With patients increasingly turning to the Internet for a “digital diagnosis” from one of the many “symptom-checker” programs available, is it any wonder that they would also choose electronic interactions with their physicians? One such diagnostic website works from a database of 6,000 diseases to help users identify their problems. Another lets users check waiting times and register in advance at the local emergency department, while yet a third allows physicians to conduct an online review of patients’ symptoms checks to determine if the patients actually need to be seen.


Published 11/1/2013
S. Terry Canale, MD

Email Office Visit: Third-Rate Romance, Low-Rent Rendezvous

Recently, I have read an increasing number of articles concerning physicians who communicate with patients by email about their medical conditions and treatments. The Wall Street Journal has reported that 33 percent of physicians exchanged emailed with patients in 2012, up from 27 percent 5 years earlier; the percentage who text with patients rose from 12 percent to 18 percent.

S. Terry Canale, MD

Why should patients waste time sitting in an actual doctor’s office when they can see a “digital doc” 24/7? Why should they bother with trying to call and navigate a frustrating telephone tree when they can shoot off an email at their convenience?

It should be pointed out at the very beginning that using email or other social media to notify patients of office visits, appointment times, and test schedules is very different from having an active dialogue with a patient via email or social media about a diagnosis or treatment plan. Only the latter is controversial.

We all get too many emails every day, including unnecessary answers to emails. I’m sure you know people who always let you know that they received your email by replying “I got it” or “Thanks,” sent not only to you but as a “reply to all.” So 400 others get “I got it,” and it becomes a ping-pong match. “I got it,” “I got it,” “OK, I got it!”

But I’m more concerned about the emails between a doctor and a patient that involve consultation, advice, and treatment recommendations. “Mrs. Jones, I’m not sure what’s wrong with you. Take two aspirins and email me again in the morning.” That says it all, doesn’t it? First, the physician doesn’t know what’s wrong with the patient because it’s difficult to make the diagnosis based on an e-history and e-physical. Nor can the doctor tell the severity and acuteness of the condition. Finally, using email in this way leaves the physician “hanging out to dry” concerning liability and malpractice.

It reminds me of the old country-and-western song written by Russell Smith in 1975, “Third-Rate Romance and Low-Rent Rendezvous.” This is a third-rate interaction, low-rent communication, and no patient-physician relationship. This is especially worrisome now because physicians are being challenged on their communication skills and personal interactions with patients. Moreover, email changes the doctor-patient relationship: The more emails that are exchanged, the less formal the relationship, and suddenly the patient becomes a “special best friend.” We’ve all treated that type of patient!

Even more worrisome in this low-rent rendezvous is the expectation of free treatment, delivered casually, that can possibly result in inferior outcomes.

What happens to confidentiality?
Confidentiality is a problem. We all know that most email is not secure. The news is full of horror stories about email leaks and hackers. How bad it really is, I’m not sure, but I am certain about one thing: There are some very specific protocols concerning the privacy of patients’ health records and specifically any email records related to diagnosis and treatment.

Under the Health Insurance Portability and Accountability Act (HIPAA), the privacy of healthcare information must be protected by using only encrypted and secure emails. Email providers have actually established “secure encrypted portals” for delivering information to patients and complying with HIPAA guidelines. This corresponds to provisions of the Affordable Care Act that allow and provide for better access to information for providers, hospitals, and patients themselves.

Confidentiality is important to patients, and they may not want the sensitive information in their medical records to go anywhere electronically, whether it is secured or not. I may not want anyone to know that I have “the gout” because I am an “over-indulger”!

Electronic companies are already making encrypted and secure portals available (at a cost), which may make the confidentiality question moot. But right now, it is hard to capture all of the facts—a little like “pushing Jello uphill.” I’m going to outline what I see as the pros and cons of email medicine so you, the readers of AAOS Now, can decide for yourself and let me know how you feel. Remember, this discussion is about emails other than those used as part of a process.


  1. Patients are able to be “engaged” quickly, easily, and with fewer aggravations than in a face-to-face office visit where they must contend with long waiting times, scheduling issues, and other hassles. The patient is what it is all about and the reason we are in business.
  2. Questions can be answered without long waits, playing phone “tag,” or going through a third party.
  3. Physicians can do a quick check on a patient’s status after surgery or an office procedure.
  4. Increased electronic communications nicely dovetail with electronic medical records, healthcare reform, and the Affordable Care Act.
  5. The physician’s popularity may increase (according to some) because the physician responds to patient emails.
  6. Email addresses can serve as a good marketing tool to grow a physician’s practice.


  1. Diagnosis and treatment are problematic when the physician relies only on email.
  2. Email isn’t the same as face-to-face communication and may result in the loss of a personal doctor-patient relationship.
  3. An impersonal email can’t convey the intensity, magnitude, or acuteness of the problem, resulting in potentially missed diagnosis and misinterpreted treatment. The physician can’t practice the “art” of medicine via email.
  4. If patient information is sent through an unsecured non-encrypted portal, the physician may be in violation of HIPAA rules.
  5. The physician is unable to establish a rapport with the patient and to charge for the time spent on email.
  6. The patient may misunderstand the email, and the physician may not know whether the email was received and acted on.
  7. It all adds up to increased liability for physicians.

Although many people believe that the possibilities for using email and the Internet in medicine are endless and that medicine actually lags behind other fields in the electronic arena, I have my doubts. A recent study on physician use of email confirms that we probably have a long way to go before this practice becomes routine. (See “Can You Read Me Now?”) Till then, I’ll keep humming that old country tune.

“Third-rate Romance and Low-Rent Rendezvous” was originally recorded in 1975 by the Amazing Rhythm Aces and enjoyed only moderate success, but became a big hit 20 years later when country-and-western star Sammy Kershaw recorded it.

To me, email medicine today is “third-rate romance and low-rent rendezvous”; in 20 years or less, I’m sure that it will be a big hit!

S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org