The Click That Broke the Camel’s Back

I’m a third-year Family Medicine resident, focusing on mastering my craft — things like: avoiding unnecessary antibiotics, developing habits to practice evidence-based medicine, and studying (up to three hours per day) between patients. Of course, I’m also supplementing my learning with podcasts, case-based learning from HumanDx, practice problems, and etc. I work hard and it shows (I was recently notified that I passed my specialty boards).

Despite everything though, I’m feeling unprepared. Not for the medicine. What I don’t know yet, I’ll learn. I’ll happily spend the rest of my life learning to practice better medicine, to provide patients excellent care, and to teach the next generation of doctors. I know I’ll be supported wherever I go by caring and efficient colleagues, specialists, nurses, and ancillary staff who I will both learn from and lean on.

It’s not the patient load, either — I’m even content with that. While I would prefer to spend more time with my patients, I understand that there’s more demand than the current supply of primary care physicians. We simply do need to see more patients each day.

No, what I’m feeling unprepared for is the constant, dehumanizing march of administration, billing, and insurance companies. After working hard through high school to get into a good college, deferring typical college frivolity to study for MCATs, going through medical school, and spending three years with an “MD” behind my name, I’m not prepared to set aside my ego. I have no problem being called by my first name — or “sweetie” — by patients; by all means, as a white male, I suffer fewer indignities than any other demographic. But when administrators put themselves between me and the patient, I find the situation intolerable.

The past several years, I have borne witness to the addition of oversight after oversight. Nowhere is this more visible than the electronic health record. Examining each “requirement” within its purview is like walking down a graveyard of autonomy, independence, and physician trust.

Your patient’s BMI is > 25? Better click that you counseled them that a high BMI is unhealthy.

… Oh, you didn’t click that you counseled them on exercise separate from the general obesity counseling? That means you mustn’t have done the counseling, and it’ll be a quality metric “ding.”

Does your patient have high blood pressure? Well, unless you clicked the right button, there’s no chance you counseled on lifestyle modifications.

Smoker? Gotta click that counseling box.

Reviewed the chart? Either you click the button or the Big Brother of Insurance can’t verify that you even looked at this unnecessarily bulky medical record.

Opening a lab report “costs” four clicks. Refilling a medication? Five clicks if the patient calls in, 14 if the pharmacy “automatically” sends the request.

When you initial a document with the date and scan it in? The cost is another six clicks.

The thing is, I know this doesn’t improve patient care. It doesn’t help the physicians I refer my patients to. It doesn’t help me to remember the patient I saw 18 months ago.

Does this benefit anyone except for the insurance companies? And if not, why do we care?

Recently, after another quarterly staff meeting, our clinic was instructed to add another click to our workflow. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) inspection occurred at our institution this fall, and one of the lasting ramifications was simple: one more click. Now, we have been informed that we are not meeting metrics unless every time we prescribe we also select the button that indicates, “I have discussed the potential benefits and risks of this medication.” But when a physician prescribes a medication, it is a process: (1) extracting a history of the illness, (2) a physical exam, (3) ordering and interpreting appropriate lab tests. Then, at least in the minds of the chart reviewers and quality metrics personnel, one of two things happens next: (4a) the physician writes a prescription to the patient, without telling them what it is, what it’ll do, or what to watch out for — in essence, the apocryphal “take two aspirin and call me in the morning”

or

(4b) the physician discusses the risks and benefits of the prescription, and engages in patient-centered care.

So, what is the best way to know whether a doctor did one versus the other? The correct button was clicked.

… Now, this is the point in the article where I’m supposed to include a call to action: Pester your congressman! Sign a petition! Donate to a PAC!

The problem is, I don’t see a solution here. Every year there are more requirements, and every year those requirements result in more burnout. I don’t have an easy fix, but even in my early career stage, I do know that this way isn’t right.

Where do we go from here?


Brian Templet is a graduating Chief Resident in Family Practice. He is planning on serving an underserved community and contributing to medical education. He has worked through residency to prepare to treat populations such as transgender patients, people with substance use disorder, and to educate future generations of clinicians.

More from Op-Med