Monday morning, medication refills. I used to do these for four clinicians at once, about 200 requests on any given Monday. It’s a lot, but it’s the kind of work you can build a rhythm around if everything is set up well.
This was not set up well.
Part of our workflow had our medical assistants forward a block of structured text to support the refill decision. I am so sorry I made you read that android sentence. That wall of text was 60 lines. Probably still is. 60 lines. Dropdown options that had been outdated for years. Nothing highlighted when it was relevant, so nothing scannable. A comment field buried so far below the scroll, and used so rarely, that nobody checked it anymore.
The things I actually needed were almost never in there. When was this person last seen for their chronic conditions? If it wasn’t recent, was there something on the books already? The continuity check. A primary care panel runs to thousands of patients. Someone can go years without seeing me and still look current, because the chart only asks whether they were seen by anyone in the building. These were the patients no one was going to hear from, not because they’re avoiding coming in, but because nobody ever told them they were supposed to. Pulling it by hand took about twenty seconds, and it was how I caught the people who needed to be seen before an automated flag would point this out six months late.
Twenty seconds times 200 refills is a little over an hour every Monday, broken into caltrop-shaped pieces and scattered across a day that has other things in it. An hour of clinical time, every week, lost to a data entry problem.
So I rebuilt it. Just the continuity check. Everything else our system already displayed, or it did not matter. Two lines. Two instead of 60. A win for everyone. I brought it to the clinical operations manager and the medical assistant lead. They got it immediately. They also could not implement it.
What they said was that the old format might be required documentation somewhere, but that they did not know who to ask. What I think they meant was that the cost of getting the change approved was higher than the cost of me living with it. When it came down to it, not only was I asking them to go digging for a person to have an argument with, I was asking them to argue over 20 seconds. Why bother? Real problem, viable solution, no path forward.
I went back to my desk and stared into space for five minutes. At my going rate, fifteen refills.
And after that, I stopped doing the twenty seconds.
I made decisions based on what the wall of junk put in front of me and moved on. On paper getting the information had been a dozen medical assistants’ job. In practice it was optional because nobody owned enforcement, and doing it correctly caused too much friction. So I had been quietly doing it myself for years. Teaching moments never changed that because the problem was never the people. The workflow was built so that skipping the step cost nothing for anyone except me.
I started following the philosophy of my colleagues. First, the patients who are well and truly overdue will eventually become obvious on their own, so you do not have to go looking. Second, “we cannot care more about their health than they do.” I told myself the harm was minimal, that I was now following the same workflow as everyone else. But it felt gross. It felt like giving up.
Continuity and close follow-up are most of what makes primary care worth anything. They are how you build a real read on a patient, and a relationship the patient can rely on, instead of running a refill and referral farm. I had been funding those things personally, in twenty second increments and a dozen other ways, because the organization never agreed it had to.
And that brings me to the question underneath all of it. Who absorbs the friction?
Three candidates. The medical assistant, who could push back. Me, who could push back, and eventually did. And the patient.
Push it onto a patient hard enough and eventually they complain. Then a manager takes you out for a cup of coffee and asks you, kindly, to stop generating complaints. That is friction behaving the way friction is supposed to behave. Something got worse, somebody noticed, the noise traveled back.
But nobody files a complaint about a phone call they never got and never expected. Satisfaction scores can measure a bad visit. They have nothing to say about a visit that never got scheduled. So of the three places that friction could land, one of them is silent, which makes it the cheapest. Nobody sat down and chose that. It’s just built into the design. It worked perfectly.
I could see what was broken, design a fix, and occasionally be right about it. Implementing it required authority I did not have, incentives I could not change, and adoption I could not enforce. So I absorbed it, over and over, the way you do when you care more about the work than about what the work is costing you.
I have also done medicine out of a van in homeless encampments, with a laptop and a backpack. I’ve done it in a tent in a disaster zone with a medication chest and a few cots. It’s hot, it’s smelly, but it’s so much more fun. Both felt right in a way the clinic never did. The difference is that the dysfunction is acknowledged.
In the van and the tent, the dysfunction is the explicit task. The job is figuring out what resources are available, what processes must exist, because you’re starting with duct tape and zip ties and a sign with ‘Aid Station’ Sharpie’d on it. There is no organizational layer between you and the problem, and nobody expects you to absorb the constraints quietly and then perform as though they were never there. They know. You don’t get a pat on the back about it, but you don’t pretend it’s not there, either.
In the clinic, the dysfunction is made invisible. You are expected to deliver the same care whether or not the scheduling system undermines continuity, whether or not prior auth adds two unpaid hours to your week, whether or not a sixty line block of text is slowing you down. The pressure is real. The company line is everything is working great.
Every organization I’ve practiced in optimized scheduling for availability and utilization rather than continuity, because those numbers are easy to count and continuity is not. Hit the productivity target without complaints and you are considered good at this. Each time I raised my concerns, in one form or another, I was told that this was the reality. I was told that maybe primary care just was not for me.
That answer is cheaper, in effort and social capital and dollars, than fighting for the redesign of a refill workflow. Of a scheduling template. Of panel size.
The Monday of the refills was not the day I changed. It was the day I noticed I already had. For years I had been practicing above the standard that organizations held me to. My colleagues might say I had been practicing in a way that was unsustainable. I was absorbing that friction for free. Then I stopped.
I can defend that for about three refills before it starts to sound like an excuse. At the very least, patients were getting less than they had been getting the week before. I do not actually know what the harm was, I stopped looking. And I worry this sounds like a clinician who gave up and then built a systems argument around why it’s OK. I have spent more time steeling myself against that accusation than I care to admit.
So I left. It’s been almost three months. It still hurts.
Nobody at that clinic is losing sleep over the sixty lines. Nobody there is counting out the twenty seconds. And I’m happy for them. So very jealous of them. But it’s not me.