Patient Portal Messages | Why Writing Style Impacts Responses

Writing Style as a Predictor for Doctor Response

A recent study published in JAMA Network Open suggests that the structure and tone of a patient portal message influence whether a doctor responds directly. Researchers analyzed over 3 million message threads within the Mass General Brigham electronic health record system to determine why response rates vary significantly between patient groups. The findings indicate that writing style accounts for roughly half of the observed disparities in responses for marginalized populations, including non-white patients and those using Medicaid.

Dr. Mitchell Tang, an assistant professor of health policy and management at Columbia University, led the investigation. His team found that simple formatting choices often dictate the outcome of a communication. While providers frequently express a preference for brief, concise messages, the data reveals a different trend. Longer, more descriptive messages were more likely to reach the intended clinician, as complexity often serves as a signal for triage systems to escalate the inquiry to a doctor rather than a nurse or medical assistant.

The Role of Etiquette and Punctuation

Specific greeting styles emerged as a primary factor in identifying the sender's recipient. Messages that included a formal greeting like "Dear Dr. (Last Name)" showed higher rates of direct clinician responses. Including a first name increased these odds further. Tang suggests that these greetings help identify the doctor, which makes it more likely the system routes the message to the correct person rather than filtering it through a general support queue.

Punctuation and tone also played a role in how messages were received. The study observed that messages with expressive punctuation, such as multiple question marks or exclamation points, were processed differently by the system. Furthermore, positive sentiment expressed within the text, such as noting that a condition is showing signs of improvement, correlated with higher response rates. Conversely, expressions of sadness or frustration appeared to correlate with a slight decrease in the likelihood of a direct response from the physician.

Systemic Limitations and Future Considerations

These findings highlight a significant gap between patient intuition and system performance. Many patients assume that brevity is the best approach to respect a doctor's time. However, the triage systems embedded in modern health portals operate on different logic. When a message is too brief, it may be categorized as a minor query and handled by staff members. When a message is detailed, it triggers the escalation pathways that lead to a physician's inbox. This mechanism inadvertently favors those who are comfortable with formal, detailed communication styles.

Tang emphasizes that the burden should not fall on the patient to perform specific writing styles. Instead, the focus should remain on improving the back-end infrastructure of health records systems to ensure equitable access. As health systems experiment with AI tools to assist doctors in drafting replies, there is potential to develop similar software that helps patients format their queries for clarity. This could bridge the gap for those who currently struggle to navigate the portal interface effectively.

Patients should also recognize the limitations of these digital tools. Physicians often stress that complex health issues require an office visit rather than a typed message. If a health concern is urgent, the patient portal is not the appropriate channel. Most systems are designed for non-emergency communication, with a typical turnaround time of two business days. The study is limited by its focus on a single health system and English-language messages, meaning these results might not apply to every clinic, yet they provide a clear signal that the design of the portal affects the quality of care provided.