booking system too (http://www.appointmentseasy.com). It solve a good part of these issues. Good to see i'm not the only one

Anonymous said...

Everybody is missing a BIG plus for E-mail:
The doctor's message is in writing!
(Better than doctor's handwriting - it's in typing!)
I can get fuzzy on remembering a phone conversation (or an office conversation), butI can read the E-mail over and over.

nutrprofe said...

E-mail is non-reimbrusible and the answer most of the time is going to be "why don't you make an appointment".

However, e-mail does make sense in a capitated reimbursement system.

Anonymous said...

The difference between a doctor and a lawyer is the way things are billed. A lawyer works by the clock whereas a physician charges for services rendered. An office visit is billed at a certain rate, etc. A lawfirm is set up different -- they bill not by services rendered by time spent. A client is not charged by a motion drafted and filed but by the time spent on drafting and filing a motion.

If you were to charge your patients by time spent, then you would be justifiied in billing for emails and phone calls. Follow-up for services rendered should not be billed. When I take my car to the mechanic, I am charged for the service they provided. If they have to do follow-up on the service they provided, such as I still hear a rattle, I better not be charged for that. That is related to the service/product rendered.

I can say that if I ever were charged for a phone call or an email, I would pay it but that would be the last time I visited that physician. I am the consumer and there are many physicians to choose from.

Lastly, when we deal with lawyers, we are aware that we are charged for a phone call as we are billed by time spent. As such, we are very careful when we would place a call to the lawyer. Do you really want to have a patient who relies on a doctor's expertise to wonder if this is a call that should be made or not? It could be dangerous to the patient who does not have the expertise to determine if it is serious or not.

Change your billing and charge by the hour and then there should be no problem charging for phone calls or email.

Some things are just part of operating a business.

tishrei~

Michael Kirsch, M.D. said...

Tishrei, you have expressed your points clearly. I have never charged for a patient and agree, that the public has an expectation that this is a free service, or somehow bundled into prior office charges. Keep in mind that physicians handle several dozen calls per week, many during evenings and weekends. Many of these latter calls are from patients we have not previouly seen, so these are, in essence, completely free. While we are not reiumbursed, we still are completely liable for the medical advice that we render. As insurance company and Medicare reimbursements continues to decline, and our expenses rise, physicians may need to consider phone calls and e-mails as revenue sources. Or, as you suggest, we may need to devise a new compensation structure. With respect to your point of not wanting a patient to avoid making a phone call because of cost, the fee would likely be modest. Physicians are paid for our medical knowledge. I think one can easily argue that providing this knowledge on the phone should be compensable.

Anonymous said...

I will share a personal example. Many years ago, I was given a prescription for something related to the stomach flu (nausea). After about a day or so, I had a weird twitch, then another and another. My hand flipped up and I hit myself in the face with my spoon. I called the doctor when it the twitching would not stop. He advised me to go to the ER and he would meet me there. Before I was able to get to the ER as I had to call someone to take me, I lost control of my tongue and it would block my air passage. I was having a reaction to the medication.

When he told me to go to the emergency room, I thought he was overreacting so I took my time in finding someone to take me. If I had waited until I was sure it was serious, my body was already doing weird twitching and I may not have been capable of making the phone call. I did not realize the seriousness until I couldn't control my tongue. When that happened, I was in full panic.

I don't know why people call doctors when they don't have some sort of patient/doctor relationship and expect medical advice. But let me share this and I hope you don't mind but while medically related, it has to do with vets. I have more experience with vets than human doctors :)

Vets provide a medical service and bill as such. My bird recently broke her leg. I paid for an office visit, x-ray, setting of her leg, cast, surgery, meds (oy to the cost). I had to bring her in weekly to be checked which I paid for each time. Birds chew on things and she chewed her cast. I paid for each time the vet fixed her cast as well as the office charge. These were charges that I expected to pay.

This is where I differ with you. About two weeks into this, I noticed one of her talons was turning dark. I called the vet. He said it was okay to wait till the next appointment. I had already developed a relationship. He was aware of the bird's injury and had noticed that there may be an issue and was watching it so he was able to advise me to wait. Turns out she needed to have the toe amputated. It was reasonable that I pay for that. If he charged me for that one phone call, I would have finished up the bird’s treatment with him but looked for another vet for the future. The bill was a good chunk of change but he provided good care. He took the time necessary. If he only charged me $1 for the phone call, I would have looked for another vet. A mere extra dollar in that $1,000 bill would have sent me looking for another vet.

If I called a vet that I found in the phone book and asked about the dark toe, he/she could not give me good advice without seeing the bird. At most they could advise is the need to see the bird so they can evaluate her.

I think it's a dangerous road to go down and charge for phone calls or emails. I probably would have waited to call my doctor when I had my experience until I was sure it was serious. I can only speak for myself but I don’t know when I have ever called to speak to a doctor directly (maybe a total of 1-2 times in my whole life if that) and that one time I mentioned above is the ONLY time I called off-hours. I am paying for expertise. I also pay for expertise when I take my car in (I'm not comparing you to a mechanic) but I know as much about medicine as I know about cars. I imagine a good policy would be to not to offer medical advice to patients you have not seen in which you would not be offering free medical expertise. They either come to see you so you can offer advice/treatment and be paid or advise to seek emergency/urgent care if they feel they cannot wait to be seen.

Interesting topic!

~tishrei~

Anonymous said...

When you say "For lawyers and other professionals, phone calls are fair game," to whom are you referring? Professional phone sex associates? I know of no other respectable profession, aside from law, that charges people by the minute for merely have a phone discussion. It seems to me that emails are quicker than phone calls, and yet you complain about how much time you spend on the phone with those awful patients. Perhaps you would be less burdened if you allowed these awful people to email you with their questions instead. Maybe you'd even get greater patient satisfaction, since they wouldn't have to play phone tag with you and your staff for 2 days straight just to have a 2 minute conversation with you. Just a thought.

Michael Kirsch, M.D. said...

Thanks for your comment. Like all physicians, I spend a lot of time with patients on the phone each day. This is free care. For the most part, I am happy enough to do it, but will not have an 'office visit on the phone'. I was drawing the contrast that attorneys bill for their phone time in 6 minute intervals. E-mailing patients is definitely worth pursuing, but their are medical, financial and confideniality aspects that would need to be addressed.

Gina M said...

Email would also mean not having to describe/discuss one's (possibly embarrassing, certainly private) medical issues while at work in an open cubicle or standing in the grocery checkout line or carpooling the JV football team or wherever one happens to be when the callback from the doctor's office comes. Yes, I've been in that situation numerous times, and sadly no, I've never had the option of email with any medical provider. It's like the last quarter of the 20th century never happened.

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