E-mail Access and Improved Communication Between Patient and Surgeon

Objective  To examine the effectiveness of e-mail communication between surgeon and patient prior to elective surgery.

Design  Prospective randomized study.

Setting  Tertiary referral center.

Patients  One hundred consecutive patients presenting for consultation prior to undergoing thyroid or parathyroid surgery.

Intervention  All were randomized to either receiving an information sheet promoting e-mail communication as the preferred method of communication (group E) or a standard information sheet (group S).

Main Outcome Measures  (1) Use of communication with the surgeon outside of the booked preoperative and postoperative consultation and (2) satisfaction questionnaire.

Results  Overall, 26 of 100 patients (26%) initiated additional perioperative communication with the surgeon, 19 of 50 (38%) in group E and 7 of 50 (14%) in group S (P < .001). Of those who initiated communication, 22 of 26 (84%) did so by e-mail; 3 (12%), by fax; and 1 (4%), by telephone. For patients using e-mail, 18 of 22 (81%) were in group E and 4 of 22 (18%), in group S (P < .02). Overall, 34 e-mails were sent by 22 patients in the study group. Most e-mails sent focused on only 1 issue; however, some patients raised multiple issues, with the most being 4 issues in a single e-mail. There were no differences in any of the outcome measures in relation to patient satisfaction with communication.

Conclusion  Despite concerns about potential medicolegal issues and other disadvantages, providing patients undergoing elective surgery with e-mail access to their surgeon results in improved levels of communication without any demonstrated impairment of satisfaction with outcomes.

The fundamental basis of the physician-patient relationship has always been face-to-face communication. However, advances in communications technology have, from time to time, challenged that assumption. E-mail is a technology that has transformed general communication worldwide, revolutionizing industries such as banking and retail. However, e-mail's promise for improving the delivery of health care remains largely untapped¹ and little has been published about its effect on physician-patient relationships other than dire warnings about the potential minefield of legal disasters and litigation that might accompany its use. More original research is needed to assess the impact of health information technology in relation to the delivery of high-quality, safe, and efficient care, including the role of e-mail.^1-3 We have previously demonstrated, in a retrospective study, that making e-mail access available to patients after their initial preoperative consultation significantly increased the level of patient communication without any detectable downside.⁴

The aim of this study was to determine, in a prospective randomized setting, the effectiveness of e-mail in a perioperative setting and to determine whether there were either risks or benefits with respect to improved communication or measured satisfaction outcomes.

This was a prospective randomized study. The study group comprised 100 patients of working age (18-65 years) referred to a single surgeon for thyroid or parathyroid surgery. All patients attending consultation were initially randomized, with those older than the age limits being subsequently excluded (since the potential for access to the Internet at work as well as at home was required). Fifty patients were thus randomized to the group where e-mail communication was made readily available (group E) and 50, to the standard communication group (group S). The patients studied composed a homogeneous group: all were undergoing elective surgery, all were referred having been previously assessed by a consultant endocrinologist as needing a surgical procedure, all required solely a thyroid or parathyroid operation, and all patients were seen in consultation by the same surgeon. All received a standardized approach to information including a detailed discussion of the indications, risks, and complications of thyroid or parathyroid surgery; a hand-drawn diagram detailing the proposed surgical procedure; and a copy of the Royal Australasian College of Surgeons brochure entitled “Patient Guide on Surgery of the Thyroid Gland and Parathyroid Glands.”⁵ All patients were given ample time to ask questions and were then provided with a typed sheet entitled “If You Have Further Questions About Your Operation,” which emphasized the need for them to have any outstanding issues or questions addressed or explained before the date of surgery. For the patients randomized to group E, the sheet then listed, in order, the surgeon's e-mail address, office telephone number, office fax number, and office mailing address, and the patients were informed by the surgeon that e-mail was the preferred mode of communication. For patients randomized to group S, the sheet was identical except that the e-mail address and statement about e-mail being the preferred mode of communication were not present. These patients still would have had access to the surgeon's e-mail address, which was available on the appointment card as well as on the Australian Endocrine Surgeons Web site, although attention was not specifically drawn to it.

Both groups were then assessed as follows: the numbers as well as the age and sex distribution of patients using any form of communication with the surgeon in the perioperative period outside of the routine booked preoperative and postoperative consultations; the method of communication used; the number of e-mails per patient when used; and the content of the e-mails. E-mail content was classified as follows: general information; risks and complications; reassurance; research participation; financial; postoperative recovery; feedback; social; compliments; and complaints. Information was also obtained about the origin of the e-mail (ie, from the patient or a relative).

Following the first postoperative consultation, a Patient Satisfaction Questionnaire was provided to all participants in the study with a reply-paid envelope for return on completion. This comprised a 10-point questionnaire seeking specific details in relation to computer and e-mail access, as well as 10 visual analog scales rating various aspects of the effectiveness of both preoperative and postoperative communication.

Data were analyzed using the Stata statistical software package (Version 7; StataCorp, College Station, Texas). Comparison of mean ages between groups was performed using the non-paired t test. Analysis of sex distribution between groups was performed using the Fisher exact test. The α for significance was set at P < .05. The study was approved by the Northern Sydney Central Coast Area Health Service Human Ethics Committee.

There were 50 patients in the group who received specific information about e-mail contact (group E, mean age, 45.1 years [range, 19-64 years]; sex distribution, 10 men and 40 women) and 50 patients in the control group who received only the standard preoperative information (group S, mean age, 48.2 years [range, 24-64 years]; sex distribution, 8 men and 42 women). There was no statistically significant difference between the 2 groups with respect to either age distribution or sex distribution (P = .18). Of the 100 patients, 3 did not proceed to surgery, 2 in group E and 1 in group S. In relation to analysis of data, use of e-mail was analyzed for the entire study population (n = 100); however, postoperative feedback was analyzed only for those undergoing surgery (n = 97).

In the overall group, 26 of 100 (26%) initiated additional communication with the surgeon. Of those, 19 of 50 (38%) were in group E and 7 of 50 (14%) were in group S (P < .001). Of those who initiated communication, 22 of 26 (84%) did so by e-mail, 3 (12%) used a fax, and 1 (4%) used the telephone. Not surprisingly, of those patients using e-mail, 18 of 22 (81%) were in group E and only 4 of 22 (18%) were in group S (P < .02). For the 22 patients who made e-mail contact, the mean age was 42.1 years (range, 19-64 years); 5 were male and 17 were female. For the 78 patients who did not make e-mail contact, the mean age was 47.9 years (range, 19-64 years); 13 were male and 65 were female. This difference was statistically significant (P = .04), with the e-mail users representing a younger group.

A total of 34 e-mails were sent by 22 patients in the overall study group. Of these patients, most sent 1 e-mail (n = 15 [68%]), with 1 patient sending 4 separate e-mails. Most e-mails sent focused on only 1 issue; however, some patients raised multiple issues, with the most being 4 issues in a single e-mail. A total therefore of 51 separate issues in 34 e-mails sent by 22 individuals required a response.

The distribution of issue content for all the e-mails in the study group is shown in Table 1. The most common reason for sending an e-mail was to obtain general clinical information (21 of 51 [41%]). There were 2 e-mails expressing a compliment and 1 complaint. An example of each type of e-mail is shown in Table 2.

Thirty-one of 34 e-mails were sent by the patient (91%); the remaining 3 were sent by family members (1 mother, 1 daughter, and 1 daughter-in-law) on behalf of the patient.

Of the 97 patients who proceeded to surgery, 74 returned a completed Patient Feedback Questionnaire, for an overall response rate of 76%. There was no difference between the 2 study groups (group E, 37 of 48 [77%] and group S, 37 of 49 [76%]). Table 3 summarizes the responses to the questionnaire in relation to access to the Internet. Table 4 summarizes the questionnaire responses to the visual analog scales in relation to patient satisfaction. Once again, there were no differences between the 2 groups with respect to any of the questions asked.

The fundamental basis of good medical care has always been considered to be face-to-face patient-physician interaction; however, each technological advance in communication has challenged that assumption. When the telephone was first coming into widespread use, it was regarded by many as the death knell for the physician-patient relationship, but few of us nowadays could survive in practice without a mobile telephone to assist with patient care. Interestingly, new communication technology has often been at the forefront of the provision of medical care. When Alexander Graham Bell invented the telephone on March 10, 1876, the first electronic transmission of speech consisted of the words: “Mr Watson, come here, I want you.” What is not generally appreciated is that the very first telephone call was also the first telephone call for medical assistance, for Bell had just upset the wet battery powering the transmitter, thus spilling sulfuric acid on his clothes and Watson was being summoned to administer first aid.⁶ Many current-day critics have also decried the use of computer-based technology as potentially interfering with physician-patient interaction. However, there are many positive examples of the use of such technology. Remote care using Internet technology and telemedicine significantly increases access to medical expertise,^7,8 while telerounding using robots to complement formal postoperative care has been shown to augment patient satisfaction.⁹ E-mail is another technology that has transformed general communication worldwide; however, almost all of the literature on e-mail communication published thus far has been on the theoretical level, such as discussing potential benefits and hazards.¹⁰

While some caution should accompany the use of any such form of communication, this study confirms that the appropriate use of e-mail can significantly enhance surgeon-patient interaction in the perioperative setting. Others have gone even further, with some authors claiming that its use “has the potential to reshape medicine and the patient-doctor relationship”^11(p24) or that it “is likely to induce cultural changes in the delivery of care even more revolutionary than managed care.”^12(p52) Car and Sheikh¹ summarized the potential advantages of e-mail as including convenience, access, information sharing, satisfaction, quality of care, and improved efficiency. Despite this, there is very little in the literature in relation to the use of e-mail for patient communication in a surgical setting. Certainly access by surgeons to e-mail is widespread, with 1 study showing that 85% of plastic surgeons used e-mail for professional communication, although its use in relation to patient interaction was limited.¹³ In the postoperative setting, e-mail communication was found to be more cost-effective than communication by either standard mail or telephone.¹⁴

Thyroid or parathyroid surgery, as used in this study, has proved an excellent setting in which to study e-mail communication, since it is almost entirely elective; there is a standard, uniform surgical insult with a highly predictable clinical course and a short period of hospitalization and disability, all patients are physically able to use the computer on postoperative day 1, most patients are young and healthy with normal cognitive function, and the time frame is very favorable for e-mail communication. Initial face-to-face consultation is followed by a 2- to 4-week window for potential e-mail communication and surgery is followed by another interval. The entire interaction spans 6 months or less in most cases. However, there may be some bias in our results, since most patients with thyroid or parathyroid disorders are female (80% of the patients in this study), and men and women use the Internet very differently, with women using e-mail more.¹⁵

Patients now have ready access to e-mail and the Internet. In this study, 81% of patients (86% in group E vs 76% in group S) had access to the Internet at home. Interestingly, the use of the Internet to find information about diseases has been increasing rapidly. An earlier Australian study demonstrated that the use of the Internet by patients prior to undergoing an elective surgical procedure was not as widespread as thought, with only 10% of patients using that source of information.¹⁶ In this study, 2 years later, that percentage had risen to 68% overall. Interestingly, both groups used the Internet equally to find information about their disease (70% in group E vs 67% in group S); however, it required encouragement and ready availability of the surgeon's e-mail address for the use of the Internet to translate into the use of e-mail to communicate with the surgeon (38% in group E vs 14% in group S).

In a recent retrospective study,⁴ we demonstrated that making e-mail access available to patients after their initial preoperative consultation significantly increased the level of patient communication without any detectable downside. This study now confirms that, in the setting of a prospective randomized controlled clinical trial, patients encouraged to use e-mail access have significantly increased the level of preoperation interaction, without any reduction in measured satisfaction outcomes. There are clearly major advantages associated with the use of e-mail as a means of communication between surgeon and patient. It avoids interruptions to office routine by avoiding the need to answer telephone calls from patients at all times of the day or having to engage in “phone tag” if calls are answered at the end of the day's work. E-mail responses can also be written undisturbed, with appropriate thought being given to the reply, ensuring that it is composed and accurate, something not readily achieved with a hurried telephone conversation. Copies of e-mails kept in the file provide clear and indisputable evidence of the responses provided, an invaluable resource should litigation ensue. Many of the responses in this study also demonstrated that many patients “open up” when using e-mail communication and often ask questions or raise personal issues that they may have felt inhibited about in a face-to-face consultation.

One major concern with the use of e-mail communication in this setting is that there are few guidelines in relation to the ethical and legal issues¹⁷ and there are clearly a number of important issues. Unsolicited e-mails should never be answered, as this may create unwittingly a patient-physician relationship, a potentially dangerous situation from the point of view of litigation. Urgent messages must never be sent by e-mail because the time of receipt of the e-mail information can never be guaranteed. Likewise, it is clearly inappropriate to tell patients bad news or important test results by e-mail. Car and Sheikh¹ list a number of other potential disadvantages of e-mail, including widening of social disparities, absence of subtle emotive cues, inability to examine the patient at the time, threats to patient privacy, and overwhelming of providers.

In this study, we have confined the use of e-mail communication to responding to patients who have already been seen in consultation by their surgeon and who have been specifically requested to use that source of information for asking questions or providing feedback. As such, this is patient-initiated, one-to-one communication, with an expectation of a response by the same medium. This avoids the many privacy and other issues governing the use of e-mail for communication between professionals or between institutions who may be passing on confidential patient data.

People who use e-mail certainly would like to have e-mail access to their physicians.² Despite the many concerns, we believe that this study shows that the provision to patients of readily available e-mail access to their surgeon provides a very effective means of improving communication prior to patients undergoing elective surgery.

Correspondence: Leigh Delbridge, MD, FRACS, Department of Endocrine and Oncology Surgery, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia 2065 (leighd@med.usyd.edu.au).

Accepted for Publication: December 13, 2006.

Author Contributions:Study concept and design: Stalberg, Ketteridge, and L. Delbridge. Acquisition of data: Stalberg, Yeh, Ketteridge, and L. Delbridge. Analysis and interpretation of data: Yeh, Ketteridge, H. Delbridge, and L. Delbridge. Drafting of the manuscript: Yeh, Ketteridge, and L. Delbridge. Critical revision of the manuscript for important intellectual content: Stalberg, Yeh, Ketteridge, H. Delbridge, and L. Delbridge. Statistical analysis: Stalberg and Yeh. Administrative, technical, and material support: Stalberg and H. Delbridge. Study supervision: Ketteridge and L. Delbridge.

Financial Disclosure: None reported.