Dr. Amy Nett: This is a fantastic question. I’m still playing with this because I absolutely agree that this is a big problem in terms of people. I’m not sure, but if it’s a new expectation because I know in medical school and even my opinion with my own health care practitioners, I don’t really feel that comfortable emailing people between visits, but there seems to be a certain expectation that patients want to be able to email a question and get a response within 24 to 48 hours. And yeah, sometimes they are saying, “Hey, what do you think about this article?” or “What do you think about this new complaint that I have? My rule of thumb and what I generally tell my patients—and again this isn’t perfect, so I think this is a great thing to sort of keep as an open discussion, but I tend to tell people that e-mail communication and our patient portal communication is really much more targeted for yes/no questions. But if it’s a simple straightforward question that I can answer in less than five minutes, that tends to be okay.
If it’s a new concern, a new prescription, then I do request at least a 15-minute appointment, and I try to leave a little wiggle room in my schedule. I hold some appointments open each week for urgent appointments, and then, if they don’t get filled, they might use a waiting list that we tend to keep running, and I’ll fill them that way so that I am generally able to fill my schedule but keep some appointments for urgent patients. I do some billing for e-consults depending on how long it takes me to reply.
But if a patient’s saying, “Hey can you review my lab results now and tell me if I need to adjust my medication, and if that requires me going back through the chart, looking at what we talked about what was the change, TSH went from this to this, and this is where we change the thyroid medication, I will generally bill based on how long it takes me. So, that takes me 10 minutes, then I will bill for 10 minutes of my time. We ask the patients ahead of time like, “Hey, do you want an e-consult for this, and then we’ll bill you for the amount of time that it takes?” Some patients are amenable to that. Some people say they’re not. One of my biggest issues with electronic communication is I personally have found that it’s just not a great way to handle patient concerns. It works for things like you said like, “Hey, which whole foods store can I buy this from?” or “Do I take this with or without meals?” But if somebody says, “I’m having this terrible fatigue in the morning what can I do?” Well, what’s changed? Is the fatigue new? What’s changed about your routine? Is there new stress what have you tried? What’s worked? What hasn’t worked? Do you have anxiety or can we try something that’s more stimulating?
I feel like more often I really want to have a conversation with the patient to make sure I’m understanding where they’re coming from. Initially I did try doing a lot more through the portal and through electronic communication, and they just didn’t feel like it was that much of a benefit for either of us. I don’t feel like the patient was getting the best care, and it’s been a little bit tricky for me because patients will say well you’re not answering through the portal just because you don’t make as much money that way. No, that’s not why. I feel like if you can explain to patients, “Look, I really feel like in a functional medicine approach, this is a therapeutic relationship. This is a partnership that you and I have, and we need to have bi-directional communication. We need to communicate so that we’re both on the same page and help one another come to the best decision the best step forward.” And that’s really better done through conversation. As we all know, electronic communications can be interpreted in different ways. We’re not always understanding things as clearly. I don’t like electronic communication. It’s such a bummer in a way that it sort of come in such a prominent piece. But again, I think it’s the current reality of practicing medicine, and that’s where the patient expectation is. I normally, at the first appointment with patients, will try to have some discussion as to “Hey, here’s what the portals for. Here’s what electronic communications for. It’s limited. I would rather talk to you.” Most people understand that this really is because I do want to provide the best care for patients. But it’s tricky, and it’s hard, so I’m always open to hearing how other people handle it, but absolutely Tara. I do think you can charge for e-consults. I think that’s completely reasonable because it ends up being a considerable amount of time. I sometimes spend 30 to 60 minutes a day dealing with electronic questions.