STEAMBOAT SPRINGS, COLO. – When Dr. Michael Rich, a.k.a. "The Mediatrician," recently visited the University of Michigan, Ann Arbor, and met with a group who had won a grant to develop a protocol for teaching pediatric residents how to use e-mail with patients effectively, he had a simple word of advice: "Don’t."
"I said ‘Don’t do it’ because not only are there all kinds of problems with liability and not being able to read the situation well, but where’s the time going to come from? ... You can’t bill for e-mail with patients, you’re not doing an assessment. So why torture yourself by getting involved in all that?" said Dr. Rich, director of the Center on Media and Child Health at Children’s Hospital of Boston.
E-mail is several steps worse than the telephone as a tool for patient communication – and the telephone has plenty of shortcomings in its own right. "E-mail has lots and lots of problems. You don’t know what the assessment of the mom is. You can tell a lot more even on the telephone just from the tone of her voice. Think about the number of times you’ve gotten an e-mail from a friend, and you attributed a nuance to it that wasn’t there," Dr. Rich noted.
Dr. Steven M. Selbst
Regarding the telephone, another speaker, Dr. Steven M. Selbst, said that while pediatricians can’t manage a practice without giving advice over the phone, they need to understand there are inherent liability risks in doing so.
"A lot of taking a good history is guided by our physical exam, and obviously you can’t do a physical exam by telephone. Instructions given during telephone management are more likely to be misunderstood, and documentation for the medical record is difficult," observed Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.
His own policy is not to give advice by phone. However, if it’s a life-threatening emergency, such as a poisoning, he’ll take the phone call and tell the family to get straightaway to the hospital.
Dr. Charlotte M. Boney took issue with Dr. Rich regarding e-mail with patients. She makes extensive use of it, albeit within a narrowly defined scope.
"Those of us who take care of a lot of patients with diabetes can all remember the cumbersome phone calls where they provided their blood sugar data. Things got better when they started faxing me their blood sugars. Now, we have lots of patients who send us their blood sugars by e-mail. I think it does have a place in patient care. The families really want to use it, and it’s more convenient than fax," commented Dr. Boney, chief of pediatric endocrinology and metabolism at Brown University in Providence, R.I.
Dr. Michael Rich
Sure, Dr. Rich replied. "But these are patients you know and have trained well, and you’re asking for objective, measurable information," he pointed out.
As an example of how not to do e-mail, he mentioned that a physician he knows came back from a vacation and found a 5-day-old email from a patient expressing suicidality. The lesson? If you’re going to use e-mail with patients, there needs to be a built-in protocol for accessing and responding to e-mails in timely fashion from remote locations. There also should be an outgoing message stating when the physician won’t be able to respond.
Dr. Beth A. Vogt, a pediatric nephrologist at Case Western Reserve University in Cleveland, said she uses e-mail to manage her patients’ blood pressure.
"It’s an enormous time-saver compared to writing all the figures down. But I educate patients that they can’t e-mail a blood pressure of 180/110 mm Hg; that requires a phone call," she said.
Also, as a matter of hospital policy, Dr. Vogt had to get a signed parental consent authorizing e-mail communication with everyone in her office: her medical assistant, nurse, and secretary.
An audience show of hands indicated fewer than 10% now utilize e-mail as a means of communicating with their patients.
Dr. Rich and Dr. Selbst reported having no relevant financial conflicts.