Dear Dr. Jeff: I am serving as the Medical Director of two facilities of similar size as well as maintaining a private practice. In both facilities, the offices of the administrator and department heads are located physically near each other, but the communication styles are dramatically different. In one, the administrative team pop in and out of each other’s offices with a lot of small group informal problem-solving and updating. In the other, everyone uses email to communicate, even when their offices are immediately adjacent. In the first facility, quarterly Minimum Data Set (MDS) and Care Plan updates are completed with a large group including every discipline present, while in the second each discipline completes its own sections of the MDS on the computer with just a brief meeting of key players available for whatever family might chose to attend. I am not computer-phobic, but I feel personally more comfortable with the face-to -face style, although I worry that I might miss or forget important information as I am only physically present for a few hours per week with limited telephone availability. What do you think? Dr. Jeff replies: The technology of communication shapes the message being delivered. “The medium is the message” was a key insight of Marshall McLuhan’s Understanding Media (1964), published before MIT computer users developed MAILBOX or Roy Tomlinson created the @ symbol to designate computer addresses. Since the means by which a message is transmitted determines its potential recipients, content, and meaning, the selection of communication system should match the intention of the sender. Distributing a new federal regulation or sharing a joke may require different communication modalities. Modern technology has tremendously enhanced our theoretical ability to communicate with others around the world and around the corner. In the 19th century, nearby postal service in many areas was so rapid that one could mail dinner invitations in the morning and receive written replies before cooking the meal, but distant communications could still require weeks to months. The telegraph totally transformed distance communication, and Marconi’s wireless telegraph expanded its reach. But these technologic advances still transmitted brief messages between fixed points. Indeed, Western Union charged for telegrams by the word, which encouraged brief, concise messages lacking warmth or subtlety. Because telegrams were frequently used to transmit urgent bad news, such as a death or serious illness, their receipt was often dreaded. Today, computer communications provide tremendous advances and opportunities. They allow for instant distribution across vast distances, among scattered sites, and to individuals who might be at unknown locations or even in transit. They allow the rapid dissemination of documents, meeting minutes, notifications, policy changes, and reminders at virtually no cost or damage to trees. The computer facilitates the scheduling of meetings among participants who have varied and complex calendars. Most email programs also offer a feature allowing confirmation that a message was opened, albeit not necessarily that it was read. Computer-based communication obviously avoids the need to repeat the same message to each recipient or to bring together a large group to provide trivial messages such as the date of the annual party or that a meeting has been canceled or its location moved. Within businesses, it has largely replaced interoffice mail and the once ubiquitous reusable brown envelopes and multiple mail rounds per day. Features such as out-of-office notifications eliminate confusion over failure to reply. Email communications, however, are ultimately permanent and never truly private — as many politicians, criminals, and garden-variety gossips have learned to their sorrow. While permanence has some advantages, such as allowing later reference, it makes them a dangerous repository of potentially damaging information or comments. Emails can be downloaded from organizational systems onto private devices with unknown readers. Even with the potential risk of hacking aside, emails remain susceptible to legal discovery. Nearly everyone has a story of an email containing derogatory comments about an individual or group winding up accidentally or deliberately in the inbox of the subject(s) being criticized or mocked. Even when an email has been deleted by every recipient, it might still have been attached at the bottom of a communications thread and inadvertently distributed to a wider audience. Every viewer of television crime programming or national political news is aware that deleted emails can be retrieved from servers and used by investigators. Nothing should ever be written in an email that the writer would not be willing to have made public.Communication is a two-way process of reaching mutual understanding. When the goal is simply to deliver information, the computer can be effective. But if the goal is understanding or the expression of any emotion, the computer is an inadequate substitute for conversation. Reliance on electronic communications presents several other risks as well. Within a long-term care facility, large portions of the staff are typically not on the facility email. Nursing assistants, housekeepers, dietary and laundry personnel in most facilities have minimal computer access. Security guards as well as unit licensed and registered nurses in many facilities do not routinely have facility email addresses. Medical staff members, even when given access to facility email, may not routinely check their accounts, even on the days when they are physically present in the facility; communication with the nursing staff is typically face to face and through the medical record with other members of the interdisciplinary team. Email “blasts” provide the illusion that everyone in the facility has been informed when, in fact, most of the staff have not. Changes in personnel policies, schedules for mandatory in-service training, new facility quality improvement initiatives, and work schedules are all examples of information that should not be distributed exclusively electronically as they will not reach many necessary recipients. Another concern with overreliance on email communications is the creation of a hierarchy through distribution lists. Senior personnel may be reluctant to advertise their absence from the facility, but the distribution list for this information is readily interpreted as a measure of those considered “key” employees. For facilities that are part of nursing home chains or health systems, distribution of changes at the higher levels could reasonably be seen as another measure of an individual’s status within the hierarchy. Many choose to avoid this concern by creating exhaustive distribution lists including many in middle management for whom the communication is irrelevant or unintelligible. Overreliance on email communications — with excessive distribution lists, expectations of immediate replies, replies routinely sent to All rather than Sender — ultimately create a style of spending excessive time on the computer and insufficient time thinking, or with the residents and staff, or actually accomplishing necessary tasks. Hours per day can easily be consumed quickly reviewing and deleting hundreds of emails. This represents a huge waste of time and resources for the organization and simultaneously decreases staff morale and enthusiasm. Email barrages sent at night or on weekends can make this worse. The unspoken message delivered is that leadership does not respect staff time and off-duty employees must choose between ignoring unopened communications or providing uncompensated work. Although overuse of email is a correctable problem and the risk of questionable content in emails can be taught and overcome, one of the most difficult issues to address is the tone of written communications. Often the impression is different than intended, even if the writer is extremely skilled. For example, a simple request written on the computer to bring a document to your office may sound like a peremptory order to the reader. Even adding a softening “please” can be read as impatience, irritation, or nagging. Back-and-forth discussion via email responses may rapidly degenerate into debate and controversy because computer text does not convey nods of agreement — a nuanced tone is nearly impossible to achieve. Attempts at group communication, as when a committee tries to meet via email, are rarely successful; one or two participants (who type faster, perhaps?) tend to dominate, and others may not know how to interrupt or enter the conversation. Human speech, even via telephone, affords a subtlety of communication through tone, pauses, and phrasing that cannot be duplicated in computer text. The computer is unable to convey whether your voice would go up or down at the end of a sentence. Added emojis are lame replacements for emotional subtlety. When face-to-face communication occurs, speakers read body language. They add humor or irony through facial gestures, adjust course when the group seems to become bored or fails to understand, recognize silent approval or disagreement, and encourage those who wish to speak to join in. One of America’s iconic movie lines from Cool Hand Luke, occurs when the warden says, “What we’ve got here is failure to communicate.” (This assertion, of course, is accompanied by having Luke beaten by the guards.) Delivering orders is not communication, and failure to follow instructions is not the same as not understanding them. Communication is, by definition, a two-way process of reaching mutual understanding. When the goal is simply to deliver information, the computer can be an effective mechanism. But if the goal is understanding or the expression of any emotion, whether positive or negative, the computer is usually an inadequate substitute for conversation. Dr. Nichols is past president of the New York Medical Directors Association and a member of the Caring for the Ages Editorial Advisory Board. Read this and other columns at www.caringfortheages.com under “Columns.”