(This article appeared at the New York Times website on June 3, 1997.)

By Allan Hoffman

When Rich Schafer came down with a sinus infection, he didn’t call the doctor’s office to schedule an appointment or to seek advice. Instead, he contacted his doctor by e-mail, describing his symptoms and asking what he should do about them. Within hours, he got a reply — and later, after the infection failed to clear up, a prescription.

“I hardly ever have to call the office anymore,” said Schafer, a computer engineer at Xerox Corp. in Palo Alto, Calif. “Before, when I had to call, it might not be until the next day that I got a response. Now, I usually get a response within an hour.”

Schafer’s physician, Dr. Paul Ford, is among a small but growing number of doctors who communicate with patients by e-mail about everything from test results to HMO authorizations. He fields about 10 queries a day, most of them asking for medical advice or following up on an existing condition.

“It’s taken that third person out of the loop,” Ford said. “A lot of times, the patient can come directly to us.”

As more and more people look to the Internet for medical information, they’re increasingly interested in contacting their doctors by e-mail. Doctors following the trend estimate only 1 or 2 percent of physicians exchange e-mail with patients, but they expect the numbers to grow as patients see the benefits of being able to e-mail their doctors.

Stanford Medical Group in Palo Alto, where Ford is the lead physician, provides a central e-mail address for patients to contact the clinic. A nurse reads the messages, either handling the queries herself or forwarding them to the appropriate doctor. The clinic’s eight doctors decide whether or not to share their personal e-mail addresses with patients.

Few practices have embraced e-mail with patients as wholeheartedly as Stanford Medical Group, a clinic in the heart of California’s highly wired Silicon Valley. Many doctors, in fact, would rather not add e-mail with patients to their list of responsibilities.

“A whole lot of physicians just don’t feel comfortable using e-mail, managing it, and thinking that it’s effective,” said Michael S. Brown, co-director of a study by FIND/SVP of New York and MSB Associates of Needham, Mass., about doctors’ attitudes toward the Internet. In focus groups, doctors “were adamant that they did not want to give their patients their e-mail” address, said Brown.

A separate study indicated that the main quest of consumers who use online medical resources was more information from their own doctors over the Internet. Combine that finding with the doctors’ wariness toward doctor-patient e-mail, Brown said, and you’ve got “a real conflict that’s building between physicians and their patients.”

The main concern of doctors? The added time it would take to respond to e-mail, most likely without reimbursement.

“Everyone worries about being flooded,” said Dr. John Renner, president of the Consumer Health Information Research Institute in Independence, Mo. “If a doctor would try to answer 100 e-mails a day, it could become quite a problem.”

Of course, doctors already have staff members to screen phone calls, Brown noted. The same people could be trained to screen e-mail, directing patients to a medical Web site, scheduling an appointment or sending the query on to a doctor.

Dr. Tom Ferguson, author of “Health Online,” said that doctors who accept e-mail from patients “find it not only allows them to offer much better care and have closer collaborations with their patients but actually saves them time and makes their interactions with patients more convenient.”

The benefits of doctor-patient e-mail, according to its advocates, include avoiding phone tag, added accuracy when dispensing instructions, and the chance to foster a better relationship with the patient.

Patients tend to ask more questions and be more forthcoming with details in e-mail, doctors say.

“People give information they wouldn’t give over the phone,” said Stephen Borowitz, associate professor of pediatrics at the University of Virginia and a doctor at the university’s Children’s Medical Center. “Perhaps they’re more reflective. Some people find it easier to express themselves with the written word.”

Still, even those doctors in favor of doctor-patient e-mail admit that a number of issues remain unresolved. Concerns include security, confidentiality and liability.

With the aim of providing guidance to doctors interested in exchanging e-mail with patients, Dr. Beverley Kane, the physician for Apple Computer, wrote “Guidelines for Clinical Use of Electronic Mail with Patients,” a document being considered for ratification by the American Medical Informatics Association. Kane recommends that clinics inform patients about who reads e-mail messages, establish a likely turnaround time for queries, and make it clear what actions will be permitted by e-mail.

At Stanford Medical Group, a special Web page outlines the clinic’s “electronic mail services.” Patients should consider using e-mail when an immediate answer is not required, the page said. The clinic does not discuss psychiatric diagnoses, HIV test results or work-related injuries by e-mail.

Dr. Paul Hattis, a medical consultant to Brigham and Women’s Hospital in Boston, calls the use of e-mail with patients “a murky legal area.” One particularly sensitive concern is confidentiality, said Hattis, who is also a lawyer. If a patient asks about a highly personal matter, such as a sexually transmitted disease, who will be reading the response to that message? “If you’re flippant about that, you could be creating liability for violation of physician-patient confidentiality,” he said.

No one denies that doctor-patient e-mail remains in an embryonic stage. Its use will increase, Kane suggests, when “every clinic puts up a Web site,” allowing doctors to “use e-mail to refer patients to sources of online education and other resources.”

Dr. Douglas Fridsma, a fellow in medical informatics at Stanford University, sees patients, rather than doctors, as the driving force leading to the widespread adoption of e-mail as an accepted form of communication between doctors and patients.

“As more and more people get online, they’re going to choose physicians who have e-mail,” Fridsma predicted. “That’s how I chose my personal physician. That’s the way I communicate with most people.”