Your email is going to spam
Patients say they never got your message. Before assuming the worst, work through these checks in order — the answer is usually in the first three.
“The patient says they never got it.” Work through these in order — they are arranged cheapest-first, and the cause is usually found in the first three.
1. Check your authentication records
This is the cause perhaps half the time. If SPF, DKIM and DMARC are missing or wrong, Gmail and Outlook increasingly filter you by default — both now require authentication for bulk senders. Run a DMARC checker against your domain, or see SPF, DKIM and DMARC explained.
The specific things that bite practices: a second SPF record added when a new service was signed up for; DKIM enabled at the provider but never published in DNS; SPF still listing a mail host you left two years ago.
2. Check whether you are on a blocklist
Look up your sending IP and your domain on a blocklist checker. A listing is usually the symptom of something else — a compromised mailbox sending spam, or a shared host where a neighbour misbehaved.
3. Check what you are sending
Content matters less than it used to, but these still hurt:
- A single large image with almost no text. Classic spam shape.
- Link shorteners and links whose visible text does not match their destination.
- Attachments that are executables, or archives with passwords.
- Mismatched From and Reply-To, which looks like a forgery.
- ALL CAPS SUBJECTS, rows of exclamation marks, “URGENT”, “ACT NOW”.
4. Check how you are sending bulk mail
Newsletters and recall campaigns should not go out from your normal mailbox. Sending a few hundred messages at once from a practice mail account is one of the fastest ways to get the whole domain filtered. Use a proper bulk provider, authenticate it, and keep an unsubscribe link in every message.
news.yourpractice.com. If a campaign damages your reputation, your clinical and billing mail is insulated from it.
5. Check list hygiene
Repeatedly mailing dead addresses is a strong negative signal. Every hard bounce should be removed from your list immediately, not retried monthly. Never buy or import a list you did not collect yourself.
6. Check the recipient’s side
Sometimes it is genuinely not you. A single practice or hospital with an aggressive filter, one recipient who once hit “report spam”, or a corporate gateway that quarantines all outside mail. Ask the recipient to add you to their contacts or safe-senders list, and to release the message from quarantine if they can — that teaches their filter.
What to do about it right now
Stop guessing
Run an authentication check on your domain and note exactly which of SPF, DKIM and DMARC are missing or failing.
Fix authentication first
It is the highest-impact change and the one filters weigh most heavily.
Turn on DMARC reporting
p=nonewith arua=address, so you can see what is sending as you and whether it passes.Send a test and read the headers
Mail yourself at a Gmail address, open the message, and use “Show original”. You want to see
SPF: PASS,DKIM: PASSandDMARC: PASS.Give it two weeks
Reputation recovers gradually. Keep volume normal and steady rather than sending a burst to prove it works.
FAQ
Only Gmail recipients have the problem. Why?
Gmail weighs authentication and engagement heavily, so it tends to show the problem first. Treat it as an early warning — the underlying cause usually affects everyone, just less visibly.
It started suddenly and nothing changed.
Something usually did: a new service was signed up for and added a second SPF record, a mailbox password leaked and is being used to send spam, or a certificate or DNS record expired. Check your sent folder and your DNS first.
Can we just ask patients to whitelist us?
It helps individual recipients, but it is a workaround rather than a fix, and you cannot scale it. Fix authentication — it is the part that actually moves you back to the inbox.