I saw that Cleveland Clinic will be charging for MyChart messages and I have to comment on this, because portal messaging has been one of the banes of my career - the other one being shitty EHRs all around. And it’s not the patient’s fault; healthcare companies advertise portal messaging as a perk to draw in more patients - I mean “customers”. It’s not the first time I’ve seen healthcare companies market something they can’t deliver.
Having worked in a big HMO and a small startup that both promote “free” and “unlimited” messaging, I can say, like most doctors and the rest of the clinical team, that I am sick and fed up with having my free time and medical expertise exploited by companies. When a company tells its “customers” that they have unlimited access to their doctor via messaging, it’s both a volunteering of their doctor’s time and a disrespect for their time. It breeds unrealistic patient expectations and entitlement, then disappointment, which comes back to bite the doctor in the form of patient complaints.
“But isn’t this part of what I pay you for?” Eh, not really. You pay the company (including the insurance company) directly, not the doctors. The doctors and other clinicians don’t get an extra penny whether they answer 5 emails or 500 emails, or whether they spent 1 minute or 1 hour to answer your questions.
It’s just a marketing tactic to get your business.
You’re lucky if your doctor even has time to see your message, let alone respond in a timely manner. Nothing is “free.” The real cost is your doctor’s personal time and health, and cost of your time and health if your portal message needs immediate attention but gets “lost” or passed around in the system.
Most companies generate revenue from doctor-patient face-to-face visits and now, thanks to the pandemic, also for telehealth. But answering clinical emails (portal messages) was never revenue generating, not until recent years when some insurances decided they would reimburse for it. The irony is that patient messaging wasn’t considered “direct patient care,” even though it is, so dedicated patient messaging time isn’t part of the clinic schedule. (The “admin time” most doctors get is laughable.)
So if you don’t hear directly from your doctor, it’s because it’s not actually on the doctor’s schedule to answer every single email.
Doctors (and I include all clinicians on this) don’t have much control over their schedule; they’re told how many patients they need to see and can only oblige if they want to keep their job. Imagine you’ve spent 10-12 hours every day meeting with 22-30 patients and finishing chart work, only to find a dozen or more emails requesting free personal medical advice or asking for something the doctor has never evaluated them for. It is literally a second clinic. Many of you have already read about how many hours it actually takes for a primary care doctor to do their job right? This is all part of it.
Answering medical emails is not as easy as it seems. Speaking personally, I still have to review your medical history before I even make a simple recommendation like “take ibuprofen” to make sure it’s safe for you (ie, do you have bad kidney function, heart conditions, history of ulcers or any bleeding issues, or drug interactions that I have to remember?) and then instruct exactly how to take it for your condition, or find an alternative. Just like with clinic, I have to practice “cover my ass” medicine every time with emails too. There’s no visual and auditory cues or immediate back-and forth-feedback, so it’s easy to miss things or misunderstand things on both ends.
Patients think doctors know the answer right away when they ask things like “I have a bad headache all week, what do I do?” Well… I need to know more, a lot more, and back-and-forth email isn’t the most efficient or safest way to properly assess you. (Maybe you’re an elderly person with mild dementia and forgot you fell and hit your head. I can’t examine you over messaging. How do I know that it’s not potentially a subdural hematoma or something worse?). Or “Hey doc, I think I have a UTI, can you give me antibiotics?” Well, I need to know all the symptoms before I agree with your self-diagnosis. Maybe I need a urine sample. Did you forget to mention you have flank pain that you mistook for muscle soreness from lifting? Or starting to feel feverish? That changes things.
Email is not the ideal place for clinical evaluation and diagnosis. Non-clinical people don’t understand the various nuances and permutations of medical evaluation, diagnosis, and treatment. We’re still liable for the medical advice we give in your portal. That’s why your doctor will probably respond with either “Schedule an appointment” (good luck with that), or “Go to urgent care,” or if there’s any whiff of a red flag symptom - “Go to the ED.” It’s also not uncommon for clinical questions to require research before giving a meaningful answer - again, professional time unpaid for. On the flip side, it’s not uncommon for doctors to give cursory answers or “canned” and templated responses because they’re crunched for time. After all, the medical system rewards efficiency, not thoroughness or thoughtfulness.
It takes, on average, an extra 20 hours of work each week to answer patient emails, review lab results, make any necessary calls, complete extra paperwork, refill medications, finish more complex charting — on top of a schedule packed with patients. Let’s assume you’re paid for 40 scheduled hours of work. Would you work 50% more hours for free every week? Let me know, because I’ll recommend you for medical school. Remember that most doctors are salaried, so their employers don’t care how many extra hours it takes to eat all tasks that fall onto their plate. They don’t care how much pajama time and weekends you spend tackling the inbox, or that you worked through lunch or dinner to catch up, or how many special moments with family and friends you missed because you’re overloaded with work. They gaslight and blame the doctors for overworking themselves in the dysfunctional system created by the company itself.
To add insult to injury, let me tell you about “Terrible Tuesdays”. Without naming any companies, my friends who eat kaiser rolls with permanent marker know what I’m talking about. Every two weeks, on Tuesday, the company scans your Epic inbasket. If a clinician has over 70 unaddressed items - anything between portal messages, refills, unreviewed labs, open charts, etc - they’re put on a “naughty list.” If they don’t correct the situation before the next Terrible Tuesday, they’re threatened with a 10% dock in pay. How fucked up is that? To give you some context, when I was in primary care, it wasn’t unusual to get 60 new items a day popping up in my inbasket.
So not only does your doctor NOT get adequate time to barrel through the daily compounding volume of the dreaded inbasket, they’re threatened with moral and financial punishment if they don’t sacrifice their personal time dealing with it. Strangely, I’ve heard there’s more incidences of calling in sick when Terrible Tuesday comes around. Hmm, can’t imagine why. I don’t know how many other companies use this practice, but corporate health can go fuck off with that.
Medical messaging is still cognitive work that requires medical expertise and should be treated as such. It’s not like processing a refund or checking on a shipping status. Sure, many messages that don’t require a doctor’s input get routed to or triaged by nurses, MAs, or coordinators to be answered. Don’t think for a minute they’re not overburdened either.
Portal messaging doesn’t solve the issue of limited access because it doesn’t solve the root of why there is such limited access.
Moreover, emails and even text messages are not good replacements for a face to face consultation. Too many opportunities for things to be missed or misconstrued. As a real example, I’ve seen messages routed to nurses who didn’t recognize atypical signs of a stroke (not their fault), brushed it off as anxiety, and never routed the messages to the doctor. Who is liable then? This could have been you.
Bottom line is, free range clinical messaging is just a form of corporate exploitation of its employees. It devalues your doctor’s time, their worth, and takes advantage of their professionalism. Then it affects their relationships and families. If messaging generates revenue, then maybe (a big MAYBE) it will have some priority on the clinic schedule, and not during your doctor’s dinner time. Even then, there’s no guarantee your message will be answered by who you expect. Keep in mind, it does not solve access issues and is not a good substitute for a real clinical conversation and evaluation.
And, I highly, HIGHLY doubt that charging for clinical messages is padding doctors’ pockets at places like Cleveland and UCSF. (I wish, because I could have paid off a chunk of my $349K med school debt with the countless hours given away over the years. More importantly, I will never get that time back.) But any revenue goes directly to the employer. Now that certain emails are billable, corporate health can try to reduce the flood of emails they created that’s drowning everyone. This flood could have been prevented to begin with, but what would a reactive healthcare system know about being proactive?
I have always thought providers are under compensated. Bill for everything possible. And let the patient know they will be billed for portal messages. I think the volume may become a bit more reasonable.
All 👏🏾 Of 👏🏾 This👏🏾👏🏾👏🏾!! :)