1. Medical education
What parents want from emails with their pediatrician: Implications for
teaching communication skills
Jocelyn H. Schiller a,
*, Jennifer G. Christner a,b
, Robert Brent Stansfield b
, Caroline S. Watnick c
,
Patricia B. Mullan b
a
Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, USA
b
Department of Medical Education, University of Michigan Medical School, Ann Arbor, USA
c
Department of Pediatrics, Children’s Memorial Hospital, Chicago, USA
1. Introduction
Electronic mail (email) communication between physicians
and patients is on the rise [1–3]. Recent studies report 20–74% of
physicians use email with their patients [4–9]. Seventy-four
percent of parents expressed interest in emailing their child’s
physician and 80–84% felt physicians should email with parents
[10–12]. Numerous studies have confirmed the importance of
clear physician–patient communication in healthcare outcomes
[13–15]. Tools to teach and assess physicians’ communication
skills have been developed but these involve face-to-face
communication skills [16–19]. While accreditation bodies for
both undergraduate and graduate medical education emphasize
that communication skills must be taught and assessed [20,21],
there is little evidence of email communication skills being
taught across the continuum of learning, and little is known
about what patients and their families desire in emails from their
physicians.
Patients and families represent an important stakeholder in
curricular reform [22–24]. The Accreditation Council for Graduate
Medical Education recommends drawing on patients and families
as an important source for assessing communication and patient
care competencies [25]. Prior research found differences between
patient and faculty descriptions of ideal physician attributes [26].
Parents may have a different perspective from health professionals
[27] and active collaboration with parents and families may
enhance communication skills education [28]. Consequently, we
hypothesized that faculty perspectives on what parents want
communicated to them and how they want it communicated via
Patient Education and Counseling 92 (2013) 61–66
A R T I C L E I N F O
Article history:
Received 30 May 2012
Received in revised form 7 February 2013
Accepted 23 February 2013
Keywords:
Electronic mail
Medical student education
Education
Physician–patient communication
Patient–provider relationship
A B S T R A C T
Objective: Physician–patient email communication is increasing but trainees receive no education on
this communication medium. Research eliciting patient preferences about email communication could
inform training. Investigators elicited parents’ perspectives on physician–parent email communication
and compared parent and faculty assessments of medical students’ emails.
Methods: This mixed methods study explored physician–parent email communication in 5 parent focus
groups using qualitative analyses to identify themes. Differences between faculty and parent assessment
scores for students’ email responses were calculated using univariate general linear modeling.
Results: Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3)
Expectations. Parents criticized student’s statements as condescending. The sum of assessment scores by
parents and faculty were moderately correlated (r(44) = .407, P < .01), but parents gave students lower
scores on ‘‘acknowledges validity/expresses empathy’’ (P = .01) and higher scores on ‘‘provides next
steps’’ (P < .01) and ‘‘identifies issues’’ (P < .01).
Conclusion: Parents place value on students’ abilities to communicate clearly and convey respect and
empathy in email. Parent and faculty perspectives on email communication are similar but not the same.
Practice implications: Differences between parental and faculty assessments of medical students’ emails
supports the need for the involvement of patients and families in email communication curriculum
development.
ß 2013 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: Department of Pediatrics and Communicable
Diseases, University of Michigan Medical School, Mott 12-525, 1501 E. Hospital
Drive, SPC 4280, Ann Arbor, MI 48109-4280, USA. Tel.: +1 734 615 7845;
fax: +1 734 647 5624.
E-mail address: johuang@umich.edu (J.H. Schiller).
Contents lists available at SciVerse ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
0738-3991/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pec.2013.02.012

2. email may not necessarily correspond to parental needs and
preferences. We found no prior articles investigating the use of
patients or patients’ parents in assessing medical students’ or
physicians’ email communication skills.
This study sought to explore parental attitudes and behaviors
regarding ideal physician–parent email communication and to see
if differences existed between parent and faculty assessments of
student responses to a simulated email using mixed qualitative
and quantitative methods.
2. Methods
Our study builds on our previously described email communica-
tion educational intervention in our pediatric clerkship assessing
third year medical students’ knowledge, communication and
professionalism via responses to simulated email [29]. This
curriculum utilized simulated parent emails in which parents
expressed concern about their children’s medical care. Simulated
email cases were developed by expert members of the pediatric
faculty who were actively involved in medical student education.
Assessment rubrics identifying both assessment criteria and
operational definitions of scale points were also developed. During
the pediatric clerkship, students responded to one email early in the
clerkship, acting as an intern caring for the child. Students then
participated in an educational session on email communication
facilitated by an experienced pediatric faculty member in which
they responded to an email message from a parent. Two weeks later,
the students responded to a second email. Faculty assessed the
second email responses using the assessment rubric (Table 1). Our
current study drew on our database of students’ email responses and
associated faculty assessments. We randomly selected student
responses that represented a range of performance.
Parent participants were solicited from three sources: our
children’s hospital’s family-run organization for family centered
care, an internet portal connecting volunteers with research
studies, and an urban clinic. Providers were asked to give fliers to
parents at the urban clinic. However, no parents from the urban
clinic chose to participate. Participants gave verbal informed
consent and received a gift certificate for participating. The
University of Michigan Medical School IRB designated this project
as exempt.
Our study used a mixed (qualitative and quantitative) study
methodology.
2.1. Qualitative methods
To explore what parents desire in email communication with
physicians, two moderators conducted five focus group sessions
using a semi-structured interview protocol. Participants were
asked to share stories of their own email experiences with
physicians in order to identify specific attitudes and behaviors they
had experienced. Parents were then asked what they desired in
ideal physician–patient email content and communication style.
Participants were asked to read students’ email responses and
write their reactions, and then complete a structured assessment
of the emails using an assessment rubric (Table 1). Participants
were given the simulated parental email and were informed that
the responses were written by students. After participants
assessed email responses, the discussion resumed to explore what
parents thought about the students’ responses and additional
reflections on desirable traits in physician–patient email.
The audiotaped sessions lasted between 90 and 120 min and
were transcribed by an independent transcriptionist. Transcripts
were compared to field notes and proofread by one of the authors
(JS) using audiotape to assure accuracy.
Using the constant comparative method [30], each sentence of
the transcripts was read by three investigators (JS, JC, CW)
independently and independent codes were assigned. The
researchers discussed the data, codes, and themes until they
reached consensus. The transcriptions were coded using NVivo 8
Table 1
Parent grading rubric for medical student email response.
(Front page)
Please comment on your initial reactions to this email.
If you were going to give this student feedback, what would you say?
What ‘‘grade’’ would you give this email?
(Back page)
Circle either ‘‘Done well’’, ‘‘Needs Improvement’’, or ‘‘Not Done’’.
The email to the patient
1. Restates the parent’s concern
Done well Needs Improvement Not Done
2. Acknowledges the validity of the parent’s concern/expresses empathy
Done well Needs Improvement Not Done
3. Provides an appropriate next step for addressing the parent’s concern
Done well Needs Improvement Not Done
4. Minimizes or explains medical jargon
Done well Needs Improvement Not Done
5. Correctly identifies the underlying medical issue and reason for the initial decision
Done well Needs Improvement Not Done
6. Summarizes the benefits and risks of the alternative the parent is requesting vs. what was recommended
Done well Needs Improvement Not Done
7. Sites credible source of info
Done well Needs Improvement Not Done
8. Appropriately involve attending physician
Done well Needs Improvement Not Done
9. Demonstrates respect for parent
Done well Needs Improvement Not Done
J.H. Schiller et al. / Patient Education and Counseling 92 (2013) 61–6662

3. [31]. Researchers assured thematic saturation by ensuring that no
new concepts and themes were discovered in the final two focus
groups.
2.2. Quantitative methods
The quantitative component compared parent and faculty
assessments of medical students’ written performance. Students’
email responses were assessed using the 9-item assessment rubric
on a 2-point scale with 0 = not done, 1 = needs improvement,
2 = done well (Table 1). Assessment scores were classified by rater
type (faculty or parent) and item (1–9). We calculated inter-rater
reliability for both parent and faculty raters using Intraclass
Correlation Coefficient Type-2 (ICC2) [32]. ICC2 is computed as the
difference of between- and within-group variance (mean squared)
divided by the between-group variance; this is an estimate of the
reliability of group means. We also examined the magnitude of the
association between parent and faculty assessments and differ-
ences in assessing student performance using univariate general
linear modeling. Significant effects were explored using Tukey
Honestly Significant Differences post hoc tests which corrects for
multiple testing, with a = .05. Analysis was performed using R [33].
Our sample size gave us .80 power to detect small effects (a parent-
faculty overall rating difference of eta = .11 and Tukey HSD-
corrected item effects of eta = .165 or greater).
3. Results
Between July and September 2010, 19 parents participated in
one of five focus groups. 79% were female, 100% were white, 47%
had attended graduate school and 53% had an annual family
income above $100,000. Fifty-two student email responses and
their corresponding faculty assessments were used for this study.
3.1. Qualitative results – focus group themes
Qualitative analysis of the focus groups revealed three broad
themes and subthemes (Table 2). Themes included Building the
Relationship, Clarity of Communication, and Expectations. Tran-
script excerpts representative of the respondents’ perspectives are
included to capture their voice.
3.1.1. Building the Relationship
Participants wanted emails to demonstrate respect, compas-
sion and empathy, but they found many of the students’ attempts
at empathy to be patronizing. One parent said, ‘‘This one. . .said ‘I’m
sorry for your current situation, I know that having a sick child can
be a very trying time for parents.’ I just thought, you’re patronizing
me and don’t tell me how I feel.’’ Another parent said, ‘‘[The
student’s email] says, ‘I can certainly understand the frustration
you may be feeling in believing that we have not provided the best
treatment’ and I’m like, if I would have read that as my first
sentence from a doctor, I would have shut down.’’
Parents appreciated providers extending invitations to continue
communicating. A parent commented, ‘‘Some of these emails. . . I
liked better because it gave the parents. . . a way to get in touch
with the doctor sooner . . . And then there was another one that . . .
sort of blew the parent off. . . It basically said don’t [contact] me
again until three days.’’ Parents valued providers giving parents
contact information to use if concerns persisted.
Misinterpretation of written communication was frequently
mentioned. One parent who had emailed physicians in the past
said, ‘‘By the time we started emailing, we’d already had a
relationship for several years so there was less danger in. . . reading
it differently than someone intended it, you know how you can do
with email?’’ Parents recognized that their expectations might
differ depending on their relationship with the provider.
3.1.2. Clarity of Communication
Clarity of communication emerged as a key criterion partici-
pants used in judging email communications. Parents wanted a
clear plan from the physician. A parent said, ‘‘You always want to
know what the next step is and also to get a feeling that the
physician has a good understanding of what the issue is.’’ Parents
expressed wanting to know symptoms to watch for and when to
follow-up with the physician.
Participants wanted emails to be written in language they could
understand. Participants were concerned with the clarity of the
explanation of the medical decision-making and plan. Several of
the students’ email responses were criticized for being too
‘‘technical’’ for parents to understand. One parent stated, ‘‘[What
is most important to me is] that he or she speaks to you. . .that you
understand. . . you’re not a physician, you didn’t go to medical
school, so it’s the terms that they use, to dumb them down quite a
lot so that the general lay person can actually understand them.
That’s always the issue I have.’’
Participants criticized dense text. A parent commented, ‘‘Some
of these [emails] were. . . huge paragraphs, (but) this [email] was
broken up into nice sections. It had a good intro. It explained their
positions and why they didn’t want to give the kid antibiotics,
which made a lot of sense. It was easy to understand. It wasn’t too
wordy. . . it was a good email.’’ Several parents suggested that
physicians should be taught how to write an organized email.
Participants found grammatical, spelling and factual errors
disconcerting. One participant noted, ‘‘This [email] gave me some
really good information but they don’t know how to do paragraphs
and it’s not all grammatically correct. . . it’s really off putting to me
when a professional is writing something that is not grammatically
correct with proper syntax. I mean, you just lose my level of
respect.’’
Parents varied in whether they would find references useful,
but if provided, participants preferred nationally recognized sites
such as the Centers for Disease Control rather than the institution’s
own website. One parent noted, ‘‘Parents can be skeptical when
Table 2
Themes from parent focus groups.
Theme and subthemes
Building the Relationship
Respectful, not patronizing
Open Invitation: willingness to communicate, availability of physician
Addresses parental concern
Existing Relationship: changes parent expectations in email communication
Accepting responsibility
Compassion
Personalized response
Clarity of Communication
Reference: citing a source or providing link for further information
Plan: next communication, plan for follow up
Length of email
Explain: explanation of medical decision-making, includes why antibiotics not
prescribed, risks and benefits of treatment
Jargon: use of lay language
Consistent message with information given at appointment or within email
Organization of email response
Grammatical or typographical errors
Expectations
Appropriate content to email to physicians
Guidelines as to how to use, expectations of email usage
Other items that emerged
Convenience
Acknowledging time commitment for physician
Written reference to refer back to or share with family/other providers
J.H. Schiller et al. / Patient Education and Counseling 92 (2013) 61–66 63

4. you’re talking about your children. So if you’re [The-Institution]
doctor and you’re giving [The-Institution] sources, of course. . .
you’re going to agree with whatever information you’re giving me. . .
Go to the CDC. . . When you can get opinions across different
[institutions] thatmatchup, parentsare like,‘Ok,that reallyis what’s
going on out there, they’re not just Dr. Joe’s opinion. Because Dr. Joe
. . . works for [The-Institution] and [The-Institution] is paying him to
have an opinion.’ Skeptical parents will think like that when they’re
worried about their kids.’’ If Internet links were provided, parent
participants preferred to have them at the end of the email.
3.1.3. Expectations
Most participants suggested that guidelines and expectations
for both providers and patients regarding email use would be
useful. Parents voiced expectations for providers’ responses to
patient emails. Most participants expected a response within 24 h
or by the end of the workday if the email was sent in the morning.
Parents appreciated the ability to send an email at any time of day
even if the physician’s response came the next day.
Several parents expressed a preference for emailing the primary
physician directly, especially if the patient had a complex medical
history. Parents appreciated communicating directly with the
physician who knew their child, rather than explaining the
situation to staff or nurses who did not understand the nuances
of the patient’s medical history.
Participants said they would appreciate appointment remin-
ders or patient requests for prescription refills to be accomplished
via email. Most, but not all, participants would like routine test
results such as cholesterol screening results or normal X-ray
results emailed. A few participants felt that any personal medical
information should stay out of email. Participants agreed that ‘‘bad
news’’ should not be emailed.
Focus group participants indicated that use of emails should be
clearly presented as an option, not an expectation, in communi-
cating with physicians. One participant, however, noted that once
her primary care clinic instituted guidelines for email use, she felt
discouraged from using email, as if her emails were not welcomed.
3.2. Quantitative results
Three faculty members and two parents assessed each students’
email response. The reliability of the means of ratings among
faculty was strong (ICC2 = .85) and higher than that of parent
ratings (ICC2 = .52). The means of total scores were used to assess
agreement between faculty and parents for each email; despite the
lower reliability among parents, their mean rating correlated
moderately with those of the faculty (r(44) = .407, P < .01). Table 3
shows the ICC2 scores of faculty and parents on each item and for
the sum of the 9 items.
Looking at the sum of the ratings, no significant differences
between faculty and parents emerged; parents seemed no more
likely to give higher or lower scores than did faculty
(F(1,2610) = 2.26, n.s.). However, in analyses that examined ratings
across items, we found statistically significant differences between
the faculty and parents (F(8,2610) = 17.56, P < .001) (Table 4). Our
post hoc tests identified three of the nine items as eliciting ratings
from parents that were significantly different from those of faculty.
Parents graded students’ communication in ‘‘identifies issues’’
(difference in mean scores 0.42, 95% CI 0.15–0.69, P < .01) and
‘‘provides next steps’’ (difference 0.69, 95% CI 0.42–0.96, P < .01)
higher than did faculty. In contrast, parents graded students less
favorably the students’ performance on ‘‘acknowledges validity/
expresses empathy’’ (difference 0.31, 95% CI 0.58–0.04, P = .01).
Parents gave students a lower score for ‘‘demonstrates respect for
parent’’ than did faculty, although differences did not reach
statistical significance.
4. Discussion and conclusion
4.1. Discussion
We sought to elicit and reflect on factors important to parents
receiving emails from their child’s physician. We found parents
were willing and able to articulate what sentiments they
appreciate in email communication. They place value on physi-
cians’ abilities to convey respect and empathy, as well as their
ability to communicate clearly. Parents also discussed the
importance of having guidelines to set expectations for email use.
Several authors propose models defining goals of in-person
medical communication [34–39]. de Haes’ synthesis includes (1)
fostering the relationship, (2) gathering information, (3) informa-
tion provision, (4) decision-making, (5) enabling disease and
treatment-related behavior and (6) responding to emotions. These
goals are relevant to our email scenario and are similar to the
themes reported by participants. This suggests that there may be
similarities between ideal physician–patient email communica-
tion and traditional face-to-face communication. Email communi-
cation, however, has the added complexity of requiring writing
skills in order to convey the message clearly and lacks non-verbal
communication cues that can clarify the communicator’s message.
Table 4
Mean scores given by faculty and parents (on a 0–2 point scale) and difference between parent and faculty.
Item Parent
Mean score
Faculty
Mean Score
Difference (95% confidence interval) P
Restates parent concern 1.62 1.77 À0.15 (À0.42 to 0.12) 0.87
Acknowledges validity/expresses empathy 1.59 1.90 À0.31 (À0.58 to À0.04) 0.01
Provides next steps 1.69 1.00 0.69 (0.42 to 0.96) <0.01
Minimizes/explains jargon 1.82 1.87 À0.05 (À0.32 to 0.22) 1.00
Identifies issues 1.73 1.31 0.42 (0.15 to 0.69) <0.01
Explains risks/benefits 1.61 1.75 À0.15 (À0.42 to 0.12) 0.92
Cites credible source 1.44 1.40 0.04 (À0.24 to 0.30) 1.00
Appropriately involves attending 1.82 1.74 0.08 (À0.19 to 0.35) 1.00
Demonstrates respect for parent 1.68 1.89 À0.21 (À0.48 to 0.06) 0.36
Table 3
Inter-rater reliability estimated using ICC2 for faculty and parent raters on each
item individually and for the sum of all 9 items.
Item number Item Faculty Parent
1 Restates parent concern 0 .16
2 Acknowledges validity/expresses empathy .81 .32
3 Provides next steps .60 .36
4 Minimizes/explains jargon .47 .60
5 Identifies issues .64 .64
6 Explains risks/benefits .66 .13
7 Cites credible source .95 .48
8 Appropriately involves attending .72 .29
9 Demonstrates respect for parent .49 .15
Sum of 9 items .85 .52
J.H. Schiller et al. / Patient Education and Counseling 92 (2013) 61–6664

5. Our previous related research established the feasibility of
using emails as a means in the clinical curriculum to teach and
assess medical students on a communication style that is
increasing between patients and physicians [29]. Advantages of
using emails to assess students included accumulating an archive
of directly observable communication responses from students
and the flexibility for faculty to make assessments asynchronously.
An explicit assessment rubric for students’ email responses
contributed to the high reliability of faculty assessments.
The important next question this current study addressed was
the extent to which parents might concur or fundamentally
disagree with faculty perspectives about what constituted effec-
tive communication in emails directed to parents. Parents in our
study successfully completed overall ratings of students using
criteria that also guided faculty ratings. Our analysis showed that
parent and faculty assessments correlated, but scores on individual
items varied, deserving further exploration. Parent scores for
‘‘acknowledges validity/expresses empathy’’ were significantly
lower than faculty scores, echoing the sentiment of the focus
groups who characterized students’ attempts at empathy as
patronizing. Although it did not reach statistical significance,
parents also tended to score students’ performance on the email
less favorably than faculty in regards to showing respect for the
parent. This suggests that there may be subtleties in expressing
empathy and respect that are acceptable to faculty and medical
students, but that communicate negative connotations to patients
and parents. These differences may be exacerbated in written
communication. As parents explicitly said, the existing physician–
parent relationship changed their expectations and decreased
miscommunication. Further studies should be done to explore how
a trusting relationship changes parents’ perception of empathy
expressions.
Although parents gave relatively positive scores to student
emails, their comments were fairly negative. Prior work examining
faculty evaluations regarding student professional behavior found
that written comments contain unique indicators of students’
professional behavior that was not captured in Likert-type
evaluations [40]. Parents noted that their initial reactions to the
students’ emails were not necessarily reflected in their formal
assessment using the assessment rubric. One parent noted, ‘‘For
me, I almost did all ‘done wells’ for everything but that’s not
necessarily how my overall feeling was. . . [The student] may have
addressed it but not necessarily in a good way.’’ In light of the rich
information we found in the qualitative discussion with parents,
this supports the use of discussion or written comments in
assessing student communication.
Parent assessment scores given for items ‘‘provides next steps’’
and ‘‘identifies issues’’ were higher than faculty scores. We
hypothesize that faculty tended to score these two items lower
because they expected more detailed information from students.
Faculty intent may have been more focused on inferring the
knowledge base of students from these statements, rather than the
clarity and ability to anticipate next steps that parents expected.
Strengths of our study include its use of multiple research
methodologies in the study of the same phenomenon. In addition,
efforts to include patient and family perspectives in judging
communication competency constitutes a novel strategy that
could be used in other study sites.
A limitation of this study is that we were only able to get
feedback from a limited pool of parent participants. Our study
participants reported high family incomes and high levels of
education and all participants were of white race, which may over-
represent populations who are currently using email with their
providers. Further studies with a more diverse population may be
needed to confirm our findings. Other studies have shown
disparities in email communication with physicians [41]. Higher
income, higher education and white race has been associated with
higher use of email to communicate with physicians and higher
use of internet based patient communications portals [42–45].
These differences echo the disparities in internet access termed the
digital divide as Americans with lower incomes or lower levels of
education are less likely to use a computer or have internet access
[46,47]. Other recent studies, however, revealed another form of
electronic communication, text messaging, was effective in a low-
income population at increasing rate of influenza vaccination and
improving mental health care [48,49]. Email communication with
physicians may represent a new health care disparity that needs to
be addressed. It is probable that bridging differences in electronic
communication is an imperative priority regardless of type of
electronic communication or socioeconomic status.
4.2. Conclusion
Patients and families represent an important stakeholder in
curricular reform, offering a different perspective from health
professionals that enhances communication skills education.
Themes from the qualitative analysis reinforce the need to involve
parents and patients in assessment and teaching of communica-
tion. Our study establishes the feasibility of engaging parents
actively in corroborating and adjusting assessment rubrics to
reflect patient and family perspectives. Practical next steps for our
curriculum include using the parental input obtained to revise the
assessment rubric and analyzing inter-rater reliability after that
revision. Other areas for future research include proactively
seeking and incorporating parent preferences for all electronic
communication modalities as we design curricula that will allow
our graduates to skillfully navigate among these various options. In
addition, exploring the long term effect of electronic communica-
tion curricula on students’ ability to effectively communicate with
their patients, as well as effects on patient health outcomes and
patient satisfaction, is critical.
4.3. Practice implications
As use of email and other forms of technology-based
communication continue to increase worldwide, this study
supports the need for education in email communication. In
preparing faculty to teach email communication, instruction
should be informed with research directly eliciting parent
perspectives on respect and expressing empathy. An active
partnership between medical education professionals and patients
and families is essential in communication curriculum develop-
ment.
Acknowledgements
This project was supported by funding from the Council on
Medical Student Education in Pediatrics and the Schwartz
Foundation. The abstract of an earlier version of this article was
presented at the International Conference on Communication in
Healthcare, Chicago, Illinois, October 2011 and was published in
Medical Encounter 2011:25(3):52.
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