The EHR in-basket has no ceiling.

A new study from Duke’s arthroplasty team led by my friend and colleague Dr. Sean Ryan tracked patient portal use from 2017–2024. The findings:

📈 Messages grew 13-fold (7.8k → 105k).

🦵 Surgeries only doubled.

👥 20% of patients generated ~60% of the inbox.

The inbox is now one of the largest “clinical pools” in the system — and unlike OR time or clinic slots, there’s no cap. Each message is another obligation, often after-hours, rarely compensated.

The kicker: more messages don’t translate into better outcomes. Readmissions and surgical results don’t improve. What grows instead is administrative time and burnout.

We need to recognize inbox work as real clinical work — and redesign how it’s supported. Otherwise, the inbox will become the job and continue to burnout our clinicians.