E-mail communication in paediatrics: Ethical and clinical considerations
Posted: Mar 1 2010 | Reaffirmed: Feb 1 2016
The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.
S Albersheim; Canadian Paediatric Society, Bioethics Committee
Paediatr Child Health 2010;15(3):163-5
E-mail has become a commonplace ‘procedure’ in medical practice because it is efficient and inexpensive. However, there are potential misuses and abuses of this form of written communication, with clinical and ethical implications. Common uses of e-mail in paediatics include general communication with colleagues in a professional setting; electronic formal consultation, in which patient confidentiality is paramount; electronic ‘curbside’ consultation, which may be perceived as a formal consultation; electronic discussion groups, which lack peer review; communication with current patients or their parents, which should be limited to simple, nonurgent issues; and communication with individuals seeking medical advice who are not patients, which is generally ill-advised. The present practice point offers a few practical suggestions including e-mail etiquette, security measures to ensure confidentiality, development of an e-mail policy for patients and parents, and separation of personal from professional e-mail.
Key Words: Communication; Confidentiality; E-mail; Medical consultation; Professionalism
The most common ‘procedure’ in medicine is communication. Face-to-face communication is the time-honoured way of communicating, but e-mail is widely used today because it is efficient and inexpensive. However, this form of written communication has become so easy to use that it may be misused and abused, with clinical, ethical and potentially legal ramifications. It is important to remember that e-mail is not a private forum for communication; it leaves a permanent record. With a mere push of a button, the e-mail may be transmitted to thousands of recipients worldwide. The present practice point describes seven common situations in which e-mail is used in paediatrics, outlines the clinical and ethical implications of its use, and provides a few practical suggestions.
Common uses of e-mail in paediatrics
E-mail is commonly used for communication previously handled by telephone calls, letters or face-to-face meetings. However, e-mail is not confidential, so it is wise to avoid typing messages you would not write on the back of a postcard . The advantages of e-mail that make it such a powerful communications tool (such as the ability to send a message to many recipients simultaneously, to respond immediately to messages, or to modify and forward messages to others) are all potential areas for abuse . It is extremely important to be professional, respectful and kind in business e-mail communication, to be considerate of others’ time before sending a group reply and to ensure confidentiality when forwarding information. However, although e-mail has nearly the immediacy of a conversation, it is devoid of facial expression, eye contact, body language and tone of voice. Therefore, e-mail is prone to misinterpretation because interpersonal communication primarily relies on nonverbal cues, rather than words, to convey meaning . In a potentially tense situation, you should ensure that the meaning of your e-mail is clear, because it is far too easy to misinterpret an offhand comment . Generally speaking, you should “be conservative in what you send and liberal in what you receive” .
A paediatrician may use e-mail to communicate an opinion about a patient, in which case, an official consultation has taken place. Although the way in which the information is provided is novel, the nature of the interprofessional relationship has not changed. The attending physician and the consultant both have professional, ethical and legal duties to the patient, in accordance with accepted standards of practice. One advantage of electronic consultation is that the attending physician can readily re-read the consultation and ask additional questions. Patient confidentiality is also paramount. Any communication of personal health information must be in line with provincial and federal privacy legislation. You should be aware of the type of security provided by your server, and what you can do to enhance confidentiality, authenticity and integrity of e-mail transmission, such as firewalls, encryption and digital signatures -.
Electronic ‘curbside’ consultation
Paediatricians frequently engage in informal second opinions or ‘curbside’ consults, by seeking advice from a physician who has not directly examined the patient or reviewed their records. This form of consultation may provide recommendations not readily accessible from the literature, and can be a forum for education and enhanced patient care. However, the information provided may be incomplete or inaccurate, or based on a biased history or physical examination. Consequently, the information may lead to inappropriate advice. Both the requesting and consulting paediatricians have a duty to provide the best possible care, and must be prudent in this form of communication. Electronic ‘curbside’ consultation may result in harm to the patient if there is inadequate information leading to incorrect advice, and the written e-mail record may be viewed as a formal consultation.
Electronic discussion groups
This type of communication provides a forum for continuing education, and facilitates collaboration with, and support from, other paediatricians working in similar areas of practice. List serve discussion groups are similar to other types of intraprofessional communication, such as journal publications and academic conferences. Postings to electronic discussion forums may be anecdotal, including personal observations or clinical intuitions. Similar to electronic ‘curbside’ consultation, both the ‘posters’ and the respondents need to exercise caution in this forum, because comments are often based on minimal or inadequate information, and there is no peer-review process for postings.
Communicating with current patients or their parents
Many patients believe that e-mail correspondence may be an acceptable method of communication, particularly in conjunction with office visits -. It would be the case in situations in which a doctor-patient relationship already exists, and in which the aim is to enhance communication and interaction between doctors and patients, and, ultimately, to benefit the patient and the family. If a paediatrician were to provide the wrong advice over electronic means, it would be as though the same advice was provided to the patient in person, which may lead to harm for the patient, erode trust and may result in litigation. Therefore, the type of clinical information that is appropriate to provide via e-mail should be limited to simple, nonurgent issues for previously diagnosed conditions, and not involve sensitive or confidential information -. Although children today are electronically very sophisticated, e-mail communication with paediatric patients should be developmentally appropriate and avoid topics of a delicate nature.
Communicating with individuals seeking medical advice who are not patients
Communication with individuals who are not officially patients, who request advice about diagnosis, prognosis or treatment, is not uncommon . However, providing or appearing to provide medical advice without having performed a history and physical examination, or evaluated diagnostic tests, is unethical and unprofessional . Communication with potential patients is fraught with errors, both in the information provided to the physician and the subsequent advice provided by the physician. Aside from the time committed, it is not an acceptable standard of care, breaching professional, ethical and possibly legal standards. It is important to consider that Canadian physicians are generally licensed to practice medicine within specified provinces or territories. Therefore, e-mail should only be sent to patients within the physician’s licensed jurisdiction .
Although it may appear to save time to have only one e-mail address, it is wise to separate personal e-mail from professional correspondence. Employers and online services may have the legal right to review e-mail messages that pass through their system, and e-mail is indelible, even after it has been deleted .
- Be courteous, be concise, do not expect an immediate answer, and check e-mails for content, spelling and grammar before sending. Be careful with abbreviations.
- E-mail is a less formal means of communication than a letter; be cognizant of the potential for misunderstanding.
- Sensitive issues are more appropriately handled face-to-face. Do not send or reply to an e-mail when you are angry; wait until you have calmed down (24 h is a good rule of thumb).
- Be aware of the type of security provided by your server, and what you can do to enhance confidentiality, authenticity and integrity of e-mail transmission, such as firewalls, encryption and digital signatures -.
- The electronic consultation can be viewed as a formal consultation. Depending on the complexity of the patient’s condition, an official written consultation may be more appropriate.
- In a consultation, use clear patient identifiers, but be cognizant of the security of your e-mail network.
Electronic ‘curbside’ consultation and discussion groups
- If you have not seen the patient, advice should be limited to general comments about a disease, a treatment modality or recent research. Consider including a disclaimer in your postings (consult your liability insurance provider for suggestions).
Communicating with current patients or their parents
- Written policies should address how questions will be answered, who will respond, expected response times, how to ensure that the e-mail has been received, document retention practices and the limits of confidentiality -.
- Before physicians and patients/parents begin to communicate electronically, patients/parents should be informed of the potential risks, benefits and policies for e-mail communication.
- Communication with established patients should relate to previously diagnosed conditions.
- Maintain a professional relationship in e-mail despite the informal nature of the medium.
- E-mail communication relating to questions of a personal or sexual nature should not take place.
Communicating with individuals seeking medical advice who are not patients
- Responding to unsolicited e-mail communication from individuals who are not current patients or parents is not advisable. A standard response might include the following:
- “E-mail is not a substitute for a medical evaluation; it is unwise and unprofessional for a physician to provide advice without a full history and physical examination”.
- “I do not offer medical advice via e-mail for nonpatients”.
- “If you wish to make an appointment with me, please call my office at (number provided)” .
- Separate personal from professional e-mail.
E-mail presents many benefits, but also many potential hazards, in the paediatric setting. E-mail is very helpful in routine communication between professionals, for simple nonurgent communication with patients or their parents, some formal consultations and electronic discussion groups. However, it is generally inappropriate for ‘curbside’ consultations or for communication with individuals who are not currently patients. Before engaging in e-mail correspondence with anyone, including patients and family members, it is essential to develop an office policy, which must ensure confidentiality. It is also essential to review current provincial, interprovincial, national and international policies and regulations from governing boards, such as provincial licensing bodies, the Canadian Medical Association  and your liability insurance provider (eg, the Canadian Medical Protective Association) . Finally, remember the golden rule: “Send unto others as you would have others send unto you” .
Members: Susan Albersheim MD; Kevin Coughlin MD; Bob Hilliard MD; Ellen Tsai MD (Chair); Pascale Gervais MD (Board Representative)
Principal author: Susan Albersheim MD
- Solomon GL. E-mail etiquette. Med Econ 2001;78:61-6.
- Purcell TJ. Enhancing electronic communication between team members by establishing best practices: A communications specialist’s perspective. Drug Inf J 2001;35:35-40.
- O’Brien JA. Netiquette: E-mail for group practices. J Med Pract Manage 2007;22:201-3.
- Saul JM. E-mail etiquette: When and how to communicate electronically. Cause/Effect 1996;2:50-1.
- Hambridge S. Netiquette guidelines. Intel Corporation, 1995. http://www.ietf.org/rfc/rfc1855.txt (Accessed on January 29, 2010).
- Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998;5:104-11.
- Gerstle RS; American Academy of Pediatrics Task Force on Medical Informatics. E-mail communication between pediatricians and their patients. Pediatrics 2004;114:317-21.
- Canadian Medical Association Policy. Physician guidelines for online communication with patients. www.cma.ca (Accessed on January 29, 2010).
- Rosen P, Kwoh CK. Patient-physician e-mail: An opportunity to transform pediatric health care delivery. Pediatrics 2007;120:701-6.
- Neil RA, Mainous AG, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268-71.
- Harris ED Jr. Electronic mail: A physician extender? West J Med 1997;166:123-5.
- Ceresia P, Crolla DA. Using email communication with your patients: Legal risks. Ottawa: Canadian Medical Protective Association, 2009.
- American Medical Association: Guidelines for physician-patient electronic communications. Chicago: American Medical Association, 2001. www.ama-assn.org/ama/pub/category/2386.html (Accessed on January 29, 2010).
- DeVille K, Fitzpatrick J. Ready or not, here it comes: The legal, ethical, and clinical implications of e-mail communications. Semin Pediatr Surg 2000;9:24-34.
- Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA 1998;280:1333-5.
- Austin S. E-mail: So fast, so convenient, so…risky? Nursing 2006;36:76-7.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.