Over the past decade, the electronic inbox has become a defining feature of modern clinical practice. Patient portal messaging—direct communication between patients and clinicians via a portal in the electronic health record—has evolved from a supplementary communication tool to a central modality of care delivery. Prior studies have linked growing message volume to increased after-hours use of the electronic health record and clinician burnout, raising concerns that asynchronous communication, while convenient for patients, may contribute to unsustainable workloads. The COVID-19 pandemic accelerated these changes through both telehealth visits and patient portal messaging. Yet despite widespread recognition of this shift, national trends in patient portal messaging have not been described, nor how messaging relates to more traditional care modalities, such as telephone encounters and office visits.