When you’re a psychiatrist, there’s no such thing as a typical day.
But if you’re working in a clinic setting (like one of us, Jessi, is currently, and the other, Simone, has done previously), one thing is for sure: You’re busy. And it’s not just about seeing patients — it’s the seemingly ever-increasing electronic messages.
On most days, you are scheduled for a full day of patients, both old and new, for 30 minutes or an hour, respectively. In each appointment, you evaluate and diagnose patients, discuss their lives and current stressors, and go over medication options, risks, and benefits. Outpatient psychiatrists’ schedules have only become more swamped since the beginning of the pandemic and the increase in overall demand for mental health care it brought about. The need has become so high that many psychologists report that they no longer have room to see new patients, and as a result, their wait lists have grown.
The electronic health record inbox only adds to this burden. Every day, our inboxes are full of patient messages asking for medication refills or input on symptoms, side effects, a dose change, or any other clinical question. All messages need to be answered promptly, but that’s impossible. In 2011-2014, clinicians spent as much or more time answering patient messages as they did on face-to-face care — something that’s almost certainly gotten worse.
Not unreasonably, a lack of timely response can affect patient satisfaction. In fact, one study found that patient satisfaction correlated with message response time and decreased sharply if patients waited longer than two business days.
That cuts both ways. Physician burnout is significantly related to electronic health record use, perceived work overload, and after-hours work, particularly for women, with messaging falling into all of these categories. Even prior to Covid-19, burnout was as high as 78% for psychiatrists, much more than the physicians’ average. When physicians are burned out, they are less effective and work overloaded, causing many to leave their jobs ultimately. For example, work overload led to a 2.10 greater risk for intent to leave in one study. As it stands, there is already a significant shortage of psychiatrists. Compounding the shortage only worsens access, which means patients have longer wait times, including between visits. This means more messages, as well, leading to a vicious cycle. Burnout can also lead to more patient errors and increased depression in physicians.
Despite this additional task burden and its effect on patients and providers alike, in many systems, patient messaging is not financially considered a part of the job. Unlike phone or email conversations in non-medical fields, like with an attorney, which is typically billable, the time clinicians take to respond to messages is not typically reimbursed.
Our new study in JAMA Network Open quantifies the substantial increase in patient message volume to mental health professionals during the pandemic in our system. We found an 861.5% increase in monthly message volume from pre-pandemic (June 2, 2018-March 18, 2020) to post-pandemic (March 19, 2020-Jan. 3, 2022). And it doesn’t show signs of stopping. Even when Covid-19 infection rates went down, and patients could come to appointments in person, we saw a rise in messages. Anecdotally, it seems clear that it continues to increase.
This persistent rise tells us this is not a temporary or pandemic-related issue. To help sustain the workforce and ensure patients have access to the care they need, systems need to take messaging into account.
One method of doing this is billing patients who qualify under specific message criteria. In 2022, the University of Washington system had more than 1.5 million patient messages. As a result, starting in June 2023, they began to bill for messages in 10-minute increments with charges ranging from $7-$98 depending on insurance type or directly to the patient if they are uninsured. The University of California, San Francisco has implemented a similar system.
Of course, it is possible these fees will deter patients from seeking medical care, or at least asking timely, needed questions. Yet, early evidence from UCSF suggests that though the volume of weekly messages decreased, the rates of actual visits increased, possibly indicating that instead of messaging back and forth, patients came in to talk more thoroughly about their questions. It may have also helped prevent the inevitable messages that could have waited until the next visit, or ones that were less necessary. The chart makes asking your doctor a question seem like texting a friend — but it’s not, and sometimes a little reminder goes a long way at preventing overuse.
Though we don’t think every message should be charged to every patient, charging for messaging can play an important role in the future of mental health care. We need to feel like the hours we are putting in, which show no signs of decreasing, are going to be valued by the systems we work in. As it stands, that comes through billing. As such, a change in the function of messaging and the cost of it, is key.
It’s true that billing for messages might not work in all settings, and it might make sense to consider other improvements instead, or in addition. For example, additional administrative time could be given to clinicians to manage this increase in messaging burden, and flexibility could be provided to have emergency appointment times for people who need immediate care, even if those appointment times might not always get filled. Another option is hiring more support staff to help triage and respond to questions, removing that additional workload from the physician, and allowing the physician to focus on face-to-face care.
No matter what solution is put into place, we need a solution. Frankly, we physicians are desperate. The growing burden from messaging affects everyone, from mental health clinicians and their patients to other specialties that see patients with mental health conditions, like primary care providers, who end up treating patients who don’t or can’t see psychiatry. If we don’t create a solution soon, we run the risk of further breaking a mental health system already in crisis, and increasing the rates of clinician burnout.
Simone Bernstein, M.D., MHPE, is a psychiatrist in Bethesda, Md. Jessi Gold, M.D., M.S., is an assistant professor and director of wellness, engagement, and outreach at Washington University School of Medicine in St Louis.
