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Technology, Computing, and Simulation: Review Article

E-mail as the Appropriate Method of Communication for the Decision-Maker When Soliciting Advice for an Intellective Decision Task

Prahl, Andrew*; Dexter, Franklin MD, PhD; Swol, Lyn Van PhD*; Braun, Michael T. PhD; Epstein, Richard H. MD, CPHIMS§

Author Information
doi: 10.1213/ANE.0000000000000658


The May 2014 issue of Anesthesia & Analgesia included a collection of articles about the Perioperative Surgical Home. The Perioperative Surgical Home is an approach adopted by the American Society of Anesthesiologists, designed in part to increase quality, patient safety, and shared decision-making and to decrease costs per patient by reducing waste.1,2 Among the articles was a review of the economics of the Perioperative Surgical Home.3 The review showed that the substantive opportunities for net cost reduction are for activities wherein anesthesiologists serve principally as managers and/or experts in informatics.3 Management roles include directing the operating rooms (ORs), running the preoperative evaluation clinic, managing perioperative informatics, etc.

The anesthesiologists playing these roles in organizations can average >100 e-mails sent or received daily. Yet, although spending >1 hour per day on e-mail, many of these individuals may not understand the science behind e-mail as a communication channel. In our companion paper,4 we consider prompt asynchronous written communication (i.e., e-mail) for use in changing clinical decision-making. In the current paper, we consider its use for managerial decision-making.

For many of the cost-reduction problems in OR and anesthesia group management, there are tasks with optimal decisions, and yet experienced personnel tend to make decisions that are worse or no better than random chance (see Appendix, Supplemental Digital Content,–12 Such decisions include staff scheduling, case scheduling, moving cases among ORs, and choosing patient arrival times.5–12 We recently reviewed relevant experimental studies in small-group decision-making and concluded that in such settings, quality OR management leadership decision-making is made best while following an autocratic style, rather than a participative group style.13 Autocratic style decision-making calls for managers to solicit and consider feedback from stakeholders in the decision outcome, but then to make the decisions themselves using both their expert judgment and the feedback received.13,14 In other words, the final decision is made by the manager, not the group. Such a model is practical because typically only a handful of anesthesiologists are involved in staff scheduling, case scheduling, moving cases, and/or programming anesthesia and/or OR information systems. Surgical committees often are (appropriately) more interested in tactical and strategic issues, such as capital purchasing, implant and disposable contracts, and patient safety initiatives.

Tasks with correct answers are hereafter referred to as intellective tasks. Intellective tasks vary in how demonstrable they may be, that is, how easy it is to demonstrate the correctness of the answer to an intellective task to others.15 The demonstrability of the task depends on many factors, such as expertise of the audience, complexity of the answer, or the skill of the advisor in communicating the answer.15 For this review, we focus on tasks that are intellective but not highly demonstrable (i.e., personnel can only understand and apply the decision-making process if they have attained knowledge through an educational course or research).a,13,16–18 These include the processes for staff scheduling, case scheduling, moving cases among ORs, and choosing patient arrival times.5–12 For these and other tasks, often the decision-maker needs to rely on advice and trust the advisor’s expertise without fully understanding the details and reasoning behind the advice.

Our review is intended for operational OR management decisions, including management of preoperative clinics,3 because these are intellective tasks that are not easily demonstratable. The review is not intended for nonintellective management decisions (e.g., choosing which of 2 suitable vascular surgeon recruitment candidates to hire). The review also is not intended for clinical decisions because they generally have high demonstratability (e.g., a 225-word abstract summarizing a randomized clinical trial result).

A challenge for the OR manager is that often it is unclear, without expert advice, whether a task is one for which there is an optimal decision.18 Because that is determined by scientific study, it can be easier to ask an expert advisor essentially “what paper should I read?” rather than trying to find the relevant paper through a database search.18 We recently showed that PubMed search to find relevant article(s) independently is ineffective for many OR management decisions because the searcher needs to know the precise vocabulary before searching, unlike for most clinical topics.18

Literature review and/or Internet searches are effective and commonly used by managers in professional environments to identify expert advisors with whom they wish to communicate, especially when the experts are outside the managers’ organization. As such, in this narrative review, we seek to answer 3 questions: Once an expert is identified, why is e-mail such an appropriate communication channel through which to solicit advice? What disadvantages are there instead to using face-to-face, video conference, telephone, live electronic chat (“chat rooms”), and discussion group (e.g., listserv or other social media)? Under what circumstances does e-mail (i.e., prompt asynchronous written communication) offer substantial benefits as a communication channel to both managers and advisors? The novel result of our narrative review is the finding that previously performed observational and experimental studies from the communication sciences are sufficient to answer these 3 questions.


Our article is organized with an Appendix (Supplemental Digital Content, in secondary digital content summarizing the observational and experimental (psychological) study results referenced. We wrote the article so that readers interested in the scientific details can read the Appendix (Supplemental Digital Content, synchronously with the text. Readers interested just in the summary and implications can skip the detailed material of the Appendix (Supplemental Digital Content,

Table 1:
Methodology of the Appendix

Table 1 is an example of our methods. In 2011, the senior communication investigator (Dr. Van Swol) published experimental studies comparing written and face-to-face interactions between decision-makers and advisors.19 Table 1 shows an example of the fact that although we considered hundreds of papers to identify specific findings relevant to our current topic, many (most) of these results were not the focus of the previously published paper for the communication sciences community. For example, the published abstract from Reference 19 reproduced in Table 1 matches neither the results nor the conclusions relevant for the current paper. Table 1 also shows that whenever possible, we used the listed sample sizes and quantitative summary statistics to repeat calculations so that the reproducibility of findings would be known precisely and our statements in the paper based on them. For example, instead of P < 0.05 reported in Reference 19 from the t-statistic and sample size, we report P = 0.0078. Finally, Table 1 and the Appendix (Supplemental Digital Content, show that our review is a summary of experimental and observational results. For example, we explain below, in the section Taking the Advice, that an advisor’s written expressions of confidence in a recommendation signals that the advisor is competent.19 This is not our opinion but a narrative summary of the experimental result provided in Table 1 and the Appendix (Supplemental Digital Content,


Communication channels differ in their richness.20 Richness can be thought of as the amount of information that is transmitted across the channel using such features as capacity for immediate feedback, ability to convey multiple cues, and ability to personalize messages.20 For example, video conferencing is a richer channel than telephone because the former transmits not only sound but also more cues with visual information (e.g., facial expressions and/or charts).

We focus on understanding e-mail, accessed using a modern e-mail client (e.g., allowing use of search terms, folders, conversation views) by personnel who are experienced users and have received education in how best to use e-mail.21,22 For example, suppose that a decision-maker (manager), his or her hospital analyst, and an advisor work on a project. “Reply All” repeatedly is reasonable, provided the 3 team members (e.g., in the same corporation) are using an e-mail client with conversation views (i.e., if away for a day and the resulting conversation has generated 17 e-mails, only the most recent appears). In other words, we are not studying e-mail used to discuss a hiring decision among 12 members of a faculty. In addition, we differentiate e-mail from discussion boards (online forums) or discussion groups wherein many people ask questions to many unknown people simultaneously. We do not consider in the current paper group/team collaboration support systems because our focus is on communication between a decision-maker with basic knowledge (e.g., after OR management course)13,16,17 and an advisor typically external to the organization.

E-mail has emerged as the preferred communication channel through which to seek advice in numerous professions, academia, and research library science.23,24 For example, greater than three-quarters of academic clinicians responded to an e-mail question from a trainee about the appropriate use of a new technology, and most offered to help.25 Teledermatology using image storage and forwarding (i.e., e-mail) is used more often than live communication.26

E-mail combines many of the features of earlier communication channels. For example, like leaving a phone messageb or sending a letter, e-mail is asynchronous. Additionally, it is a low-cost method (in terms of time and effort) for the sender to disseminate information to a large audience.27,28 Memos that used to be printed and posted into department mailboxes can now be e-mailed simultaneously to everyone. Financially, e-mail is an inexpensive form of communication, even when taking into account time wasted reading non–work-related e-mail.29


Trust is defined as relying upon or making oneself vulnerable to another person; when a manager accepts the advice of an expert, the manager is vulnerable to the possibility that the advisor is providing low-quality advice attributable either to low competence or ill will.30 Perceptions of expertise, shared goals, and benevolence (i.e., good will) increase the likelihood that an individual trusts another.31 For intellective tasks, trust is developed almost exclusively from the advisor’s expertise and perceived competence.19,30 These are established through scientific reputation, publications, and participation (membership) in respected organizations. For example, when a physician calls the Malignant Hyperthermia Association of the United States Hotline, the physician expects the consultants to be competent and thus likely trusts the advice.

For intellective tasks, face-to-face communication is not necessary to judge the advisor as trustworthy.19,30 The development of personal rapport associated with richer channels of communication is less important for developing trust because intellective tasks are not a matter of taste but correctness.19 Furthermore, even in a group decision-making scenario (in which personal interaction variables such as rapport and cooperation can be more salient), an autocratic leader will still be the sole final decision-maker. If the decision-maker can demonstrate the correctness of his or her answer to the group, it is logical the group will likely accept it.

Most decision-makers only contact advisors they judge to have expertise in relevant areas. Furthermore, cues to the advisor’s expertise (e.g., degrees, job titles, and publications) are easily available through a quick Internet search. Therefore, developing trust is not a salient concern. Rather, an objective is to present the request for advice in terms that are acceptable and not obtrusive to the advisor. Consequently, soliciting advice through the channel that most facilitates obtaining, understanding, and use of the advice is key.

Many decision-makers search for appropriate advisors on the Internet. Thus, decision-makers often do not have strong ties with the advisor they choose.32 The ties are usually weak or latent ties. Latent ties describe situations in which a connection is available technically (e.g., Internet search and e-mail), but a relationship has not been activated yet through interaction.33 E-mail is a common method to reach out to weak ties and activate latent ties.24,32–34 In academia, for example, 73% of authors of articles in a clinical journal responded to e-mail inquiries from someone with whom they had no prior affiliation.35

A written channel such as e-mail allows the decision-maker to construct (frame) the message carefully to increase the likelihood of receiving a useful response.36 For example, physicians seeking consultation advice via electronic messages had a greater chance of receiving actionable recommendations when specific information about the situation was included in the message (e.g., from the study, “I have a 67-year-old man who is getting up 3 times a night to void. He is on terazosin 10 mg a day … without orthostatic symptoms. Should I add finasteride?”).36

A written channel such as e-mail also allows advisors to use strategies to increase the use of advice provided. One such strategy is the advisor stating his or her confidence in the advice19 (see below under Taking Advice). Another is the controlling of cues.37 Cues can activate stereotypes and preconceptions in an interaction with a partner. When these cues are negative, masking them can help relationships grow closer and more productive.37–39 For example, a position title (i.e., cue) may be more easily conveyed in an e-mail than in person because bringing up that kind of information in a face-to-face interaction sometimes seems odd or perceived as boasting, whereas including it in an e-mail signature is common practice. E-mail facilitates masking over cues that are irrelevant or may hinder acceptance of advice (e.g., an unlikeable personality).40

If a presenter (advisor) wants to be perceived as credible and to be persuasive, the advisor should construct the best possible self-representation. E-mail gives the advisor time to work on the message and come across as they choose.37 The advisor can edit the message, which can cause the recipient to view the sender more favorably.41 The advisor can focus more mental resources on constructing the message and fewer on worrying about personal perception as in a face-to-face interaction. The advisor can focus on the clarity of the writing rather than the color of the fonts in the slides, choice of suit, and/or appearance of one’s hair. Some interpersonal relationships develop more easily when there are reduced cues (e.g., e-mail) than would develop face-to-face.37 Lower cue channels are associated with greater perceived involvement and partner credibility.41 Whether the presenter is likeable and makes a good impression (versus unlikeable and makes a bad impression) has negligible effect on persuasiveness when written communication channels are used.40


When considering channels through which to seek advice, understanding the dynamics of advice use is a key consideration. Decision-makers accept and use advice from expert advisors more than novice advisors.30,42 When exchanging knowledge in organizations, higher perceived expertise is associated with higher knowledge transfer between the knowledge seeker/recipient and the advisor.43 Decision-makers are especially likely to accept advice when they are novices, unable to understand the decision-problem, or when they have not had a chance to think independently about the problem before receiving advice.44,45 Yet, decision-makers should be wary that often they underuse appropriate advice and fail to change their decision sufficiently to include advice.44

When participants do not interact face-to-face and tasks have a correct answer, use of advice and trust develop from the advisor’s written expressions of high confidence, which signals that the advisor is competent.19 Confidence is defined as “a person’s degree of belief that his or her decision is accurate and correct.”46,47 Confidence is expressed in research by asking the participant to indicate either (1) his or her confidence assessment, (2) his or her subjective probability of being correct, or (3) a range that contains the correct answer with a certain certainty.30,45,47 For example, advisors may express confidence (that their advice was correct) from 0% (have no confidence that their answer is correct) to 100% (complete confidence that their answer is correct).30 Without other indicators of expertise (titles, degrees, past experience with advisor, reputation, etc.), written expressions of confidence are one of the strongest predictors of use of advice, especially on tasks with a correct answer.19,30,45,47 Among participants communicating only through writing, advisors’ high confidence increases decision-makers’ use of advice and trust in the advisor.30 Among participants interacting verbally face-to-face on a task with a correct answer, decision-makers took the advice more often when advisors’ written expressions of confidence were greater.30 Even when a study was designed for the confidences to be strategically and deceptively inflated, decision-makers accepted advice from more confident advisors.46 When advisors give conflicting advice, the more confident advisor usually has more influence.45 Thus, e-mail may be an ideal channel with which advisors can give advice because the e-mail message can include written expressions of competence, thus increasing the value of the advice to the decision-maker.

Another factor that increases advice use is prepaying for expert advice.42,48 Paying for advice before receiving it sets up a process of justification and commitment in which the decision-maker wants to justify the compensation by using the advice.48 However, e-mail can present a confusing scenario for both the decision-maker and the advisor in terms of compensation (e.g., does the decision-maker intend for the advisor to be paid). Unclear reimbursement guidelines are a major inhibitor to the greater use of teledermatology by e-mail.49


The principal cost of e-mail is the associated time, not the e-mail itself. Although there is some cost to all parties involved in electronic exchanges and consultations in the form of storing or archiving messages, this is likely only problematic when large media files such as videos or pictures like those required for digital pathology are involved.50,51 That situation is unlikely for the management scenarios considered in our article.

The amount of time e-mail use consumes varies among users.52 For example, some people take 5 minutes to write and send an e-mail that takes other people 1 minute.52 Fortunately, training has been shown to be effective for making users more proficient in e-mail use (see below section on Learning E-Mail).21,22,52–54 Because it is important that a manager seeking advice uses a communication channel in which they are proficient or can become proficient with training, e-mail appears to be ideal in this respect because it is ubiquitous and easily used by nearly all professionals.

In many situations, the expert advisor resides outside the organization of the decision-maker, thus making a communication channel that more easily reaches across organizational boundaries is desirable. For example, academic librarians became more likely to contact latent (weak) ties outside of their own organization using e-mail.24 Physicians at remote Antarctic research stations and military outposts use e-mail extensively for advice.55–57

Asynchronous communication channels allow users to send/receive information at different times (e.g., between time zones without expectation of immediate responses). Synchronous channels such as face-to-face, video conferencing, or the telephone require that participants be actively engaged (i.e., not distracted) at the time of the communication. Users feel the need to respond immediately to synchronous communication.28 In contrast, if a manager or advisor receives an e-mail, he or she can wait until not distracted to write an answer because there is not such expectation for asynchronous communication.28 Many managers and advisors may not be in their offices to receive a telephone call or have an undistracted video conference. E-mail provides them with the ability to ask and receive questions when convenient.13

Managers and advisors can treat e-mails as tasks (e.g., set follow-up flags including reminders).58 For those readers who do not do this routinely using their e-mail client, we emphasize again that our review is based on the use of e-mail by trained users, and there is clear value to training (see below).21,22,52–54


Discussion forums and some social media applications share all of the time cost advantages of e-mail. However, there are disadvantages to group discussion forums, social media, and listservs for seeking advice compared with e-mail. These disadvantages relate to accountability.

With a general call for advice in a listserv, social media post (e.g., Twitter or LinkedIn), or group discussion forum, a specific advisor has not been contacted and personally asked for a reply. The decision-maker may not reach the advisor with the most expertise because this person is not following the group discussion forum or is not motivated to reply to a general call. Lack of accountability in teams increases diffusion of responsibility, and people exert less effort toward achieving a goal when they work in a group than when they work alone (i.e., “social loafing”).59 Without being personally responsible for answering the request, group members may reason that someone else will answer the request, especially if answering the request is an unwelcome demand on their time.60 In contrast, with e-mail, the request is direct, and professional courtesy requires that the advisor reply with advice or explain why he or she cannot or will not assist. This accountability reduces diffusion of responsibility and social loafing and increases the guarantee that the advisor has seen the advice request.60

Social dominance “involves the tendency to behave in assertive, forceful, and self-assured ways.”61 Socially dominant people participate in groups at a greater rate than other group members.61 Socially dominant group members are more likely to offer solutions to a problem in a group discussion forum.61 Socially dominant members are more influential and perceived as being more competent because of their higher contributions to the group discussion.61 However, social dominance is not a statement of knowledge (i.e., is unrelated to expertise). Socially dominant individuals do not necessarily have more or less knowledge in the discussion domain. This suggests that social dominance, rather than expertise, can have more influence in a group discussion forum than in e-mail.

As a reminder to readers, we are considering e-mail and not face-to-face group discussion because we showed previously that participative decision-making is suboptimal for the relevant OR management decisions unless all or nearly all group members have education (see Introduction).13 When decision quality is compared between groups with all members having knowledge (education) needed for the intellective decision versus groups having just 1 or 2 of the members having the specialized knowledge, the median odds ratio of superior decisions was >100.13 If the advisor will work with a group, because the advice will likely not be used, the advantage still goes to e-mail because of its lower time cost (see preceding section).


E-mail is generally perceived as a print medium rather than an interactive medium.62 In terms of complicated advice to a highly technical problem with a correct solution, e-mail offers an easy, text-based way to communicate technical answers to questions, such as inclusion of mathematical formulas. The ability to attach supporting documentation or explanatory images to e-mail enhances an advisor’s ability to explain the correct answer. Furthermore, e-mail as a written medium is easily archived and searchable. A manager, if ever in need of demonstrating the reason behind a decision, can more easily be able to call upon and demonstrate a correct answer by copying the e-mail they received from an expert advisor.

For the decision-maker, understanding the message may best be facilitated in a situation in which the decision-maker is less distracted and can read over the advice several times to try to understand it63 (see footnote b, above, in the section Overview About E-mail). The decision-maker can reply with well-posed follow-up questions as needed. In addition to letting the decision-maker choose when to read the message, e-mail results in a reduced cognitive load on the decision-maker versus when receiving face-to-face or video conference advice. The reason is that gaze in face-to-face communication requires cognitive resources.64 Face-to-face communication is cognitively demanding.64 The receiver must monitor the communicators’ face for nonverbal cues and develop a synchronous response.64 Cognitive load is an important predictor of learning or problem solving.65 E-mail lowers cognitive load.

Considerable research has examined the use of robots, computer avatars (e.g., the short-lived Microsoft Office 2003 Assistant Clippy),c and other animated computer agents to provide advice. Robot advisors can introduce too many unnecessary cues that increase cognitive load on the receiver and are distracting.66–68 For example, use of life-like avatars is often perceived as eerie to the receiver, particularly if an otherwise human-like avatar has 1 atypical human feature (e.g., big or pointed ears).68 Even less life-like computer agents are often perceived as weird and distract the receiver with unnecessary visual cues such as lip synchronization.66 This is not withstanding that the development and maintenance of computer avatars and robots to deliver advice is (extremely) expensive.

There is no strong evidence for value in expending the time and expense of using computer agents to dispense advice in most scenarios.67 For example, when a realistic embodied computer agent named Gretad gave advice about healthy eating, the proportion of correct answers was less than when the advice was given in writing (P = 0.03).69 Greta was rated as being harder to understand than text.69 Participants’ mean ratings of their likelihood of following the recommendations for healthy eating were no greater for Greta than for text.69 Participants in the text group were no less likely to engage in healthy eating than in any other group.69 Overall, the results did not justify the expense of Greta for dispensing advice.69


Although e-mail offers many advantages to managers seeking advice from outside experts, it is not without its disadvantages. Routine use of e-mail for work carries with it the risk of exposing oneself to extra e-mail that is not work related.28,70 Nevertheless, such personal e-mail does not increase stress.70 Rather, personal “orientations” to e-mail differ among individuals.27 Individuals with a stressed orientation toward e-mail see e-mail as a less effective channel and as a source of stress for them. Personality traits such as self-esteem are correlated with different orientations;27 thus, individual differences may present different drawbacks to e-mail for different people. When facing a scenario that involves risk, such as asking for a pay raise, individuals with lower self-esteem prefer to use e-mail more so than individuals with higher self-esteem.71

Training improves e-mail skills (e.g., constructing effective subject lines and writing clear messages).54 If a user is not skilled in e-mail use, considerable time may be needed to use advanced e-mail features such as uploading/downloading images or using rich text features. Such lack of competence may lead to e-mail (or similar technology such as store-and-forward teledermatology software72) losing its time edge over other communication channels.

Training also can improve user-perceived control over the receipt of e-mail.52 Clear organizational guidelines and worker training can reduce the problem of e-mail overload.21 For example, workers can apply personal productivity techniques to quickly identify and respond to important e-mails.21 Many heavy e-mail users organize e-mail into folders and use organizational features of other e-mail programs.22,53 The search functions of e-mail clients save time and increase the success rate for e-mail retrieval tasks compared with searching through folders for the target e-mail.22 In sum, ineffective users of email can become proficient through training or by adjusting e-mail management strategies to increase productivity.


To summarize the research findings (Appendix, Supplemental Digital Content, for operational issues in the OR and anesthesia group management with optimal decisions (i.e., intellective tasks) and cognitive biases (e.g., staff scheduling and case scheduling),5–12 autocratic decision-making with the advice of an external advisor is the appropriate method of decision-making. When faced with the need for advice on an intellective task, asynchronous written communication (i.e., e-mail) is currently a dominant communication channel for the autocratic decision-maker (manager), and the science that we have summarized shows that it should be that way. Its benefits include improved time management via asynchronicity, low cognitive load, the ability to hide undesirable and irrelevant cues, the appropriateness of adding desirable cues (e.g., titles and degrees), the opportunity to provide written expression of confidence, the ability to demonstrate answers for the decision-maker, and the ability to get answers from people the decision-maker knows only remotely. Given that the manager is only going to e-mail advisors whose competence the manager trusts, it is unnecessary to use a richer communication channel to develop trust. Finally, although e-mail has limitations, many of these can be rectified through training.

The implication of our results for anesthesiologists doing OR management is to use the communication channel that they are already using daily (i.e., change nothing other than to potentially obtain training in the use of e-mail).21,22,52,54 In our opinion, an alternative communication channel would be unlikely to be used unless substantially better than e-mail. The Appendix (Supplemental Digital Content, illustrates multiple observational and experimental studies from many domains showing not only absence of superiority of other communication channels but also the benefit of e-mail. Therefore, in our opinion, it would be a low scientific priority to redo the research that we have organized for our specific application to OR and anesthesia group management.

Although we performed this review of e-mail as a follow-up to our previous summary13 of experimental communication studies of leadership style relevant to some anesthesia group and OR management decisions with cognitive biases,5–12 the specific results summarized in this review were not limited to problems with cognitive biases. We expect this review to be useful in other areas of anesthesia that include mathematical and engineering problems.e For example, when statistical reviews are handled by a medical journal, relevant references can be included (e.g., when there is an issue about interpreting P values, one can rely on Monte-Carlo simulations studying reproducibility of results).73,74 Thus, (quality) evaluation is an intellective task, relying on knowledge of the results of simulation studies.75 This review showed the value in handling these mathematical questions by e-mail. Another anesthesia example is the evaluation of engineering and informatics systems, such as an anesthesia group working with a hospital, companies, and advisors on messaging system latencies and influence on alerts and supervision of ORs.76–80 Despite the evolution of communication technology and associated user preferences, we expect that decades from now, e-mail (i.e., asynchronous writing) between an expert and decision-maker will remain the dominant means of communication for intellective tasks. To emphasize, this means communication between 2 people including multiple replies for follow-up questions and answers (see Cognitive Load, above).

Finally, although our review in total and our conclusions do not apply to clinical decision-making (see Introduction),4 some of the information summarized seems relevant. For example, in the section on Cognitive Load, we included some articles on distraction.63,65 Recent articles in the lay press described anesthesia providers checking e-mail in ORs during cases.f The summarized studies show value to concentrating on management decisions in isolation.63,65 Furthermore, as we explain in the section on Overview About E-mail, we study e-mail using clients providing full search function and reading of attachments with equations (when appropriate), highlighting of published papers, etc.


Franklin Dexter is the Statistical Editor and Section Editor of Economics, Education, and Policy for Anesthesia & Analgesia. The manuscript was handled by Maxime Cannesson, Section Editor of Technology, Computing, and Simulation, and Dr. Dexter was not involved in any way with the editorial process or decision.


Name: Andrew Prahl.

Contribution: This author helped design the study, perform the study, and prepare the manuscript.

Attestation: Andrew Prahl approved the final manuscript.

Name: Franklin Dexter, MD, PhD.

Contribution: This author helped design the study, conduct the study, and prepare the manuscript.

Attestation: Franklin Dexter approved the final manuscript.

Name: Lyn Van Swol, PhD.

Contribution: This author helped design the study, conduct the study, and prepare the manuscript.

Attestation: Lyn Van approved the final manuscript.

Name: Michael T. Braun, PhD.

Contribution: This author helped conduct the study.

Attestation: Michael T. Braun approved the final manuscript.

Name: Richard H. Epstein, MD, CPHIMS.

Contribution: This author helped design the study and write the manuscript.

Attestation: Richard H. Epstein approved the final manuscript.


a Relevant, not demonstrable, intellective tasks15 are mostly statistical. For example, the decision of how many teams to have assist with turnovers based on maximizing productivity is well posed mathematically.12 For example, the decision of whether 2 operating room teams each work late to complete 1 waiting case or 1 operating room team completes 2 waiting cases also is well posed mathematically.5,11 Such decisions differ from decisions that involve entire organizations and include multiple frames, such as the political (e.g., power concentrated with 1 individual) and symbolic (e.g., culture). See Accessed November 4, 2014.
Cited Here

b Currently, the asynchronous voice channel in widespread use is voicemail. Typically, voice messaging is used when a telephone call does not make connection (i.e., almost no one regularly calls to leave an audio message). We consider the use of audio versus written content in the section Cognitive Load, below.
Cited Here

c Readers may alternatively remember and/or choose the dog that fetched advice. Available at: Accessed November 4, 2014.
Cited Here

d Available at: Accessed November 4, 2014.
Cited Here

e Billing questions can be answered by e-mail, but several features of our review do not apply. For OR management decisions and other engineering and mathematical questions, a literature search is difficult without an advisor because one generally must know the vocabulary before searching (see Introduction).18 From 1 appropriate paper, a decision-maker can then use citations and references to find needed information for a quality decision.18 In contrast, for anesthesia billing and regulatory questions, often a single Google search is sufficient. For example, “When anesthesiology residents cover the postanesthesia care unit, does an attending need to supervise them?” Entering that into Google (accessed June 30, 2014), the Accreditation Council for Graduate Medical Education (ACGME) requirements were the second listed item. Available at:
Cited Here

f Available at: Accessed June 30, 2014.
Cited Here


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