Consider two messages that might land in a doctor’s patient portal: One is pretty brief: “I’ve had a cough and congestion for a few days now, and it’s been pretty uncomfortable. Still no fever, but it’s been dragging on and making it harder to get through the day.” Another is longer, more descriptive and formal: “Dear Dr. Liu, I hope you’re doing well! I wanted to reach out because I’ve been experiencing some new respiratory symptoms that I’m a little concerned about and would really appreciate your perspective. Over the past two days, I’ve developed a dry, persistent cough along with some chest tightness and mild shortness of breath — especially when walking or going up stairs. I haven’t had a fever, but the symptoms are definitely noticeable and seem to be getting a bit worse, which is making me wonder if there could be something more going on? I know you’ve helped me manage my asthma in the past, could this be a flare-up or something else entirely?? Thanks so much again for all you do! I really appreciate your time and guidance. Warmly, Mitchell Tang” The first may seem simple and to-the-point, but a new study suggests the second is more likely to receive a response from the doctor it was sent to. Use of online patient portals to contact doctors has grown in recent years, but researchers have seen that there are significant disparities in response rates for historically marginalized groups, such as non-White patients, those without a college education and those who use Medicaid instead of commercial insurance — especially responses from the doctor intended to receive the message. Dr. Mitchell Tang, an assistant professor of health policy and management at Columbia University’s Mailman School of Public Health, set out to understand why. One possible contributor: writing style. Tang’s latest study, published Monday in the journal JAMA Network Open, analyzed more than 3 million patient message threads from the Mass General Brigham electronic health record system. Using a sample of 1 million messages, Tang and his colleagues found that differences in writing style — such as whether a message started with a greeting or how it used punctuation — accounted for about half of the disparities in response rates for the historically marginalized groups. For healthcare providers, this is a lesson on potential sources of bias, Tang said. “I want to be cautious not to victim-blame here,” Tang said. “The best way of dealing with this is actually to try to improve the system working on the back end.” Tang hopes that his research highlights the need for more education on the clinician side to reduce the disparities in response rates. “There is one interpretation of the results where you can say, ‘Oh, how can we get more patients starting their messages with “Dear Dr. Tang?” ’ To me, with that finding in particular, I would flip it and say, ‘Why does this matter in the system?’ ” “Unlike biases rooted in race, ethnicity, or socioeconomic status directly, biases in writing style” may be easier to manage, the study notes. Changes are already happening to standardize patient portal messaging, and they may make it more efficient for doctors and patients alike. “We talk about AI tools to help doctors draft their messages,” Tang said. “Could we have AI tools that help patients draft their messages so that we can kind of level the playing field to some degree?” When to message, when to call Use of patient portal messages has jumped since 2020, while phone calls have declined. That overwhelming amount of messages may make it harder to respond and raises concerns about physician workload and burnout. Doctors told the American Medical Association that simply scheduling an appointment may be a better option for more involved questions. If something takes more than a single message to type out, odds are it would be better to call the doctor’s office and schedule a visit. It’s also important for patients to know that messages sent through an online patient portal may not go straight to your doctor. Instead, they may first go through a kind of triage system, where they may be assessed by a medical assistant or a nurse before being answered or forwarded on to the intended recipient. “Portal messages shouldn’t be used for urgent needs,” Tang told CNN in an email. “The patient should be comfortable with the idea of getting a response within 2 business days (though many will get responded to sooner). If the need is more urgent than that, then they should probably call.” The messages more likely to get a response The new study identified some writing style characteristics in messages that were more likely to get a response. It looked only at one health system, and it included only messages written in English, so its findings won’t relate to every system or doctor’s office. It also didn’t track other methods to respond to patients, like a follow-up phone call instead of a portal response. What’s in a greeting The study found that the first sentence of a message may be one of the most important. Messages starting with “Dear Dr. (Last Name)” were more likely to get the target clinician response, and messages that included the clinician’s first name got even better response rates — nearly double as likely as those with no greeting at all. “If you start your message with ‘Dear Dr. Tang,’ we find that it’s much more likely that Dr. Tang is ultimately the one who responds to you,” Tang said. Punctuation matters Messages with expressive punctuation also got better response rates from the target clinician — and the more expressive, the better. Multiple question marks and multiple exclamation marks secured better rates than single marks, which secured better rates than none. “It adds some like color to it, somehow, that seems to be treated differently,” Tang said. Positive vs. negative Even in messages discussing what could be concerning health topics, the inclusion of positive sentiment — like that your condition is improving — seemed to improve response rate. But negative sentiment –— such as expressing frustration or sadness — slightly decreased it. Longer messages Many providers would suggest clear, concise messages from their patients. But in the study, longer messages were more likely it was to get passed along to the clinician they were intended for. Tang said this might be because these messages have more complexity or specificity, which is more likely to continue through portal triage and go to the doctor. “ ‘Long’ is a proxy for ‘complicated.’ ‘Complicated’ is a proxy for ‘escalate,’ ” Tang said. By Elise Haulund, CNN
