In an inbox every message is the same height. A one-line request and a question that someone has spent a week trying to put into words occupy identical rows, in the same type, beneath the same small mark for unread. The list is orderly in a way its contents are not. Nothing in its appearance tells the reader which row will take half a minute and which will take most of an hour.
Consider three hypothetical messages, invented for this essay and deliberately ordinary, arriving one beneath another.
The first reads: I saw my results. One of them has a flag next to it. Is that something to worry about?
The second: I start a new job on the first of the month and will be on the road for six weeks. Can my follow-up wait until I’m back, or should I come in before I go?
The third comes from a daughter who helps manage her father’s account: Dad has seemed more tired since the new medicine. He says it’s nothing. I just wanted someone to know.
The first is a request for context, and the context lives elsewhere: in the number itself, in what it was the last time and the time before, in the reason the test was ordered, in what was said at the visit, and in whatever else in the record bears on it. The second looks administrative and is in fact a clinical question wearing a calendar. Whether a visit can wait six weeks depends on why it was scheduled, what it was meant to check, and what would be lost by checking later; and the answer will decide how a man spends the last days before a new job. The third is the hardest to classify. It might be the report of a symptom, a request for a call, or a worry deposited in the record so that it will exist somewhere other than in the daughter’s head. Its author has, with some care, avoided asking a question at all, and that care is itself information.
Nothing about the rows distinguishes them. The character count is no guide; the shortest message may need the longest answer. The unread count is no guide either, since it numbers messages and not problems. A queue can show arrivals and departures. It cannot show understanding. And an inbox, unlike most queues, never closes. Messages arrive whenever someone has a moment to send them, with no instinct whatever for the end of anybody’s day.
This essay follows messages of that kind beyond their rows: into the evening in which they are written, the morning in which they are read, the branching that follows a reply, the question of who should answer, and the boundaries and measures that might make the arrangement more honest. Its question is simple and its answer awkward. What would it take for a form of conversation that is instant to send, slow to answer and never closed to be humane on both of its sides?
Two Clocks #
Return to the first message and imagine the evening in which it was written. Earlier in the day the woman who sent it opened the patient portal and found a laboratory result she had been expecting, with a small flag beside one of the numbers. She has looked at it several times since: once at work, once in the car, once after dinner. She has searched the name of the test and found pages that were either too reassuring to trust or too alarming to finish. The message she finally sends is short. It is her third attempt. The first said too much. The second sounded more frightened than she wanted to sound, and she did not want to be the kind of patient who sounds frightened.
Under the federal rules that took effect in 2021, results often reach patients as soon as they are final, sometimes before anyone has looked at them in context. Much good has come of that. People see their own information without waiting for a letter or a call, and many of them read it more closely than anyone else will. But a flagged number is a sentence without its paragraph, and her message is, in effect, a request for the paragraph.
Her clock started when she saw the flag. Since then, every hour without an answer has felt as though it might mean something. Punjabi has a plain word for the condition she is in, ਉਡੀਕ (uḍīk): waiting for someone or something expected. The folk songs of Punjab are full of it. A woman watches the road for the postman or the traveller; a crow calls from the parapet, which by an old household belief means that someone, or some news, is on the way. The songs understand what the English waiting rather understates, that waiting for a reply is an activity. It occupies the mind. It keeps a corner of attention turned toward the door.
Not everyone who writes is waiting in that way, and it would be condescending to imagine so. The man with the new job is not frightened. His clock started when he signed a contract. His urgency belongs to work, travel and planning, and he would like a straightforward answer so that he can book a visit, or not, and get on with the week. His message is as reasonable as a message can be. It is also time-sensitive in a way no flag announces: if the answer arrives after the last free afternoon before his departure, a perfectly good answer becomes useless.
The daughter’s clock is different again. She may not expect a reply at all. People sometimes write to a clinic the way one tells a neighbour that an elderly relative has seemed unsteady lately, not to commission a plan but so that the burden of noticing is shared. The inbox, it turns out, receives deposits as well as questions.
The physician’s clock starts later, when the message is opened among others, inside a different set of obligations. For him the message did not exist until then. Silence means different things on the two sides of an inbox. To the sender it can feel like an answer, and seldom a good one. To the reader it is simply the time before reading.
I want to hold these clocks in view at once without letting any of them make the others look unreasonable. The woman’s question is the one she has been carrying all day, and it deserves to be treated as more than a row. The man’s planning is legitimate; so is the daughter’s wish to be heard. The physician’s attention is finite and already promised to other people’s questions, each of which also belongs to a particular life. None of these facts cancels another. Nobody in the inbox need behave badly for it to go wrong. The form itself brings together people who live by different clocks and gives none of them a view of the others’.
By Post #
Medicine at a distance and out of step is not new. The Edinburgh physician William Cullen, who died in 1790, conducted a large practice by letter. Patients, members of their families, and the physicians and surgeons attending them wrote to him from throughout Britain and abroad, and he kept their letters together with his answers: at first as written transcripts and, from 1781, as duplicates made on a mechanical copier invented by James Watt. More than five thousand documents survive, and the Cullen Project has made them readable online. Some are brief requests. Others are sustained illness narratives, the whole story set down from the first symptom to the latest remedy by people who knew the letter might be their only chance to tell it.
Those long letters show what the form once asked of the sender. A correspondent writing to Cullen had to become, for an evening, the historian of an illness, his own or a relative’s, and the result was often a better history than a hurried visit would have produced: chronological, detailed, considered. The reply could be considered too. Neither side expected otherwise. Everyone knew roughly how long the post took between a distant county and Edinburgh, and nobody imagined that the physician had read a letter the moment it arrived.
That arrangement began to change in the nineteenth century, and the change came from the post itself. Before 1840, British postage was charged by distance and by the number of sheets, and it was usually paid by the person who received the letter, which made correspondence a luxury and gave the recipient a reason to refuse it. Rowland Hill’s pamphlet of 1837, Post Office Reform: Its Importance and Practicability, argued that the cost of carrying a letter was trivial beside the clerical labour spent on calculating and collecting its charges, and proposed a low uniform rate paid in advance by the sender. The Uniform Penny Post began in January 1840; the first adhesive stamp, the Penny Black, came into use that May. The volume of letters rose steeply. Within a generation the letter had become part of ordinary life, and in the cities, where the post came several times a day, a note sent in the morning could be answered before evening. Anthony Trollope, who spent more than thirty years in the service of the Post Office while writing his novels, is credited with bringing the roadside pillar box to the British Isles; the first stood in Jersey in 1852.
The penny post democratised sending, and with it something subtler: the expectation of reply. Once a letter cost little and arrived quickly, silence acquired a new meaning. A letter unanswered for a week, in a city with several deliveries a day, was no longer a matter of distance. It began to look like a matter of will.
Henry David Thoreau, watching the next acceleration from his cabin by Walden Pond, was unimpressed. “We are in great haste to construct a magnetic telegraph from Maine to Texas,” he wrote in Walden (1854); “but Maine and Texas, it may be, have nothing important to communicate.” He went on to the scheme for a line beneath the Atlantic, and imagined the first news to leak through into “the broad, flapping American ear” being “that the Princess Adelaide has the whooping cough.” It is hard for a physician not to smile at that. The great network of the age, in Thoreau’s satire, delivers as its first payload a clinical bulletin.
He was wrong about the woman in the evening, who has something important to communicate. But he was right in the sentence that falls between those two: “As if the main object were to talk fast and not to talk sensibly.” The electronic message has the speed of the telegraph, the form of the letter and, increasingly, the manners of conversation. Sending became instantaneous. Reading did not; it remains exactly as slow as careful reading has always been, and answering sensibly takes as long as it ever took. A good deal of the strain in modern messaging, on both sides, seems to me to come from an inference that nobody states aloud: that a message which travels in a second ought to be answerable in something like the same time. The inference is natural. The penny post taught it, the telegraph confirmed it, and a phone repeats it every time the word Sent appears beneath a paragraph. It is still false.
The Reader’s Morning #
Follow the woman’s message into the morning in which it is read. It does not arrive alone. It sits among results that came back overnight, requests from colleagues, forms awaiting signature, letters from specialists, questions from pharmacies and other patients’ messages, some longer and some shorter, with a day of scheduled visits waiting behind them all. None of this makes her question less reasonable. It does mean that the person reading it is not, at that moment, only her reader. He is the reader of everyone.
To answer her well, he has to rebuild a small world. Which number is flagged, and by how much? Was it flagged last year, and the year before? A value just outside a reference range can be new and meaningful or old and stable, and the difference lies in a history the message does not contain. Why was the test ordered: as routine monitoring, to answer a particular question, or because of something she mentioned? What was said at the visit about which result would change anything? Is she taking something that bears on it? Does another result in the same panel alter the reading of this one? A reference range describes a population. The person in the message is not a population, and the flag knows nothing about her.
This reconstruction is the hidden bulk of the work. It is invisible to the sender, who sees only the reply, and nearly invisible to the systems that record it, which see only that a message was opened and later answered. Nor does it end with understanding. The physician must then decide what, if anything, should happen: nothing, a repeat test, a visit, a call, a change. After that comes the part that often takes longest, which is putting the decision into words she can use, at the right temperature. Too brief, and a reassuring answer reads as dismissive. Too full, and a reassuring answer reads as alarming; why would anyone write three paragraphs about something that does not matter?
The reply she receives may take thirty seconds to read. It took rather longer to make, and almost none of the making shows.
Let me be plain about what I am not saying. I am not asking anyone to admire a physician for reading messages. Reading them is part of the work, and when it is done well it is some of the most useful work in medicine: a question answered this week that would otherwise have waited, with its worry, for a visit a month away. Nor am I saying that the woman should not have written. She did exactly what the system invited her to do. My point is narrower. When a form makes the work of an answer invisible, everyone begins to misjudge it. The sender reasonably supposes that a short question has a short answer. An institution that measures rows reasonably supposes the same. The only person who knows otherwise is the one doing the reconstruction, and there is no row in which to record it.
The other messages ask for reconstructions of their own. The traveller’s needs the reason for the scheduled visit and a judgement about delay, which is a clinical judgement however administrative it looks. The daughter’s needs the medication history, some sense of what more tired means for this particular father, and a decision about whether a written reply is even the right instrument. Three rows, three small worlds, each rebuilt from the record before a sentence can be written. Then the first appointment of the day begins, and the rebuilding stops, halfway through a world, until the next gap.
Ghosts on the Way #
Franz Kafka, who wrote letters with an intensity few writers have matched and trusted them less than almost anyone, would have recognised the inbox at once. Between 1912 and 1917 he wrote hundreds of letters to Felice Bauer, to whom he was twice engaged and whom he never married, often more than one in a day, and in places they read like a case history of the expectation of reply. He calculates when a letter might come and why it has not. He reads a delay as a verdict. At one point he asks her to write only once a week, so that her letter will arrive on a Sunday, because he cannot bear her daily letters. It is the expectation of reply turned inside out: a man so tuned to the post that its rhythm has become unbearable. Elias Canetti, in his study of these letters, Kafka’s Other Trial (1969), read them in part as a way of keeping a woman close enough to write to and far enough away to protect the solitude Kafka needed for his work, and the post was the instrument that allowed both at once. Some years later, writing to Milena Jesenská, Kafka gave his suspicion of the whole enterprise its most famous form: written kisses, he said, do not reach their destination, because the ghosts drink them on the way.
Kafka meant something far more desolate than anything an inbox requires, and I have no wish to borrow his anguish for a discussion of patient portals. But his image names a mechanism. Something is drunk on the way. In a conversation across a desk, a misunderstanding usually lives for seconds. The physician says slightly high and sees the patient’s face change; he adds, before she can speak, the same as last year, and not a reason for concern on its own; the correction arrives while the error is still small. A written exchange has no face. Its misunderstandings travel intact, and they may not surface until the next message, or the next visit, or ever. What the ghosts drink is everything that would have corrected them: tone, hesitation, the look that asks for more, the second draft that the woman deleted because it sounded too frightened. The physician reads the third and calmest version, and answers its calm.
The reply passes through the same ghosts on its way back. A sentence such as This is not concerning; we’ll recheck at your next visit is, to its writer, reassurance with a plan attached. To its reader at nine in the evening it may be a dismissal, or a plan whose date she does not know, or proof that he skipped the line in which she said she was worried. Each writer, composing, imagines a reader and writes to that imagined figure, a ghost of the writer’s own making. The real reader is someone else.
There is a counter-tradition, and it seems to me just as true. Mirza Ghalib, the great Urdu and Persian poet of nineteenth-century Delhi, wrote hundreds of Urdu letters to friends and pupils in a style that broke with the ornamental formality of Persian epistolary convention, and he took pride in it. He claimed, in a phrase his readers still repeat, to have turned correspondence into conversation, murāsala into mukālama, so that friends a thousand kos apart could talk with the tongue of the pen and enjoy, in separation, the pleasure of meeting. His letters open without ceremony, answer questions directly, scold, joke and gossip, and they are among the glories of Urdu prose. Ghalib’s ideal is precisely what the patient portal aspires to: a conversation that has learned to travel, not a petition to a distant authority.
Read together, Kafka and Ghalib describe the double nature of the inbox better than any manual. The message is written in the register of conversation and travels at the tempo of the letter. Its senders expect the turn-taking of talk; its readers can supply only the deliberation of correspondence. Ghalib’s letters could work as conversation because he and his friends shared a world: a city, a set of references, a common sense of how long the post took and what silence meant. Where those shared things are missing, Kafka’s ghosts get their drink. The task, then, is neither to abolish the message nor to pretend that it is a conversation. It is to supply deliberately what the shared world once supplied without effort: a sense of who is reading, when, with what authority, and what will happen next.
After the Reply #
A message can be answered without its question being settled. Return to the traveller. Suppose that the physician, having done that reconstruction, decides that the visit should not wait: whatever it was meant to check is better checked before six weeks on the road. The reply is two sentences long and entirely correct. I’d recommend we see you before you leave. Please call the office or use the scheduling link to book a visit this week. In the queue, the message is now complete.
From the traveller’s side, it is a doorway. He has to understand why the visit matters, since the reply did not say, and a reason affects whether a busy man makes room. He has to find a free hour in the last days before a new job. He has to reach the person or the screen that can schedule it, and an opening has to exist before he leaves. If any of those steps fails, nothing in the original exchange will show it. The message will remain completed. The queue is accurate about its own transaction and silent about what happened afterward.
The daughter’s message branches differently. Perhaps the right answer is a telephone call, because more tired covers a great deal of ground and is better explored by voice than by text. The call needs someone to make it, a number that works, and a father who will come to the phone and admit to being tired. It may lead to a visit, a laboratory test, a conversation with a pharmacist, a change, or simple reassurance, and each of those may involve another person and another queue. The reply that began it, Thank you for letting us know; a nurse will call you today, was accurate and kind. It was also only the first move of a sequence that the original row will never display.
None of this is waste. It would be a mistake to read every branch as inefficiency, as though a well-designed system ought to settle each concern in a single reply. Some concerns should branch; they need a voice, an examination, a second person’s expertise. The branching is often the care itself. The difficulty lies in what the word complete is being asked to mean.
It cannot mean that every consequence is known. A queue held open until then would be impossible to use. It needs instead a defined meaning, and there are several to choose from. Was information provided? Was a decision made? Was responsibility transferred to a person who accepted it? Or was a next step merely suggested, leaving the patient to carry it? These are different events, and they deserve different marks. A reply that suggests is not a reply that arranges, and the difference weighs most on those least able to carry the next step alone: the patient without a car, without paid leave, without fluent English, without a daughter who manages the account.
Patients cannot see the internal borders between tasks. From their side there is one concern moving through several exchanges, and a reply that seems final to its writer may feel to its reader like another door. I would like the design of this work to respect both views. The clinician needs a manageable account of what remains to be done; the patient needs a comprehensible route through the next step. Sometimes the improvement will be a clearer sentence: I’d like to see you before you go, because the visit was meant to check how the new medicine is working, and that’s better done now than in six weeks. Sometimes it will be a different assignment of work, in which a scheduler, and not the patient, makes the call. And sometimes it will be the admission that a message cannot carry the conversation the situation deserves, so that the right reply is an invitation to have that conversation properly. None of these improvements is captured by the satisfying sight of an unread count returning to zero.
Who Should Answer #
If one person read and answered every message, the inbox would at least have the virtue of continuity. It would also fail, sooner or later, because no single person can rebuild every small world in a day that also holds a schedule of visits. Most practices therefore share the work among several roles, and I think they are right to. A question about the timing of an appointment does not need a physician’s judgement. A question about using a device may be better answered by a nurse who teaches it every week than by the doctor who prescribed it. A question about the price of a medicine may be best answered by someone who knows what different plans will cover. Sending each question to the person best equipped to answer it is not a dilution of care. It is triage, which medicine has practised under other names for a very long time.
The strongest objection deserves its full force. A patient who writes to her doctor has chosen a person, not a department. When the reply comes from someone she has never met, signed with a title she does not recognise, she may reasonably feel that her question was processed rather than heard. Each handoff is also a fresh opportunity for loss: the nurse who calls the daughter may not know what the physician was thinking when he started the new medicine, and the physician may never learn what the daughter said on the phone. Team-based work can feel impersonal, and sometimes it is. Patients who have been passed from queue to queue have earned their suspicion.
I do not think the answer is to return every message to the physician. I think it is to be honest about where continuity actually lives. It does not live in the identity of whoever types the reply. It lives in responsibility: in someone who knows the patient’s situation, has the authority to act on it, and remains answerable for what happens next. A good delegation therefore carries three things with it. It carries context, so that the person who receives the question knows what the physician knows. It carries authority, so that the person who receives it can actually settle what they are asked to settle without sending it back for permission at every turn. And it carries a way to return uncertainty: a clear route by which a nurse or a scheduler who discovers that a simple question was not simple can hand it back to the person who should decide, and know that it will be taken up. Without those, routing amounts to moving an item to another queue.
Delegation also has a visible face, and the face matters. The patient is entitled to know who answered and in what capacity. A reply that says it comes from a nurse, after review with the physician, tells its reader something true about how her question was handled and lets her judge what kind of answer she holds. A reply that hides its author, or implies a physician’s personal attention that was never given, borrows a trust it has not earned.
An older figure helps me think about this, though he worked on the other side of the transaction. Outside post offices and courts in Punjabi towns, and in much of South Asia besides, professional letter-writers once sat with paper and pen, and later a typewriter, writing for people who could not write for themselves: to a son in the army, to an official, to a relative abroad. The voice of the letter was the sender’s. The hand was someone else’s. Everyone understood the arrangement, and its honesty lay in that common understanding. The inbox now has letter-writers on both sides. The daughter writes for her father; the nurse writes for the clinic. Neither arrangement is a deception. Either becomes one only when it is hidden.
Hours on the Door #
There is a particular unkindness in a door that looks open and is not. A shop with its hours painted on the glass disappoints no one who reads them. A shop that appears open at midnight, lights on and bell ringing, with nobody inside until morning, is a different kind of place. An inbox that accepts messages at every hour without saying when they will be read resembles the second shop. The patient who writes at night about something that cannot wait until morning is not being foolish. She is using a door that appeared to be open.
This is why I have come to think that visible boundaries make access more dependable, not less. A channel needs a stated purpose: what it is for and, as plainly, what it is not for. It needs a stated rhythm: when messages are read, and roughly how long a reply should take. And it needs a stated alternative: where to turn when a question cannot wait for that rhythm. I will not invent the details, which belong to each practice and should be set by people who know its staffing, its patients and its legal duties. The structure, though, seems to me general. A boundary the patient can see lets her choose the right door. A boundary she cannot see is still there; it simply finds her later, in the form of a delay she did not expect.
Boundaries of this kind are often described as protection for clinicians, and they are that. They are also, and I think more importantly, protection for patients. A channel with no stated limits will be used for everything, including what it is badly made to carry: the alarming symptom typed at midnight into a box that will not be opened until morning, the question about a result that deserves a conversation and receives a paragraph. The plain statement this is not the way to reach us urgently, and here is the way that is is not a refusal of access. It is a map.
There is a quieter boundary, which concerns the person on the far side. A physician who appears personally reachable at every hour is promising something no human being can deliver for long, and the promise does not become kinder by being implicit. Any useful connection between people has to be kept up by actual people, and actual people sleep, see the next patient, fall ill and take leave. To build access on the assumption that one person will always answer is to build it on the one component certain to fail. Access that survives a physician’s day off, his illness or his eventual retirement must rest on something larger than his willingness to reply.
What a Zero Proves #
If the inbox is to be improved, someone will want to measure the improvement, and the measures most easily gathered are the least informative. Volume is the obvious one. It counts arrivals and says nothing about why they came. A rising number of messages may mean that patients have found a convenient way to reach their clinic, that visits are leaving questions unanswered, that results are being released without explanation, or that one confusing reply has generated three more. Each of these calls for a different response, and the count cannot tell them apart.
Response time is better, and patients rightly care about it. But a fast reply that does not settle the question merely moves the waiting to the next message. A two-minute answer that sends the traveller to a scheduling line with no openings before his departure scores well and helps no one.
Resolution is harder to measure and closer to the point. Did the concern behind the message reach an end that the patient would recognise? Did she understand the answer? Could she say, if asked, what happens next and who is responsible for it? Those questions require asking patients, which is slower than counting rows, and that is exactly why they are seldom asked.
Then there is the work itself and the people who do it. An inbox count that falls for physicians while rising for nurses has not shrunk; it has moved. A team that answers more messages faster by staying later has not improved its system; it has borrowed against its members. Any honest measure has to follow the work to wherever it went.
The trouble with any single count is that it invites the work to bend toward it. Make the unread count the target and it will fall. Messages can be closed with suggestions instead of arrangements, routed without context, answered quickly and in part. Every one of those moves improves the number while leaving the patient exactly where she was. A count that can be improved without anyone being helped is a poor instrument to steer by, however satisfying it is to watch.
What would a real improvement demonstrate? I would want to see fewer repeated messages about the same concern, since repetition is often the sign of a first answer that did not land. I would want patients able to describe the next step in their own words. I would want urgent problems arriving through urgent channels, which is evidence that the boundaries are visible. And I would want the work of answering to sit with people who have the time, the knowledge and the authority to do it, not with whoever happens to stay latest. None of these is as satisfying as an empty list. All of them say more about whether anybody was helped.
Only the Message #
Return, finally, to the evening and the morning. The woman wrote at night, on her clock, after three drafts. The man wrote between other plans, on his. The daughter wrote, perhaps, without expecting a reply at all. The physician read in the morning, on a clock that contained them and many others, and each reading required a small world to be rebuilt before a sentence could be written. Some of the replies settled something. Others opened doors that somebody would have to walk through. One, at least, should have been a telephone call, and became one.
Nothing in this sequence requires a villain, and nothing in it is solved by heroics. The patient who writes at night is not unreasonable; the physician who replies in the morning is not negligent; the nurse who calls in his place is not a lesser substitute. The trouble lies in a form that hides each party’s clock from the others and counts its own transactions as though they were the whole of the work. The remedy, as far as I can see it, is to make the hidden parts visible: to say when messages are read and by whom, to say what a reply has actually done, to carry context with every handoff, and to measure whether people were helped, not whether rows were cleared.
Cullen’s correspondents knew how long the post took to Edinburgh, and their patience was less a virtue than a piece of shared information. Ghalib’s friends knew him, and their letters could be conversations because they shared a world. Neither condition can be restored by nostalgia. Both can be approximated by design, in a channel whose hours are posted, whose readers are named, and whose replies say plainly what happens next. That is a modest ambition. It would still make the night shorter for the person waiting on the other side of it.
Access worth having rests on organised responsibility, not on any one person’s willingness to stay awake. A door that can be written to at any hour is a real gift, and I would not give it back. But a door that never closes is tolerable only if the people behind it are allowed to rest, and only if the person writing knows when they will return. The inbox does not sleep, and it would be odd to wish that it did. Of the three parties to the imagined exchange, the woman who wrote, the physician who will read, and the message waiting between them, only the message is untroubled by the night.
Evidence and Editorial Note #
Documented findings. William Cullen (1710–1790) and his consultation correspondence: letters from patients, family members, and referring physicians and surgeons throughout Britain and abroad, kept with his replies, first as transcripts and from 1781 as duplicates made on a mechanical copier invented by James Watt; more than 5,000 documents online, including sustained illness narratives: the Cullen Project (linked, consulted November 6, 2026). The information-blocking provisions under the 21st Century Cures Act, with a compliance date of April 5, 2021, and the resulting prompt release of many results to patients: standard regulatory reference sources, described in general terms. Pre-1840 British postage charged by distance and sheets and commonly paid by the recipient; Rowland Hill’s Post Office Reform: Its Importance and Practicability (1837); the Uniform Penny Post (January 1840) and the Penny Black (in use from May 1840); multiple daily urban deliveries; Anthony Trollope’s Post Office career and the first British pillar box in Jersey (1852): standard postal histories, stated in general terms. Thoreau’s sentences on the magnetic telegraph, talking fast and sensibly, and the Princess Adelaide’s whooping cough: Walden (1854), chapter “Economy,” public domain. Kafka’s letters to Felice Bauer (1912–1917), including his request that she write only once a week, Elias Canetti’s study Kafka’s Other Trial (1969), and the image of written kisses drunk by ghosts in a letter to Milena Jesenská: described and paraphrased from the published correspondence and Canetti’s book, not quoted from any translation. Ghalib’s claim to have made correspondence (murāsala) into conversation (mukālama): his Urdu letters, paraphrased. Professional letter-writers in South Asian towns: general historical description. Vendor representations. None. The inbox and patient portal are described generically.
Recollection and tradition. The three messages, the woman who wrote at night, the traveller, the daughter and her father, and every reply quoted are hypothetical and illustrative; they do not describe real patients, real messages, real response times, any clinic’s staffing or any practice’s policy. No actual workload or schedule is described. The Punjabi word ਉਡੀਕ and the folk motif of the crow on the parapet announcing news or a guest are given as general cultural knowledge, not as a claim about any family or as a universal belief.
Analysis and forecast. The two-clocks reading of asynchronous messaging, the readings of Cullen, Thoreau, Kafka and Ghalib, the distinction between completing a message and resolving a concern, the three requirements of delegation, the argument for visible boundaries and the proposed measures of improvement are the author’s personal interpretation and preference as of November 6, 2026. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.