Why “Reply All” Can Push All the Wrong Buttons

Abstract

Technology has changed the way medicine is practiced. This commentary considers the effect of digital communications and offers advice on e‐mail etiquette.

Introduction

There is little doubt that online technologies like e‐mail, Google, and Twitter have fundamentally changed the way we practice medicine. The pros of these advances include essentially real‐time communication with experts and colleagues and rapid access to the latest medical information—all without having to leave our office or indeed home. However, equally well documented is the contribution these technologies and others are making to the increasing epidemic of stress and burnout among medical professionals [1]. Today's quibble pertains to a particularly cunning creature that lies within the sanctum of your online inbox: the “reply all” function—a seemingly harmless and frequently unnoticed e‐mail function with the potential to destroy relationships and take down institutions [2].

“Reply all” allows us to easily, and often unknowingly, deliver a message to multiple people at the click of a cursor. However, with great power comes great responsibility, the lack of which can lead to the rapid accumulation of useless e‐mails requiring precious time and energy to read and delete, not to mention the torrent of bings, bleeps, and shudders they produce from our devices. As the e‐mails amass, one can clearly see the five stages of the Kübler‐Ross grief model unfold with each reply—denial, anger, bargaining, depression, and finally, acceptance [3].

Every institution has its own reply‐all horror story. For example, in 2016 a test e‐mail was inadvertently sent to everyone in the U.K. National Health Service (NHS). This triggered nearly 500 million responses, leading to the collapse of the NHS servers [4]. Similar events have occurred globally, and these incidents tend to run a similar course. Below is one such example that occurred within Canada's largest clinical trials group (Fig. 1).

Figure 1.

Graphical representation of the emotional response to a reply‐allpocalypse. Adapted from Kübler‐Ross grief concept [3].

The Inciting Event

At 9:20 a.m. Eastern Standard Time (EST), an e‐bulletin was sent out via a distribution list managed by the group. The bulletin advertised an opening at the organization for a senior investigator, highlighted a new trial delegation log protocol, and profiled a researcher. At the bottom, in small font as typical, was a link for those who wished to unsubscribe from these e‐bulletins in the future [5].

The Aftermath

At 9:35 a.m., the first reply‐all response arrived, politely requesting removal from the group. A period of calm followed, until the next day between 4:00 and 5:15 a.m. EST, when the wind rose and an additional five reply‐all e‐mails of similar content flew in. The approaching storm could be seen on the horizon.

Denial

At 5:45 a.m., an impassioned but misguided recipient sent an additional reply‐all e‐mail requesting, “Would you please stop hitting reply all.” Why? Why would someone reply all, asking everyone not to reply all? A second, similar message arrived shortly after.

Anger

The e‐mails continued to fly in, with an additional three requests to leave the group. At 11:00 a.m., anger erupted as one furious recipient hit reply all, demanding: “WOULD YOU PLEASE STOP HITTING REPLY ALL!!!!” The use of all caps and multiple exclamation marks, being of course the online equivalent of shouting, marked the vertex of the storm.

Bargaining

By noon, however, anger led to bargaining, as recipients one by one pleaded, “Would you please, please stop replying all?!?!”

Depression

Approximately 72 hours after the first reply‐all response, the storm had passed, and the e‐mail thread fell silent with a total of 75 reply‐all messages amassed.

Acceptance

An apology e‐mail was sent out by the organization, but the harm had been done. Unfortunately, future similar incidents would demonstrate that reaching acceptance does not indicate that lessons have been learned.

Conclusion

Clearly the inappropriate use of the reply‐all function is not a unique problem, and readers will recall similar episodes they have experienced. Particularly, the more prominent, though smaller scale, reply‐all viruses emerge following group e‐mails announcing birthdays, babies, graduations, or retirements. Here once again, people feel obliged to reply all with their congratulations, turning a happy occasion into multiple e‐mails that can ultimately sour the event. Perhaps all these incidents should be viewed as minor irritations, but given the avalanche of e‐mails that can follow, otherwise smart people can end up looking less than intelligent, or even worse, uncaring. To this end, we wish to help our readers survive a potential “reply‐allpocalypse” and avoid making an “e‐barrassment” of themselves.

Advice to Senders of Group E‐mails

Make doing the right thing easier. Don't rely on people to unsubscribe by scrolling to the bottom of an e‐mail that is not of interest to them. Make the unsubscribe link more visible and move it to the top of the e‐mail. Make doing the wrong thing impossible, or at least very difficult. Remember that when you send a group e‐mail, you are creating a community. Think about whether you want them to interact with just you, or with each other. If they do not need to interact, then reply all should be disabled, or recipients should be entered in the blind carbon copy (BCC) field so that they cannot see, or communicate with, each other (Table 1).

Table 1. Key concepts in reply‐all etiquette.

Source: Hart [6].

Advice to Recipients of Group E‐mails

1. Pause and take a deep breath. Physicians should remember their Hippocratic Oath—Primum Non Nocere (first, do no harm). What are you contributing if you reply all to the group? Will it further the discussion or cause more harm?

2. Certain e‐mail servers allow you to insert a measure when you hit the reply‐all button that will offer you a moment of reflection with a prompt such as, “Do you really want to reply all?”

3. If you see the clouds of an inadvertent e‐mail storm approaching, don't get mad and reply all with a “don't reply all.” It's self‐destructive. Take shelter. Mute your e‐mail notifications through the settings function of your computer or smartphone and wait for the storm to pass.

4. If you really want to be proactive and have the technical capabilities, you can block certain senders, or create “rules” that can move specific e‐mails to junk or to a selected folder. For example, you can create a rule to send all messages with the same subject heading directly to junk mail. Or, if your e‐mail allows, use the ignore function.

Summary

Research clearly demonstrates the negative impact of digital distractions on our personal and working lives. The anger and frustration they trigger cause us to shout via e‐mail and behave nonsensically, with negative impacts on personal and working relationships, and even patient care. Thus, it is the authors’ opinion that, while difficult to truly quantify, better reply‐all usage could have innumerable positive impacts. As such, we hope this piece on reply‐all etiquette will help us take a collective step in the right direction to improve not only our own mental and emotional health, but our work environment and relationships, and ultimately patient care and outcomes.

Disclosures

John Hilton: AstraZeneca, Pfizer, PUMA, Novartis, Bristol‐Myers Squibb, Eli Lilly & Co. (SAB). The other authors indicated no financial relationships.

(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board