I'm your primary care doctor. May I take your order?

My Tuesday out of clinic started off like any other Tuesday. I got up (sluggish, still chronically sleep-deprived), scrubbed my face and brushed my teeth, slipped into workout clothes then set to getting my two girls ready for school. After packing lunches, brushing hair, and waiving to the bus, I sat down to do what most of us do on our days out of clinic: check the dreaded inbox. Who knows what fresh torment it can accumulate overnight?

After 20 years in practice, I figure not much can surprise me. And then I’m surprised (again) at how easily I’m surprised. This morning started with an especially egregious patient MyChart demand. She started by saying that she recently had COVID-19. No surprise here: Our rural midwestern community is still awash in it. She went on to say that she had read that people who were recovering from COVID-19 were at high risk for heart attacks and blood clots. She asked for a “D-dimer and troponin, 5th generation.” We are fortunate enough to have our medical assistants screen the messages before sending them to our in-baskets, but this patient was not interested in my MA’s suggestion that she make an appointment to discuss her concerns. Nope. She was having none of that! She wasn’t paying for an office visit, and now that her labs came to her phone instantaneously, she only needed a lab order. “My doctor can’t treat my heart attack anyway.” She would look at her lab results herself and decide where to get care.

Welcome to Burger King Medicine. Drive through. Have it your way.

How did we get here? Is anyone else asking this?

Don’t get me wrong. There are things about the EMR that I love: instant access to lab results and consultant notes. Neat little tabs. Searchable files. Click here to see the X-ray! I’m old enough to remember flipping through reams of paper charts. Waiting patiently for films to be sent out in the ubiquitous manila packets. I don’t miss most of that. But direct patient messaging? Instantaneous patient results? Ugh. Yesterday I had a visit with a mother whose son had committed suicide during the pandemic. I held her hand as we both cried a little. These are not conversations that can be rushed. All while the patient in the next room was messaging through her patient portal. Her labs were back! She can see them! Why isn’t the doctor coming back in my room!

My order is up. Why hasn’t it been delivered?

I could see this coming. The pandemic put electronic access into overdrive, and some of it was really good. We now have new and innovative ways to connect with our patients. I’m constantly surprised at the ability of my elderly patients to pivot and adapt. Of all of us to pivot and adapt. We do virtual visits. We send results via secure messaging. Patients make appointments online, relieving some of the stress on our understaffed and overburdened phone centers. This is good!

But with the good comes the bad. The three-page medical messages. The unique hell of an abnormal lab or imaging result that is instantly released on the weekend or your day out of clinic. Who gets to deal with that now? Who answers the frantic call? Who comforts the patient who sends a desperate message into cyberspace? Did anyone think of these things when they made these laws? Pushed us all to adapt to the digital world?

I did. I think most of us in medicine did. But our voices fell on deaf ears. Big health care systems saw this as a way to improve patient engagement. Relieve stress of phone systems. Pad the bottom line for the financially-draining primary care service line. Legislators saw it as patient empowerment. Patients deserve to have their results in real-time! Damn the consequences. Damn the cleanup that physicians are forced to do on the backside.

So I spent my morning doing uncompensated, unappreciated work. We don’t get paid to answer medical messaging demands. We physicians don’t get paid for lab-only visits, but we are expected to deal with the consequences of the results. I guess after all of these years I’ve become numb to uncompensated mental work. Goes with the territory in primary care. We don’t expect to be valued or appreciated by insurance companies, health care systems, or, even sometimes, our specialty colleagues. We have always comforted ourselves with the soothing balm of patient appreciation. At least our patients don’t take us for granted. They appreciate what we do.

Until today.

Today the expectation has become: Can I take your order?

We have come full circle in a digital service world. Today, I have become nothing but the rate-limiting enzyme between a Google search and a specialty visit.

And I’m a really bad enzyme. I refused to place the orders. I drew my line and demanded that the patient make an appointment. I know all of you would do the same.