I was talking to a fellow physician about a mutual patient. I had
information  that would help him in their  care and he was taking the
unusual step of asking me for my information.  I was impressed.

“Could you fax me those documents?” he asked.  ”Here’s my fax number.”

I scrambled to get a pen to write down his number.  Then I had a
thought: “I could email you those documents much easier.  Do you have
an email address?”


After a long pause, he hesitantly responded, “I would rather you just fax it.”  He said no more.

This is a typical reaction I get from my colleagues when suggest
using the new-fangled communication tool called email.  The palms
sweat, the speech stumbles, and the awkwardness is thick in the air.
It’s as if I am suggesting they join me in an evil conspiracy, or as
if I am asking them to join my technology nerd cult.  There is a
culture of fear in our healthcare system; it’s a wall against change, a
current of stubbornness, a root of suspicion that looks at anything
from the outside as a danger.  Instead of embracing technology, doctors
see it as a tool in the hands of others intent on controlling them.
They see it as a collar on their neck that they only wear because
others are stronger than them.

It’s the only reason I can see for the resistance of a transforming
technology.  It’s the only way to explain how they would favor a
non-system that hurts their patients over a system that can improve
their care immensely.  After all, what good is it to embrace a
technology – no matter how good – if it will take away their ability to
practice medicine?  ”It’s good for you!” they hear from politicians and
academics, but they see it as a poison pill.

What gives me cause to use such strong words?  Surely it’s not that bad!
It is, and what makes me so sure of it is the very high cost of their
resistance.  The cost of this fear is huge, and so the fear itself must
be bigger for a healer to accept that cost.  What is the cost?


We see our patients without information.  The call from the
specialist I described at the start of this post was a truly rare
event.  Most of my consultants don’t expect to get information from me,
and I expect to work without their input.  All of this has happened
despite my repeated attempts to improve our system.

  • I have offered to send our referrals with attached appropriate documents.  I can do this very efficiently using email.
  • I have tried to send labs, x-rays, and other information to
    specialists when I felt they couldn’t do their job well without them.
  • I have requested that they stop mailing their information to me, instead faxing them to our server.
  • I have offered our hospitalist physicians after-hours access to our records for our patients.

Ironically, the only physician who has embraced my offer is an ENT
at our local teaching hospital who specializes in parathyroid surgery.
I shoot him an informal email when I have a suspect calcium level and
within the day I get a response.  In exchange, he gets consults with a
full set of labs and can practice with greater efficiency.  He also
sends me quick notes on my patients when he sees them, asking me
questions to fill any gaps.


The total lack of communication results in huge cost to our system.
It’s not that the communication tools are not there, it’s that they
just are not used anywhere near where they should.  Examples?

  • A woman came to my office recently after being hospitalized.  I
    never was notified of her hospitalization, only finding out when she
    came for a “hospital follow-up” visit.  While in the hospital, she was
    found to be anemic and so had a workup for this condition.  This workup
    included a full consult by a hematologist and a gastroenterologist.  If
    my records had been looked at, they would have noticed that I did a
    workup 6 months earlier for her anemia.
  • Specialists not accepting email copies of the labs I run usually
    end up repeating the tests.  For specialists like rheumatology – where
    the diagnosis is largely made on the basis of those labs – this
    elevates the cost by several thousands of dollars.
  • I have had patients rebuffed by consultants who “didn’t know why I
    sent them.”  Nobody calls, and nobody accepts email.  I could send them
    whatever information they need in a matter of minutes if they would
    accept email.  Heck, they could even text me if they wanted.

The real cost, of course, is to the patient.  The Hippocratic oath
says we should “first do no harm” as physicians.  Yet our non-system of
communication does just that, and even kills people.

So why would presumably smart people reject a technology that could
improve care, reduce cost, and reduce frustration?  Did any of them
order gifts from Amazon?  Do any of them bank online?  I am sure they
do, and they do so because it makes things easier and more convenient.
So why does that ease and convenience not apply in medicine, which is
far more broken than shopping or banking ever was?  It’s not fear of

To be honest, I don’t really know.  My best guess is that it is the
overwhelming sense of pessimism most doctors feel about their
profession.  Docs are second-guessed by lawyers, patients, TV shows,
insurance companies, and the government.  The fate of medicine is not
in the hands of doctors, it is in the hands of politicians, corporate
executives, and malpractice attorneys.  It seems to me that the only
way to avoid more scrutiny and to hang on to some control is to hold
tightly to what we’ve got: our information.  Once that information is
on computers it is far more accessible by others, and this is a bad
thing if the goal is to retain full control.

So are docs just power hungry, wanting total control because of
their inflated egos?  Some are, but most are not.  Even the most
technologically-minded of us, however, have an increasing unease about
the intrusion of others on our ability to do our job.  I don’t want to
be thinking about attorneys when I am prescribing medications.  I don’t
want to withhold information important from the chart because I know
patients will be reading it.  I don’t want to be forced to include a
lengthy justification of a procedure in my notes to make the insurance
company happy.  As it stands, it sometimes feels like anything we
include in our records “can and will be used against us.”

If someone like me, a physician who embraces technology, feels
increasingly penned in by the increasing number of people peering at
what I do, it is very understandable that other physicians reject
technology outright.  They’ll quit before they give up their

Is it stupid?  In some ways it is.  It certainly is a rejection of
the centrality of what’s good for the patient.  But our system can’t
afford to alienate physicians at this time.  If technology is going to
be pushed, there needs to be a reassurance that this won’t be used
against them.  I am frustrated at the lack of  acceptance of
technology, but even more frustrated at a system that is hostile that
forces docs into this foxhole.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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27 Responses for “The Cost of Fear”

  1. Nate says:

    This surprises me that you didn’t mention HIPAA. When my TPAs sends or receives info to providers any pushback we get is always cloaked in a HIPAA excuse. 99% of the time they are wrong and HIPAA allows for what we are asking them to do but that doesn’t protect them in court. HIPAA is like malpratice, an ounce of prevention can save you tons of lawsuits. If you never email patient records you almost never need to worry about it falling into the wring hands and being sued. If you email a patient file and someone prints it out at the intended receiptant and then loses or discloses it your name is still at the top and you still get sued.
    This also applies to general disclosure, there are clear allowances in HIPAA for meaningful use, but that doesn’t stop you from getting sued no matter how right you are. On top of that you need to rely on a jury of “peers” to get it right.
    Clear example of unintended consiquences and how dramatic the effect can be.

  2. Stephen says:

    E-mail is like a postcard sent across the Internet. I have used a packet sniffer at work before and believe me one can read all kinds of data. I don’t want my own data being e-mailed, and I’m a healthcare IT worker! I’m certainly not afraid of e-mail, I just know what I should and shouldn’t send in e-mails.

  3. bev M.D. says:

    Faxes are far from secure either. I can’t tell you the number of times our hospital lab/pathology fax machines received a fax meant for someone else. I think this whole thing about faxing rather than emailing in medicine is just insane, and Dr. Lambert’s post is long overdue. Our lab and pathology dept. used to routinely fax results and they were invariably lost, tossed, overlooked,or didn’t go through because the dr’s office fax machine was turned off or inoperative. Then numerous accusatory and time wasting phone calls ensued trying to re-send or receive the information. Or they didn’t ensue, and the result was never conveyed.
    His comments about working without information also ring incredibly true. When you think about it,it amounts to malpractice to treat a patient without attempting to find out all pertinent past history, imaging and lab results, and other physicians’ notes – and yet it is done each and every day. This is a change – I was definitely NOT trained that way in the’70′s, where lack of tracking down past information was regarded as laziness and not to be tolerated. Medicine is truly in sad shape these days.

  4. Kim says:

    Email other than using a secure server is definitely a HIPAA no-no…faxes may or may not be more secure but the rules about their use are less prescriptive.
    The comments do go to the desirability of a more connected yet secure system, which is feasible but runs against the technology phobia/inertia that Dr. Lamberts questions. We’re going to need to help the various stakeholders understand why such connectivity is in everyone’s best interests.

  5. SB MD says:

    I agree with Stephen’s posting above. I am very technologically savvy and use email all of the time. I would love to be able to communicate patient related information in this way. However, I would never send identifiable patient information via a standard email system nor would I want my own information sent via a standard email system. It just isn’t secure. All of those individuals who think that a password means it’s secure are deceiving themselves. The sad thing is that technology is available to transmit information electronically and securely but it rarely seems to be used.

  6. Anonymous says:

    There are myriad good, inexpensive solutions for securing email. (Zix and Cisco Ironport come immediately to mind) That is a lame excuse. To secure an email in our environment requires the sender to put “secure” in the subject line. No big hassle. To retrieve the email the recipient clicks a link on a website and downloads the message.
    This isn’t rocket science anymore. The real fear is that physicians will be considered culpable if they don’t read the information and react to its contents. That’s all.

  7. Rob Lamberts says:

    Two important things:
    1. John Smoltz is harassed about this too. People come up to him all the time and ask if he knows he looks just like me. I get emails from him pestering me about this. Sorry that my fame causes you such trouble, John.
    2. We use secure email in which the actual result is sent to our server and all the patient or specialist sees is a note saying there are results they can log on to see. The server is secure and 100% HIPAA compliant. HIPAA is a non-issue here (except for the fear that is far more than it should be).
    Thanks for posting this.

  8. rbar says:

    No offense intended, but I personally think that the whole anecdote is made up … or at least not representative, like the recent snow in Florida (besides the fact that there are other reasons for preferring fax over Email as others have pointed out).
    I worked at a conservative (albeit affluent) small town in the midwest and I am now at an acadmic department progressive university town. In both settings, everyone communicated at least partially by Email, and a lot of administrative mail was/is distributed by Email only. Of course, there is the occ. technology grinch, but these are far from typical – in fact, most docs run around with iphones and blackberries and do use them.

  9. Rob Lamberts says:

    rbar: No offense taken, but no fabrication whatsoever. The academic environment is not what I represent; I work in a private practice and with other private practitioners. The lone doc I can get to do email is an academic, so I suspect the cover of the institution (not feeling as vulnerable as a private doc) along with the non-drive for money makes the academics different.
    My post is representative as far as I can tell. The community I live in is a fairly well-off and above-average educational area (lots of engineers work here). You don’t have to believe it, but it is the truth in the trenches where I work.

  10. Ben Bulkley says:

    We know that there is a distinct culture unique to each region. It’s the McCallen principle. Email some places, smoke signals in others.
    Lack of email is just one symptom of an overly atomized system. Do providers within a clinical practice dedicated to a particular medical condition, e.g., a Spine Institute, fret over the exchange of information by email?
    This is rooted in basic systems theory…yes, we should have more and easier communication. No argument. But it doesn’t solve the problem. Its too loosely coupled. Redesign the system so people are working together (to minimize the volume of email in the first place, ie, seek tighter coupling).
    Episode (at-risk) payment schemes and outcome measures are just two things that will drive out the variance, and tighten the coupling.

  11. IAI says:

    Healthcare: Killing America
    FOR MORE DETAILS VISIT IAIResearch.wordpress.com
    Americans spent an estimated $2.5 trillion to maintain our health in 2009, or roughly $8,000 per person. This is more than the gross domestic product (what is spent on everything) in every other country in the world except Japan, China, Germany, France, or the United Kingdom.
    Spiraling healthcare costs are on track to bankrupt America. Medicare will be insolvent by 2017 and is projected to generate a $37 trillion deficit. Increased healthcare costs are one more reason jobs flee America. And all this extra cost has given us very little return as most of the gain in life expectancy came during the first half of the 20th century due to improved sanitation and nutrition.
    The cost of healthcare could be cut in half, but what do our politicians want to fix first? They want the most fraud-riddled, inefficient system—our government—to take over more of our care! They want to cover 47 million Americans without insurance rather than fix the cost of care for all 307 million Americans!
    We can drive down costs to levels that existed before government decided to “fix healthcare” in 1965. This means we all have to change:
    · Consumers must live healthier lives, manage their own care, and bear more of the direct cost of care. We must remember that, insured or not, we pay for healthcare through lower wages, higher prices, or higher taxes.
    · We must find a way to live our last years without bankrupting our children, our grandchildren, and our neighbors.
    · Lawyers can no longer be allowed to pillage our medical system for private gain.
    · Providers must take a lower share of our national wealth. In return they would become less likely to be sued, go unpaid, or bear excessive overhead costs.
    · Government must back away from managing care and focus on policing illegal behaviors and driving efficiency through shared knowledge.
    Most important, government and industry leaders must push for change that is good for the country rather than for political contributors and lobbyists. Our founding fathers realized our republic would only survive if its leaders possessed public virtue. This crisis is another test of that virtue and I fear as Congress buys each vote with special interest gimmicks, our nation is further undermined.

  12. Nate says:

    how frequent was medical data really used against someone? I can’t beleive people where suffering so badly with their personal health data being captured by neferious bad doers that HIPAA has been worth it. THe damage from siloing everything has been far worse then the rare case someone is harmed by their data getting out. I doubt it is any less common then it was before HIPAA, it is just heavily litigated now.

  13. iknow says:

    What is efficient for you is not efficent for the doctors who are on the move and can not sit tethered to the devices. The devices interfere with the complex efficient multitasking that is second nature to the doctors who refuse to sit and click. Sorry. You got it all wrong.

  14. Rob Lamberts says:

    What I am doing is taking my personal experience as a practicing PCP in a private practice (for past 15 years) and IT “expert” (our practice has been nationally recognized for use of IT and I have lectured on application in small practice settings). My perspective is exactly that – a perspective. I understand it does not apply in all situations, but our setting is highly motivated for efficiency as it is almost entirely composed of for-profit practices. What that means is that efficiency is rewarded financially. Why would doctors turn away from efficiency and hence increased income?
    Having fought for IT as long as I have, I have concluded that the very strange economy of medicine is what makes it so strange in other ways. IT adoption that is nearly universal in business is in its infancy in medicine. Why? I don’t think it’s confidentiality or complexity of the medical process. IT does work in medicine, but the physician culture built by a dysfunctional payment system is a huge force against adoption – even adoption of a universal technology like email.
    This is not just an isolated phenomenon. I am mystified when I ask for a colleague’s email address and get answers like “he doesn’t have an email address.” It has happened numerous times. I don’t think our community is abnormal.

  15. ExhaustedMD says:

    God, how many times in the history of our species do we hear this basic refrain of “oh, this innovation/application/improvement will make life easier and free us from the confines of a tedious, banal existence!” Hey, last I checked, we still take less vacation time, work more hours, and have more diseases than other Western world cultures who don’t have a cell phone in every citizens’ pocket, 2 or more flat screen TVs in most homes, 1 computer to every 1.5 people in the vacinity, and an average of 3 or more prescriptions per every adult citizen over 18 years old.
    Yeah, let’s make emailing a necessity to health care. Hey, I have a better idea: let’s review how bankers back in the later 1990′s got records of people with loans who had a cancer diagnosis and had those loans called in for payment. Yeah, forgot that little story, eh, oh technology buffs! Or, maybe we don’t hear how employers get wind of their employees medical issues and then find creative ways to let them go.
    Get a life you computer idiots! Yeah, I use this technology, but for things that don’t have a great risk to harm me, or, my patients for that matter.
    So what do you do when you open your email and read Mr Jones is having chest pain, or is suicidal, or a significant other asks an allegedly innocent question that appears easy to answer for the patient’s alleged well being, but, maybe Mr Jones doesn’t want anyone to know his business? Didn’t have the chart in front of you to remember the details, eh? Oh, and the email was sent 6 hours ago. Hmmm, couldn’t check it while you were sleeping, or, spending the day seeing patients!?
    Road to hell is paved with good intentions, people!!!
    Notice the faces you tread on if you travel the path!?

  16. Margalit Gur-Arie says:

    I would like to address the last part of the post.
    Most of the privacy discussions center on patient data and it is by and large extremely important, but few ever mention physician privacy.
    Does the patient, or other providers for that matter, really have a right to everything that normally goes into a chart? There may be informal notes that a physician writes in a chart that he/she may not wish to share. Maybe some side notes that could be offensive to the patient or outright dangerous.
    I’m not talking about factual information such as diagnoses, test results, medications, etc.
    Is there anything that could be regarded as physician thought process or intellectual property or at least private information?
    Shouldn’t the electronic chart, or EHR, contain some exclusions to the sharing mandates?

  17. propensity says:

    Your notion that email for the patient centered physician is seriously flawed. Do you sit in front of the computer or the patient? Has the computer become your patient? Do you read all documents and medical literature on the screen? I suppose you assume yourself to be a capable physician because you use email. Email might be efficient for you as its chearleader but for most of us who actually care for complex patient care problems, email is a slow and inefficient mode of communicating complex thoughts. The EMR that loads up on billing associated gibberish saps an equal block of professional time. Those considering EMR purchase, think twice, calculate the costs and disruption when the “superuser” of your practice quits, and take the penalty. Do not buy.

  18. Rob Lamberts says:

    exhaustedMD has made my point eloquently (albeit ironically). That’s the prevailing attitude. Thanks.
    Square on, Margalit. Exactly my thoughts. Most people have a hard time doing something with someone looking over their shoulder. Docs (including myself) feel increasingly that this is the future of medicine: to practice with the world looking over our shoulder.
    Propensity: huh? I assume I am capable because I read my email? Perhaps you should read the post. I am defending the reluctance of docs, not attacking it. I do think that it’s a mistake to forego a communication tool that improves quality (which it can), allows quicker access to information (which it does), and allows for more informed decisions. However, the entire point of this post is that nobody is considering why exactly it is that docs resist. Why eschew a tool that with such potential? I think it is because of the potential of more harm to themselves. Why else would they be willing to work with less information?
    I assume I am a better physician and more capable of making decisions if I have correct information, and bemoan my inability to send that information to my consultants. This hurts my patients.
    I agree, by the way, about the billing associated gibberish, and have posted repeatedly on this. I wish we could document to help the patient rather than to bill them, but that is the system we have. My choice is to either chart what I think is important, billing less or risking audit, or chart what the government wants and deal with the gibberish (I call it “fluff”), getting paid what my time is worth. The system is to blame for this, not computers. Personally, EMR has been a tool that has enabled me to improve quality, get paid more, and do so while spending more time with my patients and less with their chart.

  19. bev M.D. says:

    My guess is that iknow isn’t taking the time to know much about his patients.

  20. James says:

    I used to get medical records mistakenly sent to my home fax number, which was one digit off from a doctor’s office. It happened even after I notified the sender.
    A couple of days ago I found a piece of snail mail lying in the road from Medicaid to a client. It was unopened and likely contained personally identifiable health information of some kind.
    The street near where I work has a pharmacy. I have found the bags from filled prescriptions — still with all of the patient information attached — blowing down the sidewalk. These included prescriptions for narcotics and tranquilizers.
    These are examples of the insecurity of faxes, snail mail, and printed handouts. Give me email, please.

  21. Vikram C says:

    Would it help if insurance pays doctor/office per email correspondance with patient via insurance email and if patient is satisfied clicking ‘OK’ on the satisfaction button lead to small payment to doctor’s office?
    There is definitely a cost of entering data into computer. But I have seen work arounds, doctors speaking up notes to dictatophones and then someone else in office types it up. Or how about interns, trainess, nurses etc taking notes. or how about doctors learning to use ViaVoice for voice recognition so that notes can be taken easily.
    However data entry by doctor is all about that can be excused as slightly distracting exercise. As I noted there are options to make the task easier. Anyway when did you ever see doctors writing in cursive handwriting? They end up having transcribers, data entry reps etc. So they do have help. I don’t see how they can be distracted if someone else enters data in computer.
    Once the data is in system, there is potential to use it.
    Ultimately, I think it’s just the matter of what does doctor get by putting effort into getting data into system. Until that equation is not established there is little advantage.

  22. Rob Lamberts says:

    Vikram: Agree 100%. The problem is that in a PCP office there are not big enough margins to allow reinvestment or to wait for a slower return. Our office has a huge advantage because of a good implementation. But there is nearly no motivation for there to be communication b/w providers as it is not made easy by any system.
    Our system penalizes those who spend extra time by not paying them more to do so. Why communicate when it reduces your revenue? We do, but only because it is very simple with our IT. You can’t send email, however, if it is not accepted. We use email TO patients, but not from them. They love this. Would accept patient email if it didn’t reduce revenue and increase liability.

  23. It’s understandable that doctors, who are subject to intense scrutiny, would be wary of sharing valued information. But if that information can help doctors better provide their services, then the end result would likely be a reduction of said scrutiny.

  24. After having worked in hospitals and nursing homes, I do not think there is such a thing as “privacy.” HIPAA violations are a reality in everyday health care.
    The need to streamline processes is a necessary concept. But how do we do this and give complete privacy to patients before we actually address what they are saying in an elevator?

  25. Where Cranly led me to get rich quick, hunting his sunglass wholesale winners among the mudsplashed brakes, amid the bawls of bookies on their wholesale sunglasses china pitches and reek of the canteen, over the motley slush. May I trespass on your valuable tote bags space. That doctrine of laissez faire which so often in our wholesale handbags history. The way of all our old wholesale tote bags industries. Grain supplies through the narrow handbags wholesale waters of the channel. He stepped swiftly off, his handbag wholesale eyes coming to blue life as they passed a broad sunbeam.

  26. Arthur Williams, MD says:

    My partner and I head two hospitalists groups in the Boston area, one acute care, the other a rehab hospital. For years our handoff communications went through paper mail or fax. We were very diligent about communication. Even so, specialist from acute care settings and primary care physicians in the community complained that our group was like a black box – that they were not getting good communication about the care we were providing. The hospital even setup a physician portal so that any on-staff doctor could log in remotely and access their patient’s information. But this “pull” model never caught on, as most doctors expect data to be “pushed” out to them.
    One of our new physicians suggested we look at Concentrica, which is an online network for secure clinical communication. This is free to physicians to communicate with each other. The national directory of physicians meant that we could quickly send to any physician, without having to know their fax or email. Like an online email system, recipients can reply and forward messages, so now we could get immediate feedback from colleagues in other locations, and in important cases, have a real dialog about patient care. The “Group Discussions” feature allows the specialist in town, the hospitalist, and the PCP to all join in an online dialog about one patient. The application works well on our smartphones.
    When our group wanted to send documents on our behalf, we upgraded to the subscription version, which cost less than paying someone in our office to fax the documents. There is an audit trail so we can see who received their messages. One feature we really liked was that if the message was not accessed online it was faxed, so we knew our clinical work was getting there.
    For our group it made it easy to communicate with other physicians, to get our documents out, gave a way for others to respond, and was cost effective.
    Arthur Williams, MD

  27. doxycycline says:

    communicate with each other. The national directory of physicians meant that we could quickly send to any physician, without having to know their fax or email. Like an online email system, recipients can reply and forward messages, so now we could get immediate feedback from colleagues in other locations, and in important cases, have a real dialog about patient care. The “Group Discussions” feature allows the specialist in town, the hospitalist, and the PCP to all join in an online dialog about one patient. The application works well on our smartphones.
    When our group wanted to send documents on our behalf, we upgraded to the subscription version, which cost less than paying someone in our office to fax the documents. There is an audit trail so we can see who received their messages. One feature we really liked was that if the message was not accessed online it was faxed, so we knew our clinical work was getting there.
    For our group it made it easy to communicate with other physicians, to get our documents out, gave a way for others to respond, and was cost effective.
    Arthur Williams, MD doxycycline communicate with each other. The national directory of physicians meant that we could quickly send to any physician, without having to know their fax or email. Like an online email system, recipients can reply and forward messages, so now we could get immediate feedback from colleagues in other locations, and in important cases, have a real dialog about patient care. The “Group Discussions” feature allows the specialist in town, the hospitalist, and the PCP to all join in an online dialog about one patient. The application works well on our smartphones.
    When our group wanted to send documents on our behalf, we upgraded to the subscription version, which cost less than paying someone in our office to fax the documents. There is an audit trail so we can see who received their messages. One feature we really liked was that if the message was not accessed online it was faxed, so we knew our clinical work was getting there.
    For our group it made it easy to communicate with other physicians, to get our documents out, gave a way for others to respond, and was cost effective.
    Arthur Williams, MD

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