A PIECE OF MY MIND. You've Got Mail.
You've got mail. An alert pops up announcing a new message from the portal for my electronic medical record. Previous correspondence had been mundane, but this time I was surprised to receive the results of my recent colonoscopy. I am or, until that moment, had considered myself to be a healthy person, in surprisingly good condition considering my age and my distaste for exercise, so I was blindsided to receive the pathology report describing in cold clinical terms the abnormal histology of my tissue fragment. The biopsy results suggested an unexpected benign, but chronic, disease. My mind reeled, my self image collapsed, and suddenly I was alone on a sea of alarm and confusion. Later that day, I was able to speak to my gastroenterologist on the telephone. I expressed to him my surprise at the findings and my dismay at the way I had received the results. I asked whether this had been sent to me by email because I am a physician and thus presumably more capable of understanding the information (which, it turns out, was a false assumption) "Not at all," he replied. "It is mandatory that all patients receive biopsy results and lab values within 48 hours." "Wait," I replied. "Any abnormal biopsy or lab value? Directly to the patient? In an email?" This seemed implausible. "I could get an email that says I have breast cancer or my husband could get an email to learn he has prostate cancer or diabetes?" Sounding a bit defensive, he informed me that this is an institutional rule, not his personal decision: all patients must receive all laboratory results, including biopsy results, normal or abnormal, within 48 hours. The institutional imperative to convey results promptly is admirable, but not at the expense of leaving the patient with excessive, unmanaged anxiety, especially when the news is frightening, confusing, or ambiguous. I wondered how this played out with other patients. I soon found out. A friend who had been coughing for three weeks received the following email from her internist after a clinic visit: "Chest x ray report impression: 3.6 x 2.3 x 6.0 cm; left upper lobe mass. This may represent a focal pneumonia; however, at patient's age, a primary lung malignancy is highly concerning. Recommend CT chest with contrast for further evaluation." The report was accompanied by this personal note: "Miss McGilacutty [pseudonym] please be seen in the ER if not feeling better. Clearly it's pneumonia and suspicion of malignancy that requires CT chest and pulmonary consultation. Hope all goes well, good luck with everything!" Only a smiling face emoticon could have made this more inappropriate. The guidelines for physician patient electronic communication by the American College of Physicians suggest that when physicians communicate by email, they reduce unnecessary office visits and lower operating expenses, dramatically improving office productivity.1 The Wall Street Journal points to the increasing role of email in medical care and how it can enhance communication, increase patient engagement and satisfaction, improve quality of care, and boost efficiency.2 This is well and good in the aggregate, but bad news involves important issues beyond efficiency and productivity. The words from Francis Weld Peabody's famous essay, "The Care of the Patient," come to mind: " the secret of the care of the patient is in caring for the patient."3 Did the email that I received reflect caring or simply expediency? From the vulnerable perspective of a patient, I did not feel cared for or cared about. In fact, I felt less engaged, frustrated, and less satisfied, and I therefore changed my care to another physician. Of course, there is tremendous value in expediting communication. In fact, throughout my career, I had worried that with the increasing bureaucracy of a large and busy practice, I could be responsible personally for a delay in reporting an urgent finding. I thought that I would welcome a technological innovation that would safeguard me from this error. Although modern technology is uniquely suited to improve our communication, it does have significant shortcomings. It is not, for example, appropriate in circumstances in which communicating results requires human intervention touch, compassion, explanation, response to questions, and availability to formulate a plan. Abandoning the art and the necessity of sharing unwelcome news, even citing patient preference, physicians are convincing themselves that patients do indeed welcome these "innovations." Most published articles about physicians' use of emails focus on maintenance of patient confidentiality, physician liability for giving advice without seeing the patient, and billing for electronic communication. There is barely a word about the psychological impact or distress patients may experience on receiving an email with such news. A recent article, however, indicates that many patients do not wish to receive medical information by email. In a study at the University of California San Francisco by Choudhry and associates,4 dermatologists reported that less than 3% of their patients wished to receive biopsy results by email. Two thirds of the patients surveyed preferred a telephone call from their physician to convey biopsy results, and another 20% preferred to return to clinic for a face to face discussion of the results. The authors concluded by suggesting the addition of a question on the biopsy consent form to learn patient preferences regarding notification of results.4 This may be intended to obviate problems, but when most patients give permission to use email for communication, they do not consider unwelcome reports or envision the emotional impact of such news. Their desire for convenience may cloud their A PIECE OF MY MIND
JAMA