“you’ve got mail!”: the role of e-mail in clinical breast surgical practice
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The Breast (2006) 15, 713–717
THE BREAST
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ORIGINAL ARTICLE
‘‘You’ve got mail!’’: The role of e-mail in clinicalbreast surgical practice
Amber A. Guth�, Thomas Diflo
Department of Surgery, Division of Surgical Oncology, New York University School of Medicine,New York City, NY, USA
Received 8 February 2006; received in revised form 17 February 2006; accepted 18 February 2006
KEYWORDSPatientcommunication;E-mail;Internet;Breast disease
ee front matter & 2006reast.2006.02.004
ng author. Breast & SurTel.: +1 212 731 5347;
ess: [email protected]
Summary Easy Internet access is changing the practice of medicine in the US. Atleast 137 million Americans have access to the World Wide Web, and up to one-halfwould like to communicate with their physicians by e-mail.
The membership of the American Society of Breast Surgeons was surveyed toevaluate the current role of e-mail in patient–doctor relationships. Due to theextensive discussions often involved in the evaluation of breast disease, and theelective nature of most surgical procedures, this specialty may be particularly well-suited to using e-mail communication as an extension of discussions duringtraditional office visits.
A questionnaire was e-mailed to all members of the ASBS who had provided ane-mail address. About 1236 questionnaires were sent, and 285 surgeons responded, a23% response rate. About 130 (46%) responders were female; 209 responders (73%)did not use e-mail to communicate with patients (76% of responding females, 70% ofmales).
The oldest and youngest surgeons were least likely to use e-mail to communicatewith patients. There was no gender-related difference in e-mail use. There was nodifference in e-mail use between surgeons who limit their practice to breast diseaseand those who do not. Urban and university-based surgeons were more likely to usee-mail.
Medical-legal liability concerns and confidentiality issues were the most commonreasons for not using e-mail. Among those surgeons who did use e-mail, ability toanswer at one’s own discretion, and the ability to provide an organized responsewere the major reasons for using e-mail. Overall, the membership expressed apreference for personal interaction over electronic communication.& 2006 Elsevier Ltd. All rights reserved.
Elsevier Ltd. All rights reserved.
gical Oncology Associates, NYU Clinical Cancer Center, 160 East 34th Street, 4th floor, New York,fax: +1 212 731 5574.yu.edu (A.A. Guth).
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A.A. Guth, T. Diflo714
Introduction
Easy Internet access to medical information israpidly changing the face of American medicine.More than 137 million Americans now use theInternet, and according to a recent Harris poll, upto one-half of Internet users would like to commu-nicate with their doctor on-line.1
However, e-mail communication between patientand physician remains the exception rather thanthe norm. Lacher et al.2 reported in 2000 that lessthan 7% of internists utilized e-mail communicationwith their patients. By 2003, it was estimated that10–12% of physicians were using e-mail with theirpatients.3 In a survey of pediatricians, 79% ofrespondents did not want to use electronic com-munication for the discussion of medical issues.4
In 2004, Hussain et al. published their survey ofattitudes toward e-mail communication amonginternal medicine and pediatric housestaff andfaculty, and their patients.5 They found that one-third of the faculty used e-mail with their patients,and only one of the other 36 responding physiciansexpressed interest in using e-mail in the future.
The reasons for physician reluctance to usee-mail communication with their patients includeconfidentiality issues and lack of reimbursement.However, as emphasized by Spielberg,6 e-mail maybe an easier way for patients to raise sensitiveissues, which they may find difficult to discuss inperson, and may be an attractive alternative to theoften unsuccessful attempts to reach a physiciandirectly by telephone.
Due to the elective nature of most breast surgicalprocedures, there are often multiple one-on-onediscussions between patient and surgeon. Withthe idea that this surgical specialty in particularlends itself readily to the use of electroniccommunication, the membership of the AmericanSociety of Breast Surgeons was surveyed to identifyhow frequently the Society’s members use e-mailto communicate with their patients, and thereasons for using, or not using, electronic commu-nication.
Materials and methods
With the approval of the Board of Directors, themembership of the American Society of BreastSurgeons was polled. A questionnaire was e-mailedto all members who had provided an e-mail addressto the Society (Table 1). The responses were de-identified, tabulated on an Excel spread sheet, andanalyzed using the Student’s t-test.
Results
A total of 1236 questionnaires were sent and 285surgeons replied, a response rate of 23%. Onehundred and fifty-five (54%) of responders weremale. Two hundred and nine responders (73%), didnot use e-mail to communicate with their patients;76% of females and 70% males did not usee-mail(P ¼ n.s.). The reasons for this are summar-ized in Table 2. The minority of responders usede-mail, and their responses are tabulated in Table 3.
A significant difference in e-mail use was foundamong the different age groups (Table 4), with theoldest and youngest surgeons least likely to usee-mail to communicate with their patients(Po0:001). There was not a statistically significantdifference in e-mail use between surgeons wholimit their practice to breast disease, and thosewho do not. Urban surgeons were more likely to usee-mail than their suburban or rural counterparts(Po0:025). University-based surgeons used e-mailmore frequently than community- or hospital-basedsurgeons (Po0:001).
Discussion
In 1998, Spielberg6 was among the first to discussthe evolving role of e-mail in the patient–physicianrelationship, and she identified many of thecontroversies surrounding its use, including con-fidentiality, authenticity of authorship, patientconsent, and the role of e-mail in the permanentrecord. She also discussed the concern amongphysicians of a possible depersonalization of thepatient–physician relationship.
More recently, Delbanco and Sands7 discussedissues raised by the use of e-mail in clinicalpractice. Potential problems include the securityof conventional e-mail, lack of reimbursement fortime and effort spent by the physician, and thepossibility that urgent messages may not beanswered in a timely fashion. Some advantagesof electronic communication include time forpatients to formulate questions and physicians toprepare answers, and that unlike telephone con-versations, e-mail is self-documenting. Their con-clusion was that ‘‘electronic communication willmove medicine inexorably toward transparency,enabling doctors and physicians to share know-ledge, responsibility, and decision making moreequally’’.
While the articles discussed above demonstratedthat the majority of physicians did not use e-mail,this may be changing. A recent front page article in
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Table 1 Survey contents.
1. Do you use e-mail to communicate with your patients?& Yes & No
2. If you answered no to question 1, why not? Check all that apply.& Do not check my e-mail consistently.& Concern regarding confidentiality of e-mail messages.& Concern about medical–legal liability issues.& Lack of reimbursement for time spent.& Concern about liability from delayed response to an urgent e-mail.& Concern that documentation of these messages may not be reliably transferred to the permanent medical
record.& Concern that others may have access to these e-mails, or that someone other than the patient may present as
the patient. Unlike a telephone conversation, I may not be able to tell when someone is falsely presentingthemselves as a patient.
3. If you do use e-mail communication, why?& Ability to respond to a message at your discretion, rather than the immediate response to a telephone call.& Ability to provide an organized response to a patient query.& Ability to provide links to related web-sites.& The actual conversation is documented for the medical record.
4. Your age& 30–40 & 40–50 & 50–60 & 60+
5. Your sex& Male & Female
6. Type of practice& Community & Academic & Hospital
based
7. Limited to breast surgery& Yes & No
8. Location& City & Suburban & Rural
Table 2 Reasons for not using e-mail commu-nication with patients (n ¼ 209).
Reason n(% responders)
Medical-legal liability concerns 163(78)Confidentiality 154(74)Potential liability for delayedresponses
131(63)
Concerns regarding unauthorizedaccess to e-mail messages
131(63)
Concerns regardingdocumentation in medical record
119(57)
Lack of reimbursement for timespent
100(48)
Do not routinely check e-mail 61(29)
Table 3 Reasons for using e-mail communicationwith patients (n ¼ 76).
Reason % responders
Can respond at discretion 69(91)Allows for organized response 55(72)Self-documenting 30(40)Simultaneous links to othersites on Internet
27(36)
aCurrent Procedural Terminology (CPT) codes describe medicalservices provided by physicians and other health-care providers.These were originally developed in the US to assist in Medicarereimbursements to physicians, and are now used by many privateinsurance carriers as well.
E-mail and surgical practice 715
the New York Times examined e-mail use byphysicians, and concluded that the increasinglyfrequent reimbursement for e-mail use will quicklywiden its use.8 There is now a CPT code (0074) for
online E/M services, when these interactionsconcern a new issue for the patient.a
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Table 4 Surgeon e-mail use by age.
Age(years) 30–40 40–50 50–60 60+
Use e-mail 5(10%) 38(33%) 31(34%) 2(7%)No.(% for age)Do not use e-mail 47(90%) 76(67%) 59(66%) 28(93%)No.(% for age)
Table 5 Features of e-mail communication.�
AsynchronousTerseLeaves a permanent recordInexpensiveEasy access
�Beredjiklian et al.10
A.A. Guth, T. Diflo716
Descriptions of the use of e-mail in surgicalpractice are beginning to appear.2,9-13 Beredjiklianet al. summarized the current status of e-mail inorthopedic practice,10 and highlighted what theyconsider the five most important features ofelectronic communication, and how it differs fromtelephone interactions (Table 5). Allert et al. haveaddressed e-mail communication use by plasticsurgeons.9,14 In their worldwide survey of plasticsurgeons, over 90% had access to the Internet, and85.5% used e-mail for professional matters. Theresponders’ greatest concern was of patient con-fidentiality when information is transferred acrossthe Web. Conversely, a recent poll of patientsundergoing breast reconstruction revealed that 80%felt it would be useful to communicate with theirsurgeons via e-mail.11 A recent survey of bariatricsurgery patients revealed that 89% used e-mail, and88% believed doctors should be available bye-mail.15
Kagan et al. have investigated the use of e-mailby clinicians, patients, and their families, duringthe care of head and neck cancer patients.12,13
While 96% of the head and neck surgeons usede-mail professionally, only 40% used it withpatients. Those not using e-mail cited privacy andliability concerns. One-third of patients expressedinterest in e-mailing their clinicians; however, only9.5% actually used e-mail communication, mostcommonly to request prescription refills and reportsymptoms. Almost one-third of the patients re-ported that they did not use e-mail since it had notbeen offered to them by their surgeons.
While a common physician concern is theinappropriate use of e-mail for urgent matters,
this may not pose a real problem. A population ofradiation oncology patients were sent a writtensurvey to assess their use of electronic mail andattitudes regarding physician–patient e-mail com-munication. While they favored e-mail for conve-nience, efficiency and timeliness about routinehealth matters, they did not favor its use for urgentmatters.16
As the interaction between breast surgeon andpatient is rarely urgent, e-mail would appear to bea useful adjunct for handling patient inquiries andconcerns. However, our data indicates that breastsurgeons perceive a number of drawbacks to theuse of e-mail, and the overwhelming majorityprefer not to use it. Only 27% of the respondersuse e-mail to communicate with their patients(Tables 2 and 3). Gender did not predict e-mail use:24% of females and 30% of males used e-mail.
At odds with the New York Times article, lack ofreimbursement was not the major deterrent toe-mail use. Less than one-half of the respondentscited lack of reimbursement as a reason for notusing e-mail (Table 2). Potential medical–legalramifications and issues of confidentiality were ofgreater concern to the surgeons. Liability risk is areal concern, and no case law for guidance exists.17
Possible scenarios include charges of on-line mal-practice, HIPAA privacy violations, and failure toauthenticate the users of e-mail.
Age was a factor in e-mail use, with the youngestand oldest surgeons least likely to utilize electroniccommunication (Po0:001). Based on their addi-tional comments, the younger surgeons (ages 30–40years old) were particularly concerned aboutdepersonalization of patient contact, preferringface-to-face discussions with their patients.
Geography determined e-mail use. Rural sur-geons did not use e-mail, citing widespread lack ofcomputer access or know-how among their pa-tients. Hussain et al.5 described similar results inlower socioeconomic level patients; only 30% hadever used e-mail, and none had used it tocommunicate with a physician. Both these popula-tions differ significantly from the US Census data,which details greater computer skills and readyaccess to the Internet in the general population.18
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The practice setting also influenced the use ofe-mail, with academic surgeons more likely to usee-mail than community- or hospital-based surgeons.
A shortcoming of this study was the responserate, a common issue in surveys of this sort. Clearly,the physicians who answered were interested in theissue, and willing to spend the time needed tocomplete and return the survey. However, themajority of even these technologically sophisti-cated surgeons did not use this communication toolwith their patients.
Conclusion
In summary, while the membership of the AmericanSociety of Breast Surgeons have ready access to theInternet, only 27% of those answering this surveyuse e-mail to communicate with patients. Themajor reasons for choosing not to use e-mail wereissues of confidentiality and medical–legal respon-sibility. The current lack of reimbursement for timespent was not a major deciding factor in e-mailusage. Overall, the membership expressed a pre-ference for personal interaction over electroniccommunication.
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