Friction in primary care

I love taking care of patients and have enjoyed my 37 years (and counting) as a primary care physician.  When I stop, it won’t be because I am rich, bored, or have lost interest. It won’t be because I am tired (though I am). It will be because of friction.

Friction is defined as a force that resists the relative motion of two bodies in contact with each other. Fine. I think of friction as an evil force. It exists simply to resist, to make things harder. It matters not which direction something wants to move, friction always pushes in the opposite direction. The closer the contact between two objects, the greater the impact of friction. 

In high school physics I was introduced to the four of kinds of friction: static, rolling sliding, and liquid. Later I learned about dry versus wet friction, internal friction, and lubricated friction.  None of my science classes talked about the most prevalent and infuriating form of friction:  institutional friction, the myriad things that slow you down and hold you back, making everything harder than it needs to be.



My daily life as a primary care physician involves constant friction. It is abrasive and wears away at one’s attitude. It generates heat and does damage. Some examples:

• A triage process that tells a patient at 8:30 that she has an appointment with me at 8:45, even though she lives 20 minutes away.
• There are no tissues, plastic drinking cups, or pads of paper in the exam room.
• I see a patient for follow-up of an emergency room visit five days ago for chest pain, and the emergency room note is not dictated or available for review.
• The surgeon removes the thyroid and the endocrinologist prescribes the thyroid hormone, but the patient asks me what thyroid hormone is, what it does, and why he is supposed to take it on an empty stomach. 
• A patient tells me he is having trouble finding things to drink now that he is anti coagulated with coumadin, because his favorite fruit drinks all have lots of potassium and he was told to avoid things with Vitamin K. He was told when he left the hospital that he could tell about vitamin K by looking at labels,  and he points to a juice label that has a ‘K’ next to the word potassium.
• When I add a a new, minor and self-limited problem to the problem list, it is added to the top of the list where the major and chronic problems belong, and often without a stop date, so I have to navigate to the edit section and suffer clickorrheato move it down the list and add a stop date. Ten to twenty times a day. 
• A consultant starts a patient on an expensive new medication, gives a prescription for 1 month, and expects our office to do subsequent prior authorizations.
• The neurosurgeon’s office declines to schedule my referred cervical disk herniation patient for evaluation until and MRI is done, confirming the presence of a surgical lesion, though the reason for my referral is not to have surgery, but to learn what the implications of a surgical approach would be.
• I see a patient for a suture removal and there is no suture removal set in the room.
• I want to schedule a patient for a cardiac stress test, and the standard, one-size-fits-all pre-certification form requires that I answer questions about family history of cancer, past history of cancer, prior x-rays. If I leave any of these irrelevancies blank, the form will come back to me and scheduling the test will be delayed.
• My institution has decided not to provide shaped specula to look in ears, so if I want to do ‘pneumatic otoscopy’ (use changes in air pressure through the otoscope to see how flexible the ear drum is – the only accurate way to diagnose a bacterial ear infection – redness of the drum is NOT diagnostic), so I have to purchase my own and retrieve them from my desk drawer when I need them.
• My institution refuses to have the updated medication list at the end of the visit appear in the note by default, so I have to remember to perform a set of extra clicks on every patient to prevent medication errors.
• Molasses in the CPU. It takes 15 seconds to open a patient chart, 10 seconds to print a handout, 10 seconds before I can navigate in the EHR after printing any Schedule 2 medication.
• Our expensive EHR has no search function, so when a patient asks which neurologist they saw 5 years ago or I want to see if they had a visit with cardiology or an MRI or echocardiogram,  I have to scroll through the subject lines of dozens or even hundreds of documents. (If Amazon or LLBean made me scroll through a catalog index to find the shirt I wanted, I’d shop elsewhere, for sure.)
• I am logged out of the EHR on my office desk multiple times a day (about every hour) and have to re-login with my user name and password. 
• A patient with a vision problem is put in a room and vision is not checked as part of vital signs.
• A patient I referred for nerve conduction studies calls to ask why she hasn’t heard the results. I look in the chart and the test was done and the results are there, but they were never sent to me. (This is not specific for nerve conduction studies, but applies to all manner of tests and happens several times a week.)
• A patient with a week of runny/stuffy nose, cough and sore throat has a strep test done by the nurse, and it is positive, adding 5-10 minutes to the visit to explain why the test shouldn’t have been done, overwhelmingly represents a false positive or clinically insignificant carrier state, and antibiotics are not needed.
• The patient with lower abdominal pain and vaginal discharge is not put in the room with the vaginal exam equipment.
• The patient for the scheduled shoulder injection is not given an informed consent to review before I enter the room, so I have to print it, go get it from the printer, give it to her to read before we can start our discussion. 
• The printers are located a fair distance from where I see patients, so every time I have to give them a signed prescription (often) or want to print some patient instructions and review it with them, I have to print it, log off the computer, walk to the front, get the documents, walk back, log back in.
• A third of the patients I see every day have an old problem (infected bug bite), an expired medication (antibiotic for last year’s otitis), or an allergy or medication entered ‘uncoded’ (which means it cannot trigger allergy or interaction warnings). Fixing these takes time away from attending to the patient.

I could go on for some time, but you get the idea, I am sure.

Overwhelmingly, these are individually small disruptions, but their cumulative impact is huge. One or two potholes are well tolerated by the modern automobile, but make them numerous enough and the wheels fall off. The most aggravating piece is that most of them are a result malfunctions of the systems that are supposed to be helping me work with my patients. In the military, this would be considered casualties caused by friendly fire.