As primary care physicians, we see a scene play out almost daily. A patient is sitting in front of us, explaining her symptoms: She could have difficulty breathing, stress at home, fatigue. We know there is nothing more important than being fully present.
However, our minds and eyes keep darting to the computer screen and the growing inbox of messages from other patients: “I forgot my Lipitor for a week, should I double up tomorrow?” “I’ve had a cough since starting that new medication,” “I’m traveling to Vietnam next week, do I need any vaccines?”
Today, the fastest-growing care setting isn’t the hospital or home — it’s the mobile phone. Google now receives more than 1 billion health-related searches every day, and patient messages for medical advice have increased sixfold in the past decade. The explosion in patient messaging is a clear sign that patients want more access to information about their health, despite the long wait times and often unclear responses.
As a result, physicians must balance two patients at once: one in the clinic and one in the inbox, with the latter now consuming more than an hour of unpaid physician time per day. A recent physician opinion piece described inbox management as “unbearable … an involuntary, never-ending, after-hours second job for physicians.”
This increasing burden has contributed to a sharp rise in physician burnout, which combined with an aging population, is projected to cause a shortage of more than 40,000 PCPs in the U.S. by 2040. In many cities, wait times to see a PCP already exceed 40 days — that is, if a provider is available at all.
With our health care system on the brink and PCPs drowning in inbox messages, it’s easy to see why many view patient messaging as a root cause for our impending access crisis.
But we believe that it may actually be a big part of the solution.
Asynchronous care — care delivered via messaging — is the most lightweight and low-friction form of care. It provides patients convenient access to medical expertise, particularly those who otherwise rely on Google searches and online discussion forums. Asynchronous care is especially well-suited for chronic conditions that need regular management or those with mobility challenges, including older or frail patients. Messaging allows patients and families to communicate with doctors as effortlessly as texting a friend, without the friction of scheduling appointments, traveling to clinics, or logging into video. When messaging alone isn’t enough, patients can be guided to the most appropriate care setting, ensuring scarce health care resources are used efficiently.
Messaging is also well-suited for conditions that require frequent monitoring. Recently, we were involved with a patient who developed a severe rash from an insect bite. Normally, she would have gone to urgent care. In this case, she messaged her care team a photo. A physician dedicated specifically to “inbox” medicine identified the rash as an allergic reaction, recommended an over-the-counter antihistamine, and checked-in periodically over the next two days. The result? The rash cleared up, and the patient avoided a costly and inconvenient appointment, freeing up a slot that could go to someone who needed to be seen in person. In these cases, traditional encounter-based care is clunky and ineffective whereas asynchronous care offers a low-cost and highly effective alternative — whether it’s checking-in on a patient after a lengthy hospitalization or titrating insulin doses for a patient with diabetes.
We think it’s time to lean into messaging as an important care modality for the future. PCPs can no longer balance both in-person and messaging-based care, which is why we believe it’s time for a new medical specialty: asynchronous medicine.
Building a new specialty is challenging and takes time, but we’ve done it before. Most of the specialties created in the 20th century have been in response to the emergence of new care settings and technology advancements. Intensive care emerged to handle ventilated patients during the polio epidemic, emergency medicine developed alongside the rise of emergency systems, and hospital medicine was born as inpatient care became too complex for primary care doctors to manage alongside outpatient responsibilities. Each time, the result was a leapfrog improvement in patient experience, quality, and efficiency.
The three of us are working together to develop clinical teams and tools to advance messaging-based health care. We have learned that to make asynchronous care successful as a distinct specialty, we need new approaches to training, technology, and reimbursement.
First, asynchronous care requires dedicated providers who specialize in messaging as a care modality. Only then can clinicians truly master the skill set required for digital care — for example, weaving the latest peer-reviewed literature into responses, embedding vetted educational videos, or knowing when to refer patients to an in-person provider. As the specialty evolves, we need to establish quality metrics that assess the performance of asynchronists, such as the number of messages required to resolve an issue and patient adherence to messaging-based recommendations. We envision that a subset of medical students will be uniquely drawn to this field, particularly those interested in harnessing technology to enhance care delivery and improve efficiency.
Second, we need purpose-built tools that leverage technology to assist providers in responding to messages more quickly and with greater empathy. For example, imagine a patient with hundreds of pages of medical records. Instead of a provider painstakingly combing through the chart for thirty minutes, artificial intelligence (AI) agents can instantly pull up the most relevant clinical details and display them alongside the patient’s message. As the provider types a response, AI can offer real-time suggestions to refine the tone and improve accuracy.
Asynchronous care must also be reimbursed in a way that supports its sustainability. Traditional billing codes are designed for 20th century, encounter-based care. Since that’s no longer the only way patients want to access care, we need a new reimbursement model that captures the value of messaging-based care — not just for individuals, but for how democratizing access can cut down on avoidable emergency room visits, hospitalizations, and low-value specialty care.
If we get it right, the benefits will be profound. Patients can have hundreds of digital touchpoints with clinicians each year, and their questions can be answered in minutes rather than days. Meanwhile, PCPs would be relieved of hours of inbox management, allowing them to return their focus fully to the patient in front of them.
The practice of medicine is evolving rapidly, which means we must evolve with it. Thirty years ago, hospitalists were a novel concept, met with resistance from providers hesitant to cede control of their patients. Today, hospital medicine is the fastest-growing specialty in the country.
In this era of tech-enabled care, asynchronous medicine offers similar promise to improve access, super-charge existing providers, and enhance patient experience — but only if we embrace its full potential.
Muthu Alagappan, M.D., is an AI researcher, internal medicine physician, and technology executive. He is the founder and CEO of Counsel Health, a virtual medical practice specializing in messaging-based care. Rishi Khakhkhar, M.D., M.B.A., is a practicing emergency medicine physician and the founding medical director of Counsel Health. He is the former medical director for virtual urgent care at Mount Sinai in NYC. Ben Kornitzer, M.D., is an internal medicine physician and a senior adviser to McKinsey & Company. He previously served as chief medical officer for agilon health and the Mount Sinai Health Network.