FEATURE: PERSPECTIVE

My Email—48 Hours

Laura Weiss Roberts

Received: 18 March 2014 /Accepted: 20 March 2014 /Published online: 3 April 2014# Academic Psychiatry 2014

I remember when there was no email. My professional workwas conducted on paper, by telephone, and through in-personmeetings. When I reflect on those halcyon days, I wonder,what did I do with my time? (It is a little like what I feel aboutthe very brief period of adulthood that I experienced beforehaving a child—it was quite “inefficient” in comparison withmy present multi-tasked, high-density way of life.) Whenemail was introduced, there was speculation that electroniccorrespondence would consume an hour each day. An aston-ishingly inaccurate underestimate, as it turns out. With desk-top computers, laptops, and digital phones, it is clear that “e-connection,” including email, has become part of every wak-ing moment for most of us.

In a 48-h period this past week, on my primary emailaccount (I have six), I received 235 messages (Table 1). Ofthe 235, about half involved some kind of action, analysis, ordecision. Half required some kind of communication in re-sponse, for example, follow-up notes and telephone calls.Thirty emails were “high stakes,” pertaining to a major nego-tiation, faculty matter, or patient concern, and none of thissubset of more than 100 emails was trivial. Forty-eight werefrom departmental staff or hospital administrators. One-quarter of the 235 could be read quickly or “skimmed” anddid not require response, such as mailing list server notifica-tions (n=20), out-of-office messages (n=8), and advertise-ments (n=15). Nineteen came from authors or were relatedto the journal Academic Psychiatry—of interest because thiskind of correspondence typically goes through other channels.My faculty colleagues, locally (n=56) and nationally (n=42),sent more than one-third of the emails. Not enough emails (n=9), in my view, came from trainees. This 48-h period was

unusual in that there were no email messages directly frompatients or members of the public or press. Most weeks, Ireceive many from all three origins.

To estimate more fully my “exposure” to electronic com-munication, one would need to add texts (on two phones),messages on five other email accounts, and three web-basedmanuscript management platforms. Plus one would have toinclude correspondence sent to my staff to put in front of myeyes in hard copy because most people know that I receive somuch email that this technique helps ensure a greater likeli-hood of response.

On the 2 days in which I cataloged the emails, I alsologged 9.5 h in meetings with faculty colleagues, 4 h inmeetings with staff, 2.5 h in writing manuscripts, 2.5 h ata dinner with other chairs and the dean of the school,2.5 h meeting or speaking on the phone with members ofmy research team, and 2 h in a School of Medicineexecutive committee meeting. No hour was unscheduledin 2 days at work. I spent no time on the Internet otherthan reading email, including personal accounts, and acouple of quick literature and image searches related tomy professional writing tasks. (This proportion is verydifferent from the pattern of use by most people in theUSA, who reportedly spend only 1/12 of their Internettime on email.)

Years ago, when I was a medical student on mysurgery clerkship rotation, I was astonished by howthe academic surgeons seemed to compress two work-days into every day at work—rounding with the team inthe morning and operating for hours, followed byrounding with the team again for hours at the end ofthe day. Now, all academic physicians have this sched-ule—hours of electronic work and hours of service,followed by more hours of electronic work. (I can onlyimagine that academic surgeons have somehow managedto compress three workdays into one!)

L. W. Roberts (*)Stanford University School of Medicine, Stanford, CA, USAe-mail: RobertsL@stanford.edu

Acad Psychiatry (2014) 38:373–375DOI 10.1007/s40596-014-0117-8

Perhaps it is more accurate to say that each day in thephysician’s life now is continuous “e-presence” and “e-distrac-tions,” combined with other real-time activities. In the USA,there are roughly 220 million users of the Internet, and morethan 30 h each week, on average, are dedicated to Internet-basedactivities, mostly social networking. Media and workforce ex-perts estimate that 28 % of the workweek, on average, isdedicated to email. This proportion seems likely to grow: withdata-phones in our pockets, we no longer need to be sitting atour desktop computers or carrying our bulky laptops to receiveemail; plus, we can receive texts and calls in a steady stream.

The educational implications of these observations regard-ing electronic activities of physicians are many. Lecturerscontinuously compete with students’ laptops and digitalphones, certainly, but electronically based learning methodsappear to greatly support the educational experiences oftrainees across the age spectrum and the professions [1–3].A recent observation-based and qualitative study by Solvollet al. [4] conducted in Norway examined the specific questionof how interruptions by mobile devices may disrupt physi-cians in their daily work. Along with others [5], the authorssuggest, on one hand, that modern communication devicesand applications may enhance some patient care activities.One favorable example is the use of mobile devices to retrieverelevant literature or patient data when discussing a patient onrounds. Another example is the use of modern cellular tele-phones rather than old-fashioned pagers that forced physiciansto stop what they were doing in order to find a phone torespond. On the other hand, these authors also sensibly sug-gest that electronic communication does not enhance certainother activities of physicians. Modern devices, they say,should be avoided, for instance, during team meetings, inthe operating room, when evaluating or examining patients,and while engaged in highly important conversations withpatients and their families.

Beyond disruption of routines, the confidentiality issuesin electronic communication are as daunting as the sys-tems, servers, and screens are insecure. The personalhealth information of many thousands of people has beeninadvertently and wrongly shared by institutions, but themedical student who tweets, texts, instant messages, postson Facebook, uploads images or videos to YouTube, Vine,or Snapchat, or sends personal email about an intriguingpatient can, in some instances, be disenrolled from medi-cal school as well as jeopardize the patient’s rights andinterests. A study published in JAMA in 2009 documentedthat the majority of the 80 medical school deans whoparticipated in the survey had had to deal with unprofes-sional postings in Facebook, Twitter, and other socialmedia formats [6]. Last year, a medical student in anothercountry allegedly tweeted personal health information andridiculed a patient who had undergone three pregnancyterminations, which suggests that the professionalism is-sues continue and can escalate to become exceptionallysensitive [7, 8].

Table 1 Sources of emails received over 48 h

Origin/type Number of messages received

National faculty colleagues 42

Departmental faculty colleagues 36

Institutional faculty colleagues 20

Departmental staff 24

Hospital administrators 24

Mailing list server announcements 20

Authors/editorial-related 19

Institutional notifications 15

Advertisements 15

Trainees 9

Out-of-office notifications 8

Partners/contractual 3

Total 235

Fig. 1 E-man

374 Acad Psychiatry (2014) 38:373–375

The value of the e-world is clear—sharing perspectives,vetting knowledge, giving voice, and creating dialog, syn-chronous and non-synchronous. The list of negatives associ-ated with the misuse and overuse of electronic communicationis nearly endless, however, and impact of e-communicationand e-devices on our work has been rapid, astounding, andunexpected. Preparing our early-career colleagues whowill be“e-saturated” throughout their professional lives to establishcorrect boundaries, to behave with sensitivity, to demonstratecompassion and true regard for patients, and to be time-efficient in an ever-demanding physician workflow is animportant responsibility that academic teachers now carry.Serving as role models who can engage in e-communicationto better fulfill professional duties, while managing workvolume and pace and avoiding emotional exhaustion, is an-other of our key responsibilities. Much to do in fulfilling theseimperatives, and much of it remains in the medical schoolculture’s “hidden” curriculum.

“E-Man”—a sentient and living “packet of energy” inhuman form—was a superhero created for Charlton Comicsin 1973 (Fig. 1). E-man, alas, was a short-lived character. Hemade only 72 comic book appearances before becominguncontained energy that went, like my time and email, both“everywhere and nowhere.”

Disclosure Dr. Roberts owns Terra Nova Learning Systems.

References

1. Chan CH, Robbins LI. E-learning systems: promises and pitfalls. AcadPsychiatry. 2006;30(6):491–7.

2. Wolbrink TA, Burns JP. Internet-based learning and applications forcritical care medicine. J Intensive Care Med. 2012;27(5):322–32.

3. Gordoon M, Chandratilake M, Baker P. Low fidelity, high quality: amodel for e-learning. Clin Teach. 2013;10(4):258–63.

4. Solvoll T, Scholl J, Hartvigsen G. Physicians interrupted by mobiledevices in hospitals: understanding the interaction between devices,roles, and duties. Med Internet Res. 2013;15(3):e56.

5. Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Car J, Atun R.Mobile phone messaging for communicating results of medical inves-tigations. Cochrane Database Syst Rev. 2012;6, CD007456.

6. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting ofunprofessional content by medical students. JAMA. 2009;302(12):1309–15.

7. Tan J: Med student tweets patient information. The New Paper, April20, 2013. Available at http://www.tnp.sg/content/med-student-tweets-patient-information. Last accessed March 11, 2014.

8. Lin M: NUS probing tweets with confidential patient info. The StraitsTimes, Apr 20, 2013. Available at http://www.straitstimes.com/breaking-news/singapore/story/nus-probing-tweets-confidential-patient-info-20130420. Last accessed March 11, 2004.

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