E-mail Anonymous: A Physician’s Addiction

The following is an article by Fox Chase medical oncologist Daniel M. Geynisman, MD. The piece, published in the December 15, 2014 issue of the Journal of Clinical Oncology, discusses the pitfalls and positives of being a doctor in the age of e-mail.

emailThe next time you are sitting in Grand Rounds, standing in the cafeteria line, rounding with your team, or giving a talk, take a look at your colleagues. Chances are, they are staring at a screen, and many are probably checking e-mail. E-mail has changed how physicians communicate. Whether related to patient care, academic pursuits, or administrative tasks, our interactions are now frequently conducted electronically. This form of communication has a new pressure attached: who would not prefer to collaborate with someone who responds within minutes? The patient-based aspect of e-mail reinforces the importance of a prompt reply—patient care is paramount, and therefore, checking e-mail frequently feels like something that good doctors should do. Whether the shift from live dialogue to e-mail has led to improved communication, enhanced productivity, or—most importantly—improved patient outcomes is unknown. The true extent and impact of daily e-mail use by physicians has also not been formally quantified. However, my own e-mail usage can be formally qualified. I am an e-mailaholic.

Constant communication may have its benefits. Queries are answered more quickly, both by colleagues and patients (who may feel less intimidated getting in touch with their physician via e-mail), and perhaps projects and tasks are advanced a little faster. But e-mail also decreases spoken and face-to-face interactions, arguably eroding relationships. Questions answered by e-mail may result in misunderstandings that require many follow-up e-mails. This ongoing e-mailing leads to interruptions and multitasking: patient care, writing, reading, thinking, and generally being present in any given moment become fragmented.

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Daniel M. Geynisman, MD

What is the cost of this constant switching of thought and attention? Although no prospective and unequivocal studies exist, e-mail has been associated with stress and loss of control, and in an academic environment, users spent approximately 23% of their time on e-mail, checking it up to 36 times per hour. In older adults, multitasking led to significant working memory disruption. When e-mail was shut off for 13 knowledge workers, they tended to multitask less and exhibited longer task focus; stress was also lower without e-mail. Interestingly, some companies are now asking their employees to shut off e-mail for certain lengths of time during the day to increase productivity.

The gravitational pull of e-mail is strong and draws on the variable-interval reinforcement schedule concept—reward is unpredictable and e-mail becomes addictive. Furthermore, a recent study in default-mode processing (inward-directed thought) revealed that people not only do not seem to enjoy sitting quietly and thinking with no distractions, but that 43% (67% of men and 25% of women) self-administered electric shocks rather than simply sit for 15 minutes without anything to do (all of them previously said they would pay money to avoid such a shock). With e-mail always available and someone invariably reaching out, it becomes difficult not to constantly check for new messages. Feeling trapped in the jaws of e-mail, I decided to conduct an experiment. I was leaving for a week of vacation (during which time I would normally still check my e-mail) and decided to completely disconnect. I uninstalled e-mail from my phone, activated an “and will not be available by e-mail” out-of-office automatic reply with instructions for contacting a back-up clinician, and told coworkers that I would not be checking e-mail but that I would be available by phone in case of emergencies.

As with any addiction, I went through withdrawal. In the beginning I found myself frequently thinking about what I was missing. My thumb felt useless and although I knew that I could not check my inbox, I kept mindlessly waking my phone. The blank e-mail square on the phone was menacing—hiding something important, I was sure—and my anxiety swelled. I worried about project questions going unanswered and patient e-mails in limbo. My stomach felt slightly upset and I found myself constantly searching for something to do. In my darkest moment I even reached for my wife’s phone to check her e-mail, hoping perhaps to quiet my nerves. But as the days wore on, it became easier to forget and let go. I was able to focus more on the waves gently hitting the dock and the moat around my son’s sand castle. In the end, disconnecting turned out to be wonderful, refreshing, and, I now believe, helpful in avoiding the common symptoms of burnout that are seen among physicians.

On returning to work, a total of 184 new e-mails were awaiting me, admittedly much fewer than my more senior colleagues would have amassed in the same period, some of whom receive a similar number of e-mails daily. Most were junk. It took me 1 hour to process the e-mails and whittle the list down to 39 that required action or a thoughtful reply. It took me about a week to truly get through these e-mails and answer them or appropriately address the questions they raised. About a quarter of the issues that were raised were completely resolved by the time I read the e-mails. No projects stalled, no patients experienced adverse outcomes as a result of my silence, and no urgent questions went unanswered.

The experiment taught me a number of lessons. Very rarely, if ever, is there such a thing as an emergency e-mail that involves a life-or-death matter or a project that may be critically affected by my failure to answer that e-mail immediately, and for those rare situations I have a phone number, pager, and covering colleagues. Checking and responding to e-mail in batches is most effective and time saving; many e-mail queries are even resolved without one’s intervention in a matter of hours. Managing the expectations of others is important. Once your coworkers and patients realize that they will not be receiving an answer from you instantaneously, they will adjust. Finally, answering e-mails is rarely equivalent to true productivity or communication.

Since returning from my vacation, I have worked to strike a new balance with e-mail and to modify my behavior. At first I tried to check my e-mail only several times a day, setting aside time akin to physician’s calling hours, but this proved to be too difficult. Still, I have found that the simple act of closing my e-mail browser at work has helped me to be more conscious of the decision to check e-mail, preventing unwanted interruptions and improving focus. I have not reinstalled e-mail on my phone. This has been easy to get used to, and it is the change that has made the most difference in my ability to be present in the nonwork-related parts of my life.

With further introspection, I have realized that my obsessive e-mail checking was in part about fears of failure, falling behind, missing out, and not being my best. It was also taking a path of least resistance: checking e-mail is easier than finishing a note or writing a paper. As a result I lost precious time, ability to focus, and probably creativity. Undoubtedly, e-mail is a powerful tool, and it has in some ways improved our lives. However, managing our e-mail rather than vice versa is up to us.