My patients' best e-resource? Me

In developing a patient education newsletter that now has a circulation of several thousand, the author learned a great deal herself.

People in every state and at least 15 countries read my wise words every week. Who knew when the first issue of my e-mail newsletter, Femailhealthnews, went out three years ago to a handful of my nearest and dearest, that circulation would exceed 4,000 and the endeavor would become one of the most satisfying of my professional life?

The journey from there to here has been an interesting one, fraught with the mysteries of format code, bouncebacks, the fickleness of Windows XP, a computer worm—and unending rewards. I began as a cyber-neophyte, but my technical and writing skills have flourished. And although I don't get paid for writing, I enjoy the fact that the health-related downloads and printouts my patients bring in are usually written by me.

Putting an idea into action

For years, as I plowed through my stacks of medical magazines, I thought about finding a way to share selected items with laypersons who were actively involved in their own healthcare. Thinking and doing finally came together after I read an article about e-mail newsletters. I had no idea, however, how difficult it would be to produce a well-formatted newsletter that arrived in a readable fashion no matter which Internet service provider (ISP) the recipient used.

At first, I mailed the newsletter via AOL, one address at a time. As the subscriber list grew, from 30 to more than 100 within two mailings, this proved cumbersome. It was also impractical: People abandon e-mail addresses as quickly as last season's styles. I'd no sooner send off the newsletter than my e-mail box would fill with bouncebacks—undeliverable messages sent to addresses and ISPs that no longer existed. Subscribers would write all the time, asking me to add, change, or delete their addresses from my list.

Armed with several guidebooks of the how-to-for-idiots variety (Poor Richard's E-mail Publishing, by Chris Pirillo, 1999, was the most helpful), I turned to a cyberspace mailing service—Dundee Internet Services (www.dundee.net). I now mail the newsletter just once, to Dundee. For just over $25 per month, the service makes five attempts to deliver the newsletter each week to all subscribers. Addresses with "fatal flaws" are eliminated from the list after three unsuccessful mailings. The server automatically handles readers' attempts to subscribe or unsubscribe, including confirmations and welcome notes.

I receive a subscription report each morning, and while I try not to fret over the "unsubscribes," I still celebrate each new member. When readers ask me via e-mail to handle changes and deletions, I send them the automated subscription information. Unfortunately, spam filters at some businesses and ISPs block my mailings.

Our office sign-in sheets include a space for e-mail addresses, which I add to my subscription list as time permits. New subscribers can also sign up via my Web site (www.femailhealthnews.com). I attribute most of the remarkable growth of my reader base to the ease with which subscribers forward the newsletter. I'm endlessly intrigued by the places it goes to, including Lagos, Zimbabwe, the Dominican Republic, and Greece.

Glitches, goofs, viruses, et al.

Setting up the subscription list proved to be a snap compared with sending out professional-looking manuscripts. In fact, turning word-processed documents into plain text, complete with proper margins and spacing, has been the hardest task I've faced. Those familiar with computers already know what I soon discovered: Quote marks, apostrophes, indentations, line ends, and other format-control characters are often demarcated in cryptic code within computer-generated documents.

Once I mastered the challenge of exporting documents to text on Windows 98, I thought the problem was solved. Unfortunately, when I bought a new computer and switched to Windows XP, I discovered that this operating system transmits format-control codes through the export process, and I still haven't found a way to shake them loose. In addition, some readers complained that my newsletter, when generated through Windows XP, arrived in font so tiny as to be virtually unreadable. So now I type the newsletter on my laptop, transfer it to a disc, insert the disc into the old machine that runs Windows 98, and export it for mailing from there. I know that text editor programs exist, but I'd rather stick with my current solution than attempt to learn another new technique.

The lowest point in my e-publishing career came when the "Klez worm" wriggled its way through my loosely configured list security and sent itself to everyone in my e-mail address books, including my entire subscriber list. Fortunately, only seven "infected" subscribers cut me off from their e-mail inboxes.

Deciding what to write about

Writing a weekly newsletter is, as patients and colleagues have noticed, a time-intensive hobby, but it's also a labor I love. Choosing my subjects and writing the articles comes easily, particularly now that I've defined my audience and mission. Indeed, compared with tackling all the technical troubles, writing the newsletter is a breeze. I spend my days at the office transmitting the latest in care to one patient at a time. A newsletter allows me to not only send this same information to all of my patients, but also to develop an enormous library of written materials to hand out or e-mail when questions arise during office visits. Last summer I e-mailed special editions about colonoscopies and hormone replacement therapy. I keep copies of these in my exam rooms for patients to read.

Top-quality content backed by credible research is my first editorial priority—no fads and no politics. I've written about the updated Pap test screening recommendations, screening guidelines from the US Preventive Services Task Force, and the new definitions of prehypertension and prediabetes.

I scan journals not only for items of medical interest, but also for odd and funny bits. I've written about decreased hearing among reindeer herders, ED visits for coconut-palm-tree-related injuries in the Solomon Islands, and how patients' satisfaction relates to their ability to correctly identify their doctors. Feedback indicates that readers appreciate the lighter side of serious science.

My original target audience was menopausal women: The very first newsletter contained two articles on hormone replacement therapy. My subscriber list rapidly grew beyond that demographic, though, and I now deliver current health news of general interest taken from leading medical journals. I developed a second newsletter, VintageFemail, in January 2002 to provide "up-to-date information to women of age on medical decisions through menopause and beyond." If there were enough time—and an income stream—I'd add newsletters targeted to men, diabetics, and younger women.

Keeping in touch with readers

To develop loyalty among readers, I encourage questions and comments. Replying to reader e-mails—and I answer every one—takes me less than an hour each week. Often I just send out an article I've already written or an abstract from MEDLINE. I encourage my patients to make an appointment with me, and tell nonpatients to take the information to their physicians.

About a year into this undertaking, I decided I needed a Web site to serve as a companion to the newsletter and a place to archive past issues. After struggling with a do-it-yourself site, I hired a Web site developer. The site has a newsletter application that allows me to post the current issue by cutting and pasting it. I can also access old articles for easy reruns. At the same time, I have a resource to which I can refer patients and readers. For instance, when women ask me about menopause, I encourage them to use the search function on my site and read all my articles on the subject. The site cost around $2,500 to build, but maintenance fees are minimal. Readership now averages 100 visits per day.

Pediatrician Don Berwick, president and CEO of the Institute for Healthcare Improvement, has called the face-to-face, patient-physician encounter "a dinosaur." He proposes alternative kinds of care, such as use of e-mail and telephone conferences, to answer patients' questions or to teach them to take care of themselves. I have certainly found that an e-mail newsletter is a powerful patient education tool, a satisfying way to impart health information, and a refreshing balance to the daily frustrations of private practice. If you're wondering what your patients are reading on the Internet, consider becoming their reliable source.

You, too, can be a dot.com doc

Judy Paley, author of the accompanying article, earned her on-line publishing stripes through the laborious process of trial and error. If you'd like to take an easier route, Keith Borglum, a consultant in Santa Rosa, CA, offers these e-newsletter tips.

1. Post the newsletter on your practice Web site, then send a link in an e-mail to the patient. This:

• Makes for a smaller sized e-mail, which is easier to download.

• Allows you to use photos or graphics in your newsletter.

• Allows use of HTML (formatted) content to patients who have their e-mail software set to "text only."

• Fosters creation of a newsletter archive on your Web site to which patients can return or refer their friends and family.

• Attracts more traffic to the rest of your Web site via links within the newsletter.

• May attract Web surfers to the site as long as online publishing Web-optimization protocols are observed, such as proper use of titles and meta tags. A Webmaster—someone who creates and manages the content, organization, and the technical aspects of a Web site—can help you with that.

2. Have an editor review the newsletter for you so that it appears more professional. Moonlighting newspaper editors, high school English teachers, and college journalism students all qualify.

3. Maintain continuity of image with your practice name and logo—and navigation bar, if posted online—so that patients can go directly to other parts of your Web site from the newsletter.

4. Consider diagnosis-specific customized newsletters, if you already have that information in a database or registry. For example, you can do a newsletter with an alternate lead article for your diabetic or hypertensive patients.

For a list of elements you might want to include in a practice Web site, go to the Physician Web Page Planner at Borglum's site (www.practicemgmt.com/physicianwebpageplanner.html). The Web site CompanyNewsletters.com (www.companynewsletters.com) contains several useful articles about online newsletters, including "How to know what kind of online newsletter to publish," and "How to create an effective, eye-catching Internet newsletter."

Judith Paley. My patients' best e-resource?

Medical Economics

Aug. 6, 2004;81:40.