For a growing number of patients around the globe, seeing the doctor now requires a trip to their computer. At the Palo Alto Medical Foundation in California more than 15,000 patients have agreed to pay $60 a year for e-consults. That fee gives them access to their doctors through e-mail, and they use it to set up appointments, update doctors about their progress and get answers to their medical questions when appropriate. According to the Foundation, nine in 10 of the doctors who have signed on say they are pleased with how it works, and patients continue to sign up. The Institute of Medicine has noted that e-consults could create significant savings in a health care system plagued by costs that have been advancing at five times the rate of inflation. "Instead of a $65 office visit and a half-day off work," noted the IOM, "a 2-minute e-mail communication could meet many patients' needs more responsively and at lower cost." Just months ago, a pair of medical researchers studied e-consulting and concluded that physicians and patients both stood to see significant gains from adopting more Internet-based communications. "With such a large proportion of the population now with access to e-mail, it seems unusual that this method of communication, so essential for many, is so underused by doctors and patients," concluded Dr. Josip Car from Imperial College and Professor Aziz Sheikh from the University of Edinburgh. "This review has shown that there are definite advantages to the increased use of e-mail for patient-doctor consultations." There are plenty of physicians in Tennessee, though, who see more disadvantages. "They don't feel it's a good practice," says Laurie Estes, spokesperson for Memphis Eye and Cataract Associates. "It's hard to diagnose a patient over the Internet, so we don't do any e-consulting at all." "Every case is so different, so unique," agrees Tracy Hampton, spokesperson for the oncologists at The West Clinic, that the doctors there just don't think it's right for patients. Occasionally, nurses do help by sending Internet links to patients trying to learn more through the Internet. But in general, she's quick to add, it's just not a good way to communicate. And that attitude is fairly common throughout the state. "Frankly," says Russ Miller, spokesman at the Nashville-based Tennessee Medical Association, "we don't hear a lot about it." The UK researchers, though, think some of the state's physicians may need to reevaluate their position. Time saving was one of the most important features, they wrote, finding that doctors could often replace an office visit with an e-mail exchange - especially when the doctor was managing chronic cases with regular patients suffering from ailments like diabetes and obesity. Disabled patients or people living in underserved areas benefited from swift responses. And the doctor's time was used to maximum efficiency. There are some big issues that have to be resolved, though, before e-consults become part of mainstream medicine. Insurers have yet to come up with standard reimbursement methods. Many physicians don't charge anything for online accessibility, in part because they feel there are unresolved liability questions in the event a patient experienced an adverse reaction following some recommendation delivered through e-mail. And many doctors are understandably hesitant to start offering free services when they're already working longer hours just to maintain their income. The two UK researchers also cautioned against using the service for anyone other than regular patients they had already seen in their offices. While physicians may be able to safeguard the privacy of the communications from their end, there was no guarantee that patients had a secure e-mail system. The researchers also noted that access to the Internet was still far from universal, raising troubling questions about creating a preferential system for Internet users. E-consulting, they noted, "may widen social disparities by allowing preferential access to wealthier people and young middle-class adults." But at the Palo Alto Medical Foundation, about one in four of the patients who signed up for the service was over 63. And that's another sign that e-mail access may ultimately prove one of the most efficient ways to see the doctor now.