Issue 5 / 13 February 2012

THE face-to-face consultation has always been at the heart of quality medical treatment. Despite all the wonders of new technology and the much-touted benefits of telemedicine it’s hard to see that changing radically.

Email, stripped of many of the usual cues we use to interpret what other people say, can be misleading, confusing and more likely to give offence.

But then, you could say all those things about the telephone, and there wouldn’t be many doctors who would have a blanket ban on using that piece of technology to communicate with patients.

Medicine is often said to be more resistant than other professions to new communications technology.

In a recent Wall Street Journal debate on the issue, Boston dermatologist and telemedicine expert Dr Joseph Kvedar criticised fellow clinicians for lagging behind the times: “Talk about being behind the curve: Health-care professionals are among the last, if not the last, service providers to not use email to communicate with the people they serve. And it’s the patients who pay the price, because email communication could help improve the quality of care they receive.”

Dr Kvedar believes email helps him build better relationships with patients and to deliver clear, written information about medication and treatment plans.

Concerns about privacy and liability can be addressed without too much difficulty, he says.

Not everybody agrees. Florida physician Dr Sam Bierstock argued that online communication between doctors and patients should be limited to the most basic interactions, such as appointment scheduling and prescription repeats.

Dr Bierstock could hardly be described as anti-technology (he runs an IT consulting group), but believes online consults deprive doctors of important signals about the patient: “body language, facial expressions and other silent forms of communication that allow doctors to assess patient reactions to information about their health … and the accuracy of their responses to questions”.

Both doctors make good points, but instead of asking whether email can do the same job as a face-to-face consultation — it can’t — we should perhaps be investigating the contributions such technologies might make to a total package of care.

There has been surprisingly little research in this area and, in Australia, most of it has focused on using various types of telemedicine to improve access to specialist services in the bush (this 2011 paper, for example).

An important issue, of course, but we shouldn’t limit the discussion.

It may not suit every patient, but doctors and professional groups need to come up with smart strategies for harnessing the power of electronic communication, while also managing the risks.

The Medical Board of Australia released guidelines last month, but they really don’t go much beyond saying that the normal standards of good medical practice need to apply to online consultations.

Florida internal medicine physician Dr Robert Sadaty has come up with a few more specific suggestions (though, interestingly, he stopped using email to communicate with patients after trying it out for a couple of years).

One of his ideas is that emails in either direction should be limited to a maximum of 140 characters (the length of a Twitter message), on the basis that anything that can’t be adequately explained in that space requires an appointment at the surgery.

Clearly, there are all sorts of technological, ethical and remuneration-related issues to be resolved before email becomes a standard part of every doctor’s armoury.

But, as I wait for my own doctor to ring with the results of some tests, I can’t help thinking that sending an email instead would save her time and provide the information to me in a clearer, more durable form.

Jane McCredie is a Sydney-based science and medicine writer.

Posted 13 February 2012

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4 thoughts on “Jane McCredie: Facing up to email

  1. daman langguth says:

    I have patients that see me for complex disease living as far away as Dubai, some in Papua New Guinea and many from Moree to the Torres Strait that can’t just drop in to Brisbane.
    I use email to follow up treatment plan, but also so patients can ask simple questions or even important ones, and I can triage or ask them to see their GP.
    I think this enhances my care for patients who are remote, but also allows me to function in my rooms with lots of complex patients (immunology) all over the state.

  2. Gary says:

    Hi, I comment as a health consumer and physiology researcher. I offer support for the comments of Dr Kvedar within the article as he relates how email helps him build better relationships with patients and to deliver clear, written information about medication and treatment plans. The previous commenter, Daman Iangguth supports this too.
    I ask readers to take the reference to email, a lot further. Identify the changes digital capacity has given physicians, the health system, and patients. Integrate the email communication as part of enhancing digital profiles about patient health. Accept that today there is potential for patients to enhance the discussion about their well being by facilitating a diary and recording BP readings that are now quite possible at home. Importantly too, it is opportunity for all to see the symptoms associated with failing health, as they are recorded. Potentially far more accurate and sooner than memory and consultation can provide. That will strengthen existing communications and help improve the quality of care provided and received. It will simultaneously generate greater confidence in what is possible.

  3. Michael King says:

    It’s interesting that the main proponent mentioned in the article is a dermatologist. I can’t help but feel that my practice, as an emergency physician, has challenges of communication that are quite different from those of Dr Kvedar’s, and email would have a limited role in my setting.

  4. Bill Pring says:

    I think it is useful to occasionally use email communication clinically, especially if patients are distant. I don’t think it gives as much emotional feedback as the telephone, and is therefore limited for me as a psychiatrist. The obvious other problem is getting paid for clinical time spent on email. I am sure lawyers would charge for time considering email communication, where doctors generally don’t. Unless you charged, patients would sensibly increase their email communication, rather than coming to see you. Maybe doctors could do this by establishing a boutique email subscription service, where the cost of email communication exceeded face to face costs; but short communications might still be useful, and not cost the patient too much.

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