Not too long ago, the American healthcare system was still reliant on phones and fax machines; even as email and texting were widely adopted, medical offices lagged behind. But in recent years, the rise of patient portals—online, HIPAA-compliant platforms that allow patients to securely access records and communicate with their providers virtually—has transformed how the public interacts with their doctors.
However, patient portal messaging isn’t without problems. A growing body of research suggests that people from traditionally marginalized groups are less likely to receive responses from their providers. And now, a new study found that how a message is written can affect response rates, too.
“We found that writing style is strongly associated with care team response, in particular the likelihood of response from the messages’ originally intended recipient (i.e., the doctor),” says Mitchell Tang, lead study author and assistant professor of health policy and management at Columbia University’s Mailman School of Public Health. “Additionally, differences in writing style could explain around 50% of the previously identified gaps in care team response for patients from historically marginalized groups.”
So, what does this mean for you and your messages with your doctor? Ahead, experts break it down.
Meet the experts: Mitchell Tang, Ph.D., lead study author and assistant professor of health policy and management at Columbia University’s Mailman School of Public Health; A. Jay Holmgren, Ph.D., assistant professor in the Division of Clinical Informatics and Digital Transformation and director of the Center for Clinical Informatics and Improvement Research at UCSF; Ming Tai-Seale, Ph.D., professor at the UCSD School of Medicine and director of outcomes analysis and scholarship and director of research and learning in population health services at UC San Diego Health.
What did the study find?
The study, published in JAMA Network Open, sought to determine whether writing style or message content could partly account for the lowered response rate seen by patients from marginalized groups, which the researchers defined as “Black and Hispanic patients, Medicaid beneficiaries, and patients with lower educational attainment.”
Researchers analyzed electronic health records from over half a million patients, ultimately analyzing a random sample of 1 million portal message threads. Using natural language processing tools and other methods of computational analysis, they determined how content and writing style affected response rate, both from doctors and others—nurses, administrators, etc.—working under the doctor.
Ultimately, the researchers found that the way a message was written did affect response rate. For example, messages that began with a greeting directly addressing the doctor (e.g., Dear Dr. Smith) were 13% more likely to receive a response from the doctor than those that didn’t feature a greeting at all. Additionally, longer messages were more likely to receive a response, as were those with a positive sentiment, multiple question marks, or multiple exclamation points. Still, these differences in writing style only accounted for about half of the disparities in response rate seen by marginalized groups.
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“It begs the question of: What are things that seem to matter today, that shouldn’t matter in an ideal, equitable and efficient world. For example, should a salutation really affect the way messages get addressed?” Tang says. He thinks additional staff training and changes to the patient portal itself might help—say, for instance, by standardizing the message interface to remove stylistic aspects from the equation. “This might not just be more equitable but more efficient as well, enabling faster clinician response.”
A. Jay Holmgren, Ph.D., assistant professor in the Division of Clinical Informatics and Digital Transformation and director of the Center for Clinical Informatics and Improvement Research at UCSF, believes that to truly address this disparity, health systems would need to make structural changes.
“Clinicians are often facing an enormous workload of patient messages, and when they’re triaging that work, you’re relying on quick judgments, which is exactly the type of decision-making where bias can creep in,” Holmgren says. “These messages are often real care delivery that require clinical expertise, but they’re often not fully compensated, or compensated at all. Step one would be to recognize that asynchronous, message-based care is now core to clinical work, and to protect clinician time to do that work.”
How should you message your doctor, based on this data?
To maximize the likelihood of receiving a response from your doctor, Tang suggests the below strategies:
- Opening the message with a salutation directly addressing the doctor
- Using more expressive punctuation
- Writing a more positive sentiment message
- Writing a longer, perhaps more specific message
Ming Tai-Seale, Ph.D., professor at the UCSD School of Medicine and director of outcomes analysis and scholarship and director of research and learning in population health services at UC San Diego Health, believes AI may be a useful tool for patients struggling to best phrase their requests. She points to a study she coauthored that analyzed how the characteristics of patient portal messages affected physician burnout.
“Some patient messages were rather harshly worded,” Tai-Seale says. “Having another pair of eyes or AI to review them before sending them could potentially improve the quality of their experience.”
Of course, even the most perfectly written message may not receive a response. “My advice to anyone navigating the medical system is to follow up, advocate for yourself, and be persistent,” Holmgren says. “Most importantly, though, patients should remember that the portal is not for emergencies, and if you have an urgent issue or question, always call.”
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