The expression “just one more thing” may earn its place as the leading catchphrase of modern healthcare. We all know the scenario: The patient encounter is over. You addressed the patient concerns, adjusted medications, and reviewed lab results. Then comes the familiar phrase, “just one more thing …” Every clinician knows what happens next. It may be something as simple as a medication refill. Sometimes it’s chest pain that somehow never made it into the first 20 minutes of the visit. Sometimes it’s a statement like “I should mention that I am pregnant,” that changes the entire plan of care that was already discussed.
I’ve realized that the healthcare system speaks the same language. Modern medicine operates in parallel to these scenarios and clinical workflows have become burdened by a steady accumulation of “just one more thing.”
When a patient says this, it is because they want to make sure they are heard and they are usually right to speak up. The healthcare system says it (albeit not always out loud) for a different reason. If a patient comes in with 15 more things, we eventually have the ability to stop the stream of more things and set realistic expectations for what can be handled in a single visit. When the system adds just one more check box, quality metric, click to close a chart, inbox item, compliance module, etc., we are stuck. Each new item is individually insignificant, but the accumulation of new items collectively consumes hours of time, takes attention away from patients, and gives us no place to put the breaks on and say, we’ve reached our time for today.
My EHR has reached the level of a well-meaning, but pushy relative asking things like “Have you documented tobacco exposure? What about allergies? Are you sure you want to prescribe that medication again? I see this patient has an intolerance to one that is similar, can you tell me why you are prescribing it? Oh, they already tolerated it, well go ahead and click this acknowledge button, then I’ll take you back to the page where you started and you can try again.”
We have successfully created a healthcare system in which once something is created, it rarely dies. No single person or entity created this design. Hospital leaders, insurers, regulatory agencies, professional societies, researchers, and clinicians are all invested in the infrastructure that is created to document care, protect from liability, demonstrate compliance, support research, and more. Yet each stakeholder adds requirements within their own scope of responsibility, but has no incentive or authority to eliminate the tasks imposed by others. While not the cause for this cumulative burden of tasks, the EHR serves as the vessel to quickly and easily implement new requirements at low cost. This means that in response to any adverse event or quality failure, a new field or checkbox can be implemented; a new research need or quality metric can be a hard stop to complete before signing a chart for the day. We now have checklists to make sure that we completed our checklists correctly. Now, the question isn’t whether healthcare can afford another thing. The question is how much longer it can afford not to take something away.
Healthcare hasn’t suffered from a single catastrophic inefficiency. It suffers from mountains of tiny ones. Every inefficiency arrives disguised as a small, insignificant task. No single addition breaks the system (or the person) and individually each new item may appear reasonable, necessary even. But collectively, everyone in healthcare, from nurses to physicians to administrators, must recognize the phenomenon that is slowly eroding clinical care and will continue to accumulate until clinicians spend more time serving processes than patients.
Every new responsibility used to meticulously measure outcomes comes at the opportunity cost of clinician and staff attention. Over time, this steady accumulation of “just one more thing” shifts clinician focus from patient care to clicks, fields, and forms. Eye contact is slowly lost, active listening weakens, and relationships begin to crack. The time consumed by the rising number of administrative tasks comes directly from time that would otherwise belong to patients.
This cumulative burden of small requests has become a defining feature of medicine and one that contributes to burnout, reduced access, and less time spent with patients. Yet it keeps happening. Every system wants more safety, better quality scores, more paper trails. I am not here to argue against accountability or quality improvement. Change is necessary and important. But it’s time to recognize that healthcare’s biggest inefficiencies don’t come from large mandates, but rather from the countless small additions of “just one more thing.” At the end of the day, addition is easy. Subtraction doesn’t have a seat at the stakeholder table.
Healthcare needs to grow in the discipline of subtraction. And we should use the same basic logic we use with maintaining our personal possessions: if your closet is full and you bring in a new clothing haul, you have to retire old items to make space. So the solution for reform is simple: every new requirement should require the review of existing processes and the elimination of an old one. This may seem like yet another proposed task, but while technology helped lower the cost of creating new administrative tasks, it hasn’t been fully integrated to create mechanisms for removing tasks that served problems that have since changed or when another solution has also been introduced. AI may just be the answer to this solution.
And this goes for patient-facing requests as well. For example, why are patients still being asked if they have traveled out of state in the last 30 days at check-in? This COVID era question lingers in the workflow. Not only did they already answer this question once when they completed e-check-in, this information doesn’t even get shared with the clinician if they say yes. They ask because they are told to and to be able to check a box that lets them move on to the next questions. Because at one time some committee proposed a new questionnaire, it was approved and implemented, and now it is required. Years later, it still exists and it doesn’t seem to matter if it has any impact on patient care. Could an AI EHR support identify this redundant line of questioning and help streamline the process? I think so. It may shave only a second off the time patients spend at check-in and not with us. But in healthcare, every second counts.
I hope systems will begin to weed through the outdated and time-consuming requirements before patient care visits become nothing more than a steady stream of lists and checkboxes threatening the humanity of healthcare and the burnout of clinicians. But until that happens, it is important that we continue to put patients above clicks. And the next time a patient says “just one more thing,” don’t think about the checkboxes and metrics you need to complete to close the chart; look the patient in the eye and address their concern without the background sounds of clicks and mouse shuffles.
Has your healthcare system had success in the art of subtraction? Share what worked in the comments!
