Draining the Email Swamp

David Steensma, MD
Edward P. Evans Chair in MDS Research and Institute Physician at the Dana-Farber Cancer Institute; Associate Professor of Medicine at Harvard Medical School; Editor-in-chief of ASH Clinical News

On a typical weekday, I receive 200 emails and send 40. Unless you, dear reader, are the taciturn Seattle hematologist who hasn’t responded to any of my emails since 2014, your incoming and outgoing electronic communication volume is likely similar. (If you are that guy, there is no longer any need to reply to my 2015 speaking invitation.)

This deluge is a big problem for all of us. How big? Let’s assume that 17 waking hours each day are potential emailing time. Granted, predatory publishers never seem to rest, but it still is fairly rare for a human to send an email from the depths of REM sleep. If your email volume is similar to mine, then on average you have an “email movement” every 4 minutes and 15 seconds. Per the National Cancer Institute’s Common Toxicity Criteria, that is a clear case of grade 4 diarrhea, requiring urgent intervention.

Once upon a time, email was exciting. I was an early adopter of electronic messaging: I sent my first binary-encoded missive in the 1970s via the ARPANET (Advanced Research Projects Agency Network), the Internet’s predecessor. The message was a simple “Hello!” to a family friend, typed under parental supervision on a Texas Instruments Silent 700 data terminal that used a heat-transfer printer and roll of paper instead of a display screen. By 1982, I had saved up enough money from my Newark Star-Ledger paper route to add a 300-baud VICMODEM to my Commodore VIC-20 home computer. Today, a dial-up modem like that seems as archaic a way of transmitting information as medieval hand-copied books in the Bodleian Library, but back then, the ability to reach someone electronically at any speed was radical, heady stuff.

In 1984, I upgraded to a 1200-baud Mitey Mo modem for the Commodore 64. Mitey Mo felt dazzlingly fast, like the Reagan-era version of FiOS. My sisters were a little miffed after Mitey Mo arrived because Mo tied up the only household telephone line for hours, so I eventually had to get a dedicated phone line. It was worth it: Those sizzling 1,200 bits per second opened a whole new world of bulletin board system traffic and messaging – and also exposed me to some sinister characters, the forerunners of today’s internet trolls, griefers, and other maladjusted anonymous sociopaths.

Thirty years later, email has degenerated from a “totally awesome,” Mitey Mo–era novelty to a reliable source of irritation for all of us. Checking our inboxes is a constant inducer of gastroesophageal reflux and repetitive strain injury. We all spend far too much time staring at screens, thinking about how to reply tactfully to communications that both lack nuance and never seem to stop coming. I’ve done what I can to rein in my own email beast, but there’s only so much one can do when even the simple act of scheduling a patient’s follow-up visit for a few lab tests can require 15 or more emails – not counting the requisite “Thanks!” to all and sundry for doing their jobs.

Ruthlessly unsubscribing from mailing lists helps keep the deluge a bit more manageable. If I simply erase all those messages and never unsubscribe, they just keep piling up; eventually there is so much inbox clutter that I am liable to accidentally delete something important when pounding on that key like a sewing-machine needle.

Once, trying to cut down on the dozens of daily emails about serious adverse events and trial amendments for studies I wasn’t involved with, I went just a little too far and unsubscribed from my center’s Institutional Review Board. Thankfully, our leukemia program’s regulatory team realized what I had done and saved me from a major headache.

I avoid clicking “unsubscribe” on emails from bogus conferences and fee-hungry open-access journals. For those unwanted emails, I’m convinced that the futile act of trying to unsubscribe only serves to confirm to the spammer that an email address is valid. Instead, I’ve built an elaborate group of Outlook rules and macros to ensure anything with solicitation buzzwords like “peptide synthesis” or “antibody catalog” is automatically moved to “Trash” – as do missives from the OMICS Publishing Group, Bentham Open, or any of the countless other purveyors of crap journals whose names sound plausible but are just a little off. I still haven’t figured out how to create a macro to delete any email with the subject, “Awaiting your esteemed and beloved research” and its numerous awkward, misspelled variants that are hallmarks of publisher spam.

I’ve often wondered where predatory publishers get our email addresses. Do bots troll medical journals behind paywalls to harvest email addresses from the Corresponding Author section of papers? PubMed used to include email addresses of corresponding authors in online abstracts, but the National Center for Biotechnology Information wised up and has not done that in years. To elude bots, I tried submitting manuscripts with the tell-tale “@” symbol spelled out as “AT”, but it didn’t seem to help. I suppose academics’ email addresses are like ill-advised text messages or nude photos: Once it’s out there, it’s always out there.

Some of the spam emails are good for a laugh. I recently received an email from a journal requesting my “delighted contribution” for a special issue on Farber disease, a rare lysosomal storage disease about which I’ve never published anything remotely relevant. Presumably I received this invitation only because I work at Dana-Farber Cancer Institute. I wonder what the symptoms of Dana-Farber disease might be. Developmental delay in academic promotions? (Promotion is so hard to achieve around here that we joke – uncomfortably – about Instructor Emeritus status.) Expensive parking? Or, more likely, an overwhelming sense of inadequacy in the presence of numerous brilliant local colleagues?

Every publication can bring an onslaught of odd invitations. A review article in which I briefly mentioned the marrow microenvironment “seed-versus-soil” debate unexpectedly led to dozens of come-ons from open-access agricultural journals. Invitations from food-safety journals quickly followed my Leukemia Research paper that mentioned the connection between clonality and banana cultivars. And a historical article I wrote 15 years ago about the origin of Congo red staining for amyloid earned me an invitation to several faux conferences on African policy; as a hematologist I would have felt qualified to speak only on the problem of blood diamonds. One wonders what sort of mayonnaise-related spam I would be receiving if I were still at Mayo Clinic.

A new trend in emails is to include “ACTION NEEDED” in the subject line. While this all-caps imperative is eye-catching and momentarily delays my reflex reach for the delete key, it usually turns out that the ACTION that is NEEDED is not mine.

When my institution’s new medical oncology department chair, Benjamin Ebert, MD, PhD, started his role earlier this year, one of his first acts was to consolidate many departmental email blasts into a weekly omnibus newsletter. I had thought highly of Ben before, but my esteem for him skyrocketed when he took a swing at the email monster. That is the sort of leadership we can all believe in!

Edward Creagan, MD, an oncologist in Minnesota who focuses on time use and productivity, advocates opening email only three times a day: late morning, early afternoon, late afternoon. His advice is sound; I wish I could heed it. He’s right, of course: When I lived in England, the most productive hours were in the morning, mostly because America hadn’t woken up and started sending emails yet. Now, if I don’t answer a patient-scheduling query or request for lab-order clarification, I know I’ll be paged in 15 minutes, and I can type almost as quickly and more definitively than I talk – and I can copy more people who NEED to take ACTION.

I also am one of those people who can’t help glancing at my phone a dozen times in a dull conference. Part of that is due to a mild case of attention deficit hyperactivity disorder, but I also love the (admittedly artificial) purity of an empty inbox. I sometimes glimpse screens of colleagues who have 8,352 unread emails, and I simply don’t know how they tolerate it. To me, such messaging chaos would be like living in a “Dexter” murder scene that hadn’t been tidied up after forensics finished.

Occasionally, opening email is highly rewarding. An email from an old friend or a manuscript acceptance from a journal triggers a brief microburst of happiness, a little flash of dopamine deep in the medial forebrain. The variable-payout randomness of joyful emails makes checking as addictive as pulling a slot machine arm.

Contract research organizations (CROs) are the primary source of another class of unpleasant email: the kind that makes no sense, regardless of how many times you read it. In fact, just as I started writing this essay, I received the cryptic message, “CTSU api app would like you to join the Study 10104 on iMedidata.”

Neither the actual name of the study nor its Clinicaltrials.gov designation appeared in this cryptic email. Based on experience, if I were to log in to learn what the mysterious 101014 is, inevitably my iMedidata password will have expired (if I ever had one in the first place) and I would have to go through multiple steps to reset it. After sorting that out, I likely would get an error requiring “an administrator” (who?) to fix it. Only the National Institutes of Health and the Cooperative Oncology Groups send emails full of more bureaucratic language and mysterious acronyms.

The few times I’ve looked into these emails further and found a functioning website on the other end, I found that the messages usually had no relevance to me. Every couple of weeks, I also get an email with a list of more than 20 “trainings” from ICON’s Firecrest that I allegedly have neglected to complete; I can’t make those stop no matter what I try. So I ignore all of these, only to find to my sorrow every few years that a real study where ACTION was NEEDED was buried under all the rubbish. Who knew?

Email encryption is another idea that perhaps seemed appealing in a conference room of paranoid HIPAA specialists but has been a slog in the real world. Supposedly, when sending identifiable patient information outside our own systems, we should use secure email to preserve confidentiality. Never mind that email is already far more secure than fax machines, which every medical center, pharmacy, and insurance program continues to use to fling patient information around without any special considerations. (I’ve found faxed patient reports and clinic notes on empty chairs at Logan airport, in commuter rail terminals, and blowing along Brookline Avenue. Once I even saw a urine-soaked prescription refill request from CVS lying on the tiles of a Fenway Park restroom. Appropriately, it was for Flomax.)

I have a sizable referral practice, so I regularly hear from dozens of hematologists/oncologists across the Northeast, many of whom use secure email systems, each of which requires updated passwords every few months. As a result, I need an entire Excel spreadsheet dedicated to maintaining these passwords and often give up on 21st century technology and instead use 19th century technology: telephoning the referring doctor to find out why they had emailed.

The one type of email that rarely is a burden is that from a patient. I usually give my email address to patients if they ask for it. Not everybody feels comfortable with that, but in more than 15 years, I’ve only had a few patients abuse it. Having my email gives patients great comfort that they can contact me about things that can’t wait for the next visit but aren’t urgent enough for a page. My own doctor has given me his email, for which I am grateful; I’ve used it twice in five years.

Last year, one of my daughter’s high school classes included a useful unit on “email etiquette.” Good email hygiene is a valuable skill that I hope will become a lifelong practice for her. I’ve known colleagues who could have used such a course – some are real screamers, like the owl-delivered Howler messages Ron Weasley’s mother sent in the Harry Potter series. Those email nastygrams remind me how important it is to practice the “safety pause” before sending an email when my hands are trembling from fury.

Almost every time that I have let my filter down, I have later felt like a heel. Once, burned out and exhausted after months on call and trying to deal with the chaos of a dozen hospitalized patients back home while at two back-to-back trips for investigator meetings, I even rage-quit my job via email. Cooler heads quickly prevailed (including my own), but I still felt pretty dumb.

Another problem with email is that it is yet another information stream we have to keep up with. Messages also come via pages, faxes, phone calls, voicemails, text messages, electronic health records alerts, and even by regular mail – not to mention websites and social media streams. This cacophony somehow needs to be consolidated into a single message stream.

Some Elon Musk–type innovator eventually will figure out a more effective communication method than email, and hopefully efficient systems will reduce the need for it. (Long jail sentences in solitary confinement for predatory publishers and bogus conference organizers might also help.) Until then, we’re stuck wading through a swamp that would challenge even the finest Dutch polder-making hydraulic engineers. The best we can do is to try not to let email control our lives and to be clear, kind to one another, and polite in our messages, perhaps even using archaic signoffs held over from handwritten-letter days, like

Best regards,

David Steensma, MD