So That’s Why Doctors Don’t Use E-Mail

I’ve known several doctors who refused to read e-mail from patients. They said it was simply a bad use of their time.

I also used to have a doctor who hated it whenever you came in and asked questions about some article you’d read in The Times about Lyme disease or some such. He’d get a pained look on his face — here we go again; patients pretending to be doctors — and then ignore the question.

But surely it’s in everyone’s best interest for patients to stay informed, right? For patients to do their own research, to ask lots of questions — especially of their own doctors — and so forth, right? Right?

Wrong. At least that’s what Hai Fang, Nolan H. Miller, John A. Rizzo, and Richard J. Zeckhauser write in a new working paper called “Demanding Customers: Consumerist Patients and Quality of Care.”

From the abstract:

Consumerism arises when patients acquire and use medical information from sources apart from their physicians, such as the Internet and direct-to-patient advertising.

Consumerism has been hailed as a means of improving quality. This need not be the result. Consumerist patients place additional demands on their doctors’ time, thus imposing a negative externality on other patients. … Data from a large national survey of physicians shows that high levels of consumerism are associated with lower perceived quality.


CW Thomas

Of course the doctors do not want you asking questions. My cousin had stomach pain, was dismissed twice by ER physicians, was found dead the next morning in her apartment. Cause of death was acute pancreatitis. Hospital was sued, and her kids are now heir to a 3.2 million settlement award. No amount of money can replace the loss of a loved one however, and doctors are people just like anyone else. Maybe if laws were changed to where instead of medical malpractice, the case was treated as medical neglect, an improvement in quality of care might be the result.

Steve (MD)

Fascinating discussion.

I work as a psychiatrist, although I've only been in the field for 3 years. What attracted me to the field (interesting patients, fascinating neuroscience, complex pharmacology) turns out to be irrelevant in modern psychiatric practice. The state of affairs now is to listen to a patient for 15 minutes, label it "depression," "mania," or "psychosis" and immediately prescribe an antidepressant, mood stabilizer, or antipsychotic, and maybe a sleeping med. It's terribly unsatisfying.

Now that the drug companies have realized that psychiatric diagnoses are so vague (and evaluations typically so superficial), they know they can make tons of money marketing these agents to primary care docs, whose evaluations are not that different from those of most psychiatrists, in my opinion.

As many comments have pointed out, consumerism in medicine can make patients more aware of the poor quality of their care. But when it starts to affect psychiatry, I fear-- or maybe I hope?-- that the emperor of the psychiatric profession will truly be seen to have no clothes.

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David

One assumption I see running through all these posts mystified as to why their doctor will not answer questions via email is that the requests are reasonable. 10% of the patients take up 90% of the time.

Additionally, every doctor recalls their second year of medical school when they took Pathology and learned about all the diseases that can occur. Medical students then became hypochondriacs, misinterpreting every symptom as the sign of a rare disease. Many patients who look up information on the internet fall into the same trap. A little bit of knowledge can be a dangerous thing.

Sandi Mays

Wow. I bet, deep down, these doctors all hate second opinions too.

Horrible.

Kyle

Michael,

You describe a situation in which doctors deal in cash. I agree that would be a good system, however that is not the one we have. Most patients have insurance and expect insurance to pay for their healthcare, and no insurance company reimburses for email. Please note that your lawyer and accountant are not paid for by insurance, but by you in cash and you pay by the hour. Doctors would be more than happy to work this way, but our hands are tied by the current system of healthcare funding.

Also, as much as I would love to say that it is possible to become a good doctor with hours that seem more reasonable, you have to remember that some fields really do need the amount of time that is currently used to gain the expertise and skill required. I am a neurosurgery resident, and working 88 hours a week for 7 years seems a lot less unreasonable when you realize what you will have to be able to do when your training is done. We love to say that residents shouldn't work 24 hour shifts, but we also demand that there be immediate high quality healthcare at all hours of the day. There is no easy answer to the tension that this creates.

Your suggestion that prescriptions should be abolished is rather naive. We already do allow many drugs to be available without a prescription, but most of the drugs that we prescribe would be very dangerous to let a population with minimal science background to self-prescribe. A very good example of the danger of removing controls on medications is for treatment of the flu. We already have too many people misusing antibiotics for respiratory illness that is viral in nature and this would be vastly increased if anyone with a cough could buy antibiotics. The result would be an acceleration in the development of resistance.

Finally, there is one difference between being a doctor and an engineer. Engineers have the luxury of being able to destroy what they build to see why it fails. Doctors obviously don't have that luxury and therefore work in a field with orders of magnitude more uncertainty.

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erik de koster, brussels

A major problem with internet-based information is the uneven quality of this information; a layperson has few landmarks to evaluate this quality. There is a lot of hype and self-promotion out there, not to mention some magical buzzwords (like 'laser' - everything using a laser is understood to be extraorinary). Blogs are a total mess, they are infected by hysterical and crazy people advocating the most idiotic theories and therapies. A second problem is that a lot of background is needed to completely understand quality information, which as a layperson one simply does not have. I sometimes tell my patients that in fact, during university medical studies, we just shut the door and start playing cards for 6 years; when they get the joke they start appreciating there is some reason for medical studies to be long and hard. All of this does not exclude that a patient may stumble upon good information which is important for his health, he just has no way of evaluating it.

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Chance

Well, the big complaint from doctors seems easy enough to fix.
A) provide a secure email system
B) Start charging for calls and emails.
C) Provide some liability protection.

The liability issue, can we have a lawyer comment on that? A few areas I've lived in have an "ask a nurse" phone number. They answer simple medical questions, but always state in the call that you need to visit your doctor to be safe. What has been the liability history for these services?

Margo Caulfield

Having spent years working in health care, particularly chronic conditions, the authors seemed to have missed the boat on understanding that it's their patient's life and they get to be the captain of the ship. Maybe they haven't fully grasped the idea that death isn't optional. The American public certainly hasn't.

Eighty percent, give or take, of us will live for many years with a condition that will ultimately take our lives. Becasue of this shift, our "treat and release" model of health care doesn't work. There are now national organization involved in chronic care. Among their guiding principles are- learn about your condition from a reliable resource (on-line look at the .orgs, .edus and .govs) and be responsible for the choices you make.

While many doctors advocate the chronic care model, few are happy when a patient questions a decision or would like to follow a different course. I work with many doctors that want anyone, other than themselves, to make decisions about care, particularly when it involves quality of life and life expectancy. Many of the docs I work with also prefer to get e-mails or snail mail from patients about their issues and concerns since the last visit. In that way, the doc says time in the office visit, and as we know, time is money.

Health care isn't just about the doctor/patient relationship. It's about health insurance premiums, who will pay for what, malpractice insurance, shorter allowed time for visits, lawyers, the desire for a pill to take care of the problem and the continuing idea that somehow we can avoid death. The latter still stuns me, but I've heard more discussions at funerals about how the doctor should have done x,y or z.

Get a grip here. Doc and patient alike we're all destined to be worm food so at least let's try to do this with some understanding and reasonableness.

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Michael Hoey

Considering this is in the Freakonomics section were missing the point -- Doctors are in an economic spot where they cant make money - and are annoying their customers - this will eventually lead to smarter people not wanting to enter the profession -- which in theory leads to worse care for all.

Where are the economic incentives and disincentives under your control?

One -- being a doctor is not that different than being an engineer -- yet for there is no 4 years at the best school you cant afford - pre engineering program. How about cutting to the chase and teaching how to be a doctor before 150k of schooling.

Then take a look at the multi year hazing ritual you call interning. I'm sure there is a lot to learn in medicine -- and you shouldn't be able to go from a 4 year school to starting a practice.

Please don't tell me that its the only way to make good doctors. BTW -- if any other profession had people working 24 hour shifts while dealing with life and death issues -- they would be sued out of existence. ( hmm thats happening isnt it? )

2. -- your model for charging is completely broken. I pay over 1K a month 'retainer' for my medical insurance and cant have an email conversation with you? -- My lawyer and accountant would gladly take my money. Even if its off insurance -- none of you offer for an extra 100 bucks per patient per month to take 1 hour a day and answer questions on email. How many patients have to take you up on this for it to make sense financially. And please don't say HIPPA makes it hard -- the rest of us do hard things every day to make money - if there was demand -- I or someone else will set up a HIPPA compliant secure email server for 5 bucks a month per patient -- thats
the free market where the rest of us make money.

3. Its been alluded to in some previous posts - the power of being able to write scripts. What would happen to a typical doctors practice if they lost that. What if that goes to the net like the rest of the economy. Think about it -- my kids get the flu, I need meds, and I can just go online and get what I need without having to take a day off of work to wait in a doctors office for a 5 minute visit with a known outcome. How many patients a day fit that profile. What would it do to your practice. Would it hurt your practice and make patients/customers happier? If so -- that wont last forever.

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David (MD)

The cost of physician training is so high in this country ($250,000 private undergrad, $280,000 private medical school) and then physicians train minimally for three years and sometimes much longer at near minimum wage rates (remember they train minimally for 80 hours per week) that few are going into primary care. First, public medical schools should greatly expand their medical school slots. As I recall, there are about 16,000 new medical students each year. A worthy goal would be that half those slots be run my public medical schools. Secondly, "pre-meds" should be encouraged to attend public universities instead of private schools.
Those primary care physicians that aren't working for HMOs for a salary should certainly be paid by the hour for their services as just as lawyers and plumbers in private practice are paid for their services.
Many large firms are self-insured and hire insurance firms to simply manage their health insurance plans. As such, they have control as to how the plans are administered. If you have a complaint against the insurance company it is probably something the your employer can rectify by changing their plan with the insurance company.

Another really important issue is that we have read much about "Moral Hazard" and that the taxpayer should not be subsidizing financial firms that practiced risky behavior. We have "Moral Hazard" in medical care and analogously firms and the taxpayer should not be subsidizing risky behavior such as cigarette smoking. Studies show that 12% of health care costs go towards cigarette smoking (which even contributes to Alzheimer's Disease) to the tune of $250 billion per year or $13/pack of cigarettes. The reason this is relevant is that one reason why people don't get enough face time with physicians is because of "cost-cutting" moves on the part of insurance companies and employers because of the high cost of health care. Much of the high cost of health care is because of people subsidizing the "Moral Hazard" of people deliberately risking their health.

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Surjit D.

My family physician graduated from the medical school about 30 years ago. But he is a big promoter of his patients using e-mails and communicating with him in this very efficient way. This certainly cuts down the need to go and see him in person. It is definitely true in my relationship with me. He strongly believes in the idea of informed patients. He encourages his patients to go the internet and get educated about their conditions and needs. For me, it is hard to believe that some physicians will actually be reluctant to encourage this mode of communication.

Ken Arromdee

My mother is a registered nurse, so she has some medical knowledge. She also probably has pulmonary hypertension. She's taking a drug (for another condition) that has been shown to sometimes have effectiveness against pulmonary hypertension.

Every time she goes to a physician she tries to explain that the drug is partly mitigating the symptoms and that a test will be useless unless this is taken into account. Without fail, the doctors ignore this information, give her the test, and pronounce she's normal. (Though her last test shows her pulmonary artery pressure is outside normal range even with the drug.)

How can she get a doctor to listen to her?

student

@51: I'm not sure of the differences between the NHS requirements and HIPAA, but family members, if they have been approved by the patient, are allowed to know what's going on with their loved one. Unfortunately there is a lot of misinformation out there regarding privacy laws in healthcare. Caregivers are not to be excluded because of privacy laws, although there are nurses, etc. out there who would refuse information such as "what drug are you administering to my comatose mother?" citing confidentiality. At least in the US.

Keith S

David - a lot of people expect computer shops to fix their problems for free.

People expect insurance companies and governments to be compassionate.

At parties, engineers are often asked about cracked foundation walls and which sort of TV to buy, accountants about tax problems, and auto mechanics about what is a good make of car. Police get asked about how to handle neighbours.

All professions face this issue of people wanting free help.

It is just that physicians make such a big deal about it you'd think they were the only ones.

Keith S

The problem of patients wanting a product because they saw it advertised on TV falls into the same category of problems as physicians prescribing because of drug company promotions.

Patients informed by the internet are a separate issue.

Patients properly informed of their disease by a .edu, .gov or physician-authored .com web site will know there are a variety of diagnosis that might fit their symptoms, and a variety of treatments that might work.

Keith S

Ask any auto mechanic. Your best customer is one who knows absolutely nothing about cars and has a fat wallet.

Most physicians just want to be able to process us quickly. The less time per patient, the more patients per day, the more money in the physician's wallet.

Informed patients get upset when the physician leaps to conclusions about their disease without asking the sort of questions or ordering the sort of tests that would be needed to exclude other diseases with similar symptoms.

That gets in the way of physicians making more money.

Informed patients are also more likely to complain or sue when a physicians jumping to conclusions leads to a misdiagnoses.

It is all bad for business.

pkut

Its funny reading all the response's from "intellectuals" who know just as much as physicians yet then proceeded to cite anecdotes as "proof", which is the most unscientific reasoning you could use. People seem to forget that MD's mostly play the odds. If you have abdominal pain, 95% of the time it's a viral enteritis. just because a physician didn't order the million dollar work up on your first visit doesn't mean the doctor screwed up. Just because it took three visits to diagnosis pancreatic cancer doesn't mean the physician is at fault or that you know just as much as someone who spent 7+ yrs of training beyond college because you spent 15 min's on the internet. If MD's had a similar preformance as all the whizz's on wallstreet or all the IT genuis's that gave us y2k we'd all die at 50

iratecat

I volunteer at the ER of a downtown teaching hospital. For every 5 minutes a doctor spends face-to-face with a patient, he spends 25 minutes charting, waiting for test results to come back from the lab, conferring with supervising attendings if they're residents, and writing orders. And this is in one of the very few hospitals (and the only teaching hospital, I believe) in the US with a fully computerized medical records system - I can't imagine how long it would take with a paper-based system. On friday nights (when I'm there), the beds are almost always full and so is the waiting room - not really the best environment for patients with armloads of questions.

doc in chicago

I recommend that everyone who feels like their doctor doesn't spend enough time with them stop their whining, buck up and pay the extra 1-3 thousand dollars to get a concierge service.

Although ostensibly for an "executive physical" what the retainer really buys you is an hour of your doctor's time whenever you need it, without waiting and with whatever other out of clinic contact you need. If you have complex needs with many specialists, it pays for your internist to coordinate your care and act as your medical advocate. (Work that when it is performed is almost completely un-reimbursed)

It buys the doctor the ability to cut his or her panel from 2000 to 200-300 and spend enough time with patients to really make a difference both in diagnosis and more importantly in education and primary prevention.

Before anyone cries about how $1000 a year is too much money, tell me how much your cable and cell phone bill add up to, then tell how they're much more important than your health. What's your car payment? If you're driving more than basic transportation is more important than your health?

Is everyone going to be able to afford this? Clearly not. But the current system in which the government essential dictates prices to doctors is not sustainable in the long term. The new generation of doctors isn't going to stand for it, in fact, they've voted with their feet and there is a huge shortage of primary care docs. The best students often choose lifestyle or high paying fields like derm or plastics.

What we'll probably end up with is a two tiered system of medical care, with free or traditional insurance clinics staffed with overworked foreign trained docs and NPs and PAs and then the concierge services with the better physicians. Once it becomes clear that you can pay off your loans, buy a house and send your kids to college on a primary physician's salary, more high quality students will enter the field and some of the supply constraints will ease.

I think Googling your symptoms will be useful for patients in both tiers. At the low end it might save your life, at the high end it will probably spark an interesting discussion and you might learn something new.

And if you really think you can do a better job self-diagnosing with Google then go for it. Look it up, then email that shady web-doc, who will not doubt agree and sell you whatever you want, shipped via FedEx from 'Canada' in a brown box. I am not responsible for your health, you are. All I can do is layout your options and give you what I think is the best advice. If you choose to go elsewhere for advice then that's your business. If it starts impinging on my business then all that training wasn't really worth it after all.

There's this rule in life, you get what you pay for. If you want better service from your doctor instead of whinging on a blog, try paying for it.

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D.H. Doelker

Would a "Doctor With Heart"(c) subscribe to using email to communicate with his/her patients? I am currently writing a book with the above title. I am the daughter of a father and uncle who were old time GPs. I invite any doctor to communicate with the NYT and me by e-mail, limiting their response to no more than 200 words, what it is that they do to communicate this to their patients. Personally, I have had 17 major surgeries in the past 20 years performed by doctors who practive in hospitals that have been deemed the best in Manhattan.

Personally, I can count on the fingers of two hand those who fall into this league. This is a sad statement for the medical profession.
Please communicate by email to the NYT author of this article why you should be considered for a place in the book. D.H. Doelker