Editor’s Corner
Continued from page 14
A new trend in emails is to include “ACTION NEEDED” in
the subject line. While this all-caps imperative is eye-catching
and momentarily delays my reflex reach for the delete key, it
usually turns out that the ACTION that is NEEDED is not
mine.
When my institution’s new medical oncology department
chair, Benjamin Ebert, MD, PhD, started his role earlier this
year, one of his first acts was to consolidate many departmental
email blasts into a weekly omnibus newsletter. I had thought
highly of Ben before, but my esteem for him skyrocketed when
he took a swing at the email monster. That is the sort of leader-
ship we can all believe in!
Edward Creagan, MD, an oncologist in Minnesota who
focuses on time use and productivity, advocates opening email
only three times a day: late morning, early afternoon, late
afternoon. His advice is sound; I wish I could heed it. He’s right,
of course: When I lived in England, the most productive hours
were in the morning, mostly because America hadn’t woken up
and started sending emails yet. Now, if I don’t answer a patient-
scheduling query or request for lab-order clarification, I know
I’ll be paged in 15 minutes, and I can type almost as quickly
and more definitively than I talk – and I can copy more people
who NEED to take ACTION.
I also am one of those people who can’t help glancing at my
phone a dozen times in a dull conference. Part of that is due
to a mild case of attention deficit hyperactivity disorder, but I
also love the (admittedly artificial) purity of an empty inbox.
I sometimes glimpse screens of colleagues who have 8,352
unread emails, and I simply don’t know how they tolerate it. To
me, such messaging chaos would be like living in a “Dexter”
murder scene that hadn’t been tidied up after forensics finished.
Occasionally, opening email is highly rewarding. An email
from an old friend or a manuscript acceptance from a journal
triggers a brief microburst of happiness, a little flash of dopamine
deep in the medial forebrain. The variable-payout randomness
of joyful emails makes checking as addictive as pulling a slot
machine arm.
Contract research organizations (CROs) are the primary
source of another class of unpleasant email: the kind that makes
no sense, regardless of how many times you read it. In fact,
just as I started writing this essay, I received the cryptic mes-
sage, “CTSU api app would like you to join the Study 10104 on
iMedidata.”
Neither the actual name of the study nor its Clinicaltrials.gov
designation appeared in this cryptic email. Based on experi-
ence, if I were to log in to learn what the mysterious 101014 is,
inevitably my iMedidata password will have expired (if I ever had
one in the first place) and I would have to go through multiple
steps to reset it. After sorting that out, I likely would get an error
requiring “an administrator” (who?) to fix it. Only the National
Institutes of Health and the Cooperative Oncology Groups
send emails full of more bureaucratic language and mysterious
acronyms.
The few times I’ve looked into these emails further and
found a functioning website on the other end, I found that
the messages usually had no relevance to me. Every couple of
weeks, I also get an email with a list of more than 20 “trainings”
from ICON’s Firecrest that I allegedly have neglected to com-
plete; I can’t make those stop no matter what I try. So I ignore
all of these, only to find to my sorrow every few years that a real
study where ACTION was NEEDED was buried under all the
rubbish. Who knew?
Email encryption is another idea that perhaps seemed ap-
pealing in a conference room of paranoid HIPAA specialists
but has been a slog in the real world. Supposedly, when sending
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ASH Clinical News
identifiable patient information outside our own systems, we
should use secure email to preserve confidentiality. Never mind
that email is already far more secure than fax machines, which
every medical center, pharmacy, and insurance program con-
tinues to use to fling patient information around without any
special considerations. (I’ve found faxed patient reports and
clinic notes on empty chairs at Logan airport, in commuter rail
terminals, and blowing along Brookline Avenue. Once I even
saw a urine-soaked prescription refill request from CVS lying
on the tiles of a Fenway Park restroom. Appropriately, it was for
Flomax.)
I have a sizable referral practice, so I regularly hear from
dozens of hematologists/oncologists across the Northeast, many
of whom use secure email systems, each of which requires up-
dated passwords every few months. As a result, I need an entire
Excel spreadsheet dedicated to maintaining these passwords
and often give up on 21st century technology and instead use
19th century technology: telephoning the referring doctor to
find out why they had emailed.
The one type of email that rarely is a burden is that from a
patient. I usually give my email address to patients if they ask
for it. Not everybody feels comfortable with that, but in more
than 15 years, I’ve only had a few patients abuse it. Having my
email address gives patients great comfort that they can contact
me about things that can’t wait for the next visit but aren’t ur-
gent enough for a page. My own doctor has given me his email,
for which I am grateful; I’ve used it twice in five years.
Last year, one of my daughter’s high school classes included
a useful unit on “email etiquette.” Good email hygiene is a valu-
able skill that I hope will become a lifelong practice for her. I’ve
known colleagues who could have used such a course – some
are real screamers, like the owl-delivered Howler messages
Ron Weasley’s mother sent in the Harry Potter series. Those
email nastygrams remind me how important it is to practice
the “safety pause” before sending an email when my hands are
trembling from fury.
Almost every time that I have let my filter down, I have later
felt like a heel. Once, burned out and exhausted after months
on call and trying to deal with the chaos of a dozen hospital-
ized patients back home while at two back-to-back trips for
investigator meetings, I even rage-quit my job via email. Cooler
heads quickly prevailed (including my own), but I still felt
pretty dumb.
Another problem with email is that it is yet another infor-
mation stream we have to keep up with. Messages also come via
pages, faxes, phone calls, voicemails, text messages, electronic
health records alerts, and even by regular mail – not to mention
websites and social media streams. This cacophony somehow
needs to be consolidated into a single message stream.
Some Elon Musk–type innovator eventually will figure
out a more effective communication method than email, and
hopefully efficient systems will reduce the need for it. (Long jail
sentences in solitary confinement for predatory publishers and
bogus conference organizers also might help.) Until then, we’re
stuck wading through a swamp that would challenge even the
finest Dutch polder-making hydraulic engineers. The best we
can do is to try not to let email control our lives and to be clear,
kind to one another, and polite in our messages, perhaps even
using archaic signoffs held over from handwritten-letter days,
like ...
Best regards,
David Steensma, MD
November 2018