When electronic health record in-baskets first appeared, they were sold as a convenience: a digital filing cabinet where messages, lab results, and prescription requests would flow in tidy streams instead of piling up on desks. Two decades later, the in-basket has become one of the most corrosive forces in American primary care, an unbounded workload that follows physicians home, colonizes their evenings, and quietly drives them out of a profession that can scarcely afford to lose them. A new letter to the editor published in the Journal of General Internal Medicine argues that one of the most promising countermeasures is also one of the simplest: putting the inbox on the schedule itself.
The letter, authored by Letlhogonolo Benny Tlhabano, Jobira Woldemichael, and Alexandria Jade Sutton, physicians at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina, responds to a 2025 study by Lukela and colleagues that examined the introduction of portal practice slots, dedicated blocks of clinical time in which physicians are scheduled to work through their electronic message queues rather than squeeze them into gaps between patients. The original study’s title delivers its verdict with unusual candor for a peer-reviewed journal: the intervention was, in the authors’ words, surprisingly helpful. The Wake Forest letterwriters take that finding and push it further, arguing that the approach deserves systematic adoption rather than local experimentation.
The technical logic behind portal practice slots is worth unpacking, because it reveals something important about how clinical workload actually behaves. An in-basket is what operations researchers would call an unbounded, asynchronous task queue: messages arrive continuously throughout the day, at rates determined by patient behavior rather than by any scheduling decision, and each message carries a variable cognitive cost, from a routine prescription refill to a complex result requiring a difficult phone conversation. Traditional clinic schedules allocate physician time in fixed increments, typically fifteen to twenty minutes per visit, with the implicit assumption that message work will be absorbed in the interstices, during lunch, after hours, or in the seconds between rooms. The result is a structural mismatch: bounded scheduled time colliding with unbounded asynchronous demand.
That mismatch has measurable consequences. Burnout among internists and family physicians has hovered at crisis levels for years, and the pandemic years intensified rather than created the problem; large surveys of physicians documented significant deterioration in burnout and satisfaction with work-life integration during the first two years of COVID-19, with recovery slow and uneven. Within that landscape, the in-basket occupies a special place in the burnout literature because it is the workload component most resistant to conventional fixes. Hiring more physicians does not shrink the message volume per clinician by much, because message volume tracks panel size and patient expectations, both of which expand to fill available capacity. The inbox, in other words, is a commons problem: every efficiency gain is immediately reinvested in more accessibility, and the marginal cost lands on the physician’s evening.
Portal practice slots attack the problem by changing the temporal architecture of the workday rather than the total volume of work. Instead of treating message management as an ambient background task, the intervention schedules it as a clinical activity with its own protected time, much like a procedure block or a hospital round. Physicians know when they will address the queue, patients can be told when to expect responses, and the work itself, which requires sustained attention and frequent context-switching between multiple charts, gets performed in contiguous blocks rather than fragmented slivers. The cognitive science here is straightforward: task-switching carries a measurable cost in both time and error rates, and fragmented message work is both slower and more dangerous than batched message work.
The Wake Forest physicians situate this intervention within a broader evidence base on how time allocation shapes both clinician wellbeing and patient outcomes. They point to older British research showing that lengthening consultations for complex patients in a high-deprivation practice increased patient enablement, the measurable capacity of patients to manage their own health, suggesting that how clinic time is structured matters as much as how much of it exists. They also cite more recent American work linking burnout to primary care clinicians’ perceptions of team-based scheduling support, evidence that the scheduling layer, long treated as an administrative afterthought, is in fact a primary determinant of whether clinicians experience their workload as manageable or crushing.
What makes the letter notable is its emphasis on the word surprisingly in the original study’s title. That single adverb encodes a decade of institutional pessimism. Health systems have tried a long menu of in-basket interventions, message triage by nursing staff, automated responses, pooled in-baskets, team-based documentation, and the results have been consistently underwhelming, because most of them relocate work rather than reduce it. A scheduling intervention that actually helped, and helped enough to surprise the people who studied it, suggests that the field may have been solving the wrong problem. The issue was never that physicians were inefficient with their inbox time; it was that no one had ever allocated them any inbox time at all.
The implications extend beyond individual wellbeing into workforce economics. Physician turnover is extraordinarily expensive, with replacement costs for a departing primary care physician commonly estimated in the high hundreds of thousands of dollars once recruitment, onboarding, and lost productivity are counted. Burnout is the leading driver of that turnover, and in-basket overload is among the most frequently cited burnout drivers in qualitative surveys of practicing clinicians. An intervention that costs a health system essentially nothing beyond a reconfiguration of its scheduling template, no new hires, no new software, no capital expenditure, and measurably improves the daily experience of its clinicians represents an almost embarrassingly favorable return on investment. The barrier, as the letterwriters implicitly acknowledge, is not financial but cultural: clinic schedules are sacred objects in health system operations, and carving protected time out of them for what administrators may still perceive as clerical work requires a genuine shift in how organizations classify cognitive labor.
There are open questions the letter does not resolve, and honest coverage requires naming them. The original study was conducted at a single institution, and its findings will need replication across practices with different panel sizes, staffing models, and patient populations before the approach can be declared generalizable. There is also a risk that protected inbox time becomes a target for erosion, the way lunch breaks and administrative time have been eroded in countless clinics, absorbed piecemeal whenever patient demand spikes. And scheduling inbox work does nothing to address the underlying growth in message volume, which is itself a policy problem tied to patient portal access, reimbursement structures that reward asynchronous communication poorly, and the absence of payment for the considerable clinical judgment embedded in every thoughtful message response.
Still, the core insight survives those caveats, and it is the reason this modest letter to the editor has resonated well beyond its format. The in-basket explosion was never a technology failure; it was a scheduling failure, an attempt to run unbounded asynchronous work on a bounded synchronous timetable. Portal practice slots correct that architectural error with a change so simple it can be described in one sentence, and the early evidence suggests the correction works. For a profession losing its members to exhaustion at precisely the moment demand for primary care is accelerating, the most important innovation of the year may not be an algorithm or an AI assistant, but a block of time on a calendar, defended like the clinical resource it always should have been.
Subject of Research: Portal practice slots as a scheduling intervention for physician in-basket overload and burnout
Article Title: Letter to the Editor on “Surprisingly Helpful: The Introduction of Portal Practice Slots to Address the In-Basket Explosion and Physician Burnout”
Article References: Tlhabano, L. B., Woldemichael, J., & Sutton, A. J. (2026). Letter to the Editor on “Surprisingly Helpful: The Introduction of Portal Practice Slots to Address the In-Basket Explosion and Physician Burnout”. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10796-7
Image Credits: AI Generated
DOI: 10.1007/s11606-026-10796-7
Keywords: physician burnout, in-basket overload, portal practice slots, primary care, electronic health records, scheduling intervention, work-life integration, Journal of General Internal Medicine, clinician wellbeing, health system operations, task-switching, workforce retention
News Source: Ophelia Keating. (October 17, 2026). Scheduled Portal Time Emerges as a Practical Answer to Physician Inbox Burnout. Scienmag.
