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Research paper

Assessment of email communication skills of rheumatology fellows: a pilot study Mayank K Mittal,1 Sonal Dhuper,1 Chokkalingam Siva,2 John L Fresen,3 Marius Petruc,4,5 Celso R Vela´zquez2 < An additional appendix is

published online only. To view this file please visit the journal online (www.jamia.org). 1

Department of Internal Medicine, University of Missouri-Columbia, Columbia, Missouri, USA 2 Division of Immunology and Rheumatology, Department of Internal Medicine, University of Missouri-Columbia, Columbia, Missouri, USA 3 Department of Statistics, University of Missouri-Columbia, Columbia, Missouri, USA 4 MU Informatics Institute, University of Missouri-Columbia, Columbia, Missouri, USA 5 Department of Anatomical and Pathology Sciences, University of Missouri-Columbia, Columbia, Missouri, USA Correspondence to Mayank K Mittal, MA 419, 1 Hospital Drive, University of Missouri-Columbia, Missouri 65212, USA; [email protected]

ABSTRACT Physicianepatient email communication is gaining popularity. However, a formal assessment of physicians’ email communication skills has not been described. We hypothesized that the email communication skills of rheumatology fellows can be measured in an objective structured clinical examination (OSCE) setting using a novel email content analysis instrument which has 18 items. During an OSCE, we asked 50 rheumatology fellows to respond to a simulated patient email. The content of the responses was assessed using our instrument. The majority of rheumatology fellows wrote appropriate responses scoring a mean (6SD) of 10.6 (62.6) points (maximum score 18), with high inter-rater reliability (0.86). Most fellows were concise (74%) and courteous (68%) but not formal (22%). Ninety-two percent of fellows acknowledged that the patient’s condition required urgent medical attention, but only 30% took active measures to contact the patient. No one encrypted their messages. The objective assessment of email communication skills is possible using simulated emails in an OSCE setting. The variable email communication scores and incidental patient safety gaps identified, suggest a need for further training and defined proficiency standards for physicians’ email communication skills.

Received 20 March 2010 Accepted 2 September 2010

INTRODUCTION According to a recent survey, 74% of adult Americans use the internet regularly and a majority of them (89%) receive or send an email on a daily basis.1 Survey results also confirm that patients are increasingly looking for health information online (83%) and most of them express a desire to communicate with their providers via email (74%).2e4 Although the first patientephysician email communication2 was reported almost 20 years after the introduction of email into the public domain, email is gradually emerging as an alternative communication tool, replacing routine office visits or telephone conversation for nonemergency situations such as prescription refill requests. As the number of email users rises to 1.9 billion worldwide this year,1 it is clear that use of email is going to grow in medicine as well.4 Over the last decade several authors have discussed the advantages, disadvantages, and barriers to adoption of email communication in healthcare.5e7 Similarly, the content of patient emails and the time and resources that are utilized for implementing emailing policies within institutes have also been reported.8e10 The American Medical Informatics Association11 and the 702

American Medical Association12 (AMIA/AMA) have published email communication guidelines for physicians (boxes 1 and 2).8 10 13 However, a decade later, awareness of and adherence to these guidelines are poor. In a random cross-sectional survey of over 10 000 primary care physicians in Florida, Brooks et al reported that only 6.7% adhered to half of the 13 selected email communication guidelines.14 Furthermore, certain skills, such as communication, teamwork, and procedures, are often assumed to be mastered by trainees until studies challenge this assumption.15e19 Although many physicians are nowadays comfortable with email communication, we cannot be sure that such communication is effective. To our knowledge, an objective assessment of physicians’ email communication skills has not been described in the literature. Therefore, we have performed this pilot study with the following objectives: (1) to establish whether rheumatology fellows’ email communication skills can be measured using simulated patient emails; and (2) to perform content analysis of these email responses for clarity, appropriateness, and professionalism.

METHODS ROSCE: rheumatology objective structured clinical examination Objective structured clinical examination (OSCE)20 is now used routinely for the evaluation of rheumatology fellows (rheumatology OSCE, or ROSCE). ROSCE has been validated for training and objective assessment of communication skills and professionalism, Accreditation Council for Graduate Medical Education (ACGME) core competencies that cannot be measured effectively by in-service examination.21 Fellows perceive it as a valuable educational experience because it provides immediate feedback.22 23

Study participants Fifty rheumatology fellows (first and second year) from six different fellowship programs across the Midwest participated in our ‘Highway I-70 ROSCE’ between 2005 and 2008. The fellows rotated through 10 to 12 stations designed to assess different skills such as history taking, physical examination, telephone communication, joint and soft-tissue injections, radiographs, and pathology slides.

Email communication station One of the ROSCE stations was an email communication station (see online supplementary appendix 1, available at www.jamia.org). In this

J Am Med Inform Assoc 2010;17:702e706. doi:10.1136/jamia.2010.004556

Research paper

Box 1 Summary of communication guidelines (adapted from Kane and Sands11 and (YPS) AMA12)

Box 2 Medicolegal and administrative guidelines (adapted from Kane and Sands11 and (YPS) AMA12)

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