The rise of inboxologists in healthcare: Does it really matter who responds?

Last month, Jeffrey Millstein, MD, FACP , MD, a regional medical director at Penn Medicine Primary Care, wrote an opinion piece for the Philadelphia Inquirer titled "Inboxology – The Newest Medical Specialty? ” I call attention to the question mark at the end of the title, indicating that this is more of a prediction than a statement of fact.

Dr. Millstein discusses how messages sent from patients to their physicians via the omnipresent patient portal have exploded in number since the pandemic. He mentions that while it’s certainly more convenient for patients to send something akin to an email to their doctor (no more phone trees and being on hold, better documentation in the record, etc.), it’s become overwhelming for those on the receiving end.

Most physicians have no dedicated office time for responding to messages, so they often end up logged into their work computer after dinner or even after the kids go to bed (i.e., pajama time .) Physicians are typically not reimbursed for any of this effort, and it’s often not even counted as part of their workload. Hence, it should be unsurprising that handling patient messages via the electronic health record (EHR) leads to clinician burnout .

What should we do? As Dr. Millstein writes in his op-ed, “Enter Inboxology, the newest medical “specialty" created to help remediate inbox task overload. Inboxologists are clinicians — physicians or advanced practice providers — who focus primarily on responding to their own and colleagues’ patient portal messages along with other inbox tasks such as renewing prescriptions and evaluating abnormal test results.” Is this an advancement that we should celebrate or another nail in the coffin of the primary care experience we all want? As with many things in US healthcare, the answer is … who knows?

Much like me personally, the respondents on social media were split down the middle with their reactions.

While I don’t know if I’m happy about the potential new “specialty,” I do know that this concept generated significant interest in the online physician community. Much like me personally, the respondents on social media were split down the middle with their reactions. Relationships are essential to putting the patient at the center of care, and having an unknown physician “invade” that doctor-patient dyad may be counterproductive in the long term even if it’s expedient in the short term.

One group was simply opposed to the very concept of another clinician answering a patient message clearly intended for a physician with whom they have an existing relationship. Many patients understand that their doctor or nurse practitioner isn’t a team of one, and we’re all comfortable when a nurse or medical assistant who we’ve seen in the clinic in the past responds to a portal message, especially if the answer begins with “I’ve spoken with the doctor” or “Just a heads up that Dr. Smith ordered the referral that you requested.” Yet, if the patient sent a message to Dr. Smith about an ongoing issue years in the making, it would be sub-optimal to get a generic response from Dr. Jones who can’t possibly know everything that’s been going on, even with access to the EHR.

A response to this problem would be to limit the job of the Inboxologist to certain sorts of messages from specific kinds of patients taken care of by a defined type of physicians. Adam Carewe MD , CMIO of the Colorado Permanente Medical Group (CPMG) , noted that CPMG has been doing this sort of thing for several years. They call their group the Asynchronous e-Care Team , and their clinicians (often the recently retired who want to maintain skills) principally offer their services to doctors who practice part-time, clinics with unfilled physician slots, and patients who have not yet bonded to a primary care physician (PCP). This seems like the sweet spot with mostly upside while minimizing getting in the way of strong patient-physician relationships.

An alternative to a person responding to inbox messages is to have a non-person do the job. Can an artificial intelligence (AI) take on the role of learning all about the patient, their past interactions with the healthcare system, and how the physician in question would respond? Essentially, can a digital twin of the physician be created to reliably and predictably reply to patient queries. More importantly, can the technology identify questions or messages that are out-of-scope for automatic response and properly forward them to the clinician for a personal answer? I don’t think this twin exists yet, but it would be exciting if it did!

Finally, I would argue that no matter how we seek to respond to this clinician burnout concern, we must keep the goals of primary care in mind. As documented in the National Academy of Medicine’s Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care , “[h]igh-quality primary care provides comprehensive person-centered, relationship-based care that considers the needs and preferences of individuals, families, and communities.” Without focusing both on being patient-centered and relationship-based, we might succeed at reducing pajama time but fail at the bigger picture of providing top-notch care in the way that patients want and deserve.