Portal messages have become a routine way for patients to communicate with their health care teams. But a new study from Columbia University Mailman School of Public Health suggests that how patients write those messages can play a key role in whether—and by whom—they receive a response. The findings are published in JAMA Network Open .
Researchers analyzed more than 3.6 million patient portal message threads and found that patients from historically marginalized groups were generally less likely to receive responses from their care teams, and, in particular, were less likely to receive responses from the messages’ originally intended recipient – most often their doctor. The natural next question was “why?”
While the content of a message was an important predictor of care team response, it explained little of the differences by race, ethnicity, education or insurance. Writing style — including factors such as length, formality, sentiment and how a message opened — accounted for nearly half of those differences.
“Patient portal messages are an increasingly central channel for patient-clinician communication, but there are inequities in how responsive care teams are to messages sent by patients from historically marginalized groups,” said Mitchell Tang, PhD, assistant professor of Health Policy and Management at Columbia Mailman School of Public Health. “Our findings suggest that message writing style may be a potential source of bias in message triage and point to possible ways to reduce these disparities.”
Portal messaging volumes surged during the COVID-19 pandemic and remain elevated. “Unbeknownst to many patients, these messages do not usually go directly to their doctor’s inbox,” said Tang. In many health systems, messages go through a “triage” process in which nurses, medical assistants or other care team members review them first, determine their urgency and complexity, and decide whether to respond themselves or escalate them to the patient’s doctor.
“In many message triage systems, nurses and medical assistants must quickly assess messages and make judgments about their urgency, complexity and need for escalation,” said Tang. “Given those constraints, writing style may understandably influence how messages are perceived and prioritized.”
In the cross-sectional study of 511,020 adult patients, the researchers analyzed 3,619,390 patient medical advice request messages between 2021 and 2023. Overall, patients from historically marginalized groups—including non-White patients, patients who preferred a language other than English, patients with lower educational attainment, and Medicaid or Medicare-Medicaid dual-eligible patients—were less likely to receive a response from their care team and the message’s originally intended clinician. Compared with White patients, Black patients had a 3.7-percentage-point lower response rate from the intended clinician.
Using natural language processing, the researchers analyzed the content and writing characteristics of the messages and used statistical analysis to determine how much those factors contributed to differences in response among patient groups. Writing style features accounted for 48 percent of the difference in intended clinician response for Black patients relative to White patients, 35 percent for Hispanic patients, 60.5 percent for patients with only a high school education compared with those with a college degree, and 43 percent for Medicaid patients compared with commercially insured patients.
“One of the most important writing-style features was the message’s salutation,” Tang said. “Simply beginning a message with ‘Dear Dr. Tang’ seemed to make it much more likely that Dr. Tang would end up responding.”
The findings build on Tang’s previous research in a 2024 study showing racial and ethnic disparities in the triaging of patient portal messages and 2025 research examining differences associated with insurance type and preferred language in addition to race and ethnicity.
“The results could help health systems identify potential sources of bias in portal-message triage and develop more equitable approaches to digital communication,” Tang noted. “But they are also a reminder to think about how communication style can influence the way we perceive and respond to people—not only in health care, but in our everyday lives.”
Co-authors are Lisa S. Rotenstein, Brigham and Women’s Hospital and University of California, San Francisco; Ariel D. Stern, Hasso Plattner Institute, University of Potsdam and Icahn School of Medicine at Mount Sinai; Rebecca G. Mishuris, Brigham and Women’s Hospital and Mass General Brigham Digital; and Michael L. Barnett, Brigham and Women's Hospital and Brown School of Public Health.
Columbia University Mailman School of Public Health
Founded in 1922, the Columbia University Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Columbia Mailman School is the third largest recipient of NIH grants among schools of public health. Its nearly 300 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change and health, and public health preparedness. It is a leader in public health education with more than 1,300 graduate students from 55 nations pursuing a variety of master’s and doctoral degree programs. The Columbia Mailman School is also home to numerous world-renowned research centers, including ICAP and the Center for Infection and Immunity. For more information, please visit www.mailman.columbia.edu .
JAMA Network Open
10.1001/jamanetworkopen.2026.30379
Care Team Response to Patient Portal Message Content and Writing Style