Patient portals have become a routine way to communicate with primary care providers. Patients can request refills, ask questions, and schedule appointments without visiting their doctor in person or calling the office — offering a convenient way to stay on top of their health.
Some patients may assume that any message they address to their physician goes directly to that physician, but that’s not always the case. In reality, messages may enter a triage pool where another member of the care team decides how to handle them — and this raises an important question: Could how those messages are handled contribute to disparities in care? If some patient groups receive different responses, portal communication could become another source of unequal access to care.
A new cross-sectional study published in JAMA Network Open examined whether different message content or writing style might help explain disparities in care team responses to portal messages sent from patients from historically marginalized racial and ethnic groups.
Researchers reviewed 3,619,390 patient message threads sent by 511,020 patients. Messages were sent between 2021 and 2023 to non-trainee physicians, nurse practitioners, or physician assistants in primary care. They used natural language processing to examine both message content and writing style.
Black patients represented 3.7 percent of the message threads in the study population. Compared to white patients, Black patients had a 3.7 percentage-point lower response rate from the originally intended clinician. This translated to an 11.6 percent relative reduction in the likelihood of receiving a response from that clinician.
Researchers concluded that writing style may explain about half of the observed disparities in care team responses, underscoring it as a potential source of bias in message triage and a target for intervention.
For clinicians, the findings suggest the disparity wasn’t simply about what patients were writing about. Instead, the researchers found that differences in writing style may have played an important role.
The researchers found that message content was associated with clinician response but didn’t explain the observed racial disparities. A patient’s writing style, however, accounted for about 48 percent of the response-rate difference between Black and white patients.
The research team examined portal message characteristics, including word count, reading level, punctuation, greetings, and other stylistic features. They found that certain writing style characteristics were strongly associated with higher rates of target clinician response, such as:
One particularly important insight stood out: two patients could communicate essentially the same underlying clinical request but use different writing styles, which may have influenced how the message was handled. However, this finding doesn’t mean Black patients are responsible for the disparity because of how they write. Rather, these findings raise questions about whether clinicians or triage systems may respond differently to communication styles associated with different patient populations.
For Black patients who already experience significant disparities in access, trust, communication, and quality of care, unequal responses to portal messages could create another barrier.
A delayed or missed response can have practical consequences when patients are asking about:
The study also found that message topics varied considerably, with common categories including medication refills, appointments, laboratory/imaging results, respiratory symptoms, and musculoskeletal pain.
Digital communication is not necessarily neutral in the healthcare system. The way clinicians, care teams, and digital tools interpret patient messages can influence whose concerns receive attention and how quickly.
For clinicians, equity efforts need to extend beyond the exam room to the digital front door of healthcare. This is particularly relevant when communicating with Black patients — many of whom may already have concerns about whether the healthcare system will listen to and respond to their needs.
Providers and their staff should triage patient portal messages by clinical need, not writing style. How a patient writes their message should not determine how, or even when, providers answer their concerns.
Practical strategies can help reduce communication issues in portals, including:
Patient portals have become part of routine care for many practices, so equity efforts should include what happens after a patient clicks “send.” The study doesn’t establish that writing style causes racial disparities in clinician response — it’s observational and identifies writing style as a potential contributing factor. However, the findings give providers and health systems a reason to examine whether their portal workflows unintentionally disadvantage certain patients.
The goal is not to teach patients how to “write better.” Rather, it should be to build systems that recognize and respond equitably to patients regardless of how they communicate.
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